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Older Adults are Open to Cognitive Assessment for Dementia in Primary Care But Obstacles Loom Large, a New Study Finds
A study reveals low clinician engagement in digital cognitive assessments for dementia in primary care, highlighting workflow and other barriers to early detection.
A large-scale implementation study of digital cognitive assessments for Alzheimer disease and related dementias (ADRD) in primary care found that clinicians completed screenings in only 11% of eligible patient encounters, despite relatively high patient acceptance rates, raising questions about the feasibility of widespread dementia screening in busy primary care settings.
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Researchers from Indiana University School of Medicine, Purdue University, and the Regenstreif Institute in Indianapolis, conducted the 12-month pragmatic clinical demonstration project across 7 primary care clinics, selected to represent suburban and urban locations and a racially and socioeconomically diverse sample of adults presenting to primary care. The study tested tablet-based cognitive assessments for adults aged 65 years and older. Of the 16,708 eligible encounters, clinicians declined to offer screening or deemed encounters out of scope 55% of the time, while patients declined only 22% of the time when approached.
The study addresses a critical gap in dementia care, the authors stressed, as more than half of older primary care patients who meet diagnostic criteria for Alzheimer disease and related dementias never receive a diagnosis,2 according to research cited in the study. Further, even though requirements built into the Medicare annual wellness visit include screening for and detection of cognitive impairment, studies show that less than one-third of older adults report having an assessment by a primary care clinician.3 With new monoclonal antibody therapies available for mild cognitive impairment and early-stage Alzheimer disease, early detection has become increasingly important, yet no standard workflows exist for cognitive screening in routine primary care, the authors wrote, underscoring the need for evaluation of pragmatic approaches for real-world use.
Corresponding and first author Nicole R Fowler, PhD, MHSA, of the Indiana University Center for Aging Research in Indianapolis, and colleagues selected the Linus Health Core Cognitive Evaluation through consultation with physicians, clinic staff, and patient advisors. The tablet-based assessment includes digital clock drawing, 3-word recall tasks, and a questionnaire about cognitive status. Scores range from 0-5, with 0-1 indicating cognitive impairment, 2-3 as borderline, and 4-5 showing no impairment.
Participating clinics developed customized workflows for implementing the assessment through structured planning sessions that determined when and how to administer it. The pragmatic design of the project gave participants the opportunity to refuse the digital assessment or to not finish if if started. Clinicians had the opportunity to decline offering the assessment at any encounter, Fowler et al explained.
FINDINGS
During all encounters for adults aged 65 and older, cognitive assessments were completed 11% of the time, lower than the authors had hypothesized, they said. The low rate of refusal to take the assessment (22%) suggests willingness to engage on the matter. In fact, Fowler and colleagues note this proportion is "lower than reported values from randomized controlled trials in primary care settings that require informed consent to undergo routine cognitive evaluation."
Clinician engagement fell well short of expectations, with more than half (55.3%) of physicians either declining to offer screening (19.5%) or following workflows that deemed encounters out of scope (35.7%). "There appears to have been tension between the potential benefits of early detection for patients and that of a primary care system that is unprepared for widespread implementation of cognitive assessments in routine workflows," Fowler and colleagues wrote.
Among the 1,722 unique participants who completed assessments, 44% scored as unimpaired, 37% as borderline, and 14% as impaired. An additional 6% produced inconclusive results. Patients with impaired or borderline results were significantly older, had fewer years of education, were less likely to be White, lived in neighborhoods with higher social deprivation, and had more medical comorbidities including hypertension, diabetes, and chronic kidney disease, according to the results.
Fowler and colleagues found significant variation in follow-up care within 90 days. Among patients with impaired scores, 36% received vitamin B12 testing, 36% had thyroid function tests, and 17% underwent brain imaging. Neurologists saw 12% of impaired patients, while 63% were referred to the Brain Health Navigator. However, only 2% of patients with impaired results received new Alzheimer disease or related dementia (ADRD) diagnoses and 5% received mild cognitive impairment diagnoses within 90 days.
The study's 14% rate of cognitive impairment slightly exceeds the estimated 11% prevalence of ADRD in the general population over age 65, though the researchers note this reflects screening results rather than confirmed diagnoses. The finding that 50% of screened patients showed borderline or impaired results suggests substantial undetected cognitive issues in the primary care population.
The researchers conclude that while digital cognitive assessments can be implemented in primary care and have utility for early detection, successful implementation requires additional resources and workflow adaptations beyond existing primary care infrastructure. Without embedded systematic changes, "clinician and patient demand for cognitive assessments will remain low," limiting early detection potential in the primary care setting where most older adults receive healthcare.
