Dementia: Cognitive Assessment

Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month period

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An estimated 5.8 million of adults in the US were living with dementia in 2019. Dementia is often characterized by the gradual onset and continuing cognitive decline in one or more domains including memory, communication and language, ability to focus or pay attention, reasoning and judgment and visual perception (Alzheimer’s Association, 2019). Cognitive deterioration represents a major source of morbidity and mortality and poses a significant burden on affected individuals and their caregivers (Daviglus et al., 2010). Although cognitive deterioration follows a different course depending on the type of dementia, significant rates of decline have been reported. For example, one study found that the annual rate of decline for Alzheimer's disease patients was more than four times that of older adults with no cognitive impairment (Wilson et al., 2010). Nevertheless, measurable cognitive abilities remain throughout the course of dementia (American Psychiatric Association, 2007). Initial and ongoing assessments of cognition are fundamental to the proper management of patients with dementia. These assessments serve as the basis for identifying treatment goals, developing a treatment plan, monitoring the effects of treatment, and modifying treatment as appropriate.

Ongoing assessment includes periodic monitoring of the development and evolution of cognitive and noncognitive psychiatric symptoms and their response to intervention (Category I). Both cognitive and noncognitive neuropsychiatric and behavioral symptoms of dementia tend to evolve over time, so regular monitoring allows detection of new symptoms and adaptation of treatment strategies to current needs... Cognitive symptoms that almost always require assessment include impairments in memory, executive function, language, judgment, and spatial abilities. It is often helpful to track cognitive status with a structured simple examination (American Psychiatric Association, 2007).

The American Psychiatric Association recommends that patients with dementia be assessed for the type, frequency, severity, pattern, and timing of symptoms (Category 1C). Quantitative measures provide a structured replicable way to document the patient's baseline symptoms and determine which symptoms (if any) should be the target of intervention based on factors such as frequency of occurrence, magnitude, potential for associated harm to the patient or others, and associated distress to the patient. The exact frequency at which measures are warranted will depend on clinical circumstances. However, use of quantitative measures as treatment proceeds allows more precise tracking of whether nonpharmacological and pharmacological treatments are having their intended effect or whether a shift in the treatment plan is needed (American Psychiatric Association, 2016).

Conduct and document an assessment and monitor changes in cognitive status using a reliable and valid instrument, e.g., MoCA (Montreal Cognitive Assessment), AD8 (Ascertian Dementia 8) or other tool. Cognitive status should be reassessed periodically to identify sudden changes, as well as to monitor the potential beneficial or harmful effects of environmental changes (including safety, care needs, and abuse and/or neglect), specific medications (both prescription and non-prescription, for appropriate use and contraindications), or other interventions. Proper assessment requires the use of a standardized, objective instrument that is relatively easy to use, reliable (with less variability between different assessors), and valid (results that would be similar to gold-standard evaluations) (California Department of Public Health, 2017).

Recommendation: Perform regular, comprehensive person-centered assessments and timely interim assessments.
Assessments, conducted at least every 6 months, should prioritize issues that help the person with dementia to live fully. These include assessments of the individual and care partner’s relationships and subjective experience and assessment of cognition, behavior, and function, using reliable and valid tools. Assessment is ongoing and dynamic, combining nomothetic (norm based) and idiographic (individualized) approaches (Fazio, Pace, Maslow, Zimmerman, & Kallmyer, 2018)

Recommendation: Assess cognitive status, functional abilities, behavioral and psychological symptoms of dementia, medical status, living environment, and safety. Reassess regularly and when there is a significant change in condition (U.S. Department of Health and Human Services, 2016).

