eCQM Title | # Dementia: Cognitive Assessment
eCQM Identifier (Measure Authoring Tool) | 149 | eCQM Version Number | 12.2.000
NQF Number | 2872e | GUID | 7c443b9b-1ad1-4467-b527-defc445701ff
Measurement Period | January 1, 20XX through December 31, 20XX
Measure Steward | American Academy of Neurology
Measure Developer | American Academy of Neurology
Measure Developer | American Medical Association (AMA)
Measure Developer | PCPI(R) Foundation (PCPI[R])
Endorsed By | National Quality Forum
Description |
    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
Copyright |
    Attribution: The American Psychiatric Association’s (APA), PCPI’s, and American Medical Association’s (AMA) significant past efforts and contributions to the development and updating of the Measure are acknowledged.

    Copyright: (C)2023 American Academy of Neurology Institute (AANI). All rights reserved.
Disclaimer |
    Limited proprietary coding may be contained in the Measure specifications for convenience. A license agreement must be entered prior to a third party’s use of Current Procedural Terminology (CPT[R]) or other proprietary code set contained in the Measure. Any other use of CPT or other coding by the third party is strictly prohibited. AANI, APA, AMA, and the former members of the PCPI disclaim all liability for use or accuracy of any CPT or other coding contained in the specifications.

    CPT(R) contained in the Measure specifications is copyright 2004-2022 American Medical Association. LOINC(R) is copyright 2004-2022 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2022 International Health Terminology Standards Development Organisation. ICD-10 is copyright 2022 World Health Organization. All Rights Reserved.
Measure Scoring | Proportion
Measure Type | Process
Stratification |
    None
Risk Adjustment |
    None
Rate Aggregation |
    None
Rationale |
    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.
Clinical Recommendation Statement |
    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., Montreal Cognitive Assessment (MoCA), Ascertain Dementia 8 (AD8) 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).
Improvement Notation |
    Higher score indicates better quality
Reference |
    Reference Type: CITATION
    Reference Text: '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'
Reference |
    Reference Type: CITATION
    Reference Text: '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'
Reference |
    Reference Type: CITATION
    Reference Text: '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'
Reference |
    Reference Type: CITATION
    Reference Text: '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'
Reference |
    Reference Type: CITATION
    Reference Text: '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'
Reference |
    Reference Type: CITATION
    Reference Text: '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'
Reference |
    Reference Type: CITATION
    Reference Text: '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'
Reference |
    Reference Type: CITATION
    Reference Text: '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.'
Definition |
    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
Guidance |
    Use of a standardized tool or instrument to assess cognition other than those listed will meet numerator performance if 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 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.
Transmission Format |
    TBD
Initial Population |
    All patients, regardless of age, with a diagnosis of dementia who have two or more visits during the measurement period
Denominator |
    Equals Initial Population
Denominator Exclusions |
    None
Numerator |
    Patients for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month period
Numerator Exclusions |
    Not Applicable
Denominator Exceptions |
    Documentation of patient reason(s) for not assessing cognition
Supplemental Data Elements |
    For every patient evaluated by this measure also identify payer, race, ethnicity and sex

## Table of Contents

- Population Criteria
- Definitions
- Functions
- Terminology
- Data Criteria (QDM Data Elements)
- Supplemental Data Elements
- Risk Adjustment Variables

### Population Criteria

- - Initial Population

    - -     exists "Dementia Encounter During Measurement Period"
              and ( Count("Qualifying Encounter During Measurement Period")>= 2 )

- - Denominator

    - -     "Initial Population"

- - Denominator Exclusions

    - -     None

- - Numerator

    - -     exists "Assessment of Cognition Using Standardized Tools or Alternate Methods"

- - Numerator Exclusions

    - -     None

- - Denominator Exceptions

    - -     exists "Patient Reason for Not Performing Assessment of Cognition Using Standardized Tools or Alternate Methods"

