Sharon A. Brangman, MD:
I wear 2 hats because I provide primary care, but I also serve as a specialist for geriatric patients as Director of a Center of Excellence for Alzheimer's Disease.

When I speak to primary care practitioners in my area, I emphasize that they should not ignore any patient’s complaints about memory problems or reflexively dismiss them as normal age-related experiences, but take them seriously and investigate. There are differences between normal cognitive aging and mild Alzheimer’s disease (AD), and it is important to identify early signs of dementia, so a patient can be identified as early as possible and we have the greatest opportunity to guide them and avoid a crisis. Whether primary care practitioners can do the evaluation or feel they do not have the ability and prefer to refer patients to a specialist, the main thing is to take those concerns seriously. A good referral base is very valuable, but neurologists are also under strain with staffing shortages and high patient loads, so wait times can be a consideration. You might proceed differently knowing that the patient could have a several-month wait for a visit to a specialist, rather than being seen in 2 weeks.

Sharon A. Brangman, MD:
The other reality is that most primary care practitioners operate within practice windows of 15 minutes for existing patients or 30 minutes for new patients, which is not much time to cover multiple aspects of a patient’s health. For example, in a primary care visit, a particular patient may need to discuss diabetes, chronic pain, immunizations, and even advance care directives for older patients; there is not much time left to discuss brain health. Our health system does not do well with the management of multiple complex diseases. We are always running behind schedule, and it is just not practical to expect to have these conversations in small aliquots of time, especially if patients bring family members to their appointments. In particular, geriatric patients have many chronic health issues simultaneously, so we may be managing chronic diseases such as heart failure and diabetes and chronic obstructive pulmonary disease in a single patient and then attempting to also address memory loss, all within a limited amount of time. We can design a workup procedure with detailed steps to use when patients report cognitive symptoms, but it still may be a challenge to incorporate this into a busy office schedule.

Anton P. Porsteinsson, MD:
Some HCPs make a point to cover a few basic concepts regarding brain health within the short time that they have. It is most difficult to fit this topic in at the end of a visit after covering many other medical problems, which is typically when questions about memory come up, and there is no way to provide the attention required in those last few minutes. I see 3 general patterns in primary care practitioners’ responses to memory complaints from patients: Some normalize or minimize the issue to end the conversation; some automatically refer patients to a memory clinic such as mine for any symptoms indicating a potential memory disorder; and some do try to carve out more time in follow-up and perform basic cognitive assessment. 

Sharon A. Brangman, MD:
The reality is that in primary care, conversations about prevention or even dementia management are not reimbursable. We use time-based reimbursement, and additional reimbursement is only possible for performance of procedures. We can be reimbursed for discussions about advance directives such as Medical Orders for Life-Sustaining Treatment (MOLST), but conversations that are needed to discuss dementia management are not covered and add to the length of an office visit. Any time spent on phone conversations with family members is also not covered, so if a family member calls with questions about symptoms or medication dosing, we are not reimbursed for that time.

Anton P. Porsteinsson, MD:
Billing in the primary care setting is different than in a specialty clinic such as mine. We have the option of billing based on the complexity of a case, but that requires documenting quite extensively and carries the potential of an audit either by payers or by your own institution. For primary care practitioners, billing simply based on time is the only practical option for this purpose. You just see so many patients in a day.

Sharon A. Brangman, MD:
It is difficult because of the large number of problems and standards we have to meet for quality evaluations. Every disease specialty has a standard, and in primary care, we cover a lot of disease areas. In terms of prevention, we need to talk to patients about mammograms, colonoscopy, and immunizations, for example. Cognitive screening is currently not included as a mandated quality indicator. The US Preventive Services Task Force does not recommend regular cognitive screening because there is currently no cost benefit to performing it, so we are not penalized for omitting it in the same way we are penalized if we do not order routine screening such as a mammogram or colonoscopy.¹ However, at my clinic, we perform routine cognitive screening because we believe it is a best practice and I recommend that other primary care practitioners do the same. An easy way is to incorporate it into the Medicare Annual Wellness visits or similar routine clinical visits, and to include a basic cognitive assessment such as the Mini–Mental State Examination or Mini-Cog to complete when a patient is being placed in an exam room.² Medical assistants can be trained to conduct these screenings and incorporate brain heath questions into basic health interviews. This way we have basic information in the patient record, which allows subtle longitudinal change to be detected. 

Sharon A. Brangman, MD:
For a patient who gives us cause for concern based on the initial cognitive assessment, I would recommend speaking with the patient about a referral to an appropriate memory clinic. Depending on primary HCPs’ comfort level, they could perform some basic workup, such as ordering an MRI to look for any structural abnormalities and laboratory testing to exclude treatable causes, including measurements of vitamin B₁₂ and folate levels, thyroid function tests, a comprehensive metabolic panel, and a complete blood cell count.³ There are a number of treatable conditions that can cause cognitive changes, so it is important to do a workup to exclude those first. This also reduces the work for the dementia specialist, because the specialist will already have these results at the first referral visit without having to spend time ordering these assessments and delaying a full evaluation until the next patient visit. 

