Dementia Among U.S. Primary Care Patients Ages 55 Years and Older without Previously Diagnosed Cognitive Impairment

Dementia Among U.S. Primary Care Patients Ages 55 Years and Older without Previously Diagnosed Cognitive Impairment | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Dementia Among U.S. Primary Care Patients Ages 55 Years and Older without Previously Diagnosed Cognitive Impairment Alex Federman, Jacqueline Becker, Lili Chan, Laura Curtis, Juan Wisnivesky This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8663638/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 15 You are reading this latest preprint version Abstract BACKGROUND Estimates of the prevalence of unrecognized dementia are needed to gauge the potential impact of routine dementia screening. METHODS Adults ages ≥ 55 years without dementia or mild cognitive impairment diagnoses were recruited from primary care practices in New York City, NY and Chicago, IL (n = 853). Dementia was defined as significant cognitive impairment, as indicated by score > 1.5 standard deviations below age and education adjusted norms on the Montreal Cognitive Assessment, with impairment in one or more of 7 instrumental activities of daily living (IADL). RESULTS Mean age was 67.3 years. Moderate-severe cognitive impairment was observed in 10.3% and impairment in ≥ 1 IADL in 44.8%. Estimated undiagnosed dementia prevalence was 6.2% (95% CI 4.5% to 7.7%) overall and 5.9% (95% CI 3.9% to 9.0%) among participants ages ≥ 65. CONCLUSIONS Routine screening in primary care would identify substantial numbers of individuals with previously undiagnosed dementia. undiagnosed dementia Montreal Cognitive Assessment daily functioning primary care older adults Introduction In 2020, the United States Preventive Services Task Force issued a grade of “I” for dementia screening in older adults, indicating insufficient evidence for benefit. 1 However, with increasing numbers of persons with dementia across the U.S., 2 the advent of new and effective treatments for Alzheimer’s dementia, 3 and greater availability of resources and strategies for prevention and support of people living with dementia and their caregivers, 3,4 the tide may turn in favor of screening in coming years. 5 Many health systems will likely need to expand resources to support dementia care in order to implement routine dementia screening 6 , 7 and would benefit from estimates of undiagnosed dementia prevalence to gauge the potential impact of routine dementia screening and guide their planning. While prior research provides evidence indicating that dementia is under detected in clinical settings, 7–9 few studies have estimated rates of undiagnosed dementia in primary care, where screening would most likely occur. 10 To address this gap, we estimated rates of undiagnosed dementia in primary care practices in the U.S. using data from a cognitive screening assessment and an assessment of daily functioning. Methods Subjects and Settings English speaking adults ages 55 years and older without a diagnosis of dementia or mild cognitive impairment were recruited from 4 primary care practices in New York City, NY that serve predominantly minoritized patient populations, including two hospital-based teaching practices and two multi-provider faculty practices and one hospital-based teaching practice in Chicago, IL. Potentially eligible patients were identified by medical record review and a random selection was then mailed a letter describing the study. Letters were followed by a telephone call for eligibility screening. White and Black male patients were oversampled to achieve balanced representation by sex and race. After obtaining informed consent, research coordinators administered a 30-minute interview in clinical exam rooms either before or after their visit with a primary care provider. All study procedures were approved by a single Institutional Review Board of record at the Icahn School of Medicine at Mount Sinai in accordance with the Declaration of Helsinki. Measuring Cognitive Impairment and Daily Functioning We defined dementia as cognitive impairment resulting in impairment of daily functioning. Cognitive performance was assessed with the Montreal Cognitive Assessment (MoCA). 11 – 14 The 12-item MoCA measures visuospatial/executive functioning, naming, memory, attention, language, delayed recall, and orientation. Scores range from 0 to 30. We converted raw scores to age and education adjusted z-scores; values falling below 1.0 and 1.5 standard deviation (SD) of the mean for normative data were defined as mild impairment and moderate to severe impairment, respectively. 12 , 15 – 17 Research coordinators were trained to administer the MoCA and were supervised for quality assurance by a licensed neuropsychologist (JB). Daily functioning was assessed by self-report. The instrumental activities of daily living (IADL) questionnaire included ability to use a telephone, shop, prepare food, perform housekeeping chores, do laundry, use public transportation, self-manage medications and handle finances. Responses for each item were categorized as fully independent, needs assistance or fully dependent. We operationalized dementia as moderate to severe cognitive impairment and needing assistance with or fully dependent for one or more IADL. Other Measures Other data collected during the interview included age, education, race and ethnicity, English language proficiency (ELP), country of birth, and depression. To determine ELP, participants were asked to rate their ability to speak and understand English from very poor to excellent on a 6-point Likert scale. Low ELP was defined as very poor, poor or fair. Country of birth was dichotomized as U.S. or U.S. territory-born vs. other. Depression was assessed with the Patient Health Questionnaire-8 (PHQ-8). 