Implementing routine cognitive screening of older adults in primary care: process and impact on physician behavior

Abstract

Background: Early detection of cognitive impairment is a goal of high-quality geriatric medical care, but new approaches are needed to reduce rates of missed cases.

Objective: To evaluate whether adding routine cognitive screening to primary care visits for older adults increases rates of dementia diagnosis, specialist referral, or prescribing of antidementia medications.

Setting: Four primary care clinics in a university-affiliated primary care network.

Design: A quality improvement screening project and quasiexperimental comparison of 2 intervention clinics and 2 control clinics. The Mini-Cog was administered by medical assistants to intervention clinic patients aged 65+ years. Rates of dementia diagnoses, referrals, and medication prescribing were tracked over time using computerized administrative data.

Results: Twenty-six medical assistants successfully screened 70% (n = 524) of all eligible patients who made at least 1 clinic visit during the intervention period; 18% screened positive. There were no complaints about workflow interruption. Relative to baseline rates and control clinics, Mini-Cog screening was associated with increased dementia diagnoses, specialist referrals, and prescribing of cognitive enhancing medications. Patients without previous dementia indicators who had a positive Mini-Cog were more likely than all other patients to receive a new dementia diagnosis, specialty referral, or cognitive enhancing medication. However, relevant physician action occurred in only 17% of screen-positive patients. Responses were most related to the lowest Mini-Cog score level (0/5) and advanced age.

Conclusion: Mini-Cog screening by office staff is feasible in primary care practice and has measurable effects on physician behavior. However, new physician action relevant to dementia was likely to occur only when impairment was severe, and additional efforts are needed to help primary care physicians follow up appropriately on information suggesting cognitive impairment in older patients.

Figure 1

Impact of screening on physician behaviors. Dementia diagnoses increased 3.9% (39 to 53 cases) for geriatricians and 1.5% (17 to 23) for nongeriatricians in intervention clinics, and 0.5% (30 to 35) for control clinics. Dementia specialty referrals increased 0.3% (3 to 4) for geriatricians, 1.5% (3 to 10) for nongeriatricians, and 0.1% (5 to 6) for control clinics. Dementia medication prescriptions did not change (0%, 18 in both years) for geriatricians, increased 1.2% (6 to 11) for nongeriatricians, and increased 0.35% (18 to 22) for control clinics

Figure 2

Derivation of sample for impact evaluation analyses

Figure 3

Impact of screening: patients without previous dementia indications