For Physicians

As a primary care practice, you and your staff are often the first to address a patient’s complaints—or a family’s concerns—about memory loss or possible dementia.

Primary care physicians are the gatekeepers to assessment and treatment and a potential link and referral to community resources, which can provide support, services, and education for patients and family members.

Many people who are developing or have dementia do not receive a diagnosis. One study showed that physicians were unaware of cognitive impairment in more than 40% of their cognitively impaired patients. Another study found that more than half of patients with dementia had not received a clinical cognitive evaluation by a physician. The failure to evaluate memory or cognitive complaints is likely to hinder treatment of underlying disease and additional disorders or conditions, and may present safety issues for the patient and others. In many cases, the cognitive problem will worsen over time.

Cognitive impairment in older adults has a variety of possible causes including medication side effects, metabolic and/or endocrine derangements, delirium due to other illness, depression, and dementia with Alzheimer’s dementia being most common. Some causes, like medication side effects and depression, can be reversed with treatment. Others, such as Alzheimer’s disease, cannot be reversed, but symptoms can be treated for a period of time and families can be prepared for predictable changes.

Trained staff using readily available screening tools need only about 10 minutes or less to initially assess a patient for cognitive impairment.

A primary care provider may conduct an evaluation or refer a patient to a specialist such as those at Montclair Memory Clinic.

Family members or close companions can also be good sources of information. Sometimes you may be able to speak privately with them with the patient’s permission in advance. Alternatively, the family member or close companion can be in the examining room during the patient’s visit and contribute additional information to the interview.

To the Referring Physician:

If you think your patient would benefit from a neuropsychological evaluation, please complete the Neuropsychological Referral Form and fax it along with pertinent medical records. We will then contact your patient directly to schedule the appointment and will provide you with a copy of the evaluation upon completion. If you have questions, please call the Montclair Memory Clinic.

MMC Physician Referral Form

The Medicare Annual Wellness visit was initiated in January 2011 as part of the Affordable Care Act. The yearly Medicare benefit includes the establishment of a personalized prevention plan and detection of possible cognitive impairment.

The Patient Protection and Affordable Care Act added a new Medicare benefit, the Annual Wellness Visit (AWV), effective January 1, 2011. The AWV requires an assessment to detect cognitive impairment. The Centers for Medicare and Medicaid Services (CMS) elected not to recommend a specific assessment tool because their belief is there is no single, universally accepted screen that satisfies all needs in the detection of cognitive impairment.

However, The Alzheimer's Association convened a group of practicing expert clinicians to make consensus recommendations for an effective, practical and easy process for detecting cognitive impairment in the primary care setting.

These recommendations incorporate patient history, clinician observations, and concerns expressed by the patient, family or caregiver. Because research shows the use of a cognitive assessment instrument can improve detection of dementia in primary care settings, the group identified several brief tools to evaluate cognition all of which can be administered in less than 10 minutes by a physician or other trained staff.

Detection of cognitive impairment is a step-by-step process with the use of a specific cognitive evaluation. Informal observation alone by a physician is not sufficient. Detection of cognitive impairment can be enhanced by specifically asking questions regarding changes in memory, language, and the ability to complete routine tasks.

Although no single tool is recognized as the “gold standard” for detection of cognitive impairment, an initial structured assessment should provide either a baseline for cognitive surveillance or indicate the need for further evaluation.

What’s more, a clinical staff can offer valuable observations of cognitive and functional changes in patients who are seen over time.

Family members, caregivers or others can provide valuable information about the presence of a change in cognition.

Counseling before and after cognitive assessment is an essential component of any cognitive evaluation.

Not all primary care physicians will want to conduct a full dementia evaluation. Possible indications for referral to the Montclair Memory Clinic include:

• Atypical presentation
• Behavioral/psychiatric symptoms
• Caregiver support
• Family dispute
• Inconclusive diagnosis
• Patient/family preference
• Second opinion
• Younger-onset (< 65 years)

At Montclair Memory Clinic, we are well equipped to serve as your resource and to further evaluate your patients. Feel free to reach out to us with any questions or concerns.

Below are several resources to assist you in your understanding and administration of care:

The Alzheimer’s Association Cognitive Assessment Toolkit
http://www.alz.org/documents_custom/141209-CognitiveAssessmentToo-kit-final.pdf

Alzheimer's Association Guidelines and Recommendations
http://www.alz.org/professionals_and_researchers_14899.asp

For further publications for patients and their families, and for instructional videos on patient assessment, please visit:
http://www.alz.org/health-care-professionals/cognitive-tests-patient-assessment.asp