Health plans and risk-bearing providers have become remarkably good at finding care gaps. An overdue A1c. A missed blood pressure follow-up. A patient who has not completed colorectal cancer screening. These rarely depend on a clinician remembering to ask at the right moment. They are converted into measurable objects: denominators, registries, EHR prompts, outreach lists, care-management queues, and quality dashboards.
Cognition is the conspicuous exception.
Centers for Medicare & Medicaid Services (CMS) explicitly requires detection of cognitive impairment as part of both the initial and subsequent Medicare Annual Wellness Visit, and it covers a separate cognitive assessment and care planning service when impairment is detected. Yet in many organizations, cognition still lacks the infrastructure that surrounds other major chronic conditions. There is no consistent denominator, no panel-level visibility, no standardized outreach workflow, and no closed-loop escalation pathway.
The stakes are concrete, particularly in dual-eligible populations. Medicaid spends 22 times more on a person living with dementia than on an older adult without dementia, and people with Alzheimer's or other dementias have twice as many hospital stays per year as their peers. In dual-eligible members, where medical complexity, functional limitations, social needs, and caregiver strain already intersect, an undetected cognitive gap rarely stays isolated. It cascades into missed appointments, medication errors, avoidable emergency department use, falls, unstable chronic disease control, and premature institutionalization.
Why the historical rationale no longer holds
The reason cognition has been treated differently is largely historical. Dementia was framed as a downstream specialty problem, identified after a family member raised concern or after a fall forced the issue. The old objection was blunt: if detection didn't meaningfully change outcomes, why look earlier?
That rationale is weakening on three fronts.
First, a specialty-dependent model cannot scale. More than half of primary care physicians report there are not enough dementia care specialists in their communities, and the pipeline of geriatricians and behavioral neurologists is not catching up to demographic demand.
Second, early detection now opens treatment options that didn't previously exist. Disease-modifying therapy is not appropriate for every patient, and anti-amyloid treatments bring real considerations around eligibility, amyloid confirmation, safety, and shared decision-making. But their availability has changed what's at stake when impairment goes undetected. Anti-amyloid treatments are indicated for early symptomatic Alzheimer's disease, and a passive, crisis-driven model is poorly suited to identify patients in that window.
Third, even when medication is not the answer, detection still changes the care plan in ways that matter operationally: medication adherence, fall risk, caregiver burden, advance care planning, and the support a patient needs to execute any disease-specific protocol. It also opens a window for lifestyle interventions, including sleep, diet, and physical activity, where earlier action is generally believed to have greater impact. A patient with diabetes and undetected cognitive impairment may not be 'noncompliant.' They may be unable to follow through on the care plan as designed.
Cognition as a comorbidity, not a specialty problem
This is the central reframing. Cognition should be treated less like a specialty problem and more like a comorbidity. We do not wait for a cardiologist to discover hypertension. We do not wait for an endocrinologist to notice an overdue A1c. We do not treat colorectal cancer screening as an incidental finding. We build systems that identify risk, measure status, route the next step, and track whether the gap was closed. Cognitive impairment deserves the same operational discipline because it changes how every other condition is managed. It is a modifier of execution capacity across the entire panel.
Cognitive gap closure begins with a defined denominator and a standardized workflow. Defining who gets assessed will vary by organization, but the operating principle should not: stop relying exclusively on complaint-driven detection. CMS already permits brief cognitive assessment during the AWV and a separate billable assessment when impairment is detected. The policy framework exists; the operating discipline does not. Digital cognitive assessment platforms can convert informal observation into structured, repeatable data that care teams can act on. But a positive screen should not simply generate a note. It should trigger a pathway: medication review, evaluation for reversible contributors, depression and sleep assessment, caregiver engagement, home safety review, and referral when specialty evaluation is indicated. Like other gap-closure programs, closure rates should feed back into panel-level reporting alongside diabetes or hypertension performance.
The view from full-risk care
At Element Care, we provide comprehensive medical and social services to older adults, most of them dually eligible. From inside a PACE model, undetected cognitive impairment shows up as structural risk, not a missed diagnosis. It can undermine diabetes control, destabilize hypertension management, accelerate caregiver strain, and lead to institutionalization. Systematic detection lets our interdisciplinary team adjust the plan before the crisis. We can simplify medications, involve caregivers earlier, modify transportation and day-center supports, and tailor chronic disease management to the participant's actual cognitive capacity. Knowing where someone stands cognitively also informs how we time advance care planning conversations, who needs to be in the room for them, and how we document goals of care while a participant can still articulate them.
PACE makes the logic unusually visible because we hold full accountability for total cost and quality. But the same logic applies anywhere financial and clinical risk is shared. The industry already knows the mechanics of gap closure. The missing step is to apply that same discipline to cognition. Not every patient with cognitive impairment will qualify for or choose disease-modifying therapy. Many will not. But every patient deserves a care plan that reflects their cognitive capacity, and every risk-bearing organization needs to know when cognition is the hidden reason other care plans are failing.
We would never accept a model in which diabetes, hypertension, or cancer screening became visible only after a preventable crisis. We should not accept that model for cognition.
About the author
Anthony Zizza, M.D., is a Harvard-trained geriatrician with over a decade of experience leading clinical care for older adults across New England. As chief medical officer at Element Care PACE, he leads interdisciplinary teams serving more than 1,100 PACE participants and 1,850 Senior Care Options members across Essex County, the Merrimack Valley, and Greater Boston. He also serves as an advisory board member at Creyos, a digital cognitive assessment platform. Dr. Zizza previously held senior clinical leadership roles at Optum at Home, Landmark Health, and the PACE Program at Cambridge Health Alliance/Harvard Medical School. He is committed to advancing coordinated, value-based care for older adults so they can remain safely in their homes and communities.