18 Depression was defined as score ≥ 10. The full survey is included in the appendix. Analysis We report estimated rates of undiagnosed dementia with 95% confidence intervals, as well as impairments in IADLs stratified by cognitive performance (normal or mild impairment vs. moderate to severe impairment). We conducted a multivariable logistic regression analysis of the association of participant characteristics with dementia, adjusting for age, sex, race and ethnicity, ELP and depression. All analyses were conducted in SAS, version 9.4 (SAS Institute, Cary, N.C.). Results Recruitment and Participant Characteristics Phone outreach was attempted for 3,815 persons, 2,894 (75.9%) were contacted, 1,737 (60.0%) declined participation, 208 (7.2%) did not speak English, 949 (32.8%) agreed to participation, 872 (30.1%) completed the interview and 853 (29.5%) had complete MoCA and IADL data. The mean age of participants in the analytic sample was 67.3 (8.0) years, 47.3% were male, 32.9% were Black and 26.3% were Hispanic and 61.3% had a college level or higher education (Table 1 ). Table 1 Participant Demographics (N = 853) Age, mean (sd) 67.3 (8.0) years Male 47.3% Race Black, non-Hispanic 32.9% White, non-Hispanic 32.8% Hispanic 26.3% Other 8.0% Education <12 years 15.7% High school graduate 23.0% Any college 40.1% Graduate school 21.2% Foreign born 24.1% Low English language proficiency 5.8% Depression 16.3% ≥ 1 IADL impairment 44.8% Estimated Rates of Previously Undiagnosed Dementia Moderate to severe cognitive impairment was present in 10.3%. For IADLs, 44.8% (95% confidence interval [CI] 41.5% to 48.1%) of participants reported needing assistance with one or more activity and 24.4% (95% CI 21.5% to 27.2%) were fully dependent in one or more activity. Undiagnosed dementia was observed in 6.2% (95% CI 4.5% to 7.7%) of subjects. A similar rate was observed for the subgroup of persons ages 65 years and older (5.9%, 95% CI 3.9% to 9.0%). Common Functional Impairments The IADLs for which patients most commonly needed assistance or were dependent were shopping (27.4%), housekeeping (30.8%) and food preparation (20.1%) (Table 2 ). The rates of co-occurring moderate or severe cognitive impairment and impairment for these IADLs were 4.1%, 4.1% and 3.0%, respectively. Table 2 Rates of IADL Impairments Stratified by Cognitive Function (N = 853) Cognition Instrumental Activities of Daily Living All Patients N (%) Normal or Mild Impairment N (%) Moderate-Severe Impairment N (%) Telephone Any impairment 45 (5.2) 36 (4.1) 9 (1.0) Fully dependent 2 (0.2) 2 (0.3) 0 Shopping Any impairment 238 (27.4) 202 (23.2) 36 (4.1) Fully dependent 26 (3.0) 20 (2.3) 6 (0.7) Food preparation Any impairment 175 (20.1) 149 (17.2) 26 (3.0) Fully dependent 62 (7.1) 51 (5.9) 11 (1.3) Housekeeping Any impairment 267 (30.8) 232 (26.7) 35 (4.1) Fully dependent 102 (11.7) 84 (9.7) 18 (2.1) Laundry Any impairment 203 (23.4) 173 (19.9) 30 (3.5) Fully dependent 133 (15.3) 114 (13.1) 19 (2.2) Transportation Any impairment 218 (24.1) 187 (21.6) 31 (3.6) Fully dependent 122 (14.1) 104 (12.0) 18 (2.1) Medication organization Any impairment 49 (5.6) 39 (4.5) 10 (1.2) Fully dependent 6 (0.7) 4 (0.5) 2 (0.2) Managing finances Any impairment 83 (9.6) 70 (8.1) 13 (1.5) Fully dependent 10 (1.2) 9 (1.0) 1 (0.1) Any impairment for ≥ 1 IADL 386 (44.8) 333 (38.7) 53 (6.2) Fully dependent for ≥ 1 IADL 210 (24.4) 182 (21.1) 28 (3.3) IADL, instrumental activities of daily living. Note rounding errors for some percent values in the All Patients column. Among persons with previously undiagnosed dementia, rates of any impairment for individual activities ranged from 17.0% (telephone use) to 66.0% (shopping) (Table 3 ). Full dependence in IADLs were mostly commonly reported for doing laundry (35.9%), housekeeping (34.0%), transportation (32.1%) and food preparation (20.8%). Table 3 Rates of IADL Impairments Among Patients with Previously Undiagnosed Dementia (N = 53) Any Impairment Fully Dependent Activity of Daily Living N (%) N (%) Telephone 9 (17.0) 0 Shopping 35 (66.0) 6 (11.3) Food preparation 25 (47.2) 11 (20.8) Housekeeping 34 (64.2) 18 (34.0) Laundry 30 (56.6) 19 (35.9) Transportation 30 (56.6) 17 (32.1) Medication organization 10 (18.9) 2 (3.8) Managing finances 13 (24.5) 1 (1.9) Multivariate Analysis of Undiagnosed Dementia In logistic regression analysis, men had significantly lower odds than women for undiagnosed dementia (odds ratio [OR] 0.3, 95% CI 0.2 to 0.7) and Black and Hispanic participants had higher odds than white participants (OR 11.5, 95% CI 2.4 to 56.6 and OR 9.1, 95% CI 1.8 to 45.8, respectively). Age, education, birth outside the U.S., ELP and depression were not significantly associated with undiagnosed dementia. Discussion Interpretation and Implications