Imagine a world without preventive care

John Showalter: ©Linus Health

Pop quiz time. What happens at the beginning of almost every patient appointment? Blood pressure is measured. How often do older patients get blood tests for conditions such as hyperlipidemia, diabetes, cancer, anemia and others? At least every year. Which health screenings are regularly performed for patients beginning at certain ages? Mammograms, electrocardiograms, colonoscopies, prostate-specific antigen blood tests… the list goes on.

Imagine a world without these screenings and tests. Imagine the catastrophic wave of undetected cardiovascular disease, cancers, diabetes and other conditions exacerbating and leading to mass hospitalizations, disability and early death.

If it seems unimaginable, then consider our current preventive care strategy for a highly prevalent and growing chronic condition that devastates patients and families just as much if not more than any other ailment and is enormously costly to the healthcare industry. That condition is dementia.

Historically, early screening and care pathways for its earliest stage – typically mild cognitive impairment (MCI) – have ranged from minimal to nonexistent in the primary care setting, where early detection of disease should take root. As a result, an estimated 92% of patients with MCI are undiagnosed. These undiagnosed and untreated patients can progress quickly (less than a year) to Alzheimer’s disease or other forms of dementia, which are exponentially more debilitating and more difficult and costly to manage.

The good news is early cognitive impairment screening capabilities and care pathways have vastly improved in recent years – along with reimbursement for this care. New, clinically validated screening tools leveraging advancements in data science and sensor technology are now available to primary care physicians that empower them with results that offer an abundance of data and evidence-based guidance.

By shifting the dementia focus to early detection and treatment, primary care physicians and their practices can lead the way in improving the health and quality of life of countless patients and caregivers.

The Elephant in the room

The lack of health care industry consensus around making early detection of cognitive impairment an urgent priority is confounding. After all, we know so much about the societal and economic devastation that Alzheimer’s disease and related dementias cause. Caring for patients with Alzheimer’s disease and other dementias, for example, will cost $360 billion this year alone, according to the Alzheimer’s Association, which also points out that Medicare and Medicaid (i.e. U.S. taxpayers) are responsible for most of those costs. Conversely, Medicare and Medicaid spent $207 billion combined in 2018 to treat all cardiovascular disease, cancer and diabetes, where prevention has been the standard of care for decades.

Unfortunately, the population of patients with Alzheimer’s and other dementias, as well as the associated cost growth, are expected to continue to grow if the industry fails to prioritize early detection and treatment. In 2024, an estimated 6.9 million Americans had Alzheimer’s disease, the most common form of dementia, according to the Alzheimer’s Association. Cases are expected to reach 12.7 million by 2050 while Medicare and Medicaid spending will grow to an estimated $637 billion, impacting nearly $1 for every $3 spent in Medicare.

Despite the widespread burden Alzheimer’s and other dementias will place on patients, caregivers, the health care industry and the overall country, dementia identification and treatment responsibilities today are typically confined to neurologists. Yet patients with suspected MCI or dementia often face neurology appointment wait times of three to four months, even longer if the patient lives in a rural or other provider shortage area. While such a protocol today is common for MCI, almost no physician would make patients wait months to see an oncologist before beginning to treat their cancer or visit a cardiologist before intervening with their heart failure. Our collective sense of clinical urgency must be equal to that for dementia.

Higher quality screening essential

Of course, we do know for certain what impact detecting and treating cognitive impairment early will have on the condition’s growth trajectory, but the preponderance of evidence so far demonstrates that lifestyle interventions around nutrition, physical activity, and mental health are effective at slowing the progression of MCI to dementia. By modifying lifestyles, patients can reduce or eliminate some of the 12 risk factors – including hypertension, obesity, depression and social isolation – that are associated with 40% of worldwide dementias, according to a notable report issued by a dementia prevention commission of Lancet.

Primary care physicians have been urging such lifestyle changes in their patients for decades to prevent or manage multiple other chronic conditions. What has been missing in early cognitive impairment has been impactful screening tools in the primary care setting to help emphasize the importance of these lifestyle modifications to patients and drive meaningful change.

Screening challenges in primary care setting

Historically, the most common MCI screening tools in the primary care setting are the Mini–Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA), which are most often paper-based based evaluations of patients’ visual and spatial perception, memory, executive functioning and other domains. While relatively quick to administer at around 10 minutes, the screenings yield little insight for the primary care physicians beyond supporting neurology referral decisions.

Using digital health technology available today, however, practices can analyze patients’ cognitive health with more granularity and reliability. AI can derive insights about patients’ cognitive function based not just on how they perform on screenings, but also from minute variations in drawing and hand movement when screenings are administered on an iPad.

Based on results, patient-friendly brain health action plans can give providers a functional framework for counseling on lifestyle-based interventions. That means even if a neurologist referral is scheduled for a formal diagnosis, the patient and caregiver still have practical steps to follow in the intervening months, along with meaningful screening results to motivate lifestyle change.

A GUIDE toward the future

CMS finally appears to recognize the enormous need for earlier screening and intervention with MCI and dementia. In 2023, the agency announced the Guiding an Improved Dementia Experience (GUIDE) Model, a program that offers patients and caregivers a range of care coordination, management, education, support and respite services, along with commensurate reimbursement for providers based on the severity of dementia in the enrolled patients.

Such programs are a clear recognition of how we must radically change the status quo of how we detect the earliest indications of dementia and manage affected patients. Primary care physicians can and should take the lead in that change, which will undoubtedly improve the outcomes and lives of patients and families and elevate brain health to its rightful status across the industry.

John Showalter, MD, MSIS, is an internal medicine physician and chief strategy officer at Linus Health, a digital health company focused on enabling early detection of Alzheimer's and other dementias.