Cognitive Testing
Recently the U.S. Preventive Services Task Force report found insufficient evidence to support routinely testing all older adults for cognitive impairment. Ok. Sounds great. Wait a minute, that is part of the Medicare Wellness Exam. What shall we do? Of course we will do whatever it takes to get paid. No cognitive “testing”, no pay. So get your mini-mental status forms out because coding is more important than care. Did you remember – APPLE, TABLE, PENNY?
Wait, Doug. Don’t confuse “cognitive testing” with cognitive screening. The Folstein MMSE you illustrate is really only good for evaluating recovery from delirium, useless for evaluating age-related cognitive impairment. Testing is to screening as PSA is to prostate exam. For good reason, we don’t subject older guys to PSA’s, but I’d sure home you stick a finger in the appropriate place once or twice a year in your 60 yo guys. Same here. You don’t order a wasteful cognitive battery on someone just because he/she is on Medicare, but I’d expect you to screen for simple measures of memory and abstraction several times a year.
Please look at the Medicare Wellness Exam and tell me what I am doing wrong
Medicare’s checklist only says, “Detection of any cognitive impairment.” ACP’s recommendation is, “Have the patient complete a depression screen (initial AWV only).” (Let me admit I am a psychiatrist, and have fellowship training and a few decades of practice in geriatric psych, so take everything with many grams of salt.)
For cognitive screening, in primary care, I’d use a standardized story (look up any of them online). You read it to the pt, takes about 60 seconds. Do something else for 3 minutes, then ask the pt to repeat verbatim. Stories come with score interpretation guidelines. Moderately useful for screening, but quite useful following same pt’s score year to year, looking for a drop. Different dimension of cognition is tested by Trails-B test . This one, you have to wait up to 3 min while pt goes from 1 to A to 2 to B, etc, up to 19. Test and age-normed percentile scores are free at many sites, e.g. http://www.rgpc.ca/best/GiiC%20Resources/GiiC/pdfs/3%20The%20Trails%20Tests.pdf .
But of course you are a PCP pressed for time. And you object to “extenders.” So, I don’t know, you make your choices and (your patients) live with them. You could stick with the story. If score is really bad, then do the orientation questions you learned in med school. And, yes, Brown, Tulip, Eyedropper…
As for depression, the Beck Depression Inventory (BDI-II) is completed by the pt, there are well-tested norms by age. It’s copyrighted, but costs 25-50 cents per copy. Takes seconds to score. And “Initial AWV only” is terrible advice. No harm in doing it annually.
Thanks for all your great work!!
“I’d sure home you stick a finger in the appropriate place once or twice a year in your 60 yo guys”
Twice yearly rectal exams? Why not monthly? Weekly?
Of course, the big question is why should any doc waste their and the patient’s time doing Medicare Wellness Exams in the first place?
Yeah, that’s a form that will be rapidly pencil-whipped just to move ’em through. Who gives a damn what the actual result is? Play the game, survive, stay low, keep moving.