Moderate to severe cognitive impairment with co-occurring impairment of daily activities, suggesting dementia, was found in approximately 6% of patients 55 years and older without clinically documented dementia in primary care practices in the U.S. Although findings from prior studies indicate that dementia is often undiagnosed, 7–9 estimates of undiagnosed dementia in clinical settings have been very limited. One study of federally qualified health centers in Indiana reported a 12.3% rate of dementia among patients ages 65 and older without previously diagnosed dementia or MCI. 19 A non-peer reviewed evaluation of Veteran Administration patients estimated rates of undiagnosed dementia of 9.5% to 15.3%, but used machine learning methods applied to electronic medical record data to arrive at its estimation. 20 The current study provides a lower estimate of undiagnosed dementia rates in urban primary care practices serving a diverse patient population. Taken together, the current body of literature suggests that health systems may expect 3% to 15% of their primary care patients over age 55 to have undiagnosed dementia. Consistent with prior research, our findings suggest that Black and Hispanic patients are at greater risk of having undetected dementia. 19 , 21 Routine and systematic screening in primary care settings could help reduce health inequities in dementia. The findings of this study also highlight some of the most common home support needs these patients may be facing, including needs for assistance with shopping, food preparation and housekeeping. For health systems, awareness of the prevalence of undiagnosed dementia and its attendant burdens can aid infrastructure building to support the care of this debilitating condition. Limitations An important limitation of this study is its reliance on screening tools rather than comprehensive neuropsychiatric assessment for dementia, including a determination of whether functional impairments resulted from cognitive impairment. Physical impairments could have preceded or have been independent of cognitive impairment, leading to overestimation of undiagnosed dementia rates. Conclusion In conclusion, findings from this study suggest that routine screening in primary care would identify substantial numbers of individuals with previously undiagnosed dementia. Abbreviations MoCA, Montreal Cognitive Assessment; IADL, instrumental activities of Daily living; ELP, English language proficiency; PHQ, Patient Health Questionnaire; SD, standard deviation; OR, odds ratio; CI, confidence interval Declarations Ethics approval and consent to participate : This study was approved by the Icahn School of Medicine at Mount Sinai Institutional Review Board in accordance with the Declaration of Helsinki. Informed consent was obtained prior to enrollment of all study participants. Consent for publication : Not applicable. Availability of data and materials : The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests : The authors declare that they have no competing interests. Funding : This work was supported by grant R01AG066471 from the National Institute for Aging. Authors’ contributions : AF and JW obtained funding for this research. AF, JW and LC supervised data collection. AF and JB analyzed and interpreted the data. AF prepared the manuscript. All authors read and edited the manuscript and all authors approved the final manuscript. Acknowledgements : Not applicable. References Owens DK, Davidson KW, Krist AH, et al. Screening for Cognitive Impairment in Older Adults: US Preventive Services Task Force Recommendation Statement. JAMA . 2020;323(8):757-763. Alzheimer's disease facts and figures. Alzheimers Dement . 2022;18(4):700-789. Livingston G, Huntley J, Liu KY, et al. Dementia prevention, intervention, and care: 2024 report of the Lancet standing Commission. Lancet . 2024;404(10452):572-628. Medicare introduces GUIDE model of dementia care delivery. Alzheimers Dement . 2023;19(9):4287-4289. Hilsabeck RC, Perry W, Lacritz L, et al. Improving Early Detection of Cognitive Impairment in Older Adults in Primary Care Clinics: Recommendations From an Interdisciplinary Geriatrics Summit. Ann Fam Med . 2024;22(6):543-549. King M, Peckham A, Marani H, et al. Gaps in the System: Supporting People Living with Dementia. J Aging Soc Policy . 2024;36(5):963-983. Wilkins CH, Wilkins KL, Meisel M, Depke M, Williams J, Edwards DF. Dementia undiagnosed in poor older adults with functional impairment. J Am Geriatr Soc . 2007;55(11):1771-6. Savva GM, Arthur A. Who has undiagnosed dementia? A cross-sectional analysis of participants of the Aging, Demographics and Memory Study. Age Ageing . 2015;44(4):642-7. Connolly A, Gaehl E, Martin H, Morris J, Purandare N. Underdiagnosis of dementia in primary care: variations in the observed prevalence and comparisons to the expected prevalence. Aging Ment Health . 2011;15(8):978-84. Amjad H, Roth DL, Sheehan OC, Lyketsos CG, Wolff JL, Samus QM. Underdiagnosis of Dementia: an Observational Study of Patterns in Diagnosis and Awareness in US Older Adults. J Gen Intern Med . 2018;33(7):1131-1138. Nasreddine ZS, Phillips NA, Bedirian V, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc . 2005;53(4):695-9. Rossetti HC, Lacritz LH, Cullum CM, Weiner MF. Normative data for the Montreal Cognitive Assessment (MoCA) in a population-based sample. Neurology . 