What is the case for cognitive testing?
What makes a cognitive test good?
Are patients’ cognitive changes just a part of normal decline or are they indicative of issues that need closer attention?
In 2011 Medicare began mandating a preventive wellness exam that includes cognitive testing for the detection of impending dementia and Alzheimer’s disease.
Encouraged by the Medicare mandate that allows for physician reimbursement for more routine memory testing and patient follow-up, and in response to greater demand from senior patients, physician practices have increasingly turned to specialty memory testing companies like Screen Inc. to help with the assessment of patients’ cognitive status.
Adequate test batteries examine the patient’s cognitive ability over several domains, such as memory, fluency and mental control executive functions. Effective cognitive testing is able to differentiate between memory problems that are consistent with the person’s age and education versus those that are more serious and symptomatic.
The best tests also recommend directions for diagnostic evaluations by placing the results in the context of contributing factors. For example, the CANS-MCI evaluates cognitive results in the context of reported head injuries, solvent exposure, exercise, depression, and progressive scales for pain medications, and alcohol use.
What is the value of cognitive testing to physicians?
Should I do testing or some other procedure?
Our tests are ideal for internists, family, geriatric and neurology practices, community health clinics, hospitals, HMOs and life care centers (assisted living).
Early stage detection allows referral to specialists and follow-up with additional testing (imaging, full neuropsychological evaluation, and other studies) for diagnostic accuracy.
For patients who have already been diagnosed by their physician, continued testing helps physicians judge the rate of cognitive ability changes and the effectiveness of treatment interventions.
Physicians ask, “Should I perform cognitive tests, imaging, or another procedure?”
There are several reasons that cognitive testing is preferable to any of the other detection procedures:
- Basic neuropsychological testing is more likely to provide decision-making information. The amount of change in cognitive ability can be precisely measured by periodic testing. It is at the first point of actual decline, beyond that expected with normal aging, that more invasive tests will be useful.
- A major study in the Archives of Neurology concluded that “an elderly person with a significant amyloid burden can remain cognitively normal”. An imaging evaluation costs a great deal and may indicate whether or not a propensity to develop Alzheimer’s is present, but the unique compensatory abilities of each person give cognitive tests the ability to detect when one is actually starting to develop symptoms.
- Computerized neuropsychological testing does not involve intimidating or invasive procedures that deter elderly patients from being evaluated. Imagine the reactions to saying, “We would like to take a tap of your spinal fluid to see if you are likely to develop Alzheimer’s.”
Other important questions
Select a topic below for more detailed discussion.
There are at least six good reasons to offer routine cognitive testing for senior patients:
- Many seniors who begin to have memory lapses worry unnecessarily about Alzheimer’s. Regular cognitive testing would help alleviate those worries. In most cases, testing will show that the patient has normal cognitive functioning (for age and education).
- In some cases, testing will show that the patient’s memory and executive functions are poor, not due to neurological damage, but because of emotional interference. More extensive evaluation and effective treatment can then be prescribed.
- If early testing indicates MCI, and it is diagnosed by follow-up testing, the first stages of Alzheimer’s might be slowed. Drugs can be given at its earliest stages. In addition, the earlier other treatment programs are initiated, such as treatment for depression, heart health medications, increased social activity and proper nutrition, the more effective they are in slowing the progression of Alzheimer’s. Thus, early detection through annual testing is critical.
- Medical researchers have found that the likelihood of stroke is predictably higher for people who have cognitive declines. Therefore, detecting declining cognitive patterns through annual testing allows physicians to be medically proactive with respect to circulatory health. Medication errors are seriously exacerbated by cognitive symptoms.
- For those patients who have been identified as having cognitive declines that is becoming progressively more serious, physicians and caregivers can implement early safety programs and policies for driving, cooking, and finances. There may be dementia prevention activities that are of critical importance to implement as early as possible.
- Early detection of active progression toward Alzheimer’s is a gift of time to patients who otherwise would have missed the chances to discuss medical options, to be part of family planning for their future, and to do the things they’ve always wanted to do with friends and family.
For these reasons, many recommend that people over the age of 50 should be screened for cognitive impairments once a year. Memory screening is even becoming a mandatory part of the Medicare Welcome office visit and part of annual Medicare wellness visits.
We are often asked variations of this question: “Once someone is identified as having cognitive impairments, how can they prevent progression to dementia and the resulting dependency and constricted life that will occur?”
Many habits and actions lower the risk of chronic diseases and boost overall health and well-being. It goes without saying that smoking hurts. It may be less clear but equally important to get treated for depression because that treatment can have a positive effect upon cognitive abilities. The following, in the order of the importance we think is currently established by research, have been found associated with a reduced risk of Alzheimer’s disease:
- Regular exercise. In our opinion, this is the habit with the most consistent effect upon the likelihood of further cognitive decline. It’s effect may be mediated by the improvement in brain circulation, along with changes in stress hormone levels. Whatever the mechanisms, there are clear associations between the risk of Alzheimer’s and having better control over type 2 diabetes, lower blood pressure levels, and lower cholesterol levels. If cognitive decline has already been detected, very extensive exercise may be necessary to have a decline-preventing effect.
