Clinical judgement of cognitive impairment

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Changes in memory and cognition have become common concerns for neurology practices globally (Bailey et al 2018; Herman et al 2017; Gino et al 2010; Pires et al 2012). Such issues likely stem from heightened public awareness about Alzheimer’s disease and related dementias (ADRD), as well as collective knowledge that cognitive impairment can be detected early and prior to loss of daily functions. Although the desire to evaluate and understand cognitive function is top of mind in many clinical interactions, neurologists face a number of barriers when seeking comprehensive analyses of cognitive testing, education, and interventions.

 

Cognitive concerns and objective impairment on testing are common for a wide range of medical and neurologic conditions, apart from ADRD (Grzegorski et al 2017; Vuralli et al 2018; Witt et al 2017; Zilliox et al 2016). Due to time limitations and lack of knowledge on how to best evaluate and address cognition in disorders such as MS, TBI, epilepsy, and stroke, neurologists may naturally focus on diagnosing and treating the “primary” disease(s) rather than the “secondary” cognitive difficulties that may be major contributors to loss of function or decreased quality of life. When cognitive changes are the “primary” symptom, like in ADRD or ADHD, addressing and treating cognition is considered the standard of care (Sanders et al 2017).

 

In a myriad of other conditions, however, guidelines and priorities about assessing cognition are not well documented. Additionally, patterns of cognitive deficits are less pathognomonic than in ADRD and often not part of diagnostic criteria or longitudinal care recommendations.

 

Yet, even with ample time to evaluate and intervene on cognition, neurologists may also lack adequate resources to effectively test for, educate about, and make recommendations on impairment. Some neurologists rely on colleagues in neuropsychology to administer and interpret formal assessments. However, access to and quality of these services can vary and may be beset by long wait times, poor patient experience, lengthy and inefficient testing, or geographic limitations (Allott et al 2009; Miller et al 2017). Fifty percent of neurologists think the average wait time for a cognitive assessment, whether by a neurologist or neuropsychologist, has a negative impact on diagnosis and treatment.* Other neurologists may not feel comfortable with the ever-changing, neurologic subspecialty knowledge on cognitive testing or possible intervention options.

 

These barriers highlight a notable gap in cognitive evaluation and treatment, limiting neurologists’ ability to provide optimal care to patients. To overcome limitations, one necessary step is to involve additional cognitive care education for neurologists and support staff. An equally important solution is to adopt better tools to obtain timely, evidence-based neurocognitive assessment in everyday practice — even in patients who might otherwise not be assessed.

*From an online survey of 75 US-based neurologists; commissioned by Philips and conducted by MarkeTech Group

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References

Herman L, Atri A, Salloway S. Alzheimer's Disease in Primary Care: The Significance of Early Detection, Diagnosis, and Intervention. Am J Med. 2017 Jun;130(6):756. doi: 10.1016/j.amjmed.2017.04.001. Epub 2017 Apr 25. PubMed PMID: 28449849.