Development and Validation of a Telehealth Strategy for Routine Detection of Cognitive Impairment in Primary Care: The MyCog Mobile Assessment

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PROJECT SUMMARY Our objective is to widely implement and evaluate a user-centered, scalable, telemedicine - linked strategy for the routine detection of cognitive decline during the Annual Wellness Visit. Cognitive impairment is most prevalent among adults 65 and older, yet less than half of cases are detected and/or diagnosed in primary care settings. It is now increasingly accepted that early detection is critically important to optimize care planning, sustained independence, management of chronic conditions and appropriate caregiver involvement. In 2011, Medicare initiated a covered, Annual Wellness Visit (AWV) that includes a cognitive assessment to detect impairment, Alzheimer’s disease and related dementias (ADRD). In April 2020, the Coronavirus Preparedness and Response Supplemental Appropriations Act allowed healthcare systems to conduct AWVs remotely via telemedicine to protect older patients at greater risk of adverse outcomes due to the coronavirus disease 2019 (COVID-19). The expansion of telemedicine as a viable means of healthcare deliver is likely to continue. While this presents new opportunities for case finding, implementation of AWVs in primary care, including how cognitive function is assessed, has been variable. Clinicians often rely on more basic, “paper”-based, interviewer- administered cognitive tests that may be less precise and more cumbersome to clinical workflow – affecting the fidelity of an early detection strategy. Further, many practices lack a clear protocol for referral when impairment is determined, and a process for family involvement and establishing care goals. Practical, sustainable, scalable strategies are urgently needed to help primary care providers routinely assess cognitive function as part of AWVs (or whenever a cognitive impairment is suspected), identify concerns and have a protocol for referrals and care management. Northwestern developed and continues to innovate the NIH Toolbox for the Assessment of Neurological and Behavioral Function®. Since 2017, our team has worked closely with primary care practices to develop a brief, technology-enabled, self-administered, EHR-linked cognitive assessment (MyCog) derived from the NIH Toolbox. We also devised a detailed protocol for its use and how results of a 5-7 minute test, can inform patient care. We now propose creating MyCog Mobile to enhance, validate and evaluate the feasibility of the administration of a brief cognitive assessment to detect MCI or AD delivered within an Annual Wellness visit conducted via telemedicine. Our primary aims are to: 1) Adapt the MyCog paradigm for use in telemedicine using patients’ own smartphones; 2). Validate MyCog Mobile in an existing, well-characterized and diverse cohort of adults ages 65-85; and 3). Evaluate the feasibility, acceptability, and fidelity of MyCog Mobile implementation in a primary care practice as preparation for future large-scale testing.