Recently, researchers created the 5-Cog tool, a non-education-biased, culturally sensitive, and simple five-minute cognitive evaluation tool linked with an electronic medical record (EMR)-embedded clinical decision tree. In a recent study published in Nature Medicine, researchers assess the efficacy of 5-Cog in enhancing dementia care activities for older primary care recipients with cognition problems.
Study: Non-literacy-biased, culturally fair cognitive detection tool in primary care patients with cognitive concerns: a randomized controlled trial. Image Credit: David Gyung / Shutterstock.com
Disparities in dementia care
Dementia is a prevalent global health condition that is often misdiagnosed and mistreated, particularly among older Black and Hispanic individuals. Additionally, researchers have often studied dementia care aspects in isolation, with inadequate data to determine which method may enhance dementia care in community centers facing health inequalities.
Barriers to cognitive detection in primary care settings include time-consuming and expensive methods, physician use, specialist equipment, and a lack of direction. Furthermore, many of the examinations used to diagnose dementia were initially developed for white individuals, thus disregarding cultural differences or health disparities. Cognitive detection with recommended follow-up activities and professional referrals could help eliminate these hurdles.
About the study
In the present single-blinded randomized clinical trial (RCT), researchers evaluate whether 5-Cog, combined with clinical decision assistance, may improve dementia diagnostic and treatment practices.
Individuals 65 years and older with cognitive issues seeking care at an urban primary care clinic in Bronx County, New York, who spoke Spanish or English were randomly allocated to the culturally sensitive 5-Cog paradigm or control group.
The study intervention included the PMIS, Motoric Cognitive Risk Syndrome (MCR) diagnosis, and Symbol-Match. Researchers excluded individuals with a history of dementia or moderate cognitive impairment (MCI), nursing home residents, and those with visual or hearing impairments.
The study’s primary objective was better dementia care activities, which included new MCI syndrome or dementia diagnosis and investigations, drugs, or specialist referrals for cognition-related reasons within 90 days.
The results were assessed using intention-to-treat principles, with odds ratios (ORs) obtained from multivariable logistic regression analysis. Sensitivity analyses were used to assess primary outcome data in subgroups based on gender, education, language, and ethnicity. A post-hoc study was also performed to compare the findings of individuals enrolled before and after the end of the coronavirus disease 2019 (COVID-19) pandemic.
Study findings
Of the 4,538 individuals initially identified, 1,258 were eligible for the study. Of these individuals, 1,201 were enrolled in the study between May 29, 2019, and September 15, 2022, 599 and 602 of whom were randomized to the intervention and control groups, respectively.
About 72% of study participants were women, 49% were Black, 56% were Hispanic or Latino, and 40% did not complete a high school education. All study participants resided in economically challenged areas.
Of the 63 individuals who identified with MCI or dementia, 89% were diagnosed on the appointment day, six after one month, and one after two months, as compared to 92% of controls on the visit day and one after one month.
The 5-CoG intervention was associated with a threefold increase in the likelihood of improving dementia care activities compared to the control group. Individual activities related to dementia care were significantly higher among intervention recipients, except for novel prescriptions.
Moreover, the 5-Cog cohort received more MCI or dementia diagnoses, laboratory tests, imaging reports, and referrals by specialists for cognitive reasons than controls, with ORs of 6.5, 7.6, 4.8, and 2.4, respectively.
Dementia care interventions were greater in the intervention group (19%) than in the controls (6.8%). Dementia care-related actions were observed in 44% of 5-Cog-positive individuals but only 1.4% of 5-Cog-negative study participants.
The 5-Cog group had a higher rate of incident primary care provider (PCP)- diagnosed dementia (3.5% compared to 1.5%) and MCI (7.3% compared to 0.8% of controls). New medical prescriptions were uncommon in both groups.
Over one year, no significant differences were observed between the groups in hospitalizations or emergency department visits. Moreover, the study participants did not report significant intervention-related adverse events. Similar results were observed for study participants before and after the suspension of the COVID-19 pandemic.
Conclusions
The 5-Cog tool was found to improve the diagnosis and care for individuals with cognitive issues. In fact, dementia care interventions improved three-fold in older primary care patients with cognition problems.
The 5-Cog tool addresses current implementation challenges and racial and ethnic disparities in the United States Preventive Task Force recommendations. This approach also accurately predicts primary outcomes in Black and Hispanic patients by gender, education level, and language. Importantly, this is an efficient tool that can be easily incorporated into clinical settings, particularly those in low-income communities with modest resources.
Journal reference:
- Verghese, J., Chalmer, R., Stimmel, M., et al. (2024). Non-literacy-biased, culturally fair cognitive detection tool in primary care patients with cognitive concerns: a randomized controlled trial. Nature Medicine. doi:10.1038/s41591-024-03012-8
