Systemic lupus erythematosus (SLE), commonly known as lupus, is an autoimmune disease where the immune system mistakenly attacks healthy tissues throughout the body. SLE is the most prevalent form of lupus, accounting for about 70% of lupus cases. Women, especially those between the ages of 15 and 44, are at higher risk, according to the Lupus Foundation of America.
Cognitive dysfunction, which many refer to as "brain fog" or "lupus fog,” is a prevalent issue in patients with SLE, affecting at least 38% of individuals (Rayes et al., 2018) and significantly impacting their quality of life and daily functioning.
Although cognitive testing is not commonly used by neurologists, rheumatologists, or other physicians in the management of lupus, it has demonstrated significant value. Recognizing the benefits of cognitive assessment in this population can lead to better early detection, accurate diagnosis, and effective management.
So, should neurologists and rheumatologists start implementing cognitive assessments as a routine part of care for patients with SLE?
In this article, we explore the opportunities to enhance care for SLE patients by measuring cognitive health throughout their treatment. We also provide practice guidance on reimbursement best practices that support the delivery of cognitive health services in the context of lupus care.
Understanding the prevalence of cognitive dysfunction in SLE is the first step to providing comprehensive care. The complexities of lupus extend beyond physical symptoms, which include pain, swelling, headaches, and more as listed by the Lupus Foundation of America. Cognitive dysfunction also plays a significant role in diminishing patients' quality of life, according to a paper in The Lancet Rheumatology.
Dr. Melanie Harrison likens the interplay of fatigue and cognitive dysfunction to the classic "chicken and egg" scenario. In an article for the Hospital for Special Surgery, she explains that "each symptom directly impacts the other and can wreak havoc upon the human body by forcing one to endure an ongoing cycle of confusion caused by exhaustion, which is caused by confusion, which is caused by exhaustion, and so on." This cyclical relationship creates a challenging situation for individuals to live with and poses significant diagnostic difficulties for physicians.
Additionally, Dr. Michael D. Lockshin has identified a range of cognitive symptoms that vary in quantity and severity. These symptoms include:
Cognitive issues can lead to a decrease in quality of life, creating a sense of insecurity and impacting an individual's overall well-being.
Identifying cognitive dysfunction in individuals with SLE presents several challenges:
These gaps underscore the need for comprehensive, precise, and multifaceted approaches to effectively detect cognitive dysfunction in SLE patients.
Emphasizing routine cognitive assessments and addressing cognitive impairment in SLE care can assist neurologists in providing whole-person, patient-centric care, ultimately leading to better health outcomes and improved quality of life for SLE patients.
Potential benefits of assessing cognition in SLE care include:
Incorporating routine cognitive assessment tools, such as Creyos Health, into the care of patients with SLE may be beneficial for addressing the cognitive challenges associated with the disease. The benefits extend beyond detection and diagnosis, as evidenced by improvements in cognitive function through various interventions:
Incorporating these strategies into routine care can significantly enhance the overall well-being and quality of life for patients with SLE. Cognitive assessments can assist in demonstrating that a particular patient's interventions are leading to improvements in cognition, or guide an adjustment in course to find the ideal mix of treatments.
Despite the profound impact of cognitive dysfunction in SLE, there is a substantial gap in the understanding of its etiology, clinical assessment, and management.
This lack of understanding stems from fragmented and disorganized literature, which hampers the ability to establish clear medical necessity for cognitive testing (Mizrachi et al., 2022; Lateef et al., 2012). Addressing this gap is crucial, not only for confident diagnosis and tailored treatment plans, but also for ensuring financial sustainability through value-based care and appropriate reimbursement.
To address this, neurologists and other physicians may consider the following criteria for determining the medical necessity of cognitive testing in SLE patients:
The high incidence of cognitive impairment in SLE patients necessitates systematic evaluation to:
Once a healthcare provider has identified that cognitive assessment can benefit a patient, the next step is to make sure the patient is administered an accurate assessment. This involves understanding what tools to use and how to tailor the evaluation to the patient’s unique needs.
Here, we review the key components of administering cognitive assessments and how to utilize advanced tools like Creyos Health to enhance the process.
A thorough cognitive assessment is essential for assessing various cognitive domains, such as memory, attention, executive function, and processing speed. Although quick screeners like the MoCA and MMSE are commonly used to detect severe impairment in SLE patients (Nantes et al., 2017), they do not assess specific cognitive domains, and may not detect subtle deficits and changes over time.
