Position Paper: Annual Wellness Visits to Detect Cognitive Impairment

In a February 9th PsychCentral article titled “Use Annual Wellness Exams to Detect Cognitive Impairment”, it was identified that there is a need for early identification of cognitive impairment utilizing the Medicare Annual Wellness Visit. Dr. Cara Alexander points out that the work done by Dr. Fortinsky and his group outlines a four step process in satisfying this need for early detection of cognitive impairment.

WellTrackONE and Screen Inc. have collaborated to provide a complete solution that supports Dr. Fortinsky’s four step process:

Step One: WellTrackONEtm provides a complete solution for administering the Annual Wellness Visit (AWV). WellTrackONE’s Clinical Triggerstm analyze the patient’s issues and documents the medically necessary procedures to address their cognitive issues. If a patient fails WellTrackONE’s neurocognitive screening during their AWV, it triggers the need for the patient to take Screen Inc.’s Computer Administered Neuropsychological Screen for Mild Cognitive Impairment (CANS-MCI). It is a self-administered test using a touch window to answer audible questions. The simplicity of the software allows patients with little to no computer skills to objectively take the test. A concise, yet comprehensive, two page report is provided to the practice within an hour of test completion. WellTrackONE and CANS-MCI provide physicians a complete solution that addresses Dr. Fortinsky’s four step process that is approved by Medicare and provides practices a reasonable reimbursement.

Step Two: Assess the patient if he or she is suspected of being symptomatic. The workgroup endorses use of a cognitive impairment detection tool from a menu of tools having the following properties:

Administered in five minutes or less;
The time needed to administer the CANS-MCI is less than all other test batteries, even the most abbreviated. The exceptional user friendliness1 of the CANS-MCI, along with the simplicity of its response system (single finger touches, no keyboard, stylus or mouse), allows for reliable self-administration. This eliminates the staff errors and bias that plague staff-administered tests. At the end of testing, the data are automatically sent to Screen, Inc. for scoring, and a live neuropsych technician at Screen, Inc. writes a report for the doctor.

Available free of charge; it is designed to assess age-related cognitive impairment;
“The Computer-Administered Neuropsychological Screen for Mild Cognitive Impairment (CANS-MCI) was developed specifically to meet the needs of primary care physicians, and it includes an assessment of cognition, mood, health history and risk factors, substance use and driving capabilities. The assessment of cognition includes measures of free and guided recall, delayed free and guided recognition, primed picture naming, word-to-picture matching, design matching, clock hand placement and the Stroop Test. For individuals with a high school education or less, the CANS-MCI showed sensitivity of 100% and specificity of 100%, indicating that it correctly identified all participants as either meeting criteria for MCI or as a healthy control. For individuals with 13 or more years of education, the CANS-MCI showed sensitivity of 100% and specificity of 84.8%, with an AUC of 0.96.”2

Assesses at least memory and one other cognitive domain;
The patient proceeds through nine assessments, in either English or Spanish, answering questions by touching the monitor. The test results are organized within the 3 cognitive domains most predictive of dementia, determined by empirical factor analyses: Memory, Language/Symbol Fluency, and Executive Function. The following are representative slides for each assessment. There is audio as well.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Validated in primary care or community-based samples in the U.S.;

The initial validation of the CANS-MCI3 was based upon a community sample of 310 elderly people, recruited
through senior centers, American Legion halls, and retirement homes in four counties of Washington State. Exclusionary criteria were non-English language, significant hand tremor, inability to sustain a seated position
for 45 minutes, cognitive side effects of drugs, indications of recent alcohol abuse, or inadequacies in visual acuity, reading ability, hearing, or dominant hand agility. The subjects were predominantly Caucasian (86%), female (65%), and had at least some college education (76%). Subject age ranged from 51–93 years, with the majority between 60–80 years of age (63%). With the CANS-MCI, reliable testing can be performed longitudinally2 in primary care.

Easily administered by medical staff members who are not physicians;

There is no need for staff training or expertise. The staff member simply enters the person’s identity (which becomes encrypted) and turns over the tests to the person. The following are slides the staff member completes to set up the testing session for the patient:

 

 

 

 

 

 

 

 

Relatively free from educational, language, and/or cultural bias.

The CANS-MCI has also been validated with country-specific image, text and audio in Brazil5, demonstrating the robust retention of its psychometric validity despite administration in different languages. This quality allows for valid administration within the US in either English or Spanish. Testing can be performed in different languages, without tester or cultural bias and without distortions from previous test exposure or test anxiety, to compare patients against others and against their own previous performance. Testing with the CANS-MCI requires basic literacy (grade 4-5) in the language of test administration.

References:
1. Wild K, Howieson D, Webbe F, Seelye A, Kaye J The status of computerized cognitive testing in aging: A systematic review. Alzheimer’s & Dementia 2008; 4(6): 428–437.
2. Snyder, PJ, Jackson, CE, Petersen, RC, Khachaturian, AS, Kaye, J, Albert, MS, and Weintraub, S Assessment of cognition in mild cognitive impairment: A comparative study. Alzheimer’s & Dementia, 7, 338-355, 2011.
3. Tornatore J, Hill E, Laboff J, McGann M, Self-administered screening for mild cognitive impairment: initial validation of a computerized test battery. Journal of Neuropsychiatry and Clinical Neuroscience 2005; 17:98-105.
4. M. Balasa, MD, E. Gelpi, MD, PhD, A. Antonell, PhD, M.J. Rey, MD, PhD, R. Sánchez-Valle,MD, PhD, J.L. Molinuevo, MD, PhD, A. Lladó, MD, PhD Clinical features and APOE genotype of pathologically proven early-onset Alzheimer disease. Neurology May 17, 2011 vol. 76, 1720-1725.
5. Memória CM, Yassuda MS, Nakano EY, Forlenza OV. Contributions of the Computer-Administered Neuropsychological Screen for Mild Cognitive Impairment (CANS-MCI) for the diagnosis of MCI in Brazil. International Psychogeriatrics 2014 May 7:1-9.