Cognitive impairment is common in older adults and frequently goes undetected. Analysis of pooled data in BMJ Open put the rate of undetected dementia in the community at about 62%, and a Medicare claims analysis in the Journal of the Prevention of Alzheimer's Disease found that roughly only 8% of expected cases of mild cognitive impairment (MCI) were diagnosed.
Cognitive assessment is a required element of the Medicare Annual Wellness Visit (AWV), though in a 2025 national survey published in Alzheimer's & Dementia, of 80% of beneficiaries who reported having had an AWV, just 31% underwent formal cognitive testing as part of that appointment.
Low coverage of formal cognitive assessment across a patient panel can have knock-on effects elsewhere in care, since unmanaged cognitive impairment affects medication adherence, care plan engagement, and a patient's overall ability to participate in their own care. This article considers advancing structured dementia screening and assessment as a value-based initiative that improves the quality of care physicians can offer. Cognitive assessment tools supporting value-based care do so in several indirect ways, many of them captured in the literature.
Article Highlights
- About 62% of dementia in the community goes undetected, and roughly 8% of expected mild cognitive impairment cases in the Medicare population are diagnosed.
- Earlier detection opens specific actions: medication review, treatment of contributing conditions, delirium precautions, and care planning while the patient can take part.
- In a value-based model, the value of detection extends past accurate documentation of dementia for risk adjustment, since knowing a patient's cognitive status also shapes how a care team manages medications, chronic conditions, and follow-up.
Detection opens the window, care management realizes the benefit
Proactive assessment of cognitive function informs the type of care a patient needs, and a pathway connecting a positive result to medication review, chronic disease management, and caregiver support can improve quality of life for both the patient and their caregivers.
What detecting cognitive impairment earlier allows
Cognitive impairment in older adults has several possible causes. Neurodegenerative disease — namely Alzheimer's, frequently in combination with vascular or Lewy body changes — accounts for a majority of dementia in older adults, and in many patients an early change does reflect the beginning of that process. Other contributors are treatable and can be identified, following an abnormal cognitive screen, through a structured evaluation targeted towards modifiable contributors.
Depression, vitamin B12 deficiency, and thyroid dysfunction are common examples of treatable factors that can associate with or mimic cognitive impairment. In one study of 1,000 consecutive patients assessed at a memory clinic and reported in the Journal of Neurology, Neurosurgery and Psychiatry, depression was identified in 8%, thyroid disease in 4%, and B12 deficiency in 4% as conditions that could contribute to cognitive symptoms. The same study found a potentially reversible primary cause in 19% of all patients presenting with cognitive complaints.
| Risk factor | What the evidence shows | What earlier detection allows |
|---|---|---|
| Medication burden | An estimated 30% of older Americans use at least one strong anticholinergic medication each year, and medication-related adverse events are a common cause of hospitalization among older adults. In an outpatient cognitive impairment population reported in Frontiers in Medicine, 61% were taking at least one anticholinergic medication | Structured review of the whole list, including prescriptions, over-the-counter sleep aids, bladder and allergy medications, pain medications, and supplements, with each change tied to a functional goal |
| Obstructive sleep apnea | A meta-analysis in Sleep Medicine found obstructive sleep apnea in 39% of people with MCI, with an overall association between the two conditions | Referral for sleep testing and treatment |
| Hearing loss | The 2024 Lancet Commission places hearing loss among the largest modifiable risk factors at population level. In the ACHIEVE trial, a hearing intervention slowed 3-year cognitive decline by 48% in a high-risk subgroup | Hearing assessment and treatment, with the largest expected benefit in higher-risk patients |
| Delirium during acute illness | A meta-analysis in Age and Ageing found dementia associated with incident delirium in acute medical units | Delirium precautions put in place before an admission rather than during one |
| Avoidable hospitalization | A national analysis in the Journal of the American Geriatrics Society found 40.1% of hospitalizations among older adults with diagnosed dementia were for potentially preventable conditions | Adherence support and closer chronic disease management |
| Care planning with patient participation | In a cohort of 959,405 Medicare beneficiaries newly diagnosed with cognitive impairment, AWV receipt was associated with an 86% higher rate of first advance care planning use | Planning while the patient retains capacity to take part |
Anticholinergic and sedating medications can also accumulate across prescribers and over years and in combination, contribute to cognitive impairment. The evidence for cognitive improvement after anticholinergic reduction remains mixed and is still evolving, and the risk of dementia through deprescribing (R2D2) randomized trial is currently testing that question directly in primary care. In an individual patient, safely deprescribing medications that worsen attention, balance, sleep, and function can still change what a family is able to manage.
