Using Cognitive Screening to Develop Referral Pathways between Audiologists, PCPs, and Neurologists
1. Audiologists who incorporate cognitive screening into their practices benefit from building referral pathways with Primary Care Providers (PCPs) and Neurologists to refer patients who require collaborative care.
2. Connecting with PCPs and Neurologists in the community and providing information about the benefits of cognitive screening, audiology practice protocols, and how collaboration could help shared patients and providers fosters a collaborative eco-system around cognitive health.
3. Establishing a protocol on when and how results for patients will be shared creates clear expectations, increases awareness of the AuD practice, and ensures shared baseline data for the patient.
4. Early detection of cognitive decline allows early intervention by care providers.
AudiologyOnline: Dr. Davis, how did you approach developing referral pathways in your community?
Dr. Davis: I reached out to the primary care providers who were already referring to me to let them know I started incorporating cognitive screening into my practice. I started the conversation by describing the link between hearing loss and cognitive decline, and that hearing loss is the #1 modifiable risk factor for the prevention of dementia1. Based on the Lancet Commissions’ findings, I feel that audiologists can partner with primary care to do early screening and intervention for patients. After presenting them with the reason for cognitive screenings in audiology, I asked how they prefer we handle the patients that perform below normed expectations. I received different answers depending on the practice. Some PCPs requested that I refer patients directly to the neurologist because that would be their next move and it would make it faster and easier for the patient. I contacted the recommended neurologists and we worked out a system where I use a co-morbidity screener to determine if there are other areas that need to be addressed by primary care before the patient is sent for a neurologic workup. If the patient does not have underlying conditions that contribute to low cognitive performance, a neurologist referral will be appropriate. The neurologists were also not testing patients’ hearing, so they appreciated the information on the connection between hearing loss and cognitive decline, and now they refer patients to me for audiological testing and interventions for hearing loss. Other PCPs in my community, like Dr. John Kim, preferred to receive the report and have the patient referred back to them.
If you do not have incoming primary care referrals, I suggest reaching out your patients’ physicians and call the office to explain the testing and results. There is an opportunity, which continues to be more widely recognized and invited by physicians, for audiology to partner in the holistic patient care through early identification and collaboration with the medical community and treatment of hearing loss for our patients.
AudiologyOnline: Dr. Kim, what were you using for cognitive screening before Dr. Davis approached you? Why were you interested in collaborating with Dr. Davis?
Dr. Kim: I was already using the MMSE as a cognitive screener in my practice. This test is good at detecting moderate to severe cognitive impairment, but it cannot detect early dementia or mild cognitive impairment (MCI).2 Even worse, the test is time consuming and could keep my nurse and the clinic room occupied for far too long. The Gold Standard is Neurocognitive testing by Neuropsychology. This test is very good for diagnosing MCI, but it is difficult to schedule here in Austin, with up to a 3 month wait, and a cost of $1000 for the patient. It’s also not necessary for every patient. When Dr. Davis shared the benefits of using Cognivue Thrive® with me--how it takes the ears out of the equation, it’s computerized, quick, doesn’t need to be administered by a staff member because it’s self-administered by the patient, and is sensitive enough to detect MCI--I was interested in learning more.
AudiologyOnline: Dr. Davis, when and what results do you share with other healthcare providers?
Dr. Davis: With patients’ permission, I send all results from hearing tests and cognitive screening to their doctor. It both ensures patients’ doctors have a full picture of their hearing health and also builds awareness of my practice. This alone has had a huge impact on the number of referrals I’m receiving. I find referring physicians appreciate that I’m an audiologist, but I’m approaching the patient holistically. I truly want to understand the underlying reasons for the patients’ performance on the Cognivue Thrive.
If a patient is not comfortable with me sending reports directly to their doctor, I send copies with them to share with their doctor at their next visit. It’s a great way to have the patient be an advocate for themselves and my practice.
AudiologyOnline: Dr. Davis, what is your protocol on when to refer a patient for further testing?
Dr. Davis: The patient completes a comorbidity screening at their first visit with me so I am aware of other conditions that may contribute to their score upfront.
If a patient has a low score on the Cognivue Thrive and untreated hearing loss, I have a conversation with them about increased cognitive load and how hard their brain is working to compensate for their hearing loss. Because we need good cognition to hear in background noise, I correlate their Cognivue Thrive score with their performance in the booth during speech in noise testing. I screen the patient again 60 days after we have treated their hearing loss by fitting them with hearing aids.
If the Cognivue Thrive score has not improved at the 60-day retest, we have a conversation about some of the other underlying conditions, which can be addressed with their PCP or a neurologist, that might be affecting their cognition. We re-visit the comorbidity list the patient completed earlier and discuss how these could be contributing to their results. I emphasize the importance of treating hearing loss, and also explain how hearing loss is just one component of healthy cognition and we need to have the PCP evaluate what else could be causing their performance to be lower than expected.
AudiologyOnline: Dr. Kim, how do you use the results sent to you by Dr. Davis?
Dr. Kim: If the Cognivue Thrive report shows impairment that is unimproved after correction of the patient’s hearing loss, I will then start a patient work-up that is more extensive and includes numerous other medical conditions that can affect cognition such as depression, sleep disturbance, infection (including neurosyphilis and urosepsis), and metabolic factors like thyroid disorders, vitamin B12 and thiamine deficiencies. Based on what I find, I’ll develop a treatment plan for the patient. An MRI of the brain can also be useful to detect the presence of intracranial microvascular changes that would prompt aggressive atherosclerotic disease risk factor modification. The patient may require evaluation by a Neurologist, who will often refer the patient for neuropsychiatric testing and possibly initiation of pharmaceutical treatment options.
Partnership between my medical practice and Dr. Davis’ audiology practice, particularly regarding the sharing of the Cognivue Thrive report, the comorbidity screener, and information on hearing interventions, facilitates collaboration in the patients’ care.
AudiologyOnline: Dr. Davis and Dr. Kim, what are the benefits of early detection of cognitive decline to patients and care providers?
Dr. Davis: I believe that early detection is so important. From a hearing loss standpoint, the sooner we can get started with amplification, the better, particularly since the evidence shows that patients often experience hearing loss for 10 years before getting hearing aids.3 Patients who treat their hearing loss sooner have a much higher satisfaction rate and can adjust to new technology faster than those who wait to treat their hearing loss. With the addition of cognitive screening, we have the ability to find the patients who are excellent candidates for technology (those who pass the Cognivue) and also determine who may have waited too long and will need extra care when adjusting to new devices (those who do not pass the Cognivue Thrive).
Dr. Kim: Unfortunately, dementia is too often finally detected after a patient has had significant cognitive decline. Cognivue Thrive helps detect loss of function at an earlier stage, which allows for earlier intervention. For example, in vascular dementia, early aggressive management of atherosclerotic disease risk factors can potentially slow the patient’s loss of function. As new treatment options for cognitive decline become available, having a screening that detects MCI will be even more important. Early detection also provides patients and their families more time to prepare for the upcoming life changes.
Where to Learn More:
To learn more about developing interdisciplinary referral relationships, register for a live virtual CEU course on February 25.
To learn more in a 5-star rated course with Dr. Jill Davis, watch Enhancing Audiologic Care Through Cognitive Screening.
For more information on Cognivue Thrive please visit the AudiologyOnline Partner Page
- Breton A, Casey D, Arnaoutoglou N. (2019) Cognitive tests for the detection of mild cognitive impairment (MCI), the prodromal stage of dementia: meta-analysis of diagnostic accuracy studies. Int J Geriatr Psych 34:233–242.