Implementing early detection of cognitive impairment in primary care to improve care for older adults

Abstract

Primary care is the ideal setting for early detection of mild cognitive impairment (MCI) and Alzheimer's disease and related dementias (ADRD), as it serves as the primary point of care for most older adults. With the growing aging population, reliance on specialists for detection and diagnosis is unsustainable, highlighting the need for primary care‐led assessment. Recent research findings on successful brain health prevention strategies, AD diagnostic tools, and anti‐amyloid treatments empower primary care to play a central role in early detection and intervention. Primary care‐focused resources are being developed, including tools for cognitive assessments and materials designed to educate patients about brain health and initiate discussions on lifestyle modifications, thereby making early detection more feasible and efficient. Identifying risk factors early enables providers to implement interventions that can slow cognitive decline and improve outcomes for patients and caregivers. If left undetected and unmanaged, MCI and ADRD can lead to worse outcomes, including increased falls, hospitalizations, financial vulnerability, and caregiver stress. Early detection enables the identification of reversible causes of cognitive impairment, supports the management of comorbidities worsened by cognitive decline, mitigates safety risks, and can preserve quality of life. Importantly, primary care is essential for addressing ADRD‐related health disparities that disproportionately affect racial minorities, rural populations, and those of lower socioeconomic status. With a focus on the United States healthcare system, this perspective addresses how implementing early detection practices into primary care can improve outcomes for patients and caregivers, reduce societal burdens, and promote health equity in ADRD care.

Introduction

Dementia is a syndrome characterized by cognitive impairment that includes symptoms such as memory loss, decreased executive functioning, language deficits, and reduced ability to carry out activities of daily living [1, 2]. Alzheimer's disease (AD) is the most common pathology leading to dementia, though most individuals experience brain changes associated with one or more additional forms of dementia [2, 3]. Other dementia pathologies include cerebrovascular disease, Lewy body disease, and frontotemporal lobar degeneration [1]. Mild cognitive impairment (MCI) is a high‐risk state for future development of dementia, where an individual experiences mild decline in cognitive function without major interference in daily functioning [1, 2]. Age is the leading risk factor for Alzheimer's disease and related dementias (ADRD) [4]. Approximately 14% of older adults have ADRD [5], and up to 20% have MCI in the United States (US). Of those with MCI, over 30% will develop ADRD within 5 years of symptom onset [6]. By 2050, the number of ADRD cases globally is estimated to be over 152 million [7]. In the US, it is projected that one in five older adults will be living with ADRD by 2060 [8].

In the US, ADRD is one of the most expensive conditions for older adults, costing over $360 billion annually, not including the additional ∼$347 billion in unpaid caregiving, far exceeding the cost of patients living with heart disease or cancer [2, 9]. By 2050, these costs are expected to reach approximately $1 trillion and consume an estimated 1 in 3 Medicare dollars [2, 10]. The costs of ADRD go beyond financial expenditures, contributing to reduced emotional and physical well‐being of caregivers and lost productivity [11, 12].

Despite the growing prevalence and societal impact of ADRD, underdiagnosis and delayed diagnosis remain widespread global challenges [1, 13, 14]. Cognitive decline often goes unnoticed by older adults and their caregivers, who may lack insight into their deficits or may conceal issues due to fear or stigma [15]. Healthcare providers frequently overestimate the worry or shame a patient would feel upon receiving a diagnosis while underestimating the willingness of patients to engage in discussions about brain health and lifestyle modifications to delay disease progression [16]. In 2017, it was estimated that 60.7% of ADRD cases in the US and up to 90% of cases in low‐ and middle‐income countries went undetected [17]. A more recent study using US Medicare claims data found that 40% of older adults with cognitive impairment consistent with ADRD had either a late diagnosis or no diagnosis at all [18]. Detection rates for MCI are even lower, with only approximately 8%–11% of individuals receiving a timely diagnosis [19, 20]. Delays in diagnosis disproportionally affect underrepresented and underserved groups [21]. On average, American non‐Hispanic Whites receive a dementia diagnosis approximately 31 months after symptom onset, compared to 35 months for non‐Hispanic Blacks and 44 months for Hispanics [18, 22]. The inability to obtain a timely diagnosis limits access to early interventions, including treatments for early‐stage AD, recently approved in the US and other countries [23, 24]. It also delays interventions that can reduce behavioral and psychological symptoms, caregiver burden, and hospitalization rates, as well as delay nursing home placement [25].

