How primary care physicians can catch dementia earlier

Dementia cases are climbing fast, and primary care physicians are increasingly the ones diagnosing and managing the condition — whether or not they set out to become dementia specialists. With the dementia population expected to nearly double in the coming decades and specialist wait times stretching for months in many regions, primary care physicians are often patients’ first, and only, point of contact for cognitive concerns. That raises practical questions: How can physicians spot cognitive decline before it progresses? What screening tools actually fit into a 15- to 20-minute visit? And how should a physician approach a conversation as sensitive as a dementia diagnosis?

Anna Chodos, MD, MPH, professor of medicine at the University of California, San Francisco, and executive director of Dementia Care Aware, has spent her career on these exact questions. Recent research suggests physicians may have a window of opportunity that spans years, even decades, before symptoms become obvious, making early recognition an increasingly urgent priority for primary care.

Medical Economics spoke with Chodos about this issue to learn more.

Medical Economics: We’re seeing a steady increase in dementia cases. What does that trend mean for primary care physicians in practical terms over the next five to 10 years?

Anna Chodos: We all know primary care is the foundation of our healthcare system. Everybody who feels truly cared for feels cared for by somebody who knows them well, and primary care really plays that role. We wish we had enough specialists — geriatricians, specialized neurologists, neuropsychologists — to support dementia care for every person who has it, but that’s not the reality. We’re not prepared at that level. So primary care is going to be essential for people who are starting to have symptoms of dementia, or who want to prevent it. It’s just too common a condition for primary care not to, unfortunately, really be the key point of contact.

Medical Economics: Why is early identification of cognitive decline so important for patient outcomes, even in the absence of a cure?

Chodos: I think this is a real shift. We used to think that once we find dementia, we find it — there’s no real reason to find it earlier. But now the evidence is stacked totally the other way. We know that the earlier we intervene with what our program, Dementia Care Aware, calls brain health activities, we can actually slow the progression. Right now we don’t have a treatment that can take dementia away from anybody who has it — many people, the train is on the tracks — but what we can do is slow down how fast that train is going. So instead of 10 years of living with dementia, it’s 20 years, and for the time you have it, you have much milder symptoms. That’s the goal of aggressive brain healthcare, and it ends up being more of a primary care activity, though it also spans public health and specialty care.

Medical Economics: Are there common early signs of cognitive impairment that might be missed in a routine primary care visit?

Chodos: Yes. We know that in general, people are diagnosed in later stages — moderate or severe stages of dementia — because when things are mild, it’s confusing for everyone: the person, the clinicians and the family, because it’s subtle and gradual. We should all give ourselves some grace that it’s genuinely harder to diagnose when it’s mild. The mild symptoms tend to be things the person didn’t have trouble with before that are now starting to interfere a little with regular functioning. The brain does a lot of things, so when symptoms of dementia — which is really global cognitive decline — start, they can show up in lots of areas: memory, language, behavior, motor function (like tremors), sleep, and the ability to organize and stay on top of things, which we call executive function. What I often tell colleagues, and people who are concerned about these symptoms, is: how big a change is this for you? I’m personally terrible with directions and don’t expect that to change, but some people have always been great with directions, or with names, and now they’re having trouble. Those are the subtle signs. We really start to think something’s abnormal when a symptom is quite severe — under no conditions would we expect somebody to have it — and when it’s noticeably getting worse over time.

Medical Economics: How can busy primary care physicians incorporate routine cognitive screening into annual wellness visits without overwhelming an already limited appointment time?

Chodos: That is such a great question, particularly for someone like me who used to do primary care and now does more specialty care. I always remind myself I’m most useful when I’m helping that primary care provider save time and get an evaluation done. Dementia is really, really important to pick up, but it’s not necessarily incredibly urgent, so you can break the process down. What we recommend for screening is brief tools — the MiniCog is one of the most popular. It asks the person to remember three words and draw a clock, so it’s quick. We also always add a quick functional check, since dementia, in essence, is abnormal cognitive decline severe enough to affect daily functioning. Dementia Care Aware has resources and links to some of the shorter tools out there. And if a patient is having trouble on the cognitive piece, or reporting functional difficulty, start a brain health plan right away — treating and supporting their brain no matter how long it takes to get to the next step in the workup, which is often a more involved conversation about symptoms, a physical exam, some labs, maybe a brain scan. Brain health is another way to give people the message that we’re supporting them and that we care about how their brain is doing.

Medical Economics: How does that conversation typically go when you make a first diagnosis and have to tell a patient they might have early dementia? Is there a lot of pushback?

Chodos: It’s obviously really scary — even for the clinician — to deliver what is, of course, bad news for most people. I’ve seen every possible reaction. For me, it’s really important to give the information clearly, so people have clarity and something to hang onto as they process and move forward. Honestly, a lot of people are unsurprised — they’ve noticed things going on, this has been a big fear or question for them. When I’m doing the evaluation, I often tell people what I’m looking for so they’re not surprised in the end. I start with the information I have and take them along with my thinking: you had these symptoms, we did this screening and saw some difficulty, we did some next steps in the workup, and here’s what we learned when we put that together. We call that dementia — it’s a clinical term that simply means we’re noticing abnormal cognitive decline that’s affecting day-to-day life. It doesn’t mean anything is different tomorrow from today. It does mean we now have to really focus on brain health, so this moves as slowly as possible, and that we plan for the future together so the patient has as much agency as possible. So many people get a diagnosis and don’t get a lot of support in that moment, so I want them to know I’m going to support them. I can’t take an eraser to the problem and make it go away, but there’s a way we can support them through it and make sure they do as well as they possibly can.

Medical Economics: For physicians looking for more resources on how to approach this and better understand the scope of the problem, what do you recommend?

Chodos: Our program, Dementia Care Aware, is focused on supporting clinicians who are at the front lines of this condition, giving them tools that are usable in busy primary care through training, education and available resources. I’d also point to local Alzheimer’s and dementia-focused community organizations, which are excellent at supporting people with dementia and their caregivers. I really advocate that physicians connect patients to those as soon as possible so they’re not alone — one of the surprising things about this condition, despite how common it is, is how alone people are in finding resources and finding their way. The Alzheimer’s Association is probably the biggest and best-resourced across the country and a great starting connection, and local organizations often have in-person meetings and more location-specific resources.

Medical Economics: Is there anything else you think primary care physicians need to know that we haven’t talked about?

Chodos: As we move forward addressing dementia — and we’re going to see more and more of it, on track to double by 2060 — a big message for us all to internalize is how much there is to do. This is a really active condition: working with caregivers and connecting them to resources, working on brain health, and treating things that help the brain even if they’re not specific to dementia, like hearing, vision, and making sure medications are tuned up so they’re not bogging the brain down. Making sure a patient is as socially, physically and cognitively active as possible — these are low-hanging fruit that don’t seem exciting but make a huge difference, and that’s what the evidence shows. I hope an action-oriented, supportive approach gives clinicians more to work with and a reason to look for dementia, so we can give people more time in their lives with a better brain.