What the Home Reveals: A Conversation on Earlier Dementia Detection with Heidi Schwarzwald, MD, MPH

Signify Health’s chief medical officer, Heidi Schwarzwald, MD, MPH, provides strategic leadership for Signify Health’s nationwide clinician network by championing clinical excellence in In-Home Health Evaluations (IHEs); shapes Signify Health’s clinical vision, overseeing quality and safety initiatives; and supports new product development. 

Recently, Dr. Schwarzwald authored a white paper on the innovative ways Signify Health is helping providers and health plans detect dementia earlier, supporting intervention and care planning. 

In, “Why the Home is an Ideal Setting for Dementia Detection and Care Planning,” Dr. Schwarzwald asserts that the home is often a more effective and revealing setting for identifying cognitive impairment. In the paper, she details recent developments in earlier detection and substantiates her findings with data collected from Signify Health’s national network of more than 11,000 licensed clinicians (composed of physicians, physician assistants and nurse practitioners). 

The paper is significant and timely with dementia being identified as a rising public health challenge. Currently, an estimated 6.7 million Americans aged 65 and older are affected. Alzheimer’s disease, the most common form of dementia, accounts for 60% to 80% of all cases¹.

Following the publication of her paper, we sat down with Dr. Schwarzwald to learn more.

We’ve long thought of the doctor’s office as the center of health care. What does it mean to rethink the home setting as one of the most important places for detecting cognitive decline? 

I think about a member I saw recently in his home. He is a retired lawyer and would go to his doctors appointments and pass cognitive testing pretty easily. With his level of education and focus on “getting a good score,” he did well. 

But in his home and with his spouse, I could start to see the subtle signs of decline. His conversation would drift a bit between past and present. He was forgetting dates, and while he packed his medication pill box weekly and managed to take them as prescribed, his wife was reminding him and ensuring he complied more then I think either of them were aware. These early changes may be missed in an office setting, but can be more readily seen in the home.

Families often dismiss early signs of cognitive decline as “just getting older.” What are some subtle changes that should prompt a closer look? 

This is actually a difficult question, but an important one. Some of the changes are normal aging, while others are indicators of more serious cognitive decline. For example, trouble finding a word or forgetting names can be normal. But when someone starts to become distracted mid-task, like making lunch or getting lost in places familiar to them, these can be signs that something more serious is going on.

Signify Health clinicians are trained to notice these potential warning signs in the home. Can you share what they may observe in a person’s home that they simply cannot see during an office visit?

Like the story of the retired lawyer, we can see changes in how well a person is able to keep a house clean and organized, we can see how well they know their medications. In the clinic, the member is often asked “do you take this medication?” It’s easy to say “yes.” But at home, they show us the bottles and we can see if they are taking them the correct way — there’s more insight when we’re sitting with them in the comfort of their living space. 

Your research highlights the role of stress and “stereotype threat” during cognitive testing. How can anxiety affect performance, and why does the home environment change that dynamic?

In a clinical setting, some people become very nervous. Additionally, staff may make subconscious assumptions, good or bad, about them. When we are in a member’s home, we are in the place where they feel most comfortable. We’re on their “turf.” That means they’re naturally more relaxed, they feel at home because they are at home. This allows them to do their very best on any cognitive test or task.

In your research, you compared and contrasted the results of the Mini-Cog^® with the digital cognitive screener. The findings demonstrated significantly improved identification rates compared with traditional approaches. What surprised you most about these findings?

The digital cognitive screener is much more objective in identifying some of the earliest changes in cognitive decline. It is looking for changes in processing speed and not just memory. This can be an earlier sign. We expected to detect more early cognitive changes, but I was surprised by the magnitude of the difference. The digital screener really helped open up new conversations.

Caregivers are often the first to notice that something isn’t quite right. What advice would you give caregivers who are worried about a parent, spouse or loved one but aren’t sure what to do next — or how to go about it? 

First, start the conversation, even though it can be very difficult. Individuals who are experiencing early cognitive decline may become very defensive, so it is important to approach the conversation directly but respectfully. Understanding their preferences and needs early on is important. Early discussions can help with care planning and provide caregivers the support they need when caring for their loved ones. Our clinicians in the home can help not only the member but also help family members access assistance that is available through their or their loved one’s health plan and primary care providers. It is a win for everyone when we understand what is important to someone and can plan accordingly.

A diagnosis can feel frightening, so it would make sense that a member would initially be defensive. But, it can also open doors to support. What happens after cognitive concerns are identified, and how can early action improve quality of life? 

While not original, it continues to hold true: if you (or a loved one) is diagnosed with mild cognitive impairment (or MCI), it is a great time to take action. Talk to your primary care provider about some of the medications available and if they make sense for you. Some have lots of side effects, so it is important to consider them. Make sure you have a trusted person who you check in with regularly and that your finances, estate planning and similar instructions are up to date. 

It is important for members to understand that not all MCI progresses to dementia, but if it does, you want your family to understand your wishes. Finally, if you smoke, get help to quit. If you consume alcohol, cut back or quit altogether. Add more vegetables to your diet and more movement to your day. Health plans often offer great programs to help you make these lifestyle changes and stick with them. Health plans can help you find the right care team to make decisions about your care plan. 

If you could change one misconception people have about dementia and cognitive decline, what would it be? 

The biggest misconception is that there is nothing that can be done about it. As we have said, there are changes you can make and even medications to talk with your doctors about. 

As rates of dementia continue to rise nationwide, what gives you hope about the future of detection, treatment and care? 

I have hope for the future because of early detection programs like those Signify Health incorporates into its In-Home Health Evaluations. People coming together to find out early about any cognitive changes and then are empowered to take action. There are great minds working on better treatment, and I think we will continue to see advances in that area. And we can all use the extra motivation to take better care of ourselves now.

1. Centers for Disease Control and Prevention. (n.d.). About Alzheimer’s disease and related dementias. Retrieved from https://www.cdc.gov/alzheimers-dementia/about