What primary care physicians can do to prevent and screen for dementia

Alvaro Pascual-Leone, MD, PhD

The world is on pace to see an unprecedented volume of cognitive and brain disorders and primary care physicians simply don’t have the tools to handle it.

Worldwide, there were an estimated 55 million people aged 65-plus with dementia in 2020; that number is predicted to grow to 139 million by 2050. And there simply aren’t enough neurologists to treat them.

Approximately 85% of dementia patients are first diagnosed by a primary care physician (PCP) and 55% of PCPs report that there are not enough dementia specialists to meet patient demand.

The neurologist shortage and increase in the number of cases means dealing with dementia–prevention, screening, diagnosis–is going to become an increasingly large part of PCP practices. The good news for providers is that there is new research they can share with patients on how to delay or prevent dementia, as well as new screening tools that produce more accurate results. Screening also can be a revenue source under Medicare’s reimbursement codes.

A new approach to dementia

Dementia has long been a challenge for PCPs, for a variety of reasons.

In its early stages, dementia can be difficult to diagnose. In addition, the prospect of cognitive impairment is scary for patients—which can cause them to imagine symptoms or avoid the subject entirely.

Lastly, there can be a sense of fatalism on the part of patients and providers that nothing can be done to prevent dementia or treat it. That can lead to avoiding the issue until nothing actually can be done but make a diagnosis and refer the patient to a neurologist.

While progress is being made in drug therapy, we are a long way from having an effective, affordable pharmaceutical treatment for dementia. However, new research shows that the onset and progression of the disease can be affected by environmental and lifestyle factors.

PCPs can provide a great service by integrating dementia education and screening into their practices and advising patients how to avoid it, similar to how they offer recommendations to prevent diabetes, cancer and heart disease. Patients shouldn’t be left to hope for the best while dreading the onset of dementia symptoms. Instead, they should be encouraged to participate in a lifelong program for better brain health.

Better screening tools are available

One of the challenges PCPs face when dealing with brain health is a lack of precise tools for measuring mild cognitive impairment. And many providers are unfamiliar with the tools that are available or are unsure about their ability to administer and interpret the tests. As a result, while nearly all physicians agree it is important to assess patients 60 and older for cognitive impairment, they screen only 48% of them. In an Alzheimer’s Association survey, 72% of PCPs said they struggle to differentiate cognitive impairment from normal aging and 47% said they lack expertise performing cognitive assessments.

So, to a large degree, physicians are dependent on patient self-diagnosis, which is imprecise, can come too late, and can be affected by factors such as mistaken concerns about normal changes to aging brains.

Standard pen and paper-based tests used by providers are unreliable, difficult to administer, subject to racial and cultural bias, and do not detect problems early enough.

However, newer digital assessment tools are largely free of bias, easy to administer and produce results that are clear and easy for PCPs to understand. Unlike pen-and-paper screenings, these new tools evaluate the patient’s process in completing the test, not just the end results. That makes them more sensitive and accurate.

PCPs should familiarize themselves with the latest generation of tools and incorporate them into their practices.

A brain health plan

Screening is only part of a provider’s responsibility, however. Education and guidance are also crucial.

Many patients feel they have no control over whether they will get dementia in the mistaken belief that it’s determined entirely by genetics. In fact, modifiable factors determine up to 40% of whether a patient gets dementia and half of cases are potentially preventable. This gives providers an opportunity to practice proactive brain care.

These efforts should begin early. Dementia is a concern primarily of senior citizens, but it shouldn’t be. Those with dementia typically have the disease 15 years before showing symptoms. Physicians should not wait for patients to enter their 50s or 60s before raising the subject of prevention.

They can help patients prevent and delay dementia with a brain health plan built around lifestyle recommendations that have been proven to help. These include:

Eating healthier. This includes a heavily plant-based, if not vegetarian, diet; drinking five to eight cups of water a day; and controlling weight.

Daily movement. The relationship between physical activity and mental acuity is strong. Aerobics, strength training and mind-body exercises help sharpen the mind. An ideal beginning weekly regimen would consist of at least two hours of aerobic exercise, two 30-minute sessions of strength training, and 30 minutes of mind-body exercises like yoga or tai-chi.

Ongoing learning. Education should never stop. It’s good for its own sake and it can prevent mental decline. This can include everything from reading and doing crossword puzzles to new experiences,including travel.

Good rest. Seven to eight hours of restful sleep is important. Patients can help log those hours by reducing caffeine and alcohol intake, avoiding large meals within two hours of bedtime, sleeping in cooler temperatures, and avoiding phones, laptops, and TVs before going to bed.

Staying healthy. Overall good health through weight control, exercise, not smoking and managing blood pressure and blood sugar can help prevent and delay dementia.

Mental health. Stress, depression and anxiety can harm brain health if untreated. It is important to get necessary treatment, such as therapy and antidepressants for serious cases, and to practice meditation, mindfulness and deep breathing.

Having a purpose. Having a reason to get out of bed can keep patients mentally sharp. This can include work, volunteering or faith.

Building a village. Isolation and loneliness contribute to mental decline. People should make an effort to stay in touch with family and friends. Joining a club or group of people with similar interests can also help.

All these practices should sound familiar because they’re also the blueprint for living longer, healthier, happier lives and for preventing diseases such as diabetes and hypertension. The sooner patients are able to take these steps, the more effect they will have.

By integrating brain health into primary care and offering the latest dementia screening, education and prevention recommendations, PCPs can greatly benefit their patients.

Alvaro Pascual-Leone, MD, PhD, is chief medical officer and co-founder of Linus Health, a professor of Neurology at Harvard Medical School, and a senior scientist at the Hinda and Arthur Marcus Institute for Aging Research.