Up to 5.5 million Americans are currently estimated to have dementia, which is characterized by a decline in memory, language, problem solving, and cognitive functioning. This number is projected to almost triple by 2050. The costs associated with caring for different types of dementia, such as Alzheimer’s disease, are projected to reach more than $1 trillion by 2050.
A study presented at the 2016 Alzheimer’s Association International Conference found that patients treated for dementia with the current standard of care and with indicated medications lived longer and incurred lower healthcare costs when compared with those who delayed treatment or received no treatment.
A Significant Challenge
Early assessment of cognitive impairment does not always lead to a diagnosis of dementia. Conditions that mimic dementia can be unrelated and treatable. Even in cases where dementia is the cause of impairment and drug therapy is ineffective, earlier recognition may help patients and their physicians and caregivers plan for the future. Despite the benefits of early diagnosis and treatment, identifying dementia in early stage is challenging. There is no single test or procedure that allows physicians to reliably diagnose dementia. Patients are often evaluated with a physical exam, medical history, and various laboratory and imaging tests.
Evaluation for dementia also typically involves mental status exams, such as the Mini-Mental State Exam (MMSE) and the Mini-Cog test. Using these tests, physicians refer to a questionnaire to ask patients a series of questions to explore memory recall and other indicators of brain health. The 29-point Memory Orientation Screening Test (MOST) combines four tasks of memory and executive function, incorporating 1) three-word recall, 2) orientation to time and date variables, 3) immediate recall, and 4) standardized scoring of a clock drawing. Importantly, the MOST correlated highly with standard neuropsychological outcomes, and has been shown to be more accurate and reliable than the MMSE and Mini-Cog in a large clinical validation study.
Problems With Paper-Based Screenings
While traditional mental status exams are useful, they rely on paper-based screening methods. Results from traditional paper-based tests cannot easily be transferred to or stored into an electronic health record (EHR). As a result, progression of scores is generally not easily tracked and compared over time. Paper-based screening may also be subject to interpretive bias. The reliance on paper and pen to aid disease evaluation is not taking advantage of today’s availability of hi-tech EHRs, population health analytics, and decision support technologies.
Recently, new digital diagnostic tools have been developed to overcome these barriers. A recent example, CogniSense™, a digital version of the MOST test, can be easily downloaded by clinicians and administered through an Apple® iPad™. Scoring can be transferred and stored in the patient’s EHR and integrated and viewed along with the results of various types of diagnostic tests. Physicians can track and monitor cognitive function over time based on an objective score.
The experience of physicians and patients with CogniSense™ highlights the clinical and economic value of transitioning paper-based evaluation to digital apps. Physicians with Primary PartnerCare—a leading accountable care organization (ACO) in Long Island, NY—used CogniSense on hundreds of patients. The diagnostic tool was well received by both physicians and patients, and has helped reduce the number of unnecessary referrals to specialists and premature advanced testing. Preliminary analysis also suggests that CogniSense™ helped the ACO’s physicians to improve dementia detection in early stages of disease.
As the population ages, digital cognitive assessments like CogniSense™ may help primary care practices evaluate a growing number of older patients that is at risk for dementia. Their ease of use and objective measures may also be appealing to certain types of specialists who care for patients at risk for cognitive impairment in a wide range of settings, including skilled nursing facilities, neurologists, neuropsychologists, and hospitals. Clinical trials to aid the discovery and development of drug therapies for neurological disorders may also benefit from digital technologies. Ultimately, it is possible that better evaluation of dementia may identify patients with the disease earlier in life so that they and their families can benefit from the treatment, care, and support that is needed to address this complex condition.
Edward I. Ginns, MD, PhD, DABCC, has indicated to Physician’s Weekly that he works as a consultant and paid speaker for Quest Diagnostics.
Readings & Resources (click to view)
Moyer VA, on behalf of the U.S. Preventive Services Task Force. Screening for cognitive impairment in older adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160:791-797. Available at: http://annals.org/article.aspx?articleid=1850963.
Alzheimer’s Association. 2016 Alzheimer’s Disease facts and figures. Alzheimer’s & Dementia. 2016;12(4). Available at: https://www.alz.org/documents_custom/2016-facts-and-figures.pdf.
Alzheimer’s Association. Changing the Trajectory of Alzheimer’s Disease: How a Treatment by 2025 Saves Lives and Dollars. 2015. Available at: http://www.alz.org/documents_custom/trajectory.pdf.
Assessing cognitive impairment in older patients: a quick guide for primary care physicians. National Institute on Aging. U.S. Department of Health and Human Services. Available at: https://www.nia.nih.gov/alzheimers/publication/assessing-cognitive-impairment-older-patients.
Black CM, et al. Comparison of all-cause mortality rate and economic burden between newly diagnosed Alzheimer’s disease patients who received anti-dementia treatment vs. not: a longitudinal retrospective study. Presented at: Alzheimer’s Association International Conference; July 24-28, 2016; Toronto.
Clionsky M, Clionsky E. The Memory Orientation Screening Test (MOST) accurately separates normal from MCI and demented elders in a prevalence-stratified sample. J Alzheimers Dis Parkinsonism. 2013;3:109. Available at: http://www.omicsonline.org/the-memory-orientation-screening-test-most-accurately-separates-normal-from-mci-and-demented-elders-in-a-prevalence-stratified-sample-2161-0460.1000109.pdf.