Dementia Guidelines

Effective January 1, 2001, the Affordable Care Act added a new Medicare benefit, the Annual Wellness Visit (AWV). During this annual visit, primary care physicians are required to do an assessment to detect cognitive impairment. While this assessment sounds beneficial, there does not exist a single, universally accepted screen that satisfies all needs in the detection of cognitive impairment. However, in an effort to guide physicians with the assessment and to help physicians know when referral or further testing is required, the Alzheimer's Association created a Health Risk Assessment which includes patient observation done by the physician, unstructured queries during the AWV, and use of structured cognitive assessment tools for both patients and physicians.

One of the most detrimental aspects of dementia is the prevalence of missed or delayed diagnosis. A number of studies have shown that cognitive impairment is unrecognized in 27-81% of affected patients in primary care. This missed or delayed diagnosis can be attributed, in part, to both physicians not having a standard with which to use for dementia diagnosis, as well as not taking into consideration information obtained by way of patient report or concerns raised by family members, caretakers, friends, or other people who interact in the patients' lives.

The Centers for Medicare and Medicaid Services (CMS) has finally recognized that while there is no "gold standard" for which to diagnose dementia or other cognitive impairments, having a guideline with which to use during the AWV will allow physicians to better detect cognitive impairment earlier in patients. The AWV requires that an HRA be done either before or during the visit, and that it should be reviewed for any reported signs and symptoms indicative of possible dementia. This screening combined with informant-reported data improves the accuracy of assessment. Strongly encouraging that an informant is present during the AWV is recommended, yet not always achievable. Therefore, speaking with an informant via telephone is suggested when it is not possible for an in-person interview.

The importance for guidelines in dementia diagnosis have been recognized. With the Annual Wellness Visit's HRA now required, there should be a higher instance of early detection for dementia with earlier intervention possible.