2011;77(13):1272-5. Davis DH, Creavin ST, Yip JL, Noel-Storr AH, Brayne C, Cullum S. Montreal Cognitive Assessment for the diagnosis of Alzheimer's disease and other dementias. Cochrane Database Syst Rev . 2015;(10):CD010775. Freitas S, Simoes MR, Alves L, Santana I. Montreal cognitive assessment: validation study for mild cognitive impairment and Alzheimer disease. Alzheimer Dis Assoc Disord . 2013;27(1):37-43. Trittschuh EH, Crane PK, Larson EB, et al. Effects of varying diagnostic criteria on prevalence of mild cognitive impairment in a community based sample. J Alzheimers Dis . 2011;25(1):163-73. Jak AJ, Preis SR, Beiser AS, et al. Neuropsychological Criteria for Mild Cognitive Impairment and Dementia Risk in the Framingham Heart Study. J Int Neuropsychol Soc . 2016;22(9):937-943. Busse A, Hensel A, Gühne U, Angermeyer MC, Riedel-Heller SG. Mild cognitive impairment: long-term course of four clinical subtypes. Neurology . 2006;67(12):2176-85. Kroenke K, Strine TW, Spitzer RL, Williams JB, Berry JT, Mokdad AH. The PHQ-8 as a measure of current depression in the general population. J Affect Disord . 2009;114(1-3):163-73. 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. Shao Y, Todd K, Shutes-David A, et al. Identifying probable dementia in undiagnosed Black and White Americans using machine learning in Veterans Health Administration electronic health records. medRxiv . 2023;doi:10.1101/2023.02.08.23285540 Lin PJ, Daly AT, Olchanski N, et al. Dementia Diagnosis Disparities by Race and Ethnicity. Med Care . 2021;59(8):679-686. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 06 Mar, 2026 Reviews received at journal 05 Mar, 2026 Reviews received at journal 02 Mar, 2026 Reviews received at journal 23 Feb, 2026 Reviews received at journal 23 Feb, 2026 Reviewers agreed at journal 22 Feb, 2026 Reviewers agreed at journal 22 Feb, 2026 Reviewers agreed at journal 20 Feb, 2026 Reviewers agreed at journal 20 Feb, 2026 Reviewers agreed at journal 19 Feb, 2026 Reviewers invited by journal 19 Feb, 2026 Editor assigned by journal 16 Feb, 2026 Editor invited by journal 27 Jan, 2026 Submission checks completed at journal 23 Jan, 2026 First submitted to journal 23 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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While prior research provides evidence indicating that dementia is under detected in clinical settings,\u003csup\u003e7\u0026ndash;9\u003c/sup\u003e few studies have estimated rates of undiagnosed dementia in primary care, where screening would most likely occur.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e To address this gap, we estimated rates of undiagnosed dementia in primary care practices in the U.S. using data from a cognitive screening assessment and an assessment of daily functioning.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSubjects and Settings\u003c/h2\u003e \u003cp\u003eEnglish speaking adults ages 55 years and older without a diagnosis of dementia or mild cognitive impairment were recruited from 4 primary care practices in New York City, NY that serve predominantly minoritized patient populations, including two hospital-based teaching practices and two multi-provider faculty practices and one hospital-based teaching practice in Chicago, IL. Potentially eligible patients were identified by medical record review and a random selection was then mailed a letter describing the study. Letters were followed by a telephone call for eligibility screening. White and Black male patients were oversampled to achieve balanced representation by sex and race. After obtaining informed consent, research coordinators administered a 30-minute interview in clinical exam rooms either before or after their visit with a primary care provider. All study procedures were approved by a single Institutional Review Board of record at the Icahn School of Medicine at Mount Sinai in accordance with the Declaration of Helsinki.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMeasuring Cognitive Impairment and Daily Functioning\u003c/h3\u003e\n\u003cp\u003eWe defined dementia as cognitive impairment resulting in impairment of daily functioning. Cognitive performance was assessed with the Montreal Cognitive Assessment (MoCA).\u003csup\u003e\u003cspan additionalcitationids=\"CR12 CR13\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e The 12-item MoCA measures visuospatial/executive functioning, naming, memory, attention, language, delayed recall, and orientation. Scores range from 0 to 30. We converted raw scores to age and education adjusted z-scores; values falling below 1.0 and 1.5 standard deviation (SD) of the mean for normative data were defined as mild impairment and moderate to severe impairment, respectively.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Research coordinators were trained to administer the MoCA and were supervised for quality assurance by a licensed neuropsychologist (JB). Daily functioning was assessed by self-report. The instrumental activities of daily living (IADL) questionnaire included ability to use a telephone, shop, prepare food, perform housekeeping chores, do laundry, use public transportation, self-manage medications and handle finances. Responses for each item were categorized as fully independent, needs assistance or fully dependent. We operationalized dementia as moderate to severe cognitive impairment and needing assistance with or fully dependent for one or more IADL.