Cognitive Impairment As a Barrier to Utilization of Preventive Health Services Among Older Adults

Background/Purpose: Dementia is a major cause of disability in old age and associated with substantial societal costs. Although cognitive impairment significantly predicts future needs for long-term care services, home health, and other costly care, older adults with cognitive impairment may be at risk for underutilization of preventive services because of diminished ability to self-care. Being up-to-date with recommended preventive health services can potentially prevent disease, reduce individual suffering, and societal costs. This has become increasingly important as burden of chronic disease is dramatically increasing as the demographic landscape of the nation rapidly transitions into an aging society. It may be of particular importance for older adults with cognitive impairment, who often suffer from other comorbid physical and mental illnesses. To date, however, few studies have examined the impact of cognitive impairment on utilization of preventive health services. The purpose of this study was to compare utilization of preventive health services between middle-aged and older adults with cognitive impairment and those without cognitive impairment.

Methods: Individual data came from 2010 to 2012 waves of the Health and Retirement Study (HRS), a nationally representative longitudinal health survey. Participants were selected if they were older than 50 years old and were interviewed in 2010 (n=19,331). A composite score of cognitive function, ranging from 0 to 27, was created by summing up items of immediate and delayed word recall, a serial 7