Diagnosing early-stage dementia is often delayed by time constraints in primary care visits, a shortage of dementia specialists, and long waitlists. A program at the Medical University of South Carolina (MUSC) may offer a solution, according to a paper recently published in the Journal of Geriatric Psychiatry and Neurology.
The projected increase in dementia cases coupled with a shortage of specialists has created a pressing need for efficient referral pathways to improve access and early diagnosis for patients with suspected dementia.
Referral for neuropsychological evaluation is standard of care when the primary care provider cannot confidently address issues of cognitive dysfunction. Unfortunately, PCPs frequently report difficulty accessing dementia specialists, including neuropsychologists, and wait times are long. In addition, the typical neuropsychological evaluation often lasts for four or more hours and includes procedures, such as personality or intelligence testing, unrelated to the discovery of what’s attributable to normal aging vs. dementia.
To address this challenge, lead author Travis H. Turner, PhD, of WCG and MUSC and his team developed the Rapid Access Memory Program (RAMP) for patients 65 and older. They hoped to improve access to neuropsychological services when these patients visit MUSC primary care clinics with cognitive decline concerns.
RAMP provides abbreviated neurocognitive assessment, same-day patient feedback, and expedited reporting to referring providers; it is financially self-sufficient. The goal is to decrease wait times for patients seeking a formal assessment of memory and other cognitive concerns, and to appropriately triage neurology and other specialty services. It seeks to answer the question of what constitutes normal aging vs. early dementia.
How RAMP Works
In their paper, Turner and his colleagues describe the development of RAMP and clinical outcomes during its first three years.
They structured the clinic to collect relevant clinical history from patients and caregivers, assess neurocognitive functioning, determine cognitive status and probable etiology, and provide meaningful feedback and recommendations within a two-hour visit.
The neuropsychologist conducts neurocognitive testing with only the patient present to minimize distractions. They typically use the Repeatable Battery for Assessment of Neuropsychological Status (RBANS). Findings and recommendations for treatment or further work-up are quickly relayed to the referring PCP via the EHR.
Participation in RAMP led to a new diagnosis of cognitive impairment for most patients. The abbreviated evaluation format appeared sufficient to identify the suspected etiology of cognitive impairment in most cases, resulting in treatment recommendations that were highly specific and targeted to the needs of each patient.
Of the 160 patients seen, 30% received a dementia diagnosis and 50% received a diagnosis of mild cognitive impairment. Alzheimer’s disease was the most common suspected etiology. About a third received a new psychiatric diagnosis.
The most frequent recommendations:
- medication adjustments (e.g., initiating cholinesterase inhibitors, deprescribing anticholinergics);
- safety (e.g., driving); and
- specialist referrals.
Interestingly, 17% of those patients subsequently enrolled in research being conducted at MUSC. This wasn’t a goal of the program–merely a beneficial byproduct,
The results support feasibility and utility of RAMP for connecting older adults in primary care with neuropsychological services.
RAMP met its goal of providing timely and focused neuropsychological evaluation services to older adults who turned to their primary care physicians with concerns of cognitive decline. It reduced wait times for diagnostic assessment, directed appropriate interventions, and even facilitated research recruitment.
RAMP’s ability to address the challenges of diagnosing dementia holds promise for other healthcare organizations, the authors conclude. “We present this program as a framework that other institutions might adopt and modify in accordance with their needs.”
 Turner TH, Scott EP, Barlis K, Rodriguez-Porcel F, Sartori AC, Joseph J. The Rapid Access Memory Program for Addressing Concerns of Incipient Dementia in Academic Primary Care Settings. J Geriatr Psychiatry Neurol. 2023 Dec 29:8919887231225482. doi: 10.1177/08919887231225482. Epub ahead of print. PMID: 38156442.
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