\u003c/p\u003e\n\u003ch3\u003eOther Measures\u003c/h3\u003e\n\u003cp\u003eOther data collected during the interview included age, education, race and ethnicity, English language proficiency (ELP), country of birth, and depression. To determine ELP, participants were asked to rate their ability to speak and understand English from very poor to excellent on a 6-point Likert scale. Low ELP was defined as very poor, poor or fair. Country of birth was dichotomized as U.S. or U.S. territory-born vs. other. Depression was assessed with the Patient Health Questionnaire-8 (PHQ-8).\u003csup\u003e18\u003c/sup\u003e Depression was defined as score\u0026thinsp;\u0026ge;\u0026thinsp;10. The full survey is included in the appendix.\u003c/p\u003e\n\u003ch3\u003eAnalysis\u003c/h3\u003e\n\u003cp\u003eWe report estimated rates of undiagnosed dementia with 95% confidence intervals, as well as impairments in IADLs stratified by cognitive performance (normal or mild impairment vs. moderate to severe impairment). We conducted a multivariable logistic regression analysis of the association of participant characteristics with dementia, adjusting for age, sex, race and ethnicity, ELP and depression. All analyses were conducted in SAS, version 9.4 (SAS Institute, Cary, N.C.).\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eRecruitment and Participant Characteristics\u003c/h2\u003e \u003cp\u003e Phone outreach was attempted for 3,815 persons, 2,894 (75.9%) were contacted, 1,737 (60.0%) declined participation, 208 (7.2%) did not speak English, 949 (32.8%) agreed to participation, 872 (30.1%) completed the interview and 853 (29.5%) had complete MoCA and IADL data. The mean age of participants in the analytic sample was 67.3 (8.0) years, 47.3% were male, 32.9% were Black and 26.3% were Hispanic and 61.3% had a college level or higher education (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant Demographics (N\u0026thinsp;=\u0026thinsp;853)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, \u003cem\u003emean (sd)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67.3 (8.0) years\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e47.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRace\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlack, non-Hispanic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite, non-Hispanic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHispanic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;12 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school graduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny college\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGraduate school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eForeign born\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow English language proficiency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;1 IADL impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e44.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEstimated Rates of Previously Undiagnosed Dementia\u003c/h3\u003e\n\u003cp\u003eModerate to severe cognitive impairment was present in 10.3%. For IADLs, 44.8% (95% confidence interval [CI] 41.5% to 48.1%) of participants reported needing assistance with one or more activity and 24.4% (95% CI 21.5% to 27.2%) were fully dependent in one or more activity. Undiagnosed dementia was observed in 6.2% (95% CI 4.5% to 7.7%) of subjects. A similar rate was observed for the subgroup of persons ages 65 years and older (5.9%, 95% CI 3.9% to 9.0%).\u003c/p\u003e\n\u003ch3\u003eCommon Functional Impairments\u003c/h3\u003e\n\u003cp\u003eThe IADLs for which patients most commonly needed assistance or were dependent were shopping (27.4%), housekeeping (30.8%) and food preparation (20.1%) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The rates of co-occurring moderate or severe cognitive impairment and impairment for these IADLs were 4.1%, 4.1% and 3.0%, respectively.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRates of IADL Impairments Stratified by Cognitive Function (N\u0026thinsp;=\u0026thinsp;853)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eCognition\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstrumental\u003c/p\u003e \u003cp\u003eActivities of\u003c/p\u003e \u003cp\u003eDaily Living\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll\u003c/p\u003e \u003cp\u003ePatients\u003c/p\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNormal or Mild Impairment\u003c/p\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eModerate-Severe Impairment\u003c/p\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTelephone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 (5.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36 (4.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (1.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFully dependent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (0.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShopping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e238 (27.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e202 (23.