Early detection of cognitive impairment and ADRD provides the opportunity to identify and treat reversible causes, educate patients about brain health and modifiable risk factors, develop patient‐centered treatment plans that address cognitive health and co‐existing conditions in collaboration with patients and caregivers, facilitate access to clinical trials, and initiate discussions on care goals and advance care planning—objectives endorsed by the US Preventive Services Task Force and others [1, 6, 26–32]. Additionally, a growing body of evidence supports the effectiveness of multi‐domain lifestyle interventions and brain health education in improving cognitive function [33, 34]. Recent advancements in ADRD research and care have heightened the need of early detection. For instance, regulatory authorities in the US, European Union, Great Britain, Japan, and other countries have approved disease‐modifying treatments for Alzheimer's that are only indicated for patients with MCI due to AD and mild AD dementia [23, 24]. Additionally, the US Centers for Medicare & Medicaid Services (CMS) recently launched a national alternative payment program, the Guiding an Improved Dementia Experience (GUIDE) model, which incentivizes the identification of Medicare beneficiaries with ADRD to ensure access to evidence‐based care management services for them and their family members [25].

Primary care is ideally positioned for initiating early detection of MCI and ADRD, as this setting is often the first or sometimes only point of contact with the healthcare system that many people have. Incorporating regular processes for brain health discussions and screening creates the opportunity to educate individuals and address the importance of managing risk factors to reduce the risk of ADRD. Although primary care providers often directly refer patients with cognitive complaints to specialists like neurologists and geriatricians, this approach is not scalable as the aging population grows and specialist availability becomes more limited. Although many patients with cognitive impairment will eventually require specialty care—particularly those eligible for new disease‐modifying treatments—detection, diagnosis, and counseling on treatment plans can occur within primary care. By addressing these steps before referral, primary care can help streamline the specialist referral process. As a result, establishing guidance, payment structures, and quality measures for early detection, diagnostic assessment, and care and treatment in primary care is increasingly necessary to facilitate a timely diagnosis for patients [35, 36].

When not diagnosed or effectively managed, MCI and ADRD can lead to a wide range of negative outcomes for patients and their families, including an increased risk of falls, higher rates of hospital admissions, poor chronic disease management, financial mismanagement, and motor vehicle accidents [37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50]. Caregivers of individuals with ADRD often experience heightened stress, lower quality of life, and are at a greater risk of mental health conditions and psychological distress [51, 52, 53]. Primary care plays a pivotal role in supporting the overall well‐being of older adults and improving their health outcomes. Early detection of cognitive impairment is crucial for primary care to fulfill this responsibility and ensure better outcomes for both patients and caregivers. This perspective, developed collaboratively by a group of diverse experts in ADRD, reflects shared experiences and insights on the value of early detection of MCI and ADRD within the US primary care setting. It also examines how advancements in prevention strategies, diagnostic pathways, treatments, and clinical resources can support clinicians and healthcare systems in implementing these practices.

The importance of primary care in identifying cognitive impairment to mitigate ADRD risk, address reversible causes, and promote brain health

Risk factors for ADRD have been well characterized [54, 55], and tools are available to help clinicians identify individuals at risk [56, 57, 58]. Early identification of risk factors is critical for guiding treatment plans, initiating brain health discussions, and prescribing lifestyle modifications that can prevent or slow cognitive decline and delay progression to ADRD [59]. A recent publication provides expert recommendations for reducing global ADRD risk across the life span by targeting 14 modifiable risk factors. Since the last set of recommendations in 2020, vision loss and high cholesterol have been added as new modifiable risk factors for dementia. This publication also outlines specific actions physicians can take to address these risk factors [55]. Collectively, these 14 risk factors account for ∼45% of global ADRD cases, suggesting that nearly half of these cases could be prevented or delayed throughout the life course or with early intervention in adulthood. Notably, comorbidities such as hypertension, diabetes, and obesity are included in this list of prominent risk factors, underscoring the need for physician awareness that vascular and metabolic dysfunction contribute to cognitive impairment [55, 60, 61]. Patients with these risk factors should be identified as high‐risk and managed proactively to prevent or delay the onset of cognitive impairment. Unfortunately, many patients and primary care providers are unaware of these risks and miss opportunities for patient education about brain health and risk reduction in the context of disease management [62, 63, 64, 65].

