Institutional experience on cognitive screening at the Medicare Annual Wellness Visit

Abstract

Background Screening for cognitive impairment is required at Medicare Annual Wellness Visits (AWV). Subjective or objective methods are suggested, but there is no one screening tool specified by Centers for Medicare and Medicaid Services (CMS). We assessed screening methods, its outcomes, and potential disparities in cognitive screening at AWV. Method Retrospective chart reviews were done for 1,493 adults 55+ who had initial AWV at a single academic medical center ambulatory site between January 2011 and March 2017. Demographics, assessment type, and positive screens noted by provider were collected. Subjective assessments were by history/direct observation alone. Objective assessments are noted in Table 1. Multiple logistic regression with stepwise variable selection via AIC were done. Results Mean age was 73.6 years (SD=7.9); 828 (55.5%) were female; 1191 (79.8%) were white (Table 2). 1,311 were screened for cognitive impairment, 120 were not screened, and 62 had an established diagnosis. Of those screened, 87.5% were screened using objective methods; greater age (p<0.001), African American race as compared to white race (p<0.001), and non‐English primary language (p=0.03) were associated with increased probability of positive screens. In subjective screening (n=163), speaking a non‐English primary language was associated with higher probability of positive screening (p = 0.04). In patients with positive screens through any method, 41 had no further cognitive assessment planned, 19 had plans for follow‐up, 15 were referred to neurology. Conclusion AWV are an opportunity to screen for underdiagnosed cognitive impairment. Clinicians in our study used a myriad of tests, despite each test’s unique limitations. Greater age, African American race, non‐English primary language being associated with increased probability of positive objective screening is consistent with the literature. In subjective screenings, patients with non‐English primary language were more likely to screen positive, suggesting that in AWV, non‐English speaking patients may be at a disadvantage for standard cognitive screening. Despite positive cognitive screening, the majority had no further cognitive assessment planned during the visit. Our study suggests that more research should focus on a standardized cognitive screening and decision making after a positive cognitive screening at AWV.

2022 Alzheimer's disease facts and figures

“…• Centers for Medicare and Medicaid Services The Alzheimer's Association and others, including a working group of international experts on MCI and Alzheimer's disease, have published recommendations and descriptions of operationalizing cognitive assessments, including the AWV, in primary care practice to guide this process. 586,[755][756][757]…”