MCI or CRS, why the name of a decline of memory matters.

April 2013- References to Wellness Exam etc at end.

MCI is the latest medical diagnosis that had previously been called early stage Alzheimers, which was at one time called Senile Dementia.  The Initials stand for Mild Cognitive Impairment--I'll leave the interpretation of CRS for later.  There is a little known clause in the massive Affordable Care Act- or ACA, informally known as Obamacare  that will increase this diagnosis among the elderly- with unexamined adverse effects.

This change in our acceptance of medicaliazation of old age so far has gone unnoticed, as it is packaged in the form of more vibrant longer life, and better yet, that it will come at no cost at all, rather paid for by future efficiencies.  This is illustrated in memory decline, to some degree a universal that is as ubiquitous as diminution of  balance, height and strength.  It is something that societies have dealt with from the beginning of civilization, which always includes acceptance of of all aspects of aging-- ending with death.

This paper by the Alzheimers Association describes this requirement and their recommendations for the testing.  It included this paragraph that leads to the problem I explore:

These comments are supported by a number of studies showing that cognitive impairment is unrecognized in 27%–81% of affected patients in primary care.  

Now think about this for a second.  The ACA does not say that physicians may include assessment for cognitive impairment, but that they must if you choose to have the Annual Wellness Visit.   The political-cultural aspect of this is illustrated by the contrast with another part of this session.  The cognitive assessment is required, while discussion of end of life planing, because of the objections from the right, is optional.

Note in the paragraph above that the range of those who do not recognize such impairment is as high as 81%.  What this shows is there will be a large number of elderly people who are going about their lives, maybe even laughing about their memory decline, who will be told that this condition is nothing to joke about, rather a disease that must be monitored by physicians. (So severe according to a recent N.Y. Times article that there is a one in eight change of it becoming full Alzheimers within a single year)  One way of we oldsters dealing with this is making a parody out of this "medical condition"  describing it by the alternative name in my title, CRS which we laughingly say means, "Can't Remember Shit!"

When I first discovered this aspect of the Annual Wellness Visit I wrote this essay, that was both a personal reaction and a broader description of the fiscal consequences of this mandate and other aspects of the ACA.  It is important to clarify that my objection is not to gathering data about memory decline, which is a severe problem for the individual and for society, but rather that the procedure mandating this during the Medicare Annual Wellness Visit ignores principles of informed consent and damages the doctor patient relationship, most important to people worried over memory loss.

In the essay linked above I describe my experience with an Alzheimers research project at UCSD, where one of my criticisms is that they do not collect and analyze all of the data  from everyone who goes through their screening procedure. The key difference, one that is far from trivial, is that everyone, including myself, who availed himself of their mental tests made a personal decision to do so with full knowledge that they could get feedback that would be disturbing.  Let me be clear, those who volunteer for research on dementia have my admiration, along with those medical scientists who work in this area.

There is another important point that may have been obfuscated in my previous essay, which is there certainly are neurological diseases that cause severe memory loss.  While there is presently no cure, or even treatment to forestall the severe stages of the most common of these diseases, it is certainly feasible that such could be discovered.   I highlight normal decline of memory of aging, (the tail of the bell curve of this process being similar to the disease)  because there is a dearth of those who make this point, --who defend existing coping mechanisms that preserve well being of those elderly who choose it.  For those in the early stages of one of the degenerative irreversible neurological conditions, this could be only a temporary amelioration of the emotional effects of the disease, but this coping mechanism of trivialization or denial should be an option left open to the individual, rather than negated by government policy.

Let me be clear, there are doctors who form relationships with their patients where this cognitive assessment is just a part of what one physician described as the "art and science of medical care."  Advisor, confident, conduit to treatment to preserve life and health---this is the ideal relationship that does not need this law to perpetuate.  And the rare abrupt anomalous decline of cognition should certainly be referred for immediate follow up, as this overshadows the potential harm of this mandate for the vast majority of those with degenerative or normal decline of memory.

