Five-minute test leads to better care for people with dementia in the primary care setting

The underdiagnosis of dementia, especially among Black and Hispanic patients, is a long-standing challenge in medicine. A new study, published in Nature Medicine, finds that an easy five-minute assessment, paired with recommendations built into the electronic medical record system, led to a three-fold improvement in diagnosis and treatment for patients in a primary care setting compared to a control group.

The "5-Cog paradigm," which was developed by researchers at Albert Einstein College of Medicine and Montefiore Health System, dramatically enhances the diagnosis of mild cognitive impairment and dementia, and represents a new, better way to guide initial treatment.

"Dementia is often undiagnosed in primary care—and even when diagnosed, it often goes untreated," said Joe Verghese, M.B.B.S., the paper's senior author and developer of the 5-Cog paradigm. "Until now, most approaches to detecting cognitive impairment take a long time, are expensive, and require a neurologist. And since existing tests were developed in white populations, they don't account for cultural differences. We've tried to address these inadequacies with current tests, and the findings from our study show meaningful progress on all fronts."

Dr. Verghese is professor and director of the division of cognitive and motor aging in the Saul R. Korey Department of Neurology, the Judith and Burton P. Resnick Chair in Alzheimer's Disease Research, the Murray D. Gross Memorial Faculty Scholar in Gerontology, and director of the Jack and Pearl Resnick Gerontology Center at Einstein and director of the Montefiore Einstein Center for the Aging Brain. Emmeline Ayers, M.P.H., a principal staff scientist in the department of neurology, is last author on the paper.

Dr. Verghese's 5-Cog assessment involves a picture-based memory-impairment screening test, a short picture-based symbol match, and confirmation that a patient has cognitive complaints. Previous research has found that the image-based assessment effectively addresses testing disparities resulting from a person's preferred language, education level, and gender. Importantly, the assessment can be given by minimally trained non-physician personnel who can convey results to a primary care provider. The cognitive assessment is paired with recommendations to guide primary care physicians on next steps, including referral to a specialist.

The study involved 1,201 older Bronx-residing primary care patients (median age 72.8) with cognitive concerns. Ninety-four percent of patients were Black and/or Hispanic/Latino and all of them resided in ZIP codes designated as socioeconomically disadvantaged neighborhoods. The patients were randomly assigned either to the group receiving the 5-Cog approach (599 patients) or to a control group that was not tested.

Follow-up over the next 90 days showed that compared with the control group, those patients who had undergone 5-Cog paradigm were three times likelier to have benefited from "improved dementia care actions," including being diagnosed for new mild cognitive impairment or dementia, being referred to specialists, and receiving medications.

"We're hopeful that the findings from this study could promote changes in primary care practice so that more older people with mild cognitive impairment or dementia will benefit from getting diagnosed and treated for their conditions," Dr. Verghese said.

The Nature Medicine article is titled "Non-Literacy Biased, Culturally Fair Cognitive Detection Tool in Primary Care Patients with Cognitive Concerns: A Randomized Controlled Trial." In addition to Dr. Verghese and Ms. Ayers, the other Montefiore Einstein authors on the study are Rachel Chalmer, M.D., Marnina Stimmel, Ph.D., Erica Weiss, Ph.D., Jessica Zwerling, M.D., M.S., Rubina Malik, M.D., David Rasekh, B.S., Asif Ansari, M.D., Amy R. Ehrlich, M.D., and Cuiling Wang, Ph.D., as well as Roderick A. Corriveau, Ph.D., of the National Institutes of Health.