Undiagnosed Cognitive Issues Widespread in Federally Qualified Health Centers

Many older adults receiving care at federally qualified health centers (FQHCs) are living with undiagnosed cognitive issues, with African American patients facing a particularly high risk, according to new research published in JAMA Network Open.¹

The study was conducted across 5 FQHCs in Indianapolis, IN, between 2021 and 2023, focusing on adults 65 and older with no prior diagnosis of cognitive conditions. The results revealed that 3 quarters of participants had some form of memory or thinking problems, 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 issues, while 12.3% had more serious memory problems, such as dementia. Only 25.5% showed no signs of cognitive decline.

FQHCs are federally funded nonprofit clinics that provide primary care services to medically underserved communities, offering 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 significant gaps in the detection and care of older adults who rely on these clinics.

“Unrecognized cognitive impairment is detrimental in high-risk and socially vulnerable populations, especially those with multiple other chronic conditions,” the study authors said.¹ “Delaying diagnosis limits access to resources for treatment and care management services that enhance 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 stick to their treatments for other health issues, leading to worse health outcomes and placing more stress on caregivers. Although national guidelines currently don’t strongly recommend regular dementia screening, catching these problems early can make a big difference in improving patients’ health and well-being.

Clear racial differences were highlighted in this study, which included 53% African American participants and 44% White participants. African American participants were more than twice as likely as White participants to have either MCI or dementia. Specifically, 82.4% of African American patients in the study had undiagnosed memory or cognitive issues, compared with 64.4% of White participants. These disparities remained even after accounting for factors like age, gender, and education, pointing to a need for better care pathways and early detection systems for these patients.

“The differences in diagnoses by race are likely due to both a higher prevalence of dementia in this subgroup and a lack of embedded workflows that support detection and timely diagnosis among these patients owing to patient, physician, and health care factors that need to be addressed urgently,” the authors noted.

The research points to several reasons these cognitive issues 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 issues 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 could improve their quality of life.

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

These findings highlight the need for better memory screening tools and more support for patients and doctors to catch cognitive decline early. With more timely diagnosis, older adults could receive the care they need to manage their conditions, improving their health and overall 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/