Implementing behavioral and lifestyle interventions that may reduce the risk of cognitive impairment in cognitively normal individuals or delay further cognitive decline in those with MCI or ADRD is recommended [66]. A robust body of evidence supports the effectiveness of multi‐domain lifestyle interventions in mitigating risk, slowing cognitive decline, and even improving cognition in people with measurable impairment. These interventions include management of cardiovascular risk factors, dietary modifications, regular physical exercise, increased social engagement, cognitive training, and stress management [67, 68, 69, 70, 71, 72]. Notably, benefits of implementing these lifestyle interventions have been observed for up to 5 years following a 2‐year intervention in at‐risk older adults in Europe [73]. For individuals already diagnosed with dementia, post‐diagnosis lifestyle interventions have been associated with improved physical health, enhanced quality of life, reduced hospitalizations, and prolonged community living [55]. Implementation protocols from these studies and expert recommendations are available and can be used to inform guidance from providers [55, 67–72].

Primary care is well positioned to support patients in making lifestyle modifications to reduce the burden of chronic diseases, including ADRD, but need education and support from the healthcare delivery system and from payers on how to effectively promote and implement these changes. Counseling by primary care physicians has been shown to be effective at helping patients increase physical activity and make dietary improvements [74, 75]. According to a recent American Academy of Family Physicians (AAFP) study, over 90% of family physician respondents were comfortable counseling patients on lifestyle medicine domains, with more than 75% using guidelines to advise on tobacco use, diet, and physical activity. Moreover, a survey by the American Association of Retired Persons (AARP) found that while many adults are unaware of the effects of medications, chronic diseases, and lifestyle changes on risk for cognitive decline, they are willing to make adjustments that may slow progression [16].

Many older adults experience cognitive impairment due to reversible causes, such as polypharmacy, anticholinergic medications, or deficiencies in vitamins and thiamine. Other treatable conditions that can cause cognitive impairment include thyroid dysfunction, reversible encephalopathies such as alcohol‐related or hepatic, sleep apnea, depression, and normal pressure hydrocephalus [76, 77, 78, 79]. Although uncommon, the early detection and management of these causes of cognitive impairment in primary care are essential for improving patient quality of life, reducing ADRD risk, and avoiding unnecessary treatments [76]. Primary care providers diagnose and care for patients with many of these conditions as part of their routine practice [80, 81, 82, 83, 84], and resources are available to aid in their recognition, diagnosis, and management [76, 85]. However, further research is needed to better integrate the evaluation of these conditions into the assessment of patients with cognitive concerns or identified cognitive impairment.

Early detection as a strategy to improve health and safety outcomes for individuals with or at risk of ADRD and with multiple chronic conditions

Primary care is charged with providing comprehensive care to improve overall patient outcomes. This responsibility includes coordinating care and chronic disease management for older adults. More than 70% of US older adults have two or more simultaneous chronic conditions, or multimorbidity [86]. This includes individuals with or at risk of ADRD. Approximately 60% of older adults with ADRD have three or more chronic conditions [87, 88, 89]. It is estimated that 52%–82% of older adults with ADRD also have hypertension, 16%–39% also have diabetes [87, 90], 11%–18% have chronic kidney disease [91], 9%–28% have congestive heart failure [37], and 9%–17% have chronic obstructive pulmonary disease (COPD) [50].

Undetected dementia among older adults with chronic conditions leads to higher healthcare utilization, preventable hospitalizations, and lower quality of chronic care management [37, 47–50, 92]. These individuals are also at greater risk of experiencing medication errors and developing delirium [38–40, 93]. A 2022 US qualitative study involving physician interviews found that providers often identify possible cognitive impairment in patients who struggle with medication adherence, have difficulty managing chronic conditions, experience multiple hospital readmissions, or frequently miss appointments [94].

