Time is likely to be the biggest problem for primary care physicians trying to add cognitive screening to their exams, said Dr. David Knopman, professor of neurology at the Mayo Clinic in Rochester, Minn. "If you don’t have a half an hour to obtain a history from an informant and do a mental status exam, it’s not going to get done," he said.
To do the screening properly, Dr. Knopman said physicians need to set aside enough time to perform the standardized screening tests and to speak with an informant, usually a spouse or adult child who knows the patient well. He advises practices to arrange in advance to have the informant present whenever a cognitive assessment is being performed.
Dr. Jacobo Mintzer, professor of neuroscience at the Medical University of South Carolina, Charleston, and chair of the scientific advisory committee at the Alzheimer’s Foundation of America, said he thinks that as time goes on cognitive impairment screening will become a standard part of the exam for all older adults, much like a blood pressure check. "At some point it becomes part of the basic consult that the patient receives," he said.
But not all primary care physicians will be comfortable diagnosing and treating dementia patients, he said, just as some physicians prefer to refer patients for cardiology conditions. His advice: "Know what you don’t know."
Dr. Marwan Sabbagh, a geriatric neurologist and director of the Banner Sun Health Research Institute in Sun City, Ariz., agrees that many primary care physicians aren’t comfortable making a diagnosis of Alzheimer’s disease, disclosing that diagnosis, and recommending treatment. The problem, he said, is that there just aren’t enough neurologists to go around.
There is a shortage of general neurologists, but when it comes to subspecialist neurologists who are specially trained to deal with issues of aging, the situation is even worse. The United Council for Neurologic Subspecialties have developed a certification pathway for geriatric neurologists and more fellowships in dementia and geriatric neurology are being created, Dr. Sabbagh said, but it will take years for those efforts to produce more physicians trained to care for dementia patients. "There is a huge gap," he said.