Evaluation of PROMIS Cognitive Function Scores and Correlates in a Clinical Sample of Older Adults

Feasibility of Telephone-Based Cognitive Assessments and Healthcare Utilization in US Medicare-Enrolled Older Adults Following Emergency Department Discharge

BACKGROUND

Wider screening and assessment for Alzheimer's disease and other related dementias (ADRD) may increase access to supportive care, improve allocation of medical care, and foster the use of interventions that prevent or delay disease progression. Yet, the effect of diagnostic timing on clinical and utilization outcomes is poorly understood. Community-based settings such as a hospital emergency department (ED) may be an underrecognized opportunity to assess cognition and impacts on individuals and health systems. This study assessed the feasibility of recruiting older adults for telephone-based trials following presentation to the ED and administering telephone based cognitive assessments over the phone in this population.

METHODS

Medicare-enrolled individuals 65+ years of age (n = 160) presenting to the Oregon Health & Science University Emergency Department (Portland, Oregon) between May 2022 and February 2023 were recruited by telephone. Participants were administered the Telephone Interview for Cognitive Status (TICS) Assessment and the Patient Reported Outcomes Measurement Information System (PROMIS) Cognitive Measure Questions on Mental Clarity via telephone 1-12 weeks post-discharge to evaluate cognition. Electronic medical records (EMR) were reviewed for medical care utilization including primary care provider (PCP) visits, hospital admissions, and ED visits for the 3 years prior to ED presentation.

RESULTS

Twenty-six percent of eligible ED users contacted elected for study enrollment. The TICS Assessment score had a significant relationship with the three evaluated health care utilization measures (ED, PCP visits, or hospitalizations); the PROMIS Assessment had significant but weak correlations to ED and PCP visits.

CONCLUSIONS

Older adults 65+ years presenting to the ED are amenable to enroll in telephone-based cognition-focused trials and cognitive assessments can be carried out over the telephone in this population. The PROMIS Assessment may be a better cognition assessment tool when evaluating for cognition and care utilization in this population. In addition to the limits of the screening tools used in this study, a lack of a representative sample is a limitation of the study design. Future studies could use other validated cognitive assessment tools and utilize a study design with a recruitment strategy focused on obtaining a representative sample of older ED patients.

Patient reported outcomes and the real-world use of calcitonin gene-related peptide medications in migraine

OBJECTIVE

To assess patient reported outcomes of patients with migraine receiving preventative medications, and to compare patient reported outcomes and unplanned care of patients on calcitonin gene-related peptide inhibitors (CGRPi) with those on other preventative medications.

BACKGROUND

Patient reported outcome measures can be useful in conditions such as migraine with frequent disability. CGRPi are newer migraine preventative medications that can improve patients' quality of life.

METHODS

This was a retrospective cohort analysis of Patient Reported Outcomes Measurement Information System (PROMIS) data combined with administrative claims data from a large regional health plan for adult patients (≥18 years) with migraine who were on preventative medications from January 2019 to March 2022. PROMIS scores of patients on CGRPi were compared to scores of patients who switched from other preventative medications to CGRPi (pre vs. post), between patients adherent to CGRPi versus non-adherent, and changes in all-cause/migraine-related unplanned care (emergency department) use by the CGRPi cohort.

RESULTS

There were 1245 patients on other preventative medications (antiseizure [532/1245 (43%)], antidepressants [316/1245 (25%)], and beta-blockers [397/1245 (32%)]), 148 who were on CGRPi, and 112 who had switched from other preventative medications to CGRPi. The mean age was 44 years old, 88% were females, 50% were married, and 75% were on commercial insurance. Patients with migraine had higher T-scores in pain, fatigue, anxiety, and sleep disturbance than the general population. Patients on CGRPi had a statistically significant reduction in pain T-scores (60.4 [standard deviation (SD) 7.4] to 58.4 [SD 8.2], p = 0.003) post initiation of medications, especially those who switched from other preventative medications to CGRPi (61.4 [SD 6.9] to 58.7 [SD 8.3], p < 0.001). The pain T-score reduction occurred only among the adherent group. There was a lower proportion of patients with all-cause unplanned care among patients on CGRPi (43% [64/148] to 32% [47/148], p < 0.001), but the reduction in migraine-related unplanned care was not statistically significant (9% [14/148] to 6% [9/148], p = 0.197).

