Original Research

Identifying cognitive impairment during the Annual Wellness Visit: Who can you trust?

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This study found that patients, family members, and even physicians have trouble detecting cognitive impairment. A better bet: Routinely administer an objective cognition test.




Purpose Assessing for cognitive impairment is now mandated as part of the Medicare Annual Wellness Visit. This offers an unparalleled opportunity for early detection and treatment of dementia. However, physician observation supplemented by reports of patients and informants may be less effective than an objective screening test to achieve this goal.

Methods We used visual analog cognition scales (VACS) to quantify patient and informant subjective impressions of cognitive ability and compared these scales with the Folstein Mini-Mental State Exam (MMSE) and the Memory Orientation Screening Test (MOST) on a sample of 201 elderly patients seen for neuropsychological evaluation in a tertiary memory evaluation center. Outcome measures included dementia severity and scores from 3 standardized memory tests. Depression was also considered.

Results Patients were unable to judge their own cognition. Family informants rated only slightly better. Both screening tests outperformed patients and informants. The MOST was significantly better than the MMSE for determining dementia severity and memory for the total sample, as well as a subsample of patients who were less impaired and more typical of independent community-dwelling elders. Depression did not influence the test relationships.

Conclusions Neither patient nor informant subjective reports of cognition should be relied on to identify cognitive impairment within the Annual Wellness Visit. Providers would be best served by using a valid and reliable screening test for dementia.

As of January 2011, physicians are required to include detection of cognitive impairment as part of their health risk assessment in the Medicare Annual Wellness Visit.1 The Centers for Medicare and Medicaid Services (CMS) specifically mandate an “assessment of an individual’s cognitive function by direct observation, with due consideration of information obtained by way of patient report, concerns raised by family members, friends, caretakers, or others.”2 Unfortunately, these means of assessment may be unreliable.

Why observation alone won’t work. Physicians often fail to identify cognitive impairment3-5 until it becomes quite severe.6-8 This failure to diagnose may be due to time constraints,9,10 a focus on other health measures,11 or the lack of appropriate and usable tools.11-14 Reliance on patient self-report is also likely to be a flawed approach.15 A recent study found that most patients with dementia in a community sample denied they had memory problems.16 This is consistent with our clinical experience of 30 years in a tertiary memory assessment practice. These patients believe they are no worse off than their contemporaries and minimize or rationalize even demonstrable memory and functional problems. “I remember everything I need to remember” is a common response to the question, “How is your memory?”

During the comment period preceding implementation of the CMS regulation, 38 national organizations comprising the Partnership to Fight Chronic Disease17 argued that reliance on subjective measures alone is inadequate to achieve the stated goal of the legislation. We share this concern.

Improving cognition assessment. Although family complaints have been viewed as valid in at least 1 commonly used screening instrument, the AD8 (with more than 2 of 8 complaints likely to aid in dementia detection)18 does not reflect severity of impairment, nor does it provide a score to follow a patient’s course over time.

To better quantify the subjective perceptions of cognition by patients and their families, we developed the Visual Analog Cognition Scale (VACS)—which we’ll describe in a bit—and added it to our protocol of neuropsychological tests for dementia. Visual analog scales are well-accepted measures for a variety of subjective phenomena,19 including pain,20 treatment response,21 sleep,22 affective states,23 and quality of life.24 We designed this current study to delineate the degree to which patient or informant perspective could assist physicians in the identification process.

We examined VACS responses from a consecutive sample of patients seen in our practice from July through December 2010. Our goal was to quantify the perceptions of patients and their informants regarding patients’ cognitive states across 5 important areas and to determine the relationship between these ratings and the objective results of neuropsychological evaluation. We also wanted to measure the relative accuracy of such subjective ratings with that of 2 validated screening tools, the Folstein Mini-Mental State Exam (MMSE)25 and the recently published Memory Orientation Screening Test (MOST), which we developed.26


We administered the VACS to 201 patients as part of a 4-hour comprehensive neuropsychological evaluation. Patients were referred by community-based physicians, typically in primary care, neurology, or psychiatry. The sample was 66% female (n=133), with an average age of 78.5 (±6.8) years and an average education of 13.2 (±3.2) years. Of the 201 patients, 7 could not complete the VACS because of confusion or visual impairment; 20 had no accompanying informant. Of the 181 accompanied patients, 89 informants were grown children (49%), 64 were spouses (35%), 12 were siblings (7%), and 16 were friends or paid caregivers (9%).


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