Cognitive impairment related to dementia is frequently under-diagnosed in primary care
settings despite the increasing rates of patient cognitive complaints and the
availability of numerous cognitive assessment tools. Missed detection delays treatment of
reversible conditions as well as provision of support services and critical planning.
This problem is more prevalent among older African-Americans and Hispanics than older
whites, and more common in rural than urban populations.
The investigators developed the 5-Cog brief cognitive assessment that is simple to use,
standardized, takes <5 minutes, does not require informants, and accounts for major
technical, cultural, and logistical barriers of current assessments. The investigators
are conducting a simple randomized clinical trial to examine the clinical efficacy of the
5-Cog paradigm (5-Cog brief cognitive assessment paired with a clinical decision-making
tool) to improve dementia care in 1,200 predominantly minority sample of older adults
with cognitive concerns presenting to a primary care clinic in the Bronx. Interim
analysis revealed that the 5-Cog paradigm resulted in an over 8-fold increase in new
cognitive impairment diagnoses and over 3-fold increase in improved dementia care actions
by primary care physicians compared to an active control arm. Following up on these very
promising results, the investigators propose a hybrid Type 1 effectiveness-implementation
design in real-world settings to adapt and test the effectiveness of the 5-Cog paradigm
to increase detection of cognitive impairment care in older adults presenting with
cognitive concerns.
The aim of the pragmatic cluster-randomized trial is to test the clinical effectiveness
of the 5-Cog paradigm in increasing cognitive impairment detection and improving dementia
care - ascertained via electronic medical record. Randomization will be at the clinic
level, and select 22 primary care practices; 6 in Bronx and 18 in urban and rural
Indiana. 300 participants per practice will be enrolled for a total of 6,600 older
patients with cognitive concerns. Results will also be examined in NIH designated health
disparity populations including underserved minority and socio-economically challenged
populations.
Outcomes are new cognitive impairment diagnoses (primary) and improved dementia care
(secondary) in the 90-day period following presentation of cognitive concern to the
primary care physician.
New cognitive impairment diagnoses (primary): New diagnosis of dementia or Mild
Cognitive Impairment by primary care physicians. For patients with a previous
diagnosis of Mild Cognitive Impairment in electronic medical record, only a new
diagnosis of dementia will be considered as an incident outcome.
Improved dementia care (secondary): Any of the following: 1. Tests ordered for
reversible causes of cognitive impairment as per published guidelines. 2. New
cognitive enhancing medication prescriptions or deprescribing anti-cholinergic. 3.
Referral for cognitive/dementia evaluation by specialists (Neurology, Geriatrics,
Psychiatry). 4. Referral to social worker or community-based organizations.
Implementation issues and cost-effectiveness of the 5-Cog paradigm will also be examined.
This proposed study focuses on scalable approaches to address the unmet need of early
detection of incident cognitive impairment, including in populations that experience
health disparities.