Higher score indicates better quality

Alzheimer’s Association. (2019). 2019 Alzheimer’s Disease Facts and Figures. Alzheimer’s & Dementia, 15(3), 321-387. Retrieved from https://alz.org/media/Documents/alzheimers-facts-and-figures-2019-r.pdf

American Psychiatric Association, Work Group on Alzheimer’s Disease and Other Dementias. (2007). Practice Guideline for the Treatment of Patients with Alzheimer’s Disease and Other Dementias. Retrieved from https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/alzheimers.pdf

American Psychiatric Association. (2016). Practice guideline on the use of antipsychotics to treat agitation or psychosis in patients with dementia. Retrieved from https://psychiatryonline.org/doi/pdf/10.1176/appi.books.9780890426807

California Department of Public Health. (2017). California guidelines for Alzheimer’s disease management, 2017. Retrieved from https://www.cdph.ca.gov/Programs/CCDPHP/DCDIC/CDCB/CDPH%20Document%20Library/Alzheimers'%20Disease%20Program/ALZ-CareGuidelines.pdf

Daviglus M.L., Bell, C.C., Berrettini, W., Bowen, P.E., Connolly, E.S., Cox, N.J.,…Trevisan, M. (2010). National Institutes of Health State-of-the-Science Conference Statement: Preventing Alzheimer’s Disease and Cognitive Decline. NIH Consensus and State-of-the-Science Statements, 27(4), 1-24. Retrieved from https://consensus.nih.gov/2010/alzstatement.htm

Fazio, S., Pace, D., Maslow, K., Zimmerman, S., & Kallmyer, B. (2018). Alzheimer’s Association Dementia Care Practice Recommendations. The Gerontologist, 58(S1), S1-S9. [Supplemental material]. Retrieved from the Alzheimer’s Association website: https://academic.oup.com/gerontologist/article/58/suppl_1/S1/4816759

U.S. Department of Health and Human Services, Assistant Secretary for Planning and Evaluation, Office of Disability, Aging and Long-Term Care Policy. (2016). Examining models of dementia care: Final report. (ASPE Final Report No. 0212704.017.000.001). Retrieved from https://aspe.hhs.gov/system/files/pdf/257216/ExamDCMod.pdf

Wilson, R. S., Aggarwal, N. T., Barnes, L. L., Mendes de Leon, C.F., Herbert, L.E., & Evans, D.A. (2010). Cognitive decline in incident Alzheimer disease in a community population. Neurology, 74(12), 951-955.

Cognition can be assessed by the clinician during the patient's clinical history. 
Cognition can also be assessed by direct examination of the patient using one of a number of instruments, including several originally developed and validated for screening purposes. This can also include, where appropriate, administration to a knowledgeable informant. Examples include, but are not limited to:
-Blessed Orientation-Memory-Concentration Test (BOMC)
-Montreal Cognitive Assessment (MoCA)
-St. Louis University Mental Status Examination (SLUMS)
-Mini-Mental State Examination (MMSE) [Note: The MMSE has not been well validated for non-Alzheimer's dementias]
-Short Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE)
-Ascertain Dementia 8 (AD8) Questionnaire
-Minimum Data Set (MDS) Brief Interview of Mental Status (BIMS) [Note: Validated for use with nursing home patients only]
-Formal neuropsychological evaluation
-Mini-Cog

Use of a standardized tool or instrument to assess cognition other than those listed will meet numerator performance. Standardized tools can be mapped to the concept "Intervention, Performed": "Cognitive Assessment" included in the numerator logic below.

The requirement of two or more visits is to establish that the eligible professional or eligible clinician has an existing relationship with the patient.

In recognition of the growing use of integrated and team-based care, the diagnosis of dementia and the assessment of cognitive function need not be performed by the same provider or clinician. 

The DSM-5 has replaced the term dementia with major neurocognitive disorder and mild neurocognitive disorder. For the purposes of this measure, the terms are equivalent.

This eCQM is a patient-based measure.

This version of the eCQM uses QDM version 5.5.  Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

TBD

All patients, regardless of age, with a diagnosis of dementia

Equals Initial Population

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Patients for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month period

Not Applicable

Documentation of patient reason(s) for not assessing cognition

For every patient evaluated by this measure also identify payer, race, ethnicity and sex