About the Recent AAN Cognitive Screening Guidelines for Older Adults

In September 2019, the American Academy of Neurology (AAN) recommended annual cognitive screening guidelines for older adults. The action marked the first time the AAN has proposed annual evaluation of cognitive health status as a quality metric.

“The AAN guidelines emphasize the importance of assessing cognition in older patients seen by neurologists,” explains Cleveland Clinic geriatrician Saket Saxena, MD. “If we can improve screening methods and identify cognitive problems earlier, we can gain invaluable insight into both cognitive and behavioral issues. This will allow us to work with patients and families to proactively develop care plans and improve health outcomes.”

Challenges of cognitive screening

While there are systematic processes in place for screening many conditions, cognitive diseases are not among them. In fact, no specific guidelines or standardized tests have been established for cognitive assessment.

“Historically speaking, the approach to cognition screening and diagnosis has been mostly reactive,” notes Dr. Saxena. “In spite of dementia being a common condition in older adults, most providers wait until patients raise issues about cognition before performing an assessment.”

Several factors make cognitive screening challenging in clinical practice. For example, primary care physicians have time limitations during office visits. In addition, cognitive screening usually requires special training and may create workflow delays.

AAN screening guidelines

The recommendation for annual cognitive screening comes in the form of a mild cognitive impairment (MCI) quality measurement set prepared by the American Academy of Neurology Institute (AANI) and published in Neurology. The six quality metrics in the set are based on a cohort of neurology patients 65 years and older.

The metrics, whose underlying principles can easily be applied to primary care, are as follows:

• Annual cognitive health assessment for patients 65 years and older.
• Cognitive and functional assessment for patients with MCI or memory loss.
• MCI diagnosis disclosed and counseled on treatment options.
• Assessment and treatment of factors contributing to MCI.
• Avoidance of anticholinergic medications for patients with MCI.
• Education provided to care partners of patients with MCI.

Cognitive screening at Cleveland Clinic

In 2017, Cleveland Clinic’s Center for Geriatric Medicine began implementing cognitive screening protocols. By 2018, the screening protocols were established at a primary care site, allowing cognitive health experts to establish a workflow and train physicians and other staff.

Cleveland Clinic’s cognitive screening protocols have expanded throughout Northeast Ohio — with nearly all primary care physicians trained to conduct them as well as 500+ nurses and medical assistants. These screenings are administered during extended medical appointments such as annual physicals.

“We selected the Mini-Cog© tool to assess cognition because it’s easy to implement and it takes just a few minutes to perform,” reveals Dr. Saxena. “Medical assistants can easily conduct the test and interpret the results, without impacting the clinical workflow.”

“If the screening results are abnormal, we have a process in place to provide further diagnosis and treatment,” says Dr. Saxena. “This includes internal management and support from outside entities.”

Future research requirements

The Center for Geriatric Medicine conducts over 1,000 cognitive screenings each month. This will help provide the data collection needed to evaluate the long-term safety and effectiveness of cognitive assessments in older adults.

“We still have work ahead of us to ensure that the quality of our assessments is consistent across the enterprise,” explains Dr. Saxena. “We are also working to assess the robustness of cognitive screening at different Cleveland Clinic Family Health Centers across Northeast Ohio to identify high- and low-performing sites and address barriers. This will help us make screening guidelines and implementation practices more effective.”