Pervasive undiagnosed cognitive problems in federally qualified health centers

Many older adults receiving care at federally qualified health centers (FQHCs) live with undiagnosed cognitive problems, and African-American patients face an especially high risk, according to new research published in Open JAMA Network.¹

The study was conducted at 5 FQHCs in Indianapolis, IN between 2021 and 2023, focusing on adults age 65 and older without a prior diagnosis of cognitive conditions. The results revealed that 3-quarters of the participants had some type of memory or thinking problem, such as mild cognitive impairment (MCI) or dementia, that had never been diagnosed.

African-American participants were more than twice as likely as white participants to have MCI or dementia Image credit: Atthapon – stock.adobe.com

Of the 204 participants who completed the study, 62.3% were found to have mild cognitive problems, while 12.3% had more severe memory problems, such as dementia. Only 25.5% showed no signs of cognitive impairment.

FQHCs are federally funded nonprofit clinics that provide primary care services to medically underserved communities, providing care regardless of a patient’s ability to pay and using a sliding scale fee based on income.² This high rate of undiagnosed cases highlights important gaps in the detection and care of the elderly who depend on these clinics.

“Unrecognized cognitive impairment is detrimental in high-risk and socially vulnerable populations, particularly those with multiple other chronic conditions,” the study authors said.¹ “Delay in diagnosis limits access to resources for treatment and care management services that improve patients’ quality of life and increases the likelihood of poor outcomes such as polypharmacy, falls and abuse “.

The authors also stressed that undetected memory and thinking problems can make it harder for people to adhere to their treatments for other health problems, leading to worse health outcomes and putting more stress on caregivers. Although national guidelines do not currently strongly recommend regular screening for dementia, catching these problems early can make a big difference to improving patients’ health and well-being.

Clear racial differences were noted in this study, which included 53% African American and 44% white participants. African American participants were more than twice as likely as white participants to have MCI or dementia. Specifically, 82.4% of African-American patients in the study had undiagnosed memory or cognitive problems, compared to 64.4% of white participants. These disparities remained even after factors such as age, gender and education were taken into account, pointing to the need for better care pathways and early detection systems for these patients.

“Differences in diagnoses by race are likely due to both a higher prevalence of dementia in this subgroup and a lack of integrated workflows to support timely screening and diagnosis among these patients due to patient factors, the physician and healthcare that needs to be addressed urgently,” the authors noted.

Research points to several reasons why these cognitive problems go unnoticed in primary care. Many patients avoid discussing memory problems because of stigma, misconceptions, or other pressing health and social priorities. Meanwhile, providers often struggle to identify cognitive problems due to limited time and resources, insufficient training, and the need to manage multiple chronic conditions during appointments. These obstacles can delay or prevent diagnoses, leaving patients without access to care and support services that can improve their quality of life.

While the study offers important insights, the researchers also acknowledged limitations. As the data was collected from a single city, the results may not reflect the situation in other areas. However, the researchers worked to reduce bias by recruiting all eligible patients at each clinic, ensuring that the sample closely matched the general population served by the clinics.

These findings highlight the need for better memory screening tools and more support for patients and clinicians to detect cognitive decline early. With more timely diagnosis, older people could receive the care they need to manage their conditions, improving their overall health and quality of life.

References

1. Kulshreshtha A, Parker ES, Fowler NR, et al. Prevalence of unrecognized cognitive impairment in federally qualified health centers. JAMA Netw Open. 2024;7(10):e2440411. doi:10.1001/jamanetworkopen.2024.40411
2. Federally Qualified Health Center (FQHC). CMS. Accessed October 22, 2024. https://www.healthcare.gov/glossary/federally-qualified-health-center-fqhc/