Sharon A. Brangman, MD:
I am an atypical HCP because if I see a patient with cognitive complaints, I have the ability to follow that up within my center. In community primary care, a more frequent response to a patient who reports memory loss is to begin treatment with an acetylcholinesterase inhibitor such as donepezil and refer the patient to a geriatrician. The geriatrician then has to evaluate and decide whether donepezil was a sensible choice for that patient.⁴ Another pattern is that a primary care practitioner may order biomarker testing for AD pathology even based on mild memory complaints, when there may be a 6-month wait to see a specialist who can interpret those biomarker test results. This creates unnecessary duress for the patient during that time, because the testing has been ordered without conducting primary investigations and without consideration of how the results would potentially affect patient care.

Anton P. Porsteinsson, MD:
I believe Dr Brangman and I agree that today, biomarker testing for AD pathology should be done as part of a complete cognitive workup, not performed in isolation.⁵ We may someday recommend this testing as standard screening based on age, but the field is not at that point currently.

Sharon A. Brangman, MD:
Today, we do not have enough data to know whether the increased risk of dementia associated with amyloid pathology is sufficiently predictive of actual progression to the dementia stage for any individual patient.⁶ There are some patients who demonstrate this pathology but never evolve into dementia, so we do not know whether this will ultimately be useful as a preventive diagnostic test. We also have to consider what the next step would be for patients with amyloid pathology, within our current base of knowledge. Would you start using an antiamyloid therapy? I do not believe we have enough data yet to make an informed decision about the use of antiamyloid agents in preclinical AD, especially based on blood biomarkers. 

Anton P. Porsteinsson, MD:
Currently, 3 β-amyloid positron emission tomography (PET) ligands and 3 cerebrospinal fluid (CSF) assays have been approved by the FDA for use as AD diagnostic tests.⁶

Sharon A. Brangman, MD:
We have to consider the regulatory status and testing resources. Although blood-based diagnostics for AD pathology are available in many parts of the United States, they have not been approved for use by the New York State Department of Health. If they are put into widespread use, substantial capital investment will be needed for testing at that scale. Many bureaucratic and infrastructure issues would arise and need to be resolved to support this potential integration into practice. 

Anton P. Porsteinsson, MD:
Clinical trials are investigating the potential preventive use of antiamyloid therapies in patients with amyloid pathology before development of clinical symptoms (TRAILBLAZER-AD [NCT05026866] and AHEAD-45 [NCT04468659]), so it is an area of future interest. The Primary Care Collaborative Memory Clinics (also known as MINT clinics) in Canada have trialed integration of biomarker testing into regular primary practice, and a recent Swedish study found improved AD diagnostic accuracy using blood-based biomarkers in primary care.⁷ However, I would not recommend this practice for the regular primary care setting. 

Anton P. Porsteinsson, MD:
When I speak to primary care practitioners, I find they are very interested in learning about brain health from my perspective as a memory specialist, both in regard to providing patient care and from their own personal perspectives. Dementia and cognitive decline are so widespread that we are all concerned about our own futures, not to mention our experiences with family members. However, there is a schism between their level of interest and their ability to bring this knowledge to their patients, and this is really because of the limited time available, as Dr Brangman has said. Most people go to their primary care practitioner when they have health-related questions, so having the education to answer these questions in broad themes—essentially to know a little bit about everything—is very much in the purview of primary care. Yet within our current system, primary care time is such a precious commodity. It is critical to maintain good specialist lists for referral when an issue requires more attention, in terms of not only the specialist’s greater body of knowledge but also their greater ability to take the time in investigation. 

Anton P. Porsteinsson, MD:
Many of the modifiable risk factors are solidly in the primary care corner. Cholesterol, diabetes, smoking, physical inactivity, hypertension, obesity, alcohol use, and to some degree hearing and visual loss: These are issues that are managed in the primary care office for the vast majority of people. Even for patients who see specialists to treat a particular concern, the primary care practitioner oversees the fragmented specialty care as part of the patient’s overall health. Brain health can be a valuable motivation factor from this angle as well. If patients are not diligent with following recommendations for their elevated cholesterol, hypertension, diabetes, etc, you may bring up preserving brain health and preventing dementia as part of your case for the importance of these concerns.⁸

Sharon A. Brangman, MD:
Our medical care is divided into organ specialties, but our body does not recognize these boundaries. It sees everything as a single functioning human body. Discussions with patients about the impact of their lifestyle and behaviors typically fall under the general care of a person to optimize their health, not within a particular specialty. Many of the same things that keep your kidneys healthy, keep your heart healthy, keep your brain healthy, and keep you healthy overall. So these conversations can be very efficient and effective in providing multiple health benefits from a few common threads, but the healthcare system does not really recognize the things we do that are not reimbursable procedures. That is one of the unfortunate challenges in primary care, so we work the best we can within the system that we have. 

