Primary Clinicians: Check the Brain’s Vital Signs During Medicare Annual Wellness Visit

By Nancy Wurtzel

The brain is the only vital organ not routinely assessed in clinical practice, but that’s changing, especially for patients over 65.

Since age is one of the biggest risk factors for cognitive impairment, family doctors and other front-line health providers are encouraged to include a brain check during the Medicare Annual Wellness Visit (AWV).

Rather than relying solely on observation and a brief patient conversation, clinicians instead incorporate a simple screening to identify the early stages of Alzheimer’s and other dementias. These results become part of a patient’s record and provide a baseline of mental status.

Two of the easiest instruments to gauge cognition are the General Practitioner Assessment of Cognition (GPCOG) and the Mini-Cog (cog is short for cognition). Both assessments can be performed in minutes, are free to clinicians, and do not require any special equipment or training.

Development of the CPCOG was an international collaboration. The pencil and paper test portion was created in Australia in 2002, while its web component was funded a few years later through grants from Canada and other countries.

Here are the CPCOG basics: The evaluation consists of five steps and takes about six minutes. Scoring is done manually or on their website. Patients are told an address and asked to remember it. Clinician asks the patient to give the complete date. Next, the patient draws a clock with hands pointing to a specific time. Clinician asks patient to relay a current event and finally to repeat the address. Web results are not stored in a data base, but individual patient outcomes may be saved to a PDF document. Based on a patient’s score, clinicians may be prompted to conduct a brief questionnaire with the patient-informant. If the informant is not present, questions may be completed at a later point or even by telephone.

Details about how to administer the CPCOG are available at this link.

A second cognitive screening tool, the Mini-Cog, was introduced in 2001.

The Mini-Cog is the brainchild of Dr. Soo Borson, founder of the Memory Disorders Program at the University of Washington Medical Center. Borson came up with the idea after noting memory problems were not spotted earlier. She believed annual doctor visits were a missed opportunity, and subsequently led a team to devise a three-minute brain assessment tool.

Here’s how the Mini-Cog works: At the start of the screening, the clinician tells the patient three words. The patient is asked to remember the words and repeat them later. Next, the patient is directed to draw the face of a clock and place the hands of the clock at a specific time. After the clock is completed, the clinician asks the patient to recall and repeat the three words.

Grading of the Mini-Cog is on a five-point total score. A correctly drawn clock scores two points and each recalled word is one point. Those patients scoring three points or less have not passed the screening and need additional evaluation. While it takes less time to perform and score than the CPCOG, the Mini-Cog offers no informant component.

Visit this link to learn more about and utilize the Mini-Cog.

There is no fee to health care providers for the use of either test, but modifying them is not allowed. Additionally, health care providers are prohibited from charging their patients a fee to administer the tests.

When using either testing mechanism, clinicians are encouraged to keep these points in mind:

• Optimally, patients should be healthy when an assessment is conducted
• Conduct screening at the middle or end of the appointment
• If glasses or hearing aids are normally used by the patient, they should be in place
• Speak clearly and read questions exactly how they appear
• The assessment should be uninterrupted
• Prompting by the clinician or family members will skew the results

On the surface, these quick screening tools appear deceptively simple, but the results can expose changes to the brain that are not readily apparent to the clinician, family members or even the patient. Revealing something is wrong can spur further diagnostic testing and help identify cognition problems at their earliest stages, which may lead to better outcomes.

This goal was reinforced by Dr. David Rosenbloom, clinical director of HealthPartners Memory and Aging Center in St. Paul, Minnesota. “[If] you’re diagnosing these diseases when these patients are already mistaking their medications, having motor-vehicle accidents, losing their way from home — that’s a failure,” said Dr. Rosenbloom. “We have got to get to these patients earlier.”