- - Stratification

    - -     None

### Definitions

- - Assessment of Cognition Using Standardized Tools or Alternate Methods

    - -     ( ["Assessment, Performed": "Standardized Tools Score for Assessment of Cognition"]
              union ["Intervention, Performed": "Cognitive Assessment"] ) CognitiveAssessment
              with "Dementia Encounter During Measurement Period" EncounterDementia
                such that Global."NormalizeInterval" ( CognitiveAssessment.relevantDatetime, CognitiveAssessment.relevantPeriod ) starts 12 months or less on or before day of
                end of EncounterDementia.relevantPeriod
              where CognitiveAssessment.result is not null

  - Dementia Encounter During Measurement Period

    - -     "Encounter to Assess Cognition" EncounterAssessCognition
              with ["Diagnosis": "Dementia & Mental Degenerations"] Dementia
                such that EncounterAssessCognition.relevantPeriod during "Measurement Period"
                  and Dementia.prevalencePeriod overlaps EncounterAssessCognition.relevantPeriod

  - Denominator

    - -     "Initial Population"

  - Denominator Exceptions

    - -     exists "Patient Reason for Not Performing Assessment of Cognition Using Standardized Tools or Alternate Methods"

  - Encounter to Assess Cognition

    - -     ["Encounter, Performed": "Psych Visit Diagnostic Evaluation"]
              union ["Encounter, Performed": "Nursing Facility Visit"]
              union ["Encounter, Performed": "Care Services in Long Term Residential Facility"]
              union ["Encounter, Performed": "Home Healthcare Services"]
              union ["Encounter, Performed": "Psych Visit Psychotherapy"]
              union ["Encounter, Performed": "Behavioral/Neuropsych Assessment"]
              union ["Encounter, Performed": "Occupational Therapy Evaluation"]
              union ["Encounter, Performed": "Office Visit"]
              union ["Encounter, Performed": "Outpatient Consultation"]

  - Initial Population

    - -     exists "Dementia Encounter During Measurement Period"
              and ( Count("Qualifying Encounter During Measurement Period")>= 2 )

  - Numerator

    - -     exists "Assessment of Cognition Using Standardized Tools or Alternate Methods"

  - Patient Reason for Not Performing Assessment of Cognition Using Standardized Tools or Alternate Methods

    - -     ( ["Assessment, Not Performed": "Standardized Tools Score for Assessment of Cognition"]
              union ["Intervention, Not Performed": "Cognitive Assessment"] ) NoCognitiveAssessment
              with "Dementia Encounter During Measurement Period" EncounterDementia
                such that NoCognitiveAssessment.authorDatetime during EncounterDementia.relevantPeriod
              where NoCognitiveAssessment.negationRationale in "Patient Reason"

  - Qualifying Encounter During Measurement Period

    - -     ( "Encounter to Assess Cognition"
              union ["Encounter, Performed": "Patient Provider Interaction"] ) ValidEncounter
              where ValidEncounter.relevantPeriod during "Measurement Period"

  - SDE Ethnicity

    - -     ["Patient Characteristic Ethnicity": "Ethnicity"]

  - SDE Payer

    - -     ["Patient Characteristic Payer": "Payer"]

  - SDE Race

    - -     ["Patient Characteristic Race": "Race"]

  - SDE Sex

    - -     ["Patient Characteristic Sex": "ONC Administrative Sex"]

### Functions

- - Global.NormalizeInterval(pointInTime DateTime, period Interval<DateTime>)

    - -     if pointInTime is not null then Interval[pointInTime, pointInTime]
              else if period is not null then period
              else null as Interval<DateTime>

