Research News

As new strategies to treat and slow the progression of Alzheimer’s disease and dementia are become available, patients and providers face a new challenge: diagnosing cognitive decline while interventions can help. For many patients with Alzheimer’s disease, the window for successful lifestyle interventions may close before cognitive symptoms are noticed. A multidisciplinary team at Cleveland Clinic has developed an easy, free and automated tool that may help identify older adults in the earliest, often unrecognized, stages of Alzheimer’s disease and dementia.  

The tool, published in Alzheimer's & Dementia: Diagnosis, Assessment & Disease Monitoring, is a cognitive risk calculator built from routine electronic health record (EHR) data. It integrates into the charting system, analyzing patient data during visits and alerting physicians to conduct further screening. 

Led by Darlene Floden, PhD, a neuropsychologist affiliated with Cleveland Clinic’s Center for Neurological Restoration, this automated tool aims to make early detection easier, more accurate and more accessible. 

Why is it important to get cognitive tests for dementia performed early? 

It’s important to identify people at risk for Alzheimer’s disease and dementia as early as possible, at the stage where cognitive changes are mild, because current treatments can only slow the disease down. The sooner lifestyle interventions and treatment start, the more we may be able to delay or maybe even prevent progression to dementia. Many people only get referred to cognitive testing after they have lost significant skills. 

As part of her clinical work, Dr. Floden assesses patients before they undergo surgical treatments such as deep brain stimulation for movement disorders. These treatments can worsen Alzheimer’s disease and dementia, so she has to screen patients even if they don’t have any obvious symptoms. 

When Dr. Floden gives cognitive tests, she has her patients answer questions and perform tasks that assess memory, attention, language skills, spatial abilities, problem solving, planning, organization and more. She also evaluates thinking speed by timing their responses.  

Many people never visit a specialty clinic and do not receive cognitive testing without symptoms. In primary care, where time is short and cognitive issues can be subtle, early changes often go undetected. 

“It can be very hard to spot early cognitive problems without some objective testing. This is especially difficult to do in primary care, where physicians are managing so many other chronic conditions in a short visit," Dr. Floden says. "By the time someone has clear dementia, the ship has kind of sailed.” 

Building a cognitive risk calculator from verified EHR data 

Almost all risk calculators for cognitive decline and dementia are trained on existing health data. Dr. Floden says an estimated 50% of those records may contain a misdiagnosis or lack of diagnosis for dementia. To avoid carrying that flawed data forward, the team recruited more than 300 new patients. Dr. Floden assessed them herself to ensure they had accurate diagnoses recorded in their charts. Of 300 patients, 109 were diagnosed with early cognitive impairment. 

Biostatisticians then analyzed five years of EHR data from these patients' annual visits to identify patterns that might predict cognitive decline. 

"We wanted to back up and say, OK, is there some way to identify risk just using the wealth of information we collect in primary care, with more accurate data?” Dr. Floden says. 

Dr. Floden’s research team included members from Neurological Institute, Department of Quantitative Health Sciences and Center for Geriatric Medicine. They developed a model that estimates dementia risk based on seven common variables including such as age, blood pressure and history of mood disorders. 

The final model runs in the background of EPIC, the system Cleveland Clinic physicians use to access and update patient records. Its accuracy is comparable to more complex tools that require specialized testing.  

Integrating new cognitive screening tools into clinical practice may help improve access to cognitive testing for dementia 

Cleveland Clinic is now piloting the tool in primary care. When a patient’s profile suggests elevated cognitive risk, a flag appears in their EHR. The program doesn’t trigger an automatic referral or diagnosis, but it prompts the provider to consider whether a cognitive screen is appropriate.   

“It’s not meant to be the final word,” Dr. Floden says. “It’s a nudge. A way to help busy providers know where to look more closely.” 

Early results are promising. Patients with flagged charts are being screened for cognitive issues at higher rates than those without. Dr. Floden and her team are also collecting physician feedback about how easy the tool is to use in everyday clinical practice. 

“Primary care visits are packed, so we wanted to make this as easy and painless as possible,” Dr. Floden says. “It’s meant to help physicians focus their time where it matters, and reminds patients that cognitive health is worth discussing, even before symptoms appear.” 

About this study

Cleveland Clinic is still actively recruiting caregivers to test this tool. Any prescribing provider who sees adults over 60 years old is eligible to participate. For more information please visit redcap.link/BACHstudy