Primary Care Portal
Primary care providers play an invaluable role in the detection, diagnosis and management of patients with mild cognitive impairment and dementia. The resources below include guidance for providers to implement our 5-step dementia workup, disclose a diagnosis, start a care plan, manage medications and bill for services.

The 5-Step Brain Health Work-up

 

Mild Cognitive Impairment and Dementia

We know that there a lot of folks getting older, and Alzheimer’s disease and other dementias are a major issue that is only going to get bigger as the years go by. You know your patients better than anyone else. Just listen to your patients and their families. Trying to identify these folks before they get to a stage where it is too late to intervene will really help your patients. There are a lot of resources out there, in addition to medications and other treatments.

Family Medicine Doctor

Here are the key terms and ICD codes for diagnosing mild cognitive impairment and dementia, including Alzheimer’s disease and non-Alzheimer’s disease.

  • Mild cognitive impairment (ICD code 331.84) is a general term used to refer to deficits in memory or other thinking skills that do not significantly impact daily functioning. For example, memory problems may be mild and hardly noticeable to the individual. Writing reminders and taking notes allow a person to compensate for memory difficulties. These cognitive deficits in mild cognitive impairment may remain stable for years, and about 60% of patients will progress to dementia.
  • Dementia (ICD code F03.90 or F03.91) is a general term used to refer to a new and progressive decline in cognitive function over at least six months that does significantly impact daily functioning. Of note, the term dementia has been replaced in the DSM-V manual for psychiatric diagnosis with the term major neurocognitive disorder, but the term dementia is still commonly used in neurology and by many psychiatrists.
  • Causes of dementia: The most common cause of dementia is neurodegenerative disease. This is a general term for a class of disorders characterized by progressive accumulation of injurious proteins in the central nervous system that leads to neuronal dysfunction and death. Alzheimer’s disease (ICD 10 code G30) is the most common neurodegenerative disease, but other causes of dementia are also common. An overview of the key symptoms of Alzheimer's and non-Alzheimer's dementias can be found  in the Assessment of Cognitive Complaints Toolkit for Alzheimer's disease Instruction Manual on p6. Dementia can also be caused or made worse by treatable conditions including sleep problems (e.g., apnea), medications, hypothyroidism, vitamin B12 deficiency, depression, comorbid health conditions, autoimmune encephalitis, and normal pressure hydrocephalus.

Glossary/Note: Cognitive impairment is a non-specific term used to describe any one of many disorders that impact cognition. More specific terms are noted above.

Why It Is Important to Detect and Diagnose Dementia

We’ve been going to our PCP a long time, the last 20 years. So, we feel very comfortable with her and the practice in general. She’s always concerned about both of us. It was natural that she was the first person we talked to about his memory problems.

Caregiver of a person with Alzheimer’s disease
  1. Early diagnosis protects your patients. Early dementia diagnosis allows patients and families to plan ahead effectively for future medical, financial, and legal decisions. Importantly, with early diagnosis, the patient is able to contribute to decision-making about their own future.
  2. Dementia affects all aspects of medical and personal care. A dementia diagnosis, when documented in the medical record, can be taken into account to improve management of the patient’s other serious medical conditions. Care for other conditions may be simplified or family members more explicitly engaged to improve management (e.g., in diabetes) and many patients and families may wish to shift to a more palliative approach to care for these conditions. Documentation of dementia is also important when a patient presents to the ED with an emergency health problem so that the providers there can consider how dementia may be affecting the presenting problem and use this information to guide their approaches to care.
  3. Connecting persons with dementia and their families to support and education programs improves their wellbeing. There are effective supportive education and care programs for patients and families living with dementia that can be taken advantage of following diagnosis. These programs often lead to improved health-related outcomes and well-being for the person with dementia as well as reduced stress, depression, and feelings of isolation and burden for family caregivers. The Alzheimer’s Association and the Family Caregiver Alliance are good organizations for connecting families to these types of resources.
  4. Some causes of dementia are reversible. A dementia evaluation can identify treatable conditions that are either causing or exacerbating cognitive impairment.
  5. The specific type of dementia impacts treatment. Beyond diagnosis of dementia, recognizing the cause of the dementia is also important because treatments are different for different types of dementia. Examples: certain medications (e.g., anticholinergic and typical antipsychotic) should be avoided or used with caution in Lewy body dementia due to high likelihood of adverse events, acetylcholinesterase inhibitors that are effective in Lewy body dementia and Alzheimer’s disease can cause agitation in frontotemporal dementia, and persons with vascular dementia benefit from interventions to reduce the risk of future cerebrovascular events or progression of white matter injury.
  6. Patients can join research efforts and change the future of dementia treatment. Diagnosis opens the door for patients to participate in research to help discover treatments and cures.
  7. Primary Care Providers are ideally suited to detect and manage MCI and dementia. Primary Care Providers have regular and consistent contact with patients and are therefore in the ideal position to notice changes in function and cognition over time. The longitudinal relationship and trust between PCPs and their patients can facilitate assessment, diagnostic, and care management.

Dementia is massively under-detected, especially at earlier stages. Only half of people with dementia have been diagnosed by a physician, and even if dementia has been diagnosed, it is often not documented in the medical record. Primary care is the place to improve detection, because most at-risk people (middle aged and older adults) see primary care regularly.