"In dementia care, deprescribing functions as active treatment, with a defined target, a monitoring plan, and a result the family can observe."
— Dr. Anthony Zizza, Chief Medical Officer, Element Care
Under the 2024 revised criteria from the Alzheimer's Association workgroup, Alzheimer's disease is defined biologically and staged along a combined clinical and biological continuum. Earlier detection of cognitive decline can also open up more opportunities for disease-modifying treatment in appropriate cases. The anti-amyloid therapies currently approved are indicated at the MCI and mild dementia stages in patients with confirmed amyloid pathology, which makes eligibility for that specific treatment option stage-dependent.
In the Care Ecosystem randomized trial, 780 patient and caregiver dyads were assigned either to a telephone and web-based dementia care management program delivered by a care navigator and a clinical team, or to usual care. Over 12 months, the program improved patient quality of life, reduced emergency department visits, and lowered caregiver depression and burden compared with usual care. A five-year extension in a subgroup with high caregiver burden sustained the quality of life and caregiver benefits.
Where the clinical case meets the value-based case
An organization carrying risk for a population is measured on risk adjustment accuracy, quality performance, and total cost of care. Cognitive status touches each of these through documentation and through the care that documentation enables.
Risk adjustment depends on conditions being identified and recorded consistently. A standardized assessment administered consistently at every site produces a comparable record across a population, which supports accurate condition capture. Interobserver variability during assessments produces unreliable data, which may not accurately reflect a patient's cognitive function.
Several quality measures rest on behaviors that cognition affects, medication adherence among them. Unrecognized impairment can contribute to missed doses and missed follow-up, so knowing a patient's cognitive status may change how a care team supports adherence.
Dementia is a payment condition in the CMS-HCC risk adjustment model, assigned across three severity categories that map from the specificity of the coded diagnosis. Risk scores are recalculated each year, so a condition counts toward the following year's score only when it is documented at an encounter within the calendar year and supported by evidence that it was evaluated or treated. A patient whose cognitive impairment is never identified and therefore cannot be documented highlights the first constraint on the coded record accuracy.
Repeatable assessment also supports measurement over time. A result that can be reproduced at intervals allows a care team to distinguish a transient or stable finding from a declining one in an individual patient, and allows an organization to track detection and trajectory at the population level.
What this looked like across a senior-focused organization
Claremedica is a value-based, full-risk Medicare Advantage primary care organization serving a culturally and linguistically diverse senior population across more than 35 sites in Florida. Patients are seen 7 to 10 times a year, often by the same care team over several years. The organization had been screening for cognitive impairment with the MMSE for more than two years, and root cause analysis of hospital admissions kept returning to cognition.
The clinical leadership set four requirements before evaluating alternatives: clinical validity first, then operational scalability across sites, compatibility with a linguistically diverse population, and direct integration with existing data infrastructure. Before rollout, the organization closed operations for an hour so that every staff member could attend a scientific presentation on what earlier detection makes possible.
Adoption reached over 95% on the first day, the highest of the ten go-lives in the organization's disease detection program. And over the first seven months, more than 34,000 assessments were completed, including repeat assessments to follow individual patients over time.
Dr. Gheewala, Claremedica's Chief Medical Officer, shared that Claremedica has more than doubled the prevalence of dementia identified compared with the previous tool, and over 90% of newly identified patients were at an early or mild stage. More than 80% of those patients had been with the organization for years and had already been assessed with the MMSE.
A positive assessment connects patients to clinical pathways covering medication review, chronic disease management, depression and mood screening, and social engagement. Average screening time fell from roughly 12 minutes with the MMSE to about 6 minutes, which across a caseload of 15 to 16 patients a day returns roughly 90 minutes per clinician to patient-facing care.
"Creyos hasn't just changed things for our patients and their caregivers. It has changed the way our primary care providers think about what is possible when it comes to managing cognitive decline, and that is how you achieve better outcomes."
— Dr. Nehal Gheewala, Chief Medical Officer, Claremedica
The organization is now tracking how earlier identification relates to falls, avoidable hospitalizations, and cost of care over the next 12 to 24 months.
Reviewed by Dr. Gonzalez-Lara, Scientific & Healthcare Research Communications Specialist at Creyos
Dr. Laura Gonzalez-Lara earned her PhD in Medical Biophysics at Western University and is passionate about science communication. Her research interests remain focused on clinically relevant work that can directly improve people's quality of life, a commitment to accessibility that took root early in her career as a Rehabilitation Engineer at the University of Michigan.