Prevalence of Unrecognized Cognitive Impairment in Federally Qualified Health Centers

Published in the JAMA Network Open. Here is a link to the article.

Regenstrief Institute authors: Nicole Fowler, PhD, Arthur Owora, PhD, Malaz Boustani, M.D., MPH

Abstract

Importance: There is a need for early and equitable detection of cognitive impairment among older adults.

Objective: To examine the prevalence of unrecognized cognitive impairment among older adults receiving primary care from federally qualified health centers (FQHCs).

Design, setting, and participants: This cross-sectional study was conducted at 5 FQHCs providing primary care in Indianapolis, Indiana, between 2021 and 2023. Participants were adults aged 65 years and older, without a diagnosis of mild cognitive impairment (MCI), dementia, or severe mental illness. Data analysis was performed from September 2023 to April 2024.

Main outcomes and measures: The primary outcome was a diagnosis of dementia or MCI, as determined by an interdisciplinary clinical team using data from structured patient and study partner interviews, medical record reviews, and a detailed cognitive assessment, including neuropsychological testing. Differences between participants determined to have normal cognition, MCI, and dementia were assessed statistically using analysis of variance for continuous variables, χ2 or Fisher exact tests for categorical variables, or Fisher exact test alone when expected cell counts were 5 or less.

Results: A total of 844 eligible individuals were consecutively approached, 294 consented to participate, and 204 completed the study (mean [SD] age, 70.0 [5.1] years; 127 women [62.3%]). One hundred eight participants (52.9%) were African American, 5 (2.5%) were Hispanic, 199 (97.5%) were not Hispanic, and 90 (44.1%) were White. The mean (SD) duration of education was 13.1 (2.6) years, and the mean (SD) Area Deprivation Index score was 78.3 (19.9), indicating a high level of neighborhood disadvantage. In total, 127 patients (62.3%) met the diagnostic criteria for MCI, 25 (12.3%) had dementia, and 52 (25.5%) had no cognitive impairment. Compared with non-Hispanic White individuals and after adjusting for age, sex, and education level, African American individuals were more than twice as likely to have MCI or dementia (odds ratio, 2.73; 95% CI, 1.38-5.53; P = .02).

Conclusions and relevance: This cross-sectional study found that unrecognized cognitive impairment is ubiquitous among older adults from underrepresented, minoritized racial and ethnic groups and those who are socially vulnerable receiving primary care from FQHCs. To overcome the disparity in early detection of cognitive impairment, timely, equitable, scalable, and sustainable detection approaches need to be developed.

Authors:

Ambar Kulshreshtha ¹, Erik S Parker ², Nicole R Fowler ^{3 4 5 6}, Diana Summanwar ^{6 7}, Zina Ben Miled ^{5 6 8}, Arthur H Owora ⁹, James E Galvin ¹⁰, Malaz A Boustani ^{3 4 5 6}

Affiliations:

¹Department of Family and Preventive Medicine, Emory University, Atlanta, Georgia.

²Department of Epidemiology and Biostatistics, Indiana University School of Public Health, Bloomington.

³Department of Medicine, Indiana University School of Medicine, Indianapolis.

⁴Indiana University Center for Aging Research, Indianapolis.

⁵Regenstrief Institute, Inc, Indianapolis, Indiana.

⁶Center for Health Innovation and Implementation Science, Indiana University School of Medicine, Indianapolis.

⁷Department of Family Medicine, Indiana University School of Medicine, Indianapolis.

⁸Electrical and Computer Engineering, Indiana University-Purdue University, Indianapolis.

⁹Department of Pediatrics, Indiana University School of Medicine, Indianapolis.

¹⁰Comprehensive Center for Brain Health, Department of Neurology, University of Miami Miller School of Medicine, Boca Raton, Florida.