Clinical trial is first to study impact of cognitive impairment assessment in primary care

Does knowing whether older adults are cognitively impaired affect the treatment they receive from their primary care physician? Does it impact the rate of the patient's cognitive decline?

The first clinical trial to investigate the impact of primary care physicians testing their patients for cognitive impairment found that doctors given information on a patient's cognitive status provided more care focused on cognition but that care had no impact on the overall rate of the patient's cognitive decline.

"Given the high rate of under-detection of cognitive impairment in primary care and the fact that older adults with unrecognized cognitive impairment are at risk of poor outcomes, we wanted to see what doctors would do with information about cognitive status," said study first author Nicole Fowler, Ph.D. "We have demonstrated that having available cognitive information had some impact on physician behavior, it had little impact on patient outcomes."

"Although the physician response was modest, it is possible that a more significant response will be seen once more effective treatments become available and as more programs offer support to patients with cognitive impairment and their families." Dr. Fowler is a Regenstrief Institute and Indiana University Center for Aging Research investigator. She is an assistant professor of medicine at the IU School of Medicine. At the time the study was conducted, she was on the faculty of the University of Pittsburgh.

In the study of 533 older western Pennsylvania adults and the doctors in 11 primary care practices who provided their care, physicians in six practices and their patients received reports on the patient's cognitive performance. The physicians in the other five practices and their patients did not receive this information.

Physicians who received reports on the cognitive status of their patients indicating mild cognitive impairment or possible dementia also received information about the patient's health status and medications that may be impacting their condition as well as reminders to check for possible reversible causes of memory loss such as a B-12 deficiency, low levels of a thyroid hormone or a drug reaction or interaction.

Doctors who were informed of their patient's cognitive impairment were more likely to order diagnostic tests and discuss memory problems with patients than doctors not made aware of the cognitive status of their patients. These patients also were more likely to be taking either a prescription or over-the-counter, cognition-related medication over the two-year course of the study than patients not aware of their cognitive status.

The study noted that trends in health care delivery suggest that, in the future, many older adults will obtain a majority of their health care from general practitioners and will not be referred to dementia specialists. This places importance on primary care as the setting to recognize cognitive impairment or changes in cognition and to support older adults as those changes may impact their overall care and health.

The United States Preventive Services Task Force does not recommend dementia screening in primary care, citing limited evidence of effectiveness. However cognitive screening is now included in the Medicare annual wellness visit.

"While the consensus is that identifying cognitive decline early can improve patient outcomes, the jury is still out on whether screening is a good idea," said Dr. Fowler. "We need to focus on patient outcomes. Are they depressed and can we do something about the depression? Can we help them remain at home with their families?

"We found that primary care physicians clearly value information about their patient's cognitive status but they didn't know what to do with it. This study is not an indictment of physicians, but a critique of the way medicine is delivered to those with cognitive impairment. The care that we provide these vulnerable individuals could be improved if we make doctors more aware of what options are available especially as those options increase."