One Way to Spot Early Cognitive Decline? Medicare Wellness Visits

A Medicare annual wellness visit (AWV) was associated with greater recognition of mild cognitive impairment in older adults, a population-based cohort study in Texas showed.

Compared with those who didn’t have an annual visit, AWV recipients had a 21% increase in mild cognitive impairment diagnoses (HR 1.21, 95% CI 1.16-1.27) and a 4% increase in diagnoses of Alzheimer’s disease or dementia (HR 1.04, 95% CI 1.02-1.06) after propensity score matching, reported Huey-Ming Tzeng, PhD, of the University of Texas Medical Branch at Galveston, and co-authors in JAMA Network Open.

AWV recipients had a diagnosis of mild cognitive impairment 76 days earlier than those who did not receive AWVs. A sensitivity analysis that treated AWV as a time-dependent variable showed a higher association of AWV with a mild cognitive impairment diagnosis (HR 1.40, 95% CI 1.32-1.49), but a nonsignificant association with dementia diagnoses.

The findings indicate that AWV recipients had timelier first mild cognitive impairment diagnoses, but first dementia diagnoses differed little, Tzeng and colleagues said. “This study suggests that the Medicare AWV health policy may increase mild cognitive impairment identification, prompting more specialized care,” they wrote.

“Early recognition of cognitive impairment is key to optimal dementia care,” the researchers noted. “Patient access to dementia assessment often limits timely diagnosis of cognitive impairment.”

Medicare AWVs, introduced under the Affordable Care Act, offer comprehensive health evaluations that include a review of a patient’s medical history and risk factors, plus a cognitive assessment. This assessment often includes brief tests like the Mini-Cog, Memory Impairment Screen, or General Practitioner Assessment of Cognition to identify mild cognitive impairment or early dementia.

“The debate over cognitive impairment screening, whether to use a broad or targeted approach, is crucial given the complexities of early dementia detection,” observed Márlon Juliano Romero Aliberti, MD, PhD, of the University of Sao Paulo in Brazil, and co-authors in an accompanying editorial.

“Most dementia cases go undiagnosed, with symptoms often subtle, unreported, or mistaken for normal aging,” they added. “The U.S. Preventive Services Task Force and the National Institute for Health and Care Excellence both recommend targeted strategies rather than broad screening.”

Early identification allows for proactive strategies that may slow the progression of mild cognitive impairment, Aliberti and colleagues emphasized. “Patients who receive a diagnosis early can benefit from personalized care plans addressing modifiable risk factors such as hypertension, diabetes, and lifestyle choices,” they noted.

It also “opens the door for crucial conversations about goals of care and advance care planning, allowing patients and families to make informed decisions about future care preferences and end-of- life care,” they added.

But widespread early detection can place a strain on healthcare systems, upping the need for specialist referrals, diagnostic testing, and ongoing management, the editorialists pointed out. New Alzheimer’s drugs — lecanemab (Leqembi) and donanemab (Kisunla) — also have increased pressure on physicians to evaluate cognitive changes so eligible patients can be diagnosed sooner.

Tzeng and colleagues examined records of 549,516 Medicare beneficiaries in Texas with no diagnosis of mild cognitive impairment or dementia from 2015 to 2017. Mean age was about 77 years; 52.8% of beneficiaries were women and 73.6% were white.

A total of 66,433 people (12.1%) had an AWV in 2018. The primary outcome was the first mild cognitive impairment or dementia diagnosis from the 2018 AWV index date through the end of 2022.

Adults who had an AWV were more likely to be women and white than those without an AWV. They had more education, were more likely to live in a metropolitan area, had more comorbidities, and were more likely to have a primary care provider in the 12 months before the AWV date. To control for differences between beneficiaries with and without an AWV, the researchers used propensity score matching with demographic and health information as covariates.

Annual wellness visits have a patient self-selection bias, Tzeng and colleagues acknowledged. The analyses in this study were limited to Medicare billing data, and details about AWVs or referrals to neurologists or psychiatrists were not available.