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36 (4.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFully dependent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (3.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (0.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFood preparation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e175 (20.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e149 (17.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26 (3.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFully dependent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51 (5.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (1.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHousekeeping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e267 (30.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e232 (26.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35 (4.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFully dependent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e102 (11.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84 (9.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (2.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaundry\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e203 (23.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e173 (19.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30 (3.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFully dependent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e133 (15.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e114 (13.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (2.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransportation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e218 (24.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e187 (21.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 (3.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFully dependent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e122 (14.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e104 (12.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (2.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedication organization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (4.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (1.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFully dependent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (0.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eManaging finances\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83 (9.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70 (8.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (1.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFully dependent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (1.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (0.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny impairment for \u0026ge;\u0026thinsp;1 IADL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e386 (44.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e333 (38.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53 (6.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFully dependent for\u003c/p\u003e \u003cp\u003e\u0026ge;\u0026thinsp;1 IADL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e210 (24.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e182 (21.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28 (3.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eIADL, instrumental activities of daily living. Note rounding errors for some percent values in the All Patients column.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAmong persons with previously undiagnosed dementia, rates of any impairment for individual activities ranged from 17.0% (telephone use) to 66.0% (shopping) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Full dependence in IADLs were mostly commonly reported for doing laundry (35.9%), housekeeping (34.0%), transportation (32.1%) and food preparation (20.8%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRates of IADL Impairments Among Patients with Previously Undiagnosed Dementia (N\u0026thinsp;=\u0026thinsp;53)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAny Impairment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFully Dependent\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eActivity of\u003c/p\u003e \u003cp\u003eDaily Living\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTelephone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (17.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShopping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (66.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (11.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFood preparation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (47.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (20.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHousekeeping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (64.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (34.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaundry\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (56.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (35.