Digitizing the Diagnostic Pathway for Dementia

Current Diagnostic Pathway

Neurodegenerative diseases are notoriously difficult to diagnose. The diagnostic process can be long, emotionally grueling, and financially draining, requiring visits to specialists, imaging, and multiple rounds of testing to confirm the diagnosis.

“Dementia is a clinical diagnosis. It's not based on technology. Cognitive impairment can be assessed using technology, but providers must have clinical history from a patient or family member to make a formal diagnosis,” began Artz.

According to the Mayo Clinic, a dementia diagnosis typically involves a neurological evaluation, brain imaging, laboratory tests, and a psychiatric evaluation.

The neurological evaluation assesses memory, language, visual perception, attention, problem-solving, movement, senses, balance, and reflexes. Essentially, this determines whether a problem exists. The other parts of the diagnosis rule out other conditions that could be causing the neurological impairment.

Available Neurologic Tests

Artz told LifeScienceIntelligence that the Mini-Cog is often used in the primary care setting to quickly — in five or six minutes — assess whether or not a memory problem exists. Artz shares that it is “a pencil and paper test where they ask the patient to draw a clock, ask them to remember three words, and give them a simple score. That test is just a kind of simple tool. It's a pencil–paper test used throughout the United States and has been used for many years for primary care. We don't use it in neurology because we think it's not sophisticated enough.”

Although it doesn’t diagnose dementia, it can be used to assist a provider in making a clinical diagnosis.

During the conversation, Artz mentioned other diagnostic tests such as the Saint Louis University Mental Status (SLUMS) Examination, a more extensive 20-minute-long test, and Montreal Cognitive Assessment, which requires the provider to undergo a one-hour certification.

Challenges in the Current Diagnostic Pathway

Despite the need for a comprehensive, multipronged approach to diagnosing dementia, the current diagnostic pathway presents many barriers to access to care and interruptions to workflow.

Imaging

For many, imaging and access to imaging present a significant barrier. Imaging may include CT, MRI, or PET scans, but Artz mentioned that brain imaging is not always helpful. He estimates that, nearly 99% of the time, brain imaging will not give a diagnosis. Instead, it will help rule out other conditions, such as a tumor that could contribute to memory issues.

“The Academy of Neurology still recommends brain imaging for assessments of patients, which makes it a little bit harder for clinicians because it adds another level of complexity and cost into the evaluation,” he commented.

According to GoodRx Health, the average cost of a brain MRI can range from $1,600–$8,400 depending on insurance, location, and type of MRI, among other things. With MRIs necessary for a dementia diagnosis, financial constraints could lead to delays in treatment.

In addition to the financial constraints associated with imaging, there are supply chain constraints. The medical imaging community has struggled with impending and ongoing shortages of supplies necessary to conduct accurate imaging.

The first of these constraints is a contrast dye shortage, which has prevented many radiologists from running CTs with contrast. Contrast can help identify issues more clearly, and without it, radiologists are left to rely on other diagnostic methods. Despite efforts to conserve dye, many healthcare facilities are still struggling.

An obvious solution may be to turn to other imaging methods, such as MRIs, but MRIs come with their own supply chain issues. Liquid helium shortages, which are required to keep MRI machines cool enough to function, have also threatened medical imaging and its providers.

Neurologist Shortage

In addition to cost and supply chain issues associated with imaging, the lack of available providers poses an additional barrier to dementia diagnosis. Like numerous other specialties, neurology is experiencing a notable provider shortage, preventing the field from keeping up with increased diagnostic demands as the world population ages.

“Primary care doctors could make the diagnosis if they knew enough how based on history and symptoms. But often, they don't feel comfortable, and that's why neurologists are overworked,” stated Artz.

Artz explained that during an annual wellness visit for patients older than 65, primary care providers would ask some questions focused on memory, cognition, and mood issues. By including a few more questions, a primary care provider could make the clinical diagnosis of dementia. Still, Artz finds that many are hesitant to provide a diagnosis beyond memory or cognitive disorders.

LifeScienceIntelligence asked Artz to explain why this hesitation exists. “Alzheimer's — or a dementia diagnosis — brings on a new level of issues. Providers don't want to misdiagnose somebody,” he responded. “I see patients who have a complaint of memory or cognitive issues from a primary care provider, just verifying that it seems real and that it’s significant enough to warrant potentially a diagnosis of dementia.”

Neurotrack

To minimize the burden on neurologists and primary care providers when diagnosing dementia, Neurotrack developed a digital cognitive assessment that could potentially replace the Mini-Cog. Artz notes that it is a three-minute digital assessment taken on an iPad. The instructions for the test are given at the beginning, and patients provide their responses on the iPad. “The computer picks up on whether patients make the correct answers over a few minutes, how many are correct, and how long it takes to make those decisions,” he explained.

“It gives providers a percentile score, saying whether the patient is abnormal or normal based on age and gender. The test is scientifically validated for people over the age of 30. It's over 90% sensitive and specific. This means if somebody has a cognitive memory problem, this test should be able to pick that up 90% of the time. Now, it does not diagnose the cause of the problem; it just says there is an impairment,” continued Artz.

Benefits of This Tool

Artz describes multiple benefits compared to traditional diagnostic tools — the most apparent being that this test is significantly shorter than other available tests. It takes about half of the time of the Mini-Cog and 15% of the time required for the SLUMs assessment.

In addition to saving time, he notes that this tool is more accessible for patients. “It's independent of race, ethnicity, and language ability because it's based on numbers and symbols, not words,” added Artz. Aside from a quick explanation of the instructions, little to no assistance would be required for most patients to complete the test.

Finally, because the tool is digital, it can be connected with electronic health records and minimize the need for paperwork.

Looking Ahead

Tools like Neurotrack’s digital cognitive tests may help reduce barriers in the diagnostic process for dementia. With the assistance of digital health tools, primary care providers may be less hesitant to diagnose dementia. A reduction in these barriers will allow for improved diagnostic rates, improved prognosis, and reduced healthcare spending.