- Intellectually stimulating activities and social activities. We are often asked which mental exercises work the best to counteract decline. The answer from our perspective is that you want to cause a “fire” in your brain. For example, learning to juggle is tremendously stimulating to many parts of the brain. Learning to juggle while you ride a unicycle would be hugely activating. Learning a new language or a musical instrument would also be very activating. Purchasing a set of brain exercises may be useful just because the program would organize your activity, like having a personal trainer might do for your physical exercise. In both, the issue is how much time you do it, not the specifics of what you do. In fact, the issue of what you do may be more important with respect to physical exercise because you have to be very careful in your physical exercise to avoid physical injury. Learning to juggle may be dangerous to your light fixtures, but it is not important that you succeed or that you do some precisely correct mental exercise.
- An active social life. Making this happen as an active task is particularly important as you get older because your usual contacts (and your usual activities that can substitute for beneficial contacts) often become less frequent.
- Healthy weight and good nutrition. Keep your weight healthy. For many, that means shifting to fruits and vegetables.
- Mindfulness training or psychotherapy. A rigorous study* found that women who scored highest on the neuroticism scale—which measures the tendency to feel easily stressed, anxious, jealous, guilty, and depressed—were twice as likely to develop Alzheimer’s disease compared to those who scored lowest. Apparently, these psychological stressors release stress hormones in the body and can affect structures in the brain that are connected to Alzheimer’s disease. Out of the 800 women that researchers followed for almost four decades, 104 of them developed Alzheimer’s. While being either withdrawn or outgoing did not appear to raise Alzheimer’s risk alone, women who were both easily distressed and withdrawn had the highest risk of developing the disease. high neuroticism/low extraversion showed the highest risk of AD dementia. There are many ways to reduce how easily distressed or withdrawn a person is. Some of them are also ways to increase social contact, e.g. yoga or meditation classes.
- The choice of death. There are 2 main reasons this form of “prevention” is pursued: many people do not want to be a burden on their families and many do not want the vegetative institutional life they foresee if they progress to Alzheimer’s. Although many Americans believe people with Alzheimer’s should have the right to voluntary euthanasia (defined as an action taken by another to end someone’s life with their prior consent), this is illegal throughout the United States. Some guidance may be obtained by organizations such as the Final Exit Network. This leaves mentally competent people with Alzheimer’s who want to maintain control over their dying in the position of taking action while they still can or eventually losing capacity and relying on others to make treatment decisions that will result in a natural death at the first opportunity. There are cases in the US of people who, after acquiring a pledge from a physician to refer them to hospice as soon as deemed eligible, voluntarily stopped eating and drinking (VSED) and died peacefully at home, surrounded by family. VSED in conjunction with palliative or hospice care can be a relatively quick, peaceful way to die. Perhaps the single most important decision people with Alzheimer’s make is naming the right person to be their surrogate decision maker in a Durable Power of Attorney for Health Care. A solid Advanced Care Directive is also very important.
- Staying in the loop. If you have been diagnosed with cognitive impairment, it is important that you seek out the best treatments to prevent further decline. You also can seek out the best ways to avoid progressive decline. Here are some excellent resources:
Alzheimer’s Community Resource Finder
Canine Caregivers for Dementia and Alzheimer’s Patients
Dementia and Chronic Conditions Toolkit – from Australia
Association for Geriatric Psychiatry
Helping Alzheimer’s Sufferers Cope with the Loss of a Loved One
*Johansson L, Guo X, Duberstein PR, Hällström T, Waern M, Ostling S, Skoog I. Midlife personality and risk of Alzheimer disease and distress: a 38-year follow-up. Neurology. 2014 Oct 21;83(17):1538-44.
PHYSICIANS ASK: “WHICH MEMORY TESTING COMPANY SHOULD I WORK WITH?”
Regardless of the type of healthcare organization you represent—a general practice, specialty practice, HMO, community health clinic, or assisted living center—at some point you may want to use the outsourced services of a specialty memory testing company like Screen Inc. Which one should you use?
We hope you’ll choose us, but even if you don’t, we hope that you will begin to work with a specialty memory testing company, like ours, so seniors get reliable early screening and physician follow-up. The cost of training your staff to administer tests the same way each time, much less in exactly the same way as one another, should be considered when evaluating the cost of the CANS-MCI touch-screen-only tests. Cognitive screening has now become mandatory as a part of the Medicare Annual Wellness evaluation.
Screen’s tests meet all of the following criteria. If you evaluate other specialty memory testing companies, here are some questions that you might ask:
- Does the memory testing company make a very economical testing service available to its physicians?
- Are the testing equipment and software easy to set up and begin using?
- Is the battery of tests exceptionally easy for the elderly to take (no keyboard, mouse, or computer skills needed)?
- Is the staff time needed to administer the tests minimal (e.g. 10-15 minutes), even for staff training?
- Do the tests have the ability to evaluate cognitive domains other than just memory (such as executive functions), making the tests valid detectors of ALL the patterns that are predictive of decline towards dementia?
- Can the tests detect early cognitive problems, or do they only track the degree of established dementia?
- When the tests are completed, are they evaluated by a live neuropsychological testing technician, who completes the scoring, taking into account the background of the patient (e.g. age, education, depression level, alcohol use, head injuries) in addition to the cognitive scores?
- Are detailed physician reports sent to the physician within an hour after the patient finishes the test?
- Do the tests compare the patient’s abilities to sample populations based on education grouping as well as on the patient’s own past scores, in order to provide two relevant frames-of-reference (cross-sectional and longitudinal)?
- Does the physician report present visually intuitive and easy-to-interpret data, including an overall probability of MCI?
We would appreciate the chance to talk with you about how our services can help your practice and your patients more than the alternatives.
Contact us at firstname.lastname@example.org, or call us at 1-866-668-9038.