Sharon A. Brangman, MD:
Some patients are resistant to discussions about brain health, which is understandable because the thought of discovering a memory problem and potential early signs of dementia can be very scary. These can be tricky situations, because as the HCP you want to provide the best care, but you need to maintain a working relationship with the patient to do so. Some patients do not have the insight into their own observed decline or they minimize their complaints, so that it is often a family member who actually brings the issue up. In those cases, I usually suggest that the family member keep an eye on the patient. Do not cause more stress by forcing the patient to go for evaluation immediately, because the patient will be resistant and probably not follow through, but do continue to pay close attention, because any ongoing issues will be revealed as they worsen with time. Having a corroborator, whether that be a family member or someone else in close contact with the patient, is ideal to help you obtain an objective history, because patients may not even be aware of situations in which their cognitive changes can be seen.

Anton P. Porsteinsson, MD:
The challenge in primary care is how to manage patients who refuse the referrals. There are many reasons that might underlie these refusals. Commonly, people do not have insight into their limitations: They forget that they forget. Other patients have noticed some changes and are afraid of what investigation might find, so they decide to ignore the symptoms and prefer not to know anything further; we often see denial as a coping mechanism. Finally, there are those who recognize their cognitive changes but normalize them—they think this is just a part of getting old and that everyone experiences something similar.

At the memory clinic, most of the patients we see are at least somewhat willing to come. They may minimize their symptoms or a family member may be the primary driver in seeking care, but we do not usually have patients in our clinic who say they do not want to be here or do not see the need to be here. We encourage patients to bring someone along to their visits, and most patients do come accompanied by a family member or professional caregiver. Patients with no symptoms or very mild disease often come alone.

In a primary care setting, it is much more common that family members do not mention cognitive problems, because they do not want to feel like or be seen by the patient as a snitch. They know that bringing up this topic may be very upsetting to the patient and they may be afraid that the patient will lash out or that there will be some domestic repercussions. What often happens is that a family member will call the office to provide some information privately or request that the HCP be the one to broach the topic with the patient at the next visit. When I prepare to see a new patient, I may see a note in the primary care record documenting a phone call from a spouse or child who has a concern but has not been successful addressing it with the patient. These situations are not easy for HCPs, but sometimes we can be seen as more neutral parties so patients are more willing to engage with us. 

Sharon A. Brangman, MD:
We make it a habit in our office to separate the caregiver and the patient at some point during the visit, perhaps when the patient is being brought to the examination room, having blood pressure checked, or having a memory assessment, so that we have an opportunity to speak to the family member without the patient being present. This can help the family member to speak freely without feeling intimidated. It takes a bit more planning and workflow organization because we are using 2 exam rooms, but it is very useful and we can get information in a more efficient manner when the caregiver is talking freely.

Anton P. Porsteinsson, MD:
We, too, try to speak with the visit partner separately if possible. Sometimes patients may not allow it because they are uncomfortable having a family member speaking about them outside of their knowledge, which we have to respect, but most of the time, we are able to see the family member separately in some way.

Sharon A. Brangman, MD:
Many patients say, “I'm only here because my daughter made me come,” or “I’m just here to keep my wife happy.” They do not believe they have any problem and they blame the perception of cognitive decline on someone else. That is fine—we can work with that. We try to de-emphasize using the terms “dementia” or “Alzheimer's”; we try to keep them comfortable by simply saying, “You may have a memory problem and we are going to look into that.” It is very helpful, in any way that you can, to maintain the patient's confidence and maintain that patient relationship. We do not have to beat someone over the head with the dementia diagnosis in our conversations, because the most important thing is that the patient continues to come to us to get the care that will be needed. 

Sharon A. Brangman, MD:
We have the opportunity to talk to the adult children of our patients with dementia about their own brain health. Family members often bring up concerns about their own futures to their parents’ HCPs because they want to know what they can do to avoid the cognitive decline they are seeing firsthand. They want to discuss familial risk factors and consider genetic testing for themselves. These patients are at a life stage when interventions can have a substantial impact on modifiable risk factors and we can provide actionable recommendations that can reduce their risk of future cognitive decline. We can bring brain health as a topic for discussion into clinical practice just as we do with cardiovascular health and other systems that are part of overall health, but these conversations can have an especially strong impact when they arise in relevance to someone’s immediate experiences.

Anton P. Porsteinsson, MD:
As a final point, I encourage primary care practitioners to normalize asking patients about their thinking and memory as part of regular clinical assessments, especially after age 65. HCPs ask all kinds of sensitive and intrusive questions, but if the questioning is established as part of a routine, that makes it somehow less awkward for both the HCP and the patient. We can say, “These are standard questions. We're just making sure to cover everything.” Building cognitive and memory concerns into overall healthcare can go a long way toward overcoming stigma and improving our patients’ well-being. Brain health is an important component of health.

Sharon A. Brangman, MD:
To dovetail on that point, we should be careful not to minimize or disregard any patient’s complaint of a memory problem. Do not say, “What do you expect at your age?” There is a continuum between normal cognitive aging and signs that might indicate mild cognitive impairment or early AD, and it can be tricky to establish where someone is on that continuum. We need to take the time to investigate to be confident that we are helping our patients as best we can.