My position should not be confused with an earlier medical paternalism, where doctors withheld the truth about the severity of a patient's prognosis.  What I describe could be just as inexcusable, the physician imposing his/her diagnosis without the patient knowing that a condition is being evaluated. This simplistic one sentence mandate for an evolving, unreliable cognitive assessment with potential devastating emotional consequences must not be allowed to stand.

If the decision of public policy is to do otherwise, it should be only after open discussion, rather than remain unknown to the patient as is the current case of this mandated evaluation in the Medicare Annual Wellness Visit.
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References:

This MCI assessment is discussed in this article in The Journal of Family Practice,  Assessing for cognitive impairment is now mandated as part of the Medicare Annual Wellness Visit.   Finding this requirement in the actual text of the law is difficult but it can be located beginning on pp 1154 of the text.  that states,  "The Affordable Care Act stipulates that clinicians must assess individuals aged 65 and older for cognitive impairment as part of their annual wellness visit ."
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This was expanded for the article, Normal Aging or Disease-the Demarcation Fades in Sept. Oct. 2013 issue of The Humanist 
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This link is to required elements of the visit from the Medicare Service Bureau booklet:

Pg. 7. (pdf pagination adds 2)

Detection of any cognitive impairment that the beneficiary may have (includes the
assessment of a beneficiary’s cognitive function by direct observation, with due consideration of information obtained by way of patient reports or concerns raised by family members, friends, caretakers, or others);

In addition to the physician, this evaluation may be performed by:
Pg 3

A physician assistant, nurse practitioner, or clinical nurse specialist; or a medical professional (including a health educator, a registered dietitian or nutrition professional, or other licensed practitioner) or a team of such medical professionals, working under the direct supervision of a physician.

Pg 8
Medical records must document that a health professional provided, or provided and referred, all required elements of the AWV. You should use appropriate screening tools normally used in a routine physician’s practice.
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This short video produced by Medicare, explains the Annual Wellness Visit, with no mention of the cognitive evaluation that is done.
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A long personal story that relates tangentially to this essay
My Alzheimer's Screening, personal narrative and technical discussion
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This post mortem  study illustrates how MCI is in the center of continuum of normals and Alzheimers disease.  This is evidence that the three categories are billing codes rather than discrete medical conditions.

Persons with mild cognitive impairment were intermediate in terms of Braak stage and CERAD and NIA-Reagan neuropathologic criteria for AD compared to the other two groups. In multiple regression analyses, persons with mild cognitive impairment had intermediate levels of AD pathology from those without cognitive impairment and those with dementia 
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Mild cognitive impairment: historical development and summary of research

Is an extensive survey that ends with this:

Although clearly valuable as a research tool, it may be debated whether physicians in clinical practice should consider a diagnosis of MCI for individual patients. Because MCI is a heterogeneous entity comprising a variety of neuropathological and psychiatric disorders, and because dementia is not an inevitable outcome, the term may carry too little prognostic and diagnostic weight to legitimize its widespread use on a case-by-case basis. Furthermore, the lack of universally agreed upon criteria and the public's unfamiliarity with the concept could result in increasing uncertainty, anxiety, and misunderstanding

It goes on to suggest that the clinician rather give the relative prognosis based on the subsets of the MCI condition.  From reading this long survey with over a 150 references, the probability that a general practitioner, much less a para- professional,  has mastered the current state of this research is minimal.
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Report on frequency, mandated tests, and payment of annual wellness exam.
Elements of AWV:

Patient's medical history
Family history
List of patient's current physicians and other health care professionals
Height
Weight
Body mass index (or waist circumference)
Blood pressure
Other appropriate measurements based on medical history
Cognitive impairment screening
Depression screening
Functional ability and level of safety screening
Five- to 10-year schedule for preventive tests, immunizations and screenings
Lists of risk factors, including mental health or other previously identified mood disorders
Health education and referrals for preventive counseling services
Health education and referrals for promoting wellness (e.g. weight loss, physical activity, smoking cessation, fall prevention and nutrition)