### Terminology

- valueset "Behavioral/Neuropsych Assessment" (2.16.840.1.113883.3.526.3.1023)
- valueset "Care Services in Long Term Residential Facility" (2.16.840.1.113883.3.464.1003.101.12.1014)
- valueset "Cognitive Assessment" (2.16.840.1.113883.3.526.3.1332)
- valueset "Dementia & Mental Degenerations" (2.16.840.1.113883.3.526.3.1005)
- valueset "Ethnicity" (2.16.840.1.114222.4.11.837)
- valueset "Home Healthcare Services" (2.16.840.1.113883.3.464.1003.101.12.1016)
- valueset "Nursing Facility Visit" (2.16.840.1.113883.3.464.1003.101.12.1012)
- valueset "Occupational Therapy Evaluation" (2.16.840.1.113883.3.526.3.1011)
- valueset "Office Visit" (2.16.840.1.113883.3.464.1003.101.12.1001)
- valueset "ONC Administrative Sex" (2.16.840.1.113762.1.4.1)
- valueset "Outpatient Consultation" (2.16.840.1.113883.3.464.1003.101.12.1008)
- valueset "Patient Provider Interaction" (2.16.840.1.113883.3.526.3.1012)
- valueset "Patient Reason" (2.16.840.1.113883.3.526.3.1008)
- valueset "Payer" (2.16.840.1.114222.4.11.3591)
- valueset "Psych Visit Diagnostic Evaluation" (2.16.840.1.113883.3.526.3.1492)
- valueset "Psych Visit Psychotherapy" (2.16.840.1.113883.3.526.3.1496)
- valueset "Race" (2.16.840.1.114222.4.11.836)
- valueset "Standardized Tools Score for Assessment of Cognition" (2.16.840.1.113883.3.526.3.1006)

### Data Criteria (QDM Data Elements)

- "Assessment, Not Performed: Standardized Tools Score for Assessment of Cognition" using "Standardized Tools Score for Assessment of Cognition (2.16.840.1.113883.3.526.3.1006)"
- "Assessment, Performed: Standardized Tools Score for Assessment of Cognition" using "Standardized Tools Score for Assessment of Cognition (2.16.840.1.113883.3.526.3.1006)"
- "Diagnosis: Dementia & Mental Degenerations" using "Dementia & Mental Degenerations (2.16.840.1.113883.3.526.3.1005)"
- "Encounter, Performed: Behavioral/Neuropsych Assessment" using "Behavioral/Neuropsych Assessment (2.16.840.1.113883.3.526.3.1023)"
- "Encounter, Performed: Care Services in Long Term Residential Facility" using "Care Services in Long Term Residential Facility (2.16.840.1.113883.3.464.1003.101.12.1014)"
- "Encounter, Performed: Home Healthcare Services" using "Home Healthcare Services (2.16.840.1.113883.3.464.1003.101.12.1016)"
- "Encounter, Performed: Nursing Facility Visit" using "Nursing Facility Visit (2.16.840.1.113883.3.464.1003.101.12.1012)"
- "Encounter, Performed: Occupational Therapy Evaluation" using "Occupational Therapy Evaluation (2.16.840.1.113883.3.526.3.1011)"
- "Encounter, Performed: Office Visit" using "Office Visit (2.16.840.1.113883.3.464.1003.101.12.1001)"
- "Encounter, Performed: Outpatient Consultation" using "Outpatient Consultation (2.16.840.1.113883.3.464.1003.101.12.1008)"
- "Encounter, Performed: Patient Provider Interaction" using "Patient Provider Interaction (2.16.840.1.113883.3.526.3.1012)"
- "Encounter, Performed: Psych Visit Diagnostic Evaluation" using "Psych Visit Diagnostic Evaluation (2.16.840.1.113883.3.526.3.1492)"
- "Encounter, Performed: Psych Visit Psychotherapy" using "Psych Visit Psychotherapy (2.16.840.1.113883.3.526.3.1496)"
- "Intervention, Not Performed: Cognitive Assessment" using "Cognitive Assessment (2.16.840.1.113883.3.526.3.1332)"
- "Intervention, Performed: Cognitive Assessment" using "Cognitive Assessment (2.16.840.1.113883.3.526.3.1332)"
- "Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity (2.16.840.1.114222.4.11.837)"
- "Patient Characteristic Payer: Payer" using "Payer (2.16.840.1.114222.4.11.3591)"
- "Patient Characteristic Race: Race" using "Race (2.16.840.1.114222.4.11.836)"
- "Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex (2.16.840.1.113762.1.4.1)"

### Supplemental Data Elements

- SDE Ethnicity

  - -     ["Patient Characteristic Ethnicity": "Ethnicity"]

- SDE Payer

  - -     ["Patient Characteristic Payer": "Payer"]

- SDE Race

  - -     ["Patient Characteristic Race": "Race"]

- SDE Sex

  - -     ["Patient Characteristic Sex": "ONC Administrative Sex"]

### Risk Adjustment Variables

- None

Measure Set |
    None