Steven Littlehale

It was Oct. 1, 1988. As I sat on the Healy Lawn at Georgetown University in Washington, D.C., I wrestled with complex emotions. I felt honored to be attending graduate school at Georgetown, deeply grateful to have access to the many resources our nation’s capital affords its residents, students and visitors.

President Ronald Reagan’s remarks at the university’s bicentennial convocation were filled with national pride, and so was I. But I felt an underlying ambivalence. Why? I was aware that the world leader speaking before me might have Alzheimer’s disease.

Rumors had been circulating about President Reagan’s mentation. The media reported instances of him being dazed and otherwise not “with it.” Words like “confusion” and “dementia” were used to describe our 40th president throughout both his terms of office.

 As a fledgling gerontologist, I identified the subtle yet toxic ageism in these comments. Fueled by our society’s disdain of getting old and perhaps our individual fear of losing our minds, public figures are cautiously viewed once they reach a certain age. 

We now know that Ronald Reagan did, in fact, have Alzheimer’s disease. The speculation was put to rest in 1994, long after his presidency, when Reagan himself wrote a poignant letter to the American people disclosing his diagnosis earlier that year. The debate then shifted to whether he had actually been exhibiting symptoms of dementia while occupying the White House.

Obviously, the significance of the president of the United States being cognitively impaired is very different from our confrontation with dementia in nursing homes. But I wonder if the same debate, stoked by emotions and our culture’s pervasive ageism, poses challenges for how we address cognitive impairment (CI) in our work.

We care for frail elders, many of whom come to us at, or near, end of life. Even patients who might return home after skilled nursing and rehab care often have dementia diagnoses or comorbidities that affect their cognition. Over the last year, I’ve stood up in front of thousands of you to talk about the Patient-Driven Payment Model and asked the question, “What proportion of your residents have CI?” But there’s a problem: Your answers directly conflict what you record on your MDS.

You generally tell me 60% to 80% of your residents have CI. Good news! The professional literature supports you. Depending upon the study, it’s reported that 44% to 67% of nursing home residents have CI. The most compelling evidence comes from the study reported in the journal Medical Care, which looked specifically at new SNF admissions (over 2 million of them) and reported that 44% of new admissions would qualify for the SLP CI add-on. Yet your five-day MDS assessments are much lower, reporting only 13.4% met the same criteria (PointRight, 2019).

So why the disconnect, and why must we resolve this now? Do we bring the same societal view on aging to our own work? Even as many of us commit our professional lives to the betterment of our nation’s elderly, does our love for our residents minimize our willingness to assess them as cognitively impaired?

I fervently believe that we both under-document and poorly assess cognition in our population. If you follow my blog, this shouldn’t surprise you; but now we must acknowledge the consequences that our past reimbursement system (RUGs) and existing Quality Measures have had on care delivery. 

Historically, CI care was not reimbursable in FFS Medicare — and how sad it is that we let that happen. For the many of you providing excellent care to those with CI, please don’t be deterred by this. Let’s bring our industry to your high level and meet the clinical imperative we all share. We have a new incentive to do so: Under PDPM, CI care is now a reimbursable value. 

However, reimbursement for CI care depends on the accuracy of completed assessments and the steps you take after assessing your residents. Who completes your BIMS or CPS? Do these staff members have the proper skill set to produce a reliable and valid assessment? How do you ensure this in your organization? Then, what happens after the assessment is completed? 

There are many free or low-cost non-pharmacological interventions that make a difference in CI care. What outcomes are you achieving for these residents, and how do those outcomes compare to others?

Overall, it is costly to care for people with CI, and now our Medicare FFS reimbursement acknowledges this. It’s more costly to you, and to our healthcare system, to ignore the unique needs of this population. It’s time to confront the negative stigmas of aging, and especially CI, to care for all our residents with respect and dignity. 

Steven Littlehale is a gerontological clinical nurse specialist, chief innovation officer at Zimmet Healthcare Services Group, and chief clinical officer emeritus at PointRight Inc.