I’m a neurologist in a "neuro-desert," a place with a shortage of neurologists for the patient population. I work in Nevada, in a growing city built in the desert, a useful metaphor for understanding the national challenge we face in diagnosing and treating the rising Alzheimer’s crisis.
Our U.S. population is aging, and with more people aged 65 and older than ever before, it’s a population more prone to memory loss and neurological conditions like Alzheimer's and dementia. Patient demand – and undiagnosed illness – are overwhelming the supply of neurologists.The math is daunting:
- In urban areas, only 27 percent of people who need a neurologist can see one, in rural areas that drops to 21 percent.
- By 2050 the number of Americans with Alzheimer’s is projected to rise to 13 million from 6 million today,
- Among people with probable dementia, nearly 60 percent are undiagnosed.
Neurologists will never be able to adequately serve the population’s needs. One of the consequences of Alzheimer’s population growth will be even longer wait times for appointments. As patient demand continues to overwhelm the supply of neurologists, we look to primary care providers (PCPs) to help us improve the diagnosis, treatment and prevention of dementia and Alzheimers.
From a practical perspective, PCPs provide scale and access to patients who should be in the neurological care pipeline, with more than half-a-million PCPs across the country. To fill that pipeline, they need appropriate tools and the confidence to expand their role in their patients’ cognitive health.
The current cognitive health screening methods used in primary care (mostly the Mini-Cog and MoCA) are often misunderstood, misused or, more likely, not used at all. Older patients are often referred to me with some common “old age” issues such as “tip of the tongue” moments, and are worried they have early Alzheimer’s.
They are sent to me without a formal screening, a reflection of the uncertainty PCPs might have about the appropriate assessment methods to determine the need for a referral. In order for PCPs to serve the urgent demand, they require more convenient tools to screen and diagnose memory problems.
They also need to be supported with education to discuss the disease with patients as well as the interventions in midlife that can reduce risk of developing dementia and Alzheimer’s. Medicine has pushed brain health to the back in favor of other important screenings such as breast cancer, blood pressure management, and diabetes or other chronic health conditions. However, new digital tools that can quickly detect cognitive impairment, a first indicator of possible dementia or Alzheimer’s disease, can enable PCPs to be the necessary first line of assessment.
Understanding the Screening Tools
The Mini-Cog is a paper and pencil test. As a standard tool used in primary care, it involves a three-word recall exercise and a clock drawing that the administrator then evaluates. A common misconception is that the Mini Cog diagnoses dementia based on the scoring system. The score, as in other assessment tools, is not a clinical diagnosis.
Other more rigorous tools including the MMSE and MoCA present different limitations in primary care. Most significant is the time required to administer them, which typically take 10 minutes for the MMSE and 15 minutes for the MoCA, real challenges within the structures of a limited office visit.
Most PCPs do not have the time to use them. Many neurologists, such as myself, use the MoCA to help assess a clinical diagnosis; but it has limitations such as language barriers.
Sometimes I can get a translator when seeing a patient, but it can be difficult. I’m encouraged by new digital tools that can act as first-line screenings and are effective replacements for the Mini-Cog to assist primary care. They’re attractive because of their sensitivity and specificity, objectiveness in scoring, accessibility for a wider audience, and the ability to integrate an EHR.
Their efficiency allows for regular screenings and the ability to follow patient scores over time could improve care, potentially enabling providers to uncover individual changes that may indicate a problem that might otherwise not be noticed.
Where Digital Tools Can Make a Difference
To begin with, patients could be easily screened in their annual PCP checkups with the adoption of digital tools. I’ve seen screenings completed in as little as three minutes that can be administered by medical assistants, leaving the PCP to discuss the results. These first-line screeners are fast, objective, non invasive, and less costly than other diagnostic tests such as blood tests and PET scans.
They can be especially helpful in primary care to advance assessment of patients with psychological or psychiatric issues, TBI, ADHD, even long Covid and memory complaints.
Age-related concerns, such as difficulty finding words or infrequent memory problems, can also be better understood. But the greatest impact may be for general screening to ensure no potential issues go undiagnosed for years if non symptomatic, when interventions can be effective.
Starting with Education
With the right education, PCPs can take the initial step towards addressing cognition or memory recall. PCPs can work with patients regarding what signs may be significant or not and how to reduce their future risk. For instance, clarifying, “When should you worry,” discussing the frequency of forgetfulness and if it’s progressing. If it is over several months to a year, PCPs can help educate patients about when to be concerned, and how to reduce their future risk. The opportunity to talk to family members or friends regarding noticeable differences is invaluable, but digital screenings can elevate patients’ reassurance or validate their concerns. The crisis affecting millions of Americans will only be helped by changing the way we approach cognitive health. What I’m advocating isn’t theoretical. The real assets exist now – the PCPs with access to patients, the digital tools that make screening possible, the relationships between patients and doctors – to profoundly change the course of cognitive health in this country. The opportunity exists. With a health crisis this grave, we must take action.
Dr. Jonathan Artz is a neurologist with Renown Regional Medical Center in Nevada. He's also the co-host of the Let's Talk Brain Health Podcast.