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransportation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (56.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (32.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedication organization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (18.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eManaging finances\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (24.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eMultivariate Analysis of Undiagnosed Dementia\u003c/h2\u003e \u003cp\u003eIn logistic regression analysis, men had significantly lower odds than women for undiagnosed dementia (odds ratio [OR] 0.3, 95% CI 0.2 to 0.7) and Black and Hispanic participants had higher odds than white participants (OR 11.5, 95% CI 2.4 to 56.6 and OR 9.1, 95% CI 1.8 to 45.8, respectively). Age, education, birth outside the U.S., ELP and depression were not significantly associated with undiagnosed dementia.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eInterpretation and Implications\u003c/h2\u003e \u003cp\u003eModerate to severe cognitive impairment with co-occurring impairment of daily activities, suggesting dementia, was found in approximately 6% of patients 55 years and older without clinically documented dementia in primary care practices in the U.S. Although findings from prior studies indicate that dementia is often undiagnosed,\u003csup\u003e7\u0026ndash;9\u003c/sup\u003e estimates of undiagnosed dementia in clinical settings have been very limited. One study of federally qualified health centers in Indiana reported a 12.3% rate of dementia among patients ages 65 and older without previously diagnosed dementia or MCI.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e A non-peer reviewed evaluation of Veteran Administration patients estimated rates of undiagnosed dementia of 9.5% to 15.3%, but used machine learning methods applied to electronic medical record data to arrive at its estimation.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e The current study provides a lower estimate of undiagnosed dementia rates in urban primary care practices serving a diverse patient population. Taken together, the current body of literature suggests that health systems may expect 3% to 15% of their primary care patients over age 55 to have undiagnosed dementia.\u003c/p\u003e \u003cp\u003eConsistent with prior research, our findings suggest that Black and Hispanic patients are at greater risk of having undetected dementia.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e Routine and systematic screening in primary care settings could help reduce health inequities in dementia. The findings of this study also highlight some of the most common home support needs these patients may be facing, including needs for assistance with shopping, food preparation and housekeeping. For health systems, awareness of the prevalence of undiagnosed dementia and its attendant burdens can aid infrastructure building to support the care of this debilitating condition.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eAn important limitation of this study is its reliance on screening tools rather than comprehensive neuropsychiatric assessment for dementia, including a determination of whether functional impairments resulted from cognitive impairment. Physical impairments could have preceded or have been independent of cognitive impairment, leading to overestimation of undiagnosed dementia rates.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, findings from this study suggest that routine screening in primary care would identify substantial numbers of individuals with previously undiagnosed dementia.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eMoCA, Montreal Cognitive Assessment; IADL, instrumental activities of Daily living; ELP, English language proficiency; PHQ, Patient Health Questionnaire; SD, standard deviation; OR, odds ratio; CI, confidence interval\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e This study was approved by the Icahn School of Medicine at Mount Sinai Institutional Review Board in accordance with the Declaration of Helsinki. Informed consent was obtained prior to enrollment of all study participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003cstrong\u003e: \u003c/strong\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cstrong\u003e: \u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThis work was supported by grant R01AG066471 from the National Institute for Aging.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e AF and JW obtained funding for this research. AF, JW and LC supervised data collection. AF and JB analyzed and interpreted the data. AF prepared the manuscript. All authors read and edited the manuscript and all authors approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003cstrong\u003e: \u003c/strong\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eOwens DK, Davidson KW, Krist AH, et al. Screening for Cognitive Impairment in Older Adults: US Preventive Services Task Force Recommendation Statement. \u003cem\u003eJAMA\u003c/em\u003e. 2020;323(8):757-763. \u003c/li\u003e\n\u003cli\u003eAlzheimer\u0026apos;s disease facts and figures. \u003cem\u003eAlzheimers Dement\u003c/em\u003e. 2022;18(4):700-789. \u003c/li\u003e\n\u003cli\u003eLivingston G, Huntley J, Liu KY, et al. 