Cognitive measures lacking in EHR prior to dementia or Alzheimer's disease diagnosis

Abstract

Introduction: The extent that cognitive measures are documented in electronic health records (EHR) is important for quality care and addressing disparities in timely diagnosis of dementia or Alzheimer's disease (AD).

Methods: Analysis of U.S. EHR data to describe the frequency and factors associated with cognitive measures prior to diagnosis of dementia (N = 111,125) or AD (N = 30,203).

Results: Only 11% of dementia patients and 24% of AD patients had a cognitive measure documented in the 5 years prior to diagnosis. Black race, older age, non-commercial health insurance, lower mean neighborhood income, greater in-patient stays, and fewer out-patient visits were associated with lacking cognitive measures.

Discussion: Extensive missing cognitive data and differences in the availability of cognitive measures by race, age, and socioeconomic factors hinder patient care and limit utility of EHR for dementia research. Structured fields and prompts for cognitive data inputs at the point of care may help address these gaps.

Keywords: Alzheimer's disease; Mini-Mental State Examination; dementia; electronic health records; electronic medical records; healthcare disparities; mild cognitive impairment; neurocognitive tests.

FIGURE 1

Cognitive measures noted from 16,387 measures among 12,174 dementia patients with cognitive measures in the 5 years prior to the first coded dementia diagnosis. * * Proportion shown is of all cognitive measures recorded in 0 to 5 years prior (N = 16,387 measures); patients who had more than one measure recorded in the 5 years prior were counted for each in the figure. Tests that were recorded for < 0.1% of dementia patients are not depicted; these were the Cognitive Linguistic Quick Test (N = 9 dementia patients), Brief Cognitive Rating (N = 0 dementia patients). Overall in the 5 years prior, the percentage of patients (N = 12,174) with a Mini‐Mental State Examination (MMSE) was 57%; Recall Test 37%; Clock Drawing 11%; Montreal Cognitive Assessment (MoCA) 10%; Mini‐Cog 7%; and Saint Louis University Mental Status (SLUMS) 7%. Results were similar in the Alzheimer's disease patient sample (data not shown).

FIGURE 2

First provider type to record a cognitive measure, among patients prior to dementia diagnosis. * *Among patients who had an out‐patient cognitive measure in the 5 years prior to receiving a coded dementia diagnosis. Solid bar represents the percentage of patients with any of the cognitive measures listed in Table 2. Checked bar represents patients at first Mini‐Mental State Examination (MMSE). Clear bar represents patients at first Recall Test. Primary care provider includes “family practice,” “internal medicine,” and “general practice” classifications. Psychiatrist includes “psychiatry and neurology” classification. When more than one provider type was associated with the note, the primary specialty of the attending physician (rather than the admitting physician or secondary specialty) was selected as provider type. Other provider types that each accounted for <1% of provider types at the first noted cognitive measure are not depicted in the figure. Data on provider type on the date of the first noted cognitive measure was missing for 12.0% of dementia patients.