Primary Care Detection of Cognitive Impairment Leveraging Health and Consumer Technologies in Underserved Communities: The MyCog Trial

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We seek to renew our current award (UH3NS105562) as part of the Detect CID consortium and conduct a pragmatic trial to test the effectiveness + fidelity of our NIH Toolbox-derived paradigm to improve early detection and management of cognitive impairment/dementia in primary care settings serving health disparate patient populations. Early identification of cognitive impairment (CI), including Alzheimer’s disease (AD) and related dementias (ADRD), is a top public health priority. Yet in primary care settings that manage the health of the majority of community-dwelling older adults, less than half of patients with any CI are detected and/or diagnosed. Among community health centers that serve marginalized patients - by low socioeconomic status (SES), minority race or ethnicity - rates of detection may be far lower. This is of great concern, as Hispanic/Latino (H/L) and Black older adults are 1.5 to 2 times more likely to develop ADRD and to go undetected/undiagnosed compared to non-H/L Whites. Practical, scalable strategies are needed to help primary care practices better detect and manage CI, especially those caring for medically underserved, low SES communities. Since 2017, our team has been a member of the NINDS Detect CID Consortium; a network dedicated to improving clinical paradigms for early detection of CI and ADRD and its subsequent management in everyday clinical settings. Having developed the NIH Toolbox for Assessment of Neurological and Behavioral Function (Co-I: Gershon, MPI: Nowinski) and with expertise in health system re-design for patient-centered care (MPI: Wolf), we validated our own clinical paradigm, known as MyCog. This includes a brief, iPad-based, self- administered, electronic health record (EHR)-linked strategy to assess for CI during primary care visits when concerns are identified. In response to RFA-NS-22-009, we will partner with a national primary care provider (Oak Street Health) and conduct a 2-arm, clinic-randomized, pragmatic trial comparing MyCog to usual care. We will focus on populations experiencing CI/ADRD disparities: Black, H/L, and low SES older adults. Our specific aims are to: 1) test the effectiveness of the MyCog paradigm to improve early detection of CI and dementias among low SES, Black and Hispanic older adults; 2) investigate the presence of disparities in early detection of CI, its diagnosis, and rate of referrals by race and ethnicity; 3) determine the fidelity and reliability of MyCog and identify any patient, caregiver, clinician, and/or health system barriers to its optimal, sustained implementation; 4) assess the cost-effectiveness of the MyCog paradigm from a primary care perspective. Impact: Our findings will address known disparities and offer new evidence on a comprehensive, EHR-enabled, billable, scalable, primary care protocol for early detection of CI - informing future widespread dissemination.