Undetected cognitive impairment in primary care continues to be a nationwide problem, recent studies showed.
"Unrecognized cognitive impairment and dementia is a major problem in the U.S. and has consequences for patients, families, and the healthcare system," said Ambar Kulshreshtha, MD, PhD, of Emory University in Atlanta, who presented new research on the topic at the 2024 (AGS) scientific meeting.
"Delayed diagnosis of cognitive impairment and dementia means that patients are identified in later stages when their symptoms are worse, and they already have complications leading to hospitalizations and challenges with placement," Kulshreshtha pointed out.
"As a result of this, some of the resources and newer treatment options that could have potentially slowed the disease are not received," he added. "We lose a critical window when we could have helped the patient and their families with lifestyle intervention, aggressive control of risk factors, and medication management."
Federally Qualified Health Centers
At the 2024 AGS meeting, Kulshreshtha reviewed highlights from a cross-sectional study that assessed unrecognized cognitive impairment and dementia in five (FQHCs) in Indiana that were primary care clinics for low-income people. One in 12 people in the U.S. rely on FQHCs for care, Kulshreshtha said.
The group studied 204 patients ages 65 and older. Mean age was 70 years, 62.3% were women, and 52.9% were Black.
No study participant had a pre-existing diagnosis of mild cognitive impairment or dementia, a prescription for a cholinesterase inhibitor or memantine, serious mental illness, or permanent residence in a nursing facility. All had at least one health provider visit in the last 12 months and 3 years of available data.
Cardiovascular risk factors and conditions were highly prevalent in the cohort; 93% had hypertension, 52% had diabetes, 23% had heart disease, and 10% had a history of cerebrovascular disease.
After a comprehensive diagnostic assessment -- including structured patient and study partner interviews, medical record review, neurological examination, and neuropsychological testing -- a neurologist, geriatrician, and neuropsychologist produced one of three diagnoses: normal cognition, mild cognitive impairment, or dementia.
Unrecognized cognitive impairment and dementia were ubiquitous in FQHCs, Kulshreshtha said. "Overall, 62% of patients met criteria for mild cognitive impairment, 12% for dementia, and 26% had no cognitive impairment," he reported. In the subgroup of participants with dementia, 24% had cerebrovascular disease.
Overall, Black patients had higher odds of undetected mild cognitive impairment or dementia compared with white patients (OR 2.58, 95% CI 1.35-5.06, P=0.024), which persisted after adjusting for covariates.
The burden of dementia in the U.S. falls disproportionately on Black older adults, Kulshreshtha noted. Many prevalence studies suggest that Black older adults are to have Alzheimer's disease or related dementias as white older adults.
"Undetected cognitive impairment is also a problem for non-English speaking people, immigrants, and people living in remote geographic locations where access to healthcare is limited," he pointed out.
"There continues to be prevailing stigma and misinformation in communities, and primary care providers struggle with a lack of time, resources, and referral options," Kulshreshtha added. "Late diagnosis also puts an undue burden on caregivers when they have to cope with the financial challenges and advanced-care planning, as some patients have progressed to lacking decision-making capacity."
General Primary Care
The FQHC findings supported those of a recent study that examined the cognitive performance of adults in general primary care clinics in two U.S. cities.
In a 2023 paper published in the , Alex Federman, MD, MPH, of the Icahn School of Medicine at Mount Sinai in New York City, and colleagues evaluated 872 English-speaking adults ages 55 or older without known cognitive impairment.
Participants were recruited from primary care practices in New York City and Chicago. Their mean age was about 67 years, 44.7% were men, and 32.9% were Black.
Undiagnosed cognitive impairment was defined by age- and education-adjusted z-scores on the Montreal Cognitive Assessment (MoCA) compared with .
The researchers identified undiagnosed cognitive impairment in 20.8% of study participants. Impairment was mild in 10.5% and moderate-to-severe in 10.3%.
Rates of undiagnosed cognitive impairment of any severity were markedly higher for Black patients (26.8%) and Latinx patients (28.2%) than for white patients (6.9%).
Patients with depression were more than twice as likely as those without it to have moderate or severe cognitive impairment, Federman and colleagues added.
Several factors may be driving high rates of undiagnosed impairment. While advocacy groups like the call for routine cognitive screening, the practice remains controversial. The Centers for Medicare & Medicaid Services supports cognitive screening by including it in the but the U.S. Preventive Services Task Force for older adults without signs or symptoms of cognitive impairment.
In 2020, a working group of Alzheimer's researchers proposed a framework to refine cognitive evaluations and promote early diagnoses of mild cognitive impairment in primary care. The ongoing also is testing iPad assessments based on the NIH Toolbox in 45,000 primary care patients to in underserved communities.
Disclosures
Kulshreshtha reported no conflicts of interest.
Federman's work was supported by the National Institute on Aging. He reported no conflicts on interest.