Referring to a neuropsychologist for an evaluation can obtain more detailed cognitive information, but wait times can be long, and full neuropsychological exams can take four to 12 hours—a time commitment that can be difficult for many SLE patients. The American College of Rheumatology recommends an assessment that takes less than one hour.
Computerized cognitive assessments, like those provided by Creyos, are an ideal middle ground. These evaluations provide a brief but detailed understanding of the specific cognitive challenges faced by patients with conditions like SLE. Upon re-testing, a physician can also track the efficacy of treatment and measure which cognitive domains improve with time, and which may benefit from further interventions (Ho et al., 2018).
Practical steps for delivering cognitive assessments include:
Based on the cognitive symptoms associated with SLE and the impacted brain regions, Creyos Health tasks such as Number Ladder (Visuospatial Working Memory), Odd One Out (Deductive Reasoning), Digit Span (Verbal Short Term Memory) can measure multiple domains typically impaired in SLE patients.
The tasks collectively cover a range of cognitive domains, including memory, reasoning, planning, and attention. Each selected task targets specific brain regions associated with cognitive functions. Brain abnormalities are present in many SLE patients, even when newly diagnosed (Petri et al., 2008).
Furthermore, these instruments have been rigorously validated through extensive research and case studies, ensuring their accuracy and reliability in detecting cognitive impairments.
By utilizing these validated tools, healthcare providers can trust that the assessments are both precise and meaningful, ultimately aiding in the effective diagnosis and management of cognitive dysfunction in SLE patients.
Neurology practices can benefit from using a combination of interviews, questionnaires, and performance-based cognitive tests that provide a comprehensive evaluation of an SLE patient’s health.
For example, self-report and informant-report questionnaires can assess factors like daily functioning and mental health comorbidities. The Patient Health Questionnaire (PHQ-9) is designed for assessing depression, which often co-occurs with cognitive impairment. The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE can help assess signs of subjective cognitive decline in older patients, while the Instrumental Activities of Daily Living (IADL) questionnaire measures functional impairments in everyday life. In Creyos Health, these questionnaires can be included in one seamless protocol alongside cognitive assessments.
Established protocols and guidelines can support neurologists in systematically evaluating cognitive function. These include using specific tests that are sensitive to the cognitive deficits commonly seen in SLE patients.
Protocols often involve:
Adhering to these standardized protocols ensures consistency and accuracy in the evaluation process, providing valuable insights for the diagnosis and management of cognitive dysfunction in SLE.
Effective management of systemic lupus erythematosus (SLE) necessitates not only initial cognitive assessments, but also regular monitoring to track the progression of cognitive impairment. This continuous evaluation is a crucial consideration for adapting treatment plans and ensuring comprehensive, patient-centric care (Raghunath et al., 2023).
By incorporating Creyos Health in these comprehensive evaluation and monitoring strategies, healthcare providers can better understand and address the cognitive challenges associated with SLE. Ultimately, this approach enhances patient care and outcomes by ensuring timely interventions, personalized treatment plans, and sustained support.
Proper documentation and adherence to best practices for reimbursement are critical for ensuring that healthcare practices remain financially sustainable while delivering exceptional patient care. Accurate coding not only facilitates appropriate reimbursement, but also supports comprehensive patient management by clearly identifying the primary and additional diagnoses involved.
The following ICD-10-CM codes and their appropriate sequencing should be considered to ensure coding accuracy and compliance:
By meticulously applying these ICD-10-CM codes, healthcare providers can ensure they capture the full spectrum of the patient's condition, facilitating accurate and justified claims. This practice supports the financial health of the organization while delivering patient-centric care that addresses both the systemic and cognitive aspects of SLE.
Given the high prevalence and significant impact of cognitive dysfunction in SLE, performing regular cognitive assessments is vital. Utilizing Creyos Health, these assessments provide data-driven insights into patients’ cognitive and mental health, enhancing the understanding, management, and treatment of cognitive symptoms in SLE patients.
Furthermore, proper documentation and adherence to best practices for reimbursement ensure that healthcare practices remain financially sustainable while delivering exceptional patient care. This comprehensive approach ultimately improves SLE patients' overall quality of life and clinical outcomes.