Quick Test Helps Detect Dementia

A quick cognitive assessment tool helped improve
dementia-related care in primary care patients, a randomized controlled
trial showed.

Compared with standard care, the 5-Cog system tripled the odds that a
patient would receive a dementia-related intervention within 90 days
(18.5% vs 6.8%, P<0.001), reported Joe Verghese, MBBS, MS, of the Albert Einstein Medical College in the Bronx, New York, and co-authors.

The primary outcome was defined as one of five actions — a new
diagnosis of dementia or mild cognitive impairment; imaging, tests, or
prescriptions ordered; or a specialist referral — within 90 days. The
adjusted odds ratio (OR) for the primary outcome (OR 3.43, 95% CI
2.32–5.07) and its components were higher in the 5-Cog arm than the
control group.

“Dementia is often undiagnosed in primary care, and even when diagnosed, untreated,” Verghese and colleagues wrote in Nature Medicineopens in a new tab or window.
“The 5-Cog paradigm, a brief, culturally adept, cognitive detection
tool paired with a clinical decision support may reduce barriers to
improving dementia diagnosis and care.”

Primary care cognitive tests can be long or require specialized
personnel, Verghese and colleagues noted. Often, they don’t provide
guidance on the next steps if a patient has a normal or abnormal result,
they added.

“Many cognitive tests were developed in white populations,” the
researchers pointed out. “These tests, therefore, do not adequately
account for cultural differences or health inequity.”

For example, the Montreal Cognitive Assessment (MoCA) test cutoffs for detecting dementia
were established in mostly white populations and were too high in a
study of mostly Black or Hispanic people, they observed. Black and
Hispanic participants in the Health and Retirement Study had missed or delayed dementia diagnoses more frequently than white participants, they added.

The
5-Cog tool combines three metrics designed to test memory recall, the
connection between cognition and gait, and the ability to match symbols
and pictures. The tests are quick and not affected by reading levels or
ethnic or cultural differences among patients, Verghese and co-authors
said. They can be administered by non-physicians who can convey results
to a primary care provider.

In the clinical trial,
the 5-minute cognitive assessment was coupled with a decision tree
embedded in a patient’s electronic medical record (EMR). The researchers
enrolled 1,201 older adults who presented to one urban primary care
clinic in the Bronx with cognitive concerns from May 2019 to September
2022. All participants lived in zip codes designated as
socioeconomically disadvantaged neighborhoods.

Mean age of participants was about 73. Most (72%) were women and 94%
were Black, Hispanic, or Latino. About 40% did not graduate from high
school.

Overall, 599 participants were assigned to the 5-Cog group and 602 to
the control group. The control intervention was matched for time and
tester exposure. It included elements that did not overlap with the
5-Cog, like grip strength instead of gait assessments.

Dementia-care
actions occurred in 43.8% patients with positive 5-Cog results and 1.4%
with negative 5-Cog. New primary care diagnoses of mild cognitive
impairment (7.3% vs 0.8%) and dementia (3.5% vs 1.5%) were higher in the
5-Cog arm than the control group. Those in the 5-Cog group had more
laboratory tests (OR 7.64), imaging tests (OR 4.80), and specialist
referrals (OR 2.38) for cognitive indications than the control group
(all P<0.001). New prescriptions were rare in both groups (1.0% vs 0.3%).

Overall, 1,042 participants completed 12 months of follow-up. No
group differences in hospitalizations or emergency department
differences were seen over 12 months.

The study has several limitations, Verghese and colleagues
acknowledged. It was conducted at a single center and involved only
patients with memory concerns, not asymptomatic older adults.

“Following up on this clinical efficacy trial, we have begun a pragmatic cluster randomized trial
that will examine the clinical effectiveness of the 5-Cog paradigm,
including the critical aspect of integration of results with
recommendations for follow-up in the EMR, in 22 primary care clinics as
well as evaluate implementation issues and economic impact,” they wrote.