Primary care can improve patient outcomes by implementing early detection practices to support the management of medical conditions that are worsened by cognitive decline. For instance, if an older patient is struggling to manage diabetes or heart disease, early awareness of their cognitive status enables clinicians to tailor treatment plans, engage family members, provide additional support, or offer increased oversight in medical care [95, 96].

Beyond chronic disease management, early detection helps mitigate financial risks, including the risk of financial scams, safety concerns, and reduced quality of life associated with cognitive decline [38, 44–46, 97–99]. White and Black older Americans with cognitive impairment are more prone to impaired financial decision‐making and more susceptible to scams, which has been associated with long‐term challenges in financial stability [45, 46, 97].

Safety risks, such as the higher likelihood of falls, also increase significantly with cognitive decline. According to a recent meta‐analysis, up to 43% of individuals with MCI experience falls [44]. For those who have progressed to ADRD, a UK study reported that risk of a fall is eight times that of an individual with normal cognition [43]. The consequences of falls are more severe for those with cognitive impairment, including slower recovery time, accelerated health decline, higher rates of hospitalization and institutionalization, and increased mortality [98, 99]. Additionally, individuals with ADRD are at higher risk for motor vehicle accidents [41, 42]. A recent study in Australia suggests the risk of an accident may be greater prior to receiving a formal diagnosis or in the early stages of disease, before interventions to ensure driving safety are recommended [41]. Early detection of cognitive decline allows for counseling and interventions to support safe driving, particularly in the MCI stage when these interventions may be most effective [100, 101]. For those with more advanced ADRD, detection tools can help inform decisions regarding driving licensure, though there remains debate about which tests best assess driving ability [102].

By detecting cognitive impairment early, primary care providers can not only manage comorbid medical conditions more effectively but also identify specific needs of patients and families, facilitating timely referrals to appropriate medical and social services when needed. This proactive approach enables more holistic care, improving overall health and quality of life for patients.

Early cognitive assessment delivered by primary care may reduce known health disparities in ADRD detection and cognitive care

In the US, significant disparities exist in the incidence, prevalence, and stage of ADRD at diagnosis among underrepresented and underserved groups [103, 104, 105]. For example, Black Americans and individuals from rural areas are twice as likely to develop ADRD compared to White Americans and individuals living in urban areas, respectively [105, 106, 107, 108, 109]. Hispanic Americans also face a 1.5 times greater risk of developing ADRD compared to non‐Hispanic White Americans [106]. These groups are more likely to be diagnosed at later stages of ADRD, experience accelerated cognitive decline, and face other adverse outcomes [18, 105, 110]. A recent claims‐based prospective cohort study showed non‐Hispanic Black and Hispanic older adults in the US experience an additional 3‐ to 12‐month delay in diagnosis compared to non‐Hispanic Whites and are often in more severe stages of disease at the time of diagnosis [18]. Living with ADRD in a rural environment is associated with earlier nursing home placement and shorter survival after diagnosis [110]. In addition, ADRD risk factors disproportionately affect racial minorities, rural populations, individuals of low socioeconomic status, and other marginalized groups [55, 105, 111, 112]. Addressing these disparities requires targeted efforts to mitigate underlying risk factors, many of which are deeply rooted in social and structural inequities, and improve access to timely diagnosis for these groups. The US Department of Health and Human Services National Plan to Address Alzheimer's Disease (Strategy 2.H) emphasizes this as a key priority, underscoring the urgent need for equitable access to early detection, diagnosis, and care for those disproportionately affected by ADRD [113].

Primary care is uniquely positioned to offer early cognitive assessments, facilitate access to treatment and clinical trials, and address misconceptions about dementia to promote health equity in ADRD care. Barriers to timely diagnosis limit patients’ opportunities to benefit from new therapies and participate in clinical trials. The delay to diagnosis for these groups means that by the time a diagnosis is received, individuals may no longer be eligible for treatments, such as monoclonal antibody therapies that are indicated for early‐stage AD.