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Effects of varying diagnostic criteria on prevalence of mild cognitive impairment in a community based sample. \u003cem\u003eJ Alzheimers Dis\u003c/em\u003e. 2011;25(1):163-73. \u003c/li\u003e\n\u003cli\u003eJak AJ, Preis SR, Beiser AS, et al. Neuropsychological Criteria for Mild Cognitive Impairment and Dementia Risk in the Framingham Heart Study. \u003cem\u003eJ Int Neuropsychol Soc\u003c/em\u003e. 2016;22(9):937-943. \u003c/li\u003e\n\u003cli\u003eBusse A, Hensel A, G\u0026uuml;hne U, Angermeyer MC, Riedel-Heller SG. Mild cognitive impairment: long-term course of four clinical subtypes. \u003cem\u003eNeurology\u003c/em\u003e. 2006;67(12):2176-85. \u003c/li\u003e\n\u003cli\u003eKroenke K, Strine TW, Spitzer RL, Williams JB, Berry JT, Mokdad AH. The PHQ-8 as a measure of current depression in the general population. \u003cem\u003eJ Affect Disord\u003c/em\u003e. 2009;114(1-3):163-73. \u003c/li\u003e\n\u003cli\u003eKulshreshtha A, Parker ES, Fowler NR, et al. Prevalence of Unrecognized Cognitive Impairment in Federally Qualified Health Centers. \u003cem\u003eJAMA Netw Open\u003c/em\u003e. 2024;7(10):e2440411. \u003c/li\u003e\n\u003cli\u003eShao Y, Todd K, Shutes-David A, et al. Identifying probable dementia in undiagnosed Black and White Americans using machine learning in Veterans Health Administration electronic health records. \u003cem\u003emedRxiv\u003c/em\u003e. 2023;doi:10.1101/2023.02.08.23285540\u003c/li\u003e\n\u003cli\u003eLin PJ, Daly AT, Olchanski N, et al. Dementia Diagnosis Disparities by Race and Ethnicity. \u003cem\u003eMed Care\u003c/em\u003e. 2021;59(8):679-686. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"undiagnosed, dementia, Montreal Cognitive Assessment, daily functioning, primary care, older adults","lastPublishedDoi":"10.21203/rs.3.rs-8663638/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8663638/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBACKGROUND\u003c/h2\u003e \u003cp\u003eEstimates of the prevalence of unrecognized dementia are needed to gauge the potential impact of routine dementia screening.\u003c/p\u003e\u003ch2\u003eMETHODS\u003c/h2\u003e \u003cp\u003eAdults ages\u0026thinsp;\u0026ge;\u0026thinsp;55 years without dementia or mild cognitive impairment diagnoses were recruited from primary care practices in New York City, NY and Chicago, IL (n\u0026thinsp;=\u0026thinsp;853). Dementia was defined as significant cognitive impairment, as indicated by score\u0026thinsp;\u0026gt;\u0026thinsp;1.5 standard deviations below age and education adjusted norms on the Montreal Cognitive Assessment, with impairment in one or more of 7 instrumental activities of daily living (IADL).\u003c/p\u003e\u003ch2\u003eRESULTS\u003c/h2\u003e \u003cp\u003eMean age was 67.3 years. Moderate-severe cognitive impairment was observed in 10.3% and impairment in \u0026ge;\u0026thinsp;1 IADL in 44.8%. Estimated undiagnosed dementia prevalence was 6.2% (95% CI 4.5% to 7.7%) overall and 5.9% (95% CI 3.9% to 9.0%) among participants ages\u0026thinsp;\u0026ge;\u0026thinsp;65.\u003c/p\u003e\u003ch2\u003eCONCLUSIONS\u003c/h2\u003e \u003cp\u003eRoutine screening in primary care would identify substantial numbers of individuals with previously undiagnosed dementia.\u003c/p\u003e","manuscriptTitle":"Dementia Among U.S. Primary Care Patients Ages 55 Years and Older without Previously Diagnosed Cognitive Impairment","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-24 16:03:24","doi":"10.21203/rs.3.rs-8663638/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-03-06T16:55:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-05T05:54:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-02T20:59:08+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-23T16:06:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-23T09:25:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"323701225292540962132728494786979594990","date":"2026-02-23T04:16:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"68582123250382318793395245957803204632","date":"2026-02-22T22:19:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"102238474300139090473310298166869648144","date":"2026-02-20T16:25:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"287042175479574411838821124591714029232","date":"2026-02-20T05:18:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"209036253528265367663950061406753009460","date":"2026-02-19T15:43:24+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-19T15:06:03+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-16T13:55:07+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-27T09:14:36+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-23T18:25:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2026-01-23T18:19:53+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0df2696d-b48d-46d9-961f-d4217b0b23b3","owner":[],"postedDate":"February 24th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-24T16:03:24+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-24 16:03:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8663638","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8663638","identity":"rs-8663638","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}