Screening and Assessment
Screening for Dementia as part of the Annual Wellness Visit
Commentary on the CMS Cognitive Assessment and Care Plan Services
Examining adults with intellectual disability as part of the Annual Wellness Visit or other assessment opportunities is often difficult for medical personnel who may be unfamiliar with intellectual disability or the adult who has an intellectual disability. This is difficulty may impede an accurate assessment of current functioning and ascribing a diagnosis of a neuropathology related to a disease or condition resulting in dementia. Differentiating presenting behavior due to cognitive decline from pre-existing cognitive limitations is often difficult absent of 'personal best' functioning data or of recent history of changes in functioning and behavior. This may be problematic for clinicians being asked to undertake a cognitive impairment assessment during the Annual Wellness Visit or other clinical visit.
To provide more guidance for clinicians who may be undertaking a cognitive impairment assessment with the population-at-large, CMS issued new guidance for cognitive assessment and care plan services. The guidance notes that these assessments can help detect cognitive impairment as part of a routine visit through direct observation or by considering information from the patient, family, friends, caregivers, and others. CMS suggests also that clinicians may also use a brief cognitive test and evaluate health disparities, chronic conditions, and other factors that contribute to increased risk of cognitive impairment. CMS notes that if the clinician detects cognitive impairment at an AWV or other routine visit, he or she may perform a more detailed cognitive assessment and develop a care plan. This additional evaluation is necessary to diagnose a person with dementia, such as Alzheimer’s disease, and to identify treatable causes or co-occurring conditions such as depression or anxiety.
This extract from the CMS guidance identifies "What’s Included in a Cognitive Assessment? "
The cognitive assessment includes a detailed history and patient exam. There must be an independent historian for assessments and corresponding care plans provided under CPT code 99483. An independent historian can be a parent, spouse, guardian, or other individual who provides patient history when a patient isn’t able to provide complete or reliable medical history.
Typically, you would spend 50 minutes face-to-face with the patient and independent historian to perform the following elements during the cognitive assessment:
Examine the patient with a focus on observing cognition
Record and review the patient’s history, reports, and records
Conduct a functional assessment of Basic and Instrumental Activities of Daily Living, including decision-making capacity
Use standardized instruments for staging of dementia like the Functional Assessment Staging Test (FAST) and Clinical Dementia Rating (CDR)
Reconcile and review for high-risk medications, if applicable
Use standardized screening instruments to evaluate for neuro-psychiatric and behavioral symptoms, including depression and anxiety
Conduct a safety evaluation for home and motor vehicle operation
Identify social supports including how much caregivers know and are willing to provide care
Address Advance Care Planning and any palliative care needs
This guidance regarding instruments may be applicable for some adults with minimal intellectual disability, but may be less apt for the majority adults with more notable lifelong intellectual disability. Some of the suggested procedures are appropriate, particularly if they do not rely on the individual to be the informant or pose an expectation that the individual may respond to requests in the same manner as neurotypical adults. Of particular concern is the use of generally applicable functional assessments (noted in the guidance) which do not recognize limitations in lifelong functioning or pick-up on decline or changes in function from previous levels.
Unfortunately, missing from the extensive guidance is a stipulation for augmenting the assessment for persons with pre-existing cognitive impairments, such as intellectual disability. The NTG is suggesting that the current CMS guidance be augmented with a notation of what alternative measures and procedure may be applied with conducting cognitive impairment assessments with adults with lifelong intellectual disability. Such procedures should include (a) drawing upon information from persons close to the individual, who have an understanding of the individual's history and optimal functional abilities, (b) using functional assessment instruments developed for specific use with adults with intellectual disability (and particularly for those who may be experiencing decline), and (c) working with primary caregivers, whether family or staff from host agencies, to design dementia care plans. Many host agencies have medical and health records that can help examining clinicians with discriminating typical functioning from those associated with emerging neuropathologies. Further, many host agencies may also have records of the use of intellectual disability-specific standardized screening instruments that can provide insights in the history or frequency of occurrence of behavioral symptoms.
This issue has been recognized by the federal Advisory Council on Alzheimer's Research, Care and Services. This and related barriers to the assessment of other atypical groups is considered in the 2021 Update to the National Plan to Address Alzheimer's Disease.
Several resources are available that can guide general practice clinicians with better understanding the specialized assessment process normally in use with aging adults with intellectual disability, particular when suspicions exists of neuropathological processes. See these publications:
Jokinen, J. Janicki, M.P., Keller, S.M., McCallion, P., Force, L.T. and the National Task Group on Intellectual Disabilities and Dementia Practices. (2013). Guidelines for structuring community care and supports for people with intellectual disabilities affected by dementia. Journal of Policy and Practice in Intellectual Disabilities, 10(1), 1-28.
Moran J.A., Rafii, M.S., Keller, S.M., Singh, B.K., & Janicki, M.P., (2013). The National Task Group on Intellectual Disabilities and Dementia Practices consensus recommendations for the evaluation and management of dementia in adults with intellectual disabilities. Mayo Clinic Proceedings, 88(8), 831-840.
Tsou, A.Y., Bulova, P., Capone, G., Chicoine, B., Gelaro, B., Odell Harville, T., Martin, B.A., McGuire, D., McKelvey, K.D., Peterson, M., Tyler, C., Wells, M., Whitten, M.S. and the Global Down Syndrome Foundation Medical Care Guidelines for Adults with Down Syndrome Workgroup. (2020). Medical care of adults with Down syndrome: A clinical guideline. JAMA, Oct 20, 324(15), 1543-1556.