Primary care providers are also largely responsible for connecting patients to clinical trials. Although Black Americans are twice as likely as White Americans to develop dementia, they comprise only 2% of AD clinical trial participants [106, 114]. Similarly, individuals from rural communities are severely underrepresented in clinical trials, despite ADRD prevalence being twice as high in these communities compared to urban areas [105, 107–109]. Exclusion from clinical trials denies individuals the opportunity to engage in valuable educational and treatment initiatives [2, 115]. Research indicates that racial and ethnic minority groups in the US are willing to participate in clinical trials when given the opportunity, especially when trial information is presented in a culturally sensitive way [115]. This highlights an opportunity for primary care to address disparities in research participation through early detection and culturally competent communication with patients.

Misconceptions, such as the belief that dementia symptoms are a normal part of aging and should be self‐addressed or managed within families, further contribute to delays in diagnosis among underrepresented and underserved groups [105, 116]. This can lead to delays in seeking treatment or other support, which limits treatment options and the patient's ability to participate in care planning [116]. Primary care‐initiated brain health discussions that address misconceptions and distinguish between normal and abnormal changes are a key factor in reducing health disparities in ADRD detection and care.

Advancements in detection tools, clinician resources, biomarkers, and treatments address barriers to early detection in primary care

As front‐line clinicians, primary care providers are well‐positioned to identify cognitive decline, initiate evaluations, and implement risk reduction strategies. However, they cannot do it on their own. To fully realize the benefits of early detection for patients, families, health systems, and society, it is crucial for policymakers, payers, health system leaders, professional societies, and other stakeholders to address barriers to the adoption of early cognitive testing. Several well‐documented barriers have limited early detection of cognitive impairment in primary care and are outlined in Table 1 [29, 64, 117–120]. Recent advancements in detection tools, clinician resources, biomarkers, and treatments are now addressing these gaps (Table 1). These developments are improving diagnostic accuracy, streamlining workflows, increasing the value of early detection, and empowering clinicians to integrate cognitive assessments more effectively into routine care, making early detection more feasible and efficient. Although the barriers and emerging solutions outlined in Table 1 are primarily based on the US healthcare system, they may also be relevant to other countries, acknowledging that each country faces unique challenges and limitations in the context of early detection.

Table 1.

Barriers to early detection and solutions in primary care.

Theme	Barrier	Solutions in primary care
Ecosystem factors	Stigma	Normalizing patient‐provider discussions on brain health and ADRD risk reduction can reduce stigma; resources are available to support primary care providers in these conversations [58, 136] Conducting routine cognitive assessments can reduce stigma by normalizing cognitive testing
	Lack of guidelines on clinical workflows that support early cognitive assessment	Published toolkits provide guidelines and evidence‐based practices on implementing cognitive assessments and other early detection practices [58, 134–136, 160], including focused primary care‐based initial work‐up guidance [132] A similar toolkit has been developed in Europe
	Limited reimbursement of costs associated with assessing cognition and providing post‐diagnostic care	Improved billing and coding structures that match recommended primary care workflows and provide adequate reimbursements will incentivize cognitive testing [136] Including brain health counseling and cognitive assessments in quality metrics for primary care, such as the Health Effectiveness Data and Information Set (HEDIS) measure, will encourage reimbursement [30]
Provider behavior and beliefs	Perceived limited benefits of early detection	Emergence of new treatments, including disease‐modifying therapies for AD and evidence‐based comprehensive dementia care models, as well as scalable biomarkers to support diagnosis, increase the value of early detection
	Lack of comfort assessing cognition and diagnosing and managing ADRD	Built in workflows and electronic health record documentation will support standardizing cognitive assessments Training resources for clinicians are available to support the diagnosis and management of ADRD throughout all stages of disease [58, 136, 160, 161, 162]
Health system factors	Insufficient time to learn and implement cognitive assessment tools or provide appropriate follow‐up	Advanced practice providers, nurses, social service providers, brain care navigators, and other healthcare professionals can be trained or may already have the expertise to conduct cognitive testing and support follow‐up care in primary care. Multiple interprofessional collaborative approaches to early detection have demonstrated effectiveness in recent studies [10, 121, 163] Machine learning advances are enhancing passive digital marker collection, which hold promise to improve efficiency in identifying at‐risk individuals in primary care [57]
	Limited capabilities and infrastructure to support cognitive testing	An implementation guide is available to support the adoption of cognitive assessments, providing evidence‐based change management and implementation strategies [132]
	Lack of clear referral pathways and communication channels with specialists for complex cases	Established relationships between primary care and specialists are needed Integrating Care Team Navigators or Brian Health Navigators with the appropriate expertise may support more efficient referral pathways and communication with specialists, while relieving burden on primary care [164] Digital health companies are also finding solutions to improve the referral pathways for individuals identified as at risk for MCI or ADRD [165]

Abbreviations: AD, Alzheimer's disease; ADRD, Alzheimer's disease and related dementias; MCI, mild cognitive impairment.

