How PCPs can get ahead of their patients' cognitive decline

In less than 15 years, the population of people 65 years and older in the U.S. is expected to grow to 80 million, up from under 55 million in 2019, per U.S. Census projections. Unfortunately though, years of life gained are often associated with health-related disability. As part of the UN Decade of Healthy Ageing (2021-2030), there is a global impetus to foster healthy aging and add life to years.

Neurological disorders, such as stroke, Parkinson’s disease, and dementia are the leading cause of disability worldwide. The WHO projects that brain-related disabilities will account for half of the worldwide economic impact of disability by 2030. Dementia is the disability adults in the U.S. fear the most and Alzheimer’s disease is the most common type of dementia. Currently, over 10% of people aged 65 and older and about one-third of people aged 80 or older have Alzheimer’s, according to the Alzheimer’s Association. Promoting brain health is critical to add life to years.

Unfortunately, the current state of brain care offers too little too late, failing to promote brain health and prevent or minimize the impact of brain-related disability. To improve care and manage the growing needs, the following challenges need to be addressed:

The current approach to brain health is largely reactive with minimal attention paid to prevention of cognitive decline and promotion of cognitive resilience. Brain care usually becomes a priority only if a patient or family member raises a concern, which delays diagnosis and shortens the window of opportunity for intervention, particularly given patients’ reluctance to raise concerns (e.g., due to stigma). The approach to heart health or cancer screening illustrates the power and promise of a different, more proactive approach to brain health.

Primary Care Providers (PCPs) face practical barriers to conducting more routine screening.A recent Alzheimer’s Association survey found that nearly all PCPs (96%) think it is important to assess patients aged 60 and older for cognitive impairment, but they currently conduct assessments for half (48%). Among key barriers, 72% of PCPs said they struggle to differentiate pathological cognitive impairment from normal aging and 47% say they lack expertise performing cognitive assessments. PCPs also report lacking access to cognitive tests as well as resources and time to administer them. Taken together, PCPs are not well-equipped to screen and monitor patients for cognitive impairment at present.

Limited access to specialty resources for specific diagnosis leads to delays in initiating care plans. Unfortunately, there is a significant dearth of specialists which often leads to wait times of three to nine months to see one. Many patients may not need a specialist referral if PCPs were better equipped to provide diagnostic and management services, especially to patients with uncomplicated cases of dementia and other brain diseases.

Early detection of cognitive impairment and specific diagnosis, such as Mild Cognitive Impairment (MCI), offers several opportunities to benefit individuals and their families:

Impact cognitive trajectory through lifestyle and health-related interventions. Research shows that preserving brain function and building cognitive resilience is a lifelong effort. Growing evidence also suggests that interventions addressing modifiable risk factors, such as obesity, hearing and/or visual impairment, nicotine use, elevated blood pressure, high cholesterol, mood disorders, medication side effects, poor diet, disrupted sleep, lack of exercise, and/or loneliness can help mitigate the risk of cognitive impairment and progression to dementia (see Lancet Commission 2020, FINGER study 2015). Encouragingly, in a 2022 Lifebrain survey, 70% of respondents said that memory problems would be a key motivator for them to improve their lifestyle (under their care team’s guidance). These results underscore the need for greater emphasis on prevention and implementation of personalized interventions as early as possible.

Plan for what matters most. Early diagnosis empowers patients and their families to define their future goals and plan for them (i.e., live the life they choose based on what matters most to them specifically). An Alzheimer’s Association survey found that 85% of older adults in the U.S. would want to know early if they had AD, citing their top two reasons as having the ability to plan with their families and obtain treatment earlier (both 70%).

Get timely care and access to clinical trials. Clear and early diagnosis helps ensure that therapies can be implemented much earlier, during windows of opportunity when the greatest improvements are possible. It also gives patients time to consider enrolling in clinical studies, enabling investigators to track them longitudinally and develop objective metrics of target engagement for novel treatments.

PCPs are well-positioned to partner with individuals and their families in promoting brain health, identifying cognitive impairment early, and ensuring interventions are aligned with what matters most to each patient. To do this, PCPs need new tools. Fortunately, the landscape of cognitive assessments is rapidly evolving as technology advances, older adult technology adoption increases, and external events – as exemplified by the COVID-19 pandemic – spur innovation.

There are several limitations to traditional cognitive screening tools. Paper-based assessments require manual workflows, involve subjective scoring and interpretation, and offer only limited insights on a person’s cognitive abilities, making them neither efficient nor scalable. In addition, larger neuropsychological batteries are required for confirmatory diagnosis and the process of implementing these tests and obtaining results can be time and labor-intensive and, thus, may introduce unnecessary delays in the clinical decision-making process.

Digital cognitive assessments are carving out a new space for proactive screening and intervention in primary care. AI-enabled assessments that measure performance on a series of tasks and analyze a wide array of metrics offer the potential for early detection and specific diagnosis, detecting subtle signs of cognitive impairment in preclinical AD and MCI subtypes. These tools are also much more efficient, can integrate easily into primary care workflows, and may not require physician administration. Automated scoring and immediate interpretation further free up time for PCPs to focus on next steps for the patient, which some digital solutions also assist with through integrated clinical decision support.

More widespread use of digitally enabled cognitive assessments can benefit patients, providers, and the larger health system. Digital solutions offer value to PCPs by improving both cognitive assessment rates and practice workflows, while also providing new revenue opportunities. They can be embedded efficiently into annual well visits, establishing a reliable practice for cognitive screening, and they can help PCPs take advantage of Medicare’s new reimbursement codes for Cognitive Assessment and Care Planning, which have been underutilized to-date. In addition, in a value-based healthcare delivery world, streamlined assessments offer the potential to help prevent complications requiring urgent or acute care by identifying those at highest risk early. By enabling broader and more efficient screening, digital assessments can help facilitate earlier and more impactful interventions, more effective triage to specialists, and opportunities for patients to take part in clinical trials.

It is never too early, but it also is never too late, to impact individual cognitive trajectories and reduce the risk of brain-related disability and dementia for patients. Gaining a deeper understanding of novel approaches to digital assessments for brain health can empower PCPs to help their patients stay ahead of cognitive decline and transform human healthspan.

Alvaro Pascual-Leone, MD, PhD is Chief Medical Officer of Linus Health, Professor of Neurology at Harvard Medical School, a Senior Scientist at the Hinda and Arthur Marcus Institute for Aging Research, and the Medical Director of the Deanna and Sidney Wolk Center for Memory Health at Hebrew SeniorLife.

Ankur Bharija, MD is Vice President of Geriatrics at Linus Health and an Assistant Professor and practicing geriatrician, primary care and population health, at Stanford University School of Medicine.