CONCLUSION

Our findings suggest that patients had an improvement in pain reduction scores after initiating CGRPi. PROMIS scores could provide important information about quality-of-life improvement for prescribers.

Perceived Cognitive Function and Glycemic Variability: Baseline Results From a Cognitive Rehabilitation Intervention

PURPOSE

The purpose of this study was to examine the association between glucose variability, diabetes self-management, and cognitive function in participants enrolled in a cognitive rehabilitation intervention for people with type 2 diabetes.

METHODS

Baseline data from the Memory, Attention, and Problem-Solving Skills for Diabetes randomized controlled trial (n = 95; mean age 65.6 years, SD 5.99; 59.3% female; 59% non-Hispanic White) were analyzed and included scores from the PROMIS Cognitive Function version 2, a measure of perceived cognitive function; glucose variability measurements from continuous glucose monitors; and scores on the Summary of Diabetes Self-Care Activities Survey.

RESULTS

Participants had higher levels of perceived cognitive dysfunction than the US average. Lower PROMIS scores were associated with higher levels of glucose variability. Better perceived cognitive health was related to better diabetes self-management. Glucose variability, measured by the coefficient of variation, was a significant predictor of perceived cognitive function.

CONCLUSIONS

Perceived cognitive function was associated with diabetes self-management and glucose variability. Understanding this association can support the development of interventions to mitigate effects associated with glucose variability and changes in cognitive function. Including measurements of perceived cognitive function in assessments has the potential to alert health care providers about the need for additional support in diabetes management and the possibility of cognitive impairment that may need further objective assessment.

Health system implementation of the PROMIS Cognitive Function Screener in the Medicare Annual Wellness Visit: framing as abilities versus concerns

BACKGROUND

Cognitive assessment is a required component of the Medicare Annual Wellness Visit (AWV). In this prospective study, we evaluated acceptability and usefulness of a patient-reported outcome measure (the PROMIS® Cognitive Function Screener, or PRO-CS) to screen for cognitive impairment during the AWV. We compared two versions of the PRO-CS: Abilities and Concerns.

METHODS

We developed PRO-CS Abilities and PRO-CS Concerns using items from the PROMIS Cognitive Function item banks. We partnered with a large health system in Pennsylvania to implement an electronic health record (EHR)-integrated version of the 4-item PRO-CS into their AWV workflow. PRO-CS Abilities was implemented in June 2022 and then replaced with PRO-CS Concerns in October 2022. We used EHR data to evaluate scores on Abilities versus Concerns and their association with patient characteristics. We gathered feedback from providers on experiences with the PRO-CS and conducted cognitive interviews with patients to evaluate their preferences for Abilities versus Concerns.

RESULTS

Between June 2022 and January 2023, 3,088 patients completed PRO-CS Abilities and 2,614 patients completed PRO-CS Concerns. Mean T-scores for Abilities (54.8) were slightly higher (indicating better cognition) than for Concerns (52.6). 10% of scores on Abilities and 13% of scores on Concerns indicated concern for cognitive impairment (T-score < 45). Both Abilities and Concerns were associated with clinical characteristics as hypothesized, with lower scores for patients with cognitive impairment diagnoses and those requiring assistance with instrumental activities of daily living. Abilities and Concerns had similar negative correlations with depression (r= -0.31 versus r= -0.33) and anxiety (r= -0.28 for both), while Abilities had a slightly stronger positive correlation with self-rated health (r = 0.34 versus r = 0.28). In interviews, providers commented that the PRO-CS could be useful to facilitate conversations about cognition, though several providers noted potential limitations of patient self-report. Feedback from patients indicated a preference for PRO-CS Concerns.

CONCLUSIONS

Our findings suggest potential utility of the PRO-CS for cognitive screening in the Medicare AWV. PRO-CS Abilities and Concerns had similar associations with patient clinical characteristics, but the Concerns version was more acceptable to patients.