Implementing early detection practices in primary care

Implementing evidence‐based, brief cognitive assessments (BCAs) and brain health discussions into routine care, such as the US Medicare Annual Wellness Visit or similar preventive visits for older adults in other countries, can help reduce the stigma associated with cognitive testing and diagnostic assessment [105, 121]. BCAs are designed to detect possible cognitive impairment and determine which patients require a comprehensive cognitive evaluation [30]. Given the number of priorities physicians address during preventative visits, BCAs can be administered by other trained professionals in primary care, increasing the feasibility of implementation.

Current efforts are focused on refining BCAs to overcome the limitations of traditional tools (which often lack sensitivity in detecting early cognitive decline and have limited validity in non‐English speaking populations and patients with lower health literacy), validate BCAs in real‐world, diverse patient populations, and integrate them into standard workflows [122, 123, 124]. Guidelines that include recommendations on validated assessment tools are now available to help primary care teams select BCAs that best suit their patient populations, cultural contexts, and clinical environments [30, 125–127].

The development of digital cognitive assessments (DCAs) offers further potential to improve early detection by increasing accessibility and reducing the time to diagnosis for a broader range of patients. DCAs offer advantages such as user convenience, reduced training requirements, integration into electronic health records, and the ability to minimize socioeconomic, language, and cultural biases common in traditional paper‐based tests [35, 128]. These tools are showing promise [129, 130, 131], but their widespread adoption is challenged by a lack of consensus on minimum standards, complex regulatory processes, and reimbursement barriers. Additionally, generating real‐world evidence and conducting implementation research will be essential for the efficient integration of DCAs into primary care. Ongoing initiatives in the US and Europe are already focused on overcoming these challenges [132, 133].

Comprehensive resources and toolkits have been developed to assist primary care providers in discussing brain health, conducting cognitive assessments, and managing post‐detection care. These toolkits may also provide guidance on reimbursement and offer resources for managing patients at risk of cognitive impairment, as well as support for caregivers [58, 85, 134–136]. Designed to be adaptable, these resources can be tailored to the unique needs of different health systems and primary care clinics.

New treatments and biomarker tests for ADRD increase the value of early detection

Recent advancements in treatments have increased the value of early detection, addressing concerns that the benefits of assessing cognition are minimal. Monoclonal antibody therapies targeting amyloid pathology have received regulatory approval in the US and other countries for early symptomatic AD. These therapies offer potential to delay cognitive and functional decline, if administered early in the disease course, creating an important opportunity for primary care providers to identify appropriate patients for treatment to ensure timely intervention [23, 24, 137, 138, 139]. There is also some evidence that these therapies may have the potential for clinically meaningful outcomes, such as improved quality of life, reduced caregiver burden, and prolonged time in less severe stages of the disease [140, 141, 142].

Primary care plays a critical role in identifying patients who may be eligible for new treatments, as well as providing initial counseling to help patients assess their goals of care. Therefore, in regions where they are approved, it is necessary for primary care providers to understand more about new monoclonal antibody therapies for AD, including which patients are most likely to benefit, as well as the known side effects and how these may vary across different populations [143]. Although specialists are recommended to initiate these treatments and confirm eligibility, identifying potential candidates and providing counseling in primary care before referral is important to avoid unnecessary delays in specialty care visits. Notably, these treatments are associated with clinically‐meaningful risks, such as amyloid‐related imaging abnormalities (ARIA) and brain atrophy, as well as access challenges, including unreimbursed costs for patients and a limited number of specialists and healthcare systems equipped to administer these treatments [144, 145, 146]. It will be crucial for patients who may meet eligibility criteria for these therapies to be able to make realistic and informed decisions about treatment after a thorough discussion with their primary care providers.

Anti‐amyloid monoclonal antibody therapies require confirmation of amyloid pathology, driving the need for scalable diagnostic approaches in primary care that include AD biomarker testing [23, 24]. Although AD biomarker methods such as cerebrospinal fluid (CSF) analysis and PET imaging have been largely inaccessible to primary care patients outside of research settings for multiple reasons, emerging blood tests offer a more scalable alternative for clinical use [147, 148, 149]. Increasing access to an AD diagnosis that includes biological data, blood tests may improve equity in timely diagnosis and reduce the rate of misdiagnosis of the etiology of cognitive impairment, observed to be 25%–30% even in specialty care when relying on clinical data alone [150].

AD blood tests can be integrated into clinical workflows for symptomatic patients as a tool to identify possible AD and may eventually serve as a confirmatory method. Expert recommendations have been published to guide clinicians on selecting and incorporating blood tests into the AD diagnostic pathway while acknowledging critical limitations, such as the lack of consensus on cutoff values and limited real‐world data in the diverse populations commonly seen in US primary care settings [147, 151, 152]. In many cases, it may not be feasible for primary care providers to both order and interpret AD blood tests; however, determining eligibility and initiating blood‐based testing in primary care can help streamline the specialist referral. Crucially, AD blood tests are emerging in a healthcare landscape already marked by disparities. To ensure these tests reduce rather than exacerbate existing disparities, their implementation must proactively address the access barriers faced by underrepresented and underserved groups [153].

Beyond blood tests, diagnostic tools based on machine learning and artificial intelligence (AI) that use data from electronic health records and MRI scans have received FDA clearance to support differential diagnosis for ADRD [154, 155]. Machine learning is also being leveraged to develop and validate passive digital markers that can identify at‐risk individuals and guide tailored risk‐reduction strategies [57]. To ensure effective implementation of these strategies in primary care, additional research is needed to identify the educational and infrastructure support required. Advancements in AI and biomarker testing hold promise to accelerate efforts to detect both early and presymptomatic stages of ADRD, a goal strongly supported by the US National Plan to Address Alzheimer's Disease (Strategy 1.C) [113].

Facilitating access to an ADRD diagnosis also enables access to non‐pharmacological treatments, such as dementia care navigation and collaborative care management [156]. These programs are designed to work with primary care to support their patients with ADRD and caregivers by assisting with the care coordination, access to home and community‐based services, and patient and caregiver education. In alignment with the US National Plan to Address Alzheimer's Disease Strategy 2.G, innovative dementia care programs, such as the CMS GUIDE program, have been developed based on evidence‐based, comprehensive dementia care models. These models have shown better care outcomes, reduced costs, improved patient and caregiver quality of life, and delayed transitions to residential care when implemented in healthcare and community settings [113, 156, 157]. Funded by CMS, the GUIDE program offers a broad range of services, including care coordination and management, caregiver education and support, and respite services [25]. Access to these services requires an ADRD diagnosis, emphasizing the importance of early detection to ensure that patients and caregivers can fully benefit. Strengths of the GUIDE model include its focus on team‐based care, the development of individualized care plans, equity‐adjusted payments, and support for caregivers [25, 158]. However, some programs within the GUIDE model rely on the availability of local resources and may not include reimbursement for certain services provided by healthcare professionals to implement these programs within their health systems [158, 159].

Conclusions

Primary care serves as the critical main entry point into the healthcare system for most patients, with many relying on this setting for the majority of their care. This underscores the importance of primary care in implementing early cognitive assessments, discussing brain health, guiding lifestyle modifications, and addressing reversible causes of cognitive decline. Early detection improves patient outcomes by preventing or slowing the progression to ADRD and has the potential to reduce health disparities, improve quality of life, and mitigate the medical, financial, and safety risks associated with cognitive impairment. Given the rising prevalence of ADRD, early detection is urgently needed.

To ensure that patients and their families can access the benefits of early detection, persistent barriers to cognitive testing and other early detection practices in primary care must be addressed. Recent advancements in detection tools, biomarkers, treatments, and clinician resources provide solutions to many of these challenges, making early detection more feasible and valuable. Integrating these practices into routine care is essential for improving patient, caregiver, and societal outcomes.

Conflicts of Interest Statement

N.R.F. has grants from the National Institutes of Health. K.A.P. and J.L. received compensation from Voices of Alzheimer's for editorial services related to this manuscript. J.T. is the founder and CEO of Voices of Alzheimer's. J.L.C. has provided consultation to Acadia, Acumen, ALZpath, Annovis, Aprinoia, Artery, Biogen, Biohaven, BioXcel, Bristol‐Myers Squib, Eisai, Fosun, GAP Foundation, Green Valley, Janssen, Karuna, Kinoxis, Lighthouse, Lilly, Lundbeck, LSP/eqt, Merck, MoCA Cognition, New Amsterdam, Novo Nordisk, Optoceutics, Otsuka, Oxford Brain Diagnostics, Praxis, Prothena, ReMYND, Roche, Scottish Brain Sciences, Signant Health, Simcere, sinaptica, TrueBinding, and Vaxxinity pharmaceutical, assessment, and investment companies. J.L.C. is supported by NIGMS grant P20GM109025; NIA R35AG71476; NIA R25AG083721‐01; NINDS RO1NS139383; Alzheimer's Disease Drug Discovery Foundation (ADDF); Ted and Maria Quirk Endowment; Joy Chambers‐Grundy Endowment. M.B. serves as a Chief Scientific Officer and Co‐Founder of BlueAgilis; the Chief Health Officer of DigiCare Realized, Inc.; and the Chief Health Officer of Mozyne health, Inc. M.B. has equity interest in Blue Agilis, Inc.; DigiCare Realized, Inc.; and Mozyne Health, Inc. M.B. sold his equity in Preferred Population Health Management LLC; and MyShift, Inc. (previously known as RestUp, LLC). M.B. serves as an advisory board member or consultant for Eli Lilly and Co.; Eisai, Inc.; Merck & Co Inc.; Biogen Inc.; and Genentech Inc. M.M.M. has served on scientific advisory boards and/or has consulted for Althira, Biogen, Eisai, LabCorp, Lilly, Merck, Roche, and Siemens Healthineers received speaking honorariums from Novo Nordisk, PeerView Institute, and Roche and receives grant support from the National Institute of Health, Department of Defense, Alzheimer's Association, and Davos Alzheimer's Collaborative. J.E.G. has grants from the National Institutes of Health, serves as Chief Scientific Officer for Cognivue, Inc., and serves as a consultant for Biogen, BMS, CervoMed, Cognivue, Cognition Therapeutics, Eisai, Eli Lilly, GE Healthcare, Lundbeck, and Roche. M.H. receives consulting fees from the Davos Alzheimer's Collaborative and Neurotrack Technologies and has served on advisory boards for Eisai, Novo Nordisk, and Eli Lilly. M.H. is a shareholder of Eli Lilly. T.M. receives consulting fees from the Davos Alzheimer's Collaborative. H.F. has consulted with Alector, LifeWorx, Mediflix, Samus Therapeutics, Otsuka Pharmaceuticals, and Pinteon Therapeutics and has served as an unpaid consultant for Eli Lilly. E.S. is a shareholder of Eli Lilly, Biogen, and AbbVie. K.K. and D.R.W. declare no conflicts of interest. J.R.B. serves on advisory boards for Eli Lilly, Eisai, and AbbVie and receives research support from Alzheimer's Association Part of the Cloud award, AbbVie, Alnylam Pharmaceuticals, Athira, Biogen, Eisai America Inc, Eli Lilly and Company, F. Hoffman‐La Roche Ltd., Washington University, Takeda Pharmaceuticals, and University of Southern California. C.U. is a paid consultant at Aga Khan University and receives research grant support from the National Institute of Health, Alzheimer's Association, UK Medical Research Council, UK Defence and Security Accelerator, Davos Alzheimer's Collaborative, and Wellcome Leap and Temasek Trust.

Fowler NR, Partrick KA, Taylor J, Hornbecker M, Kelleher K, Boustani M, et al. Implementing early detection of cognitive impairment in primary care to improve care for older adults. J Intern Med. 2025;298:31–45.

Data Availability Statement

Data sharing is not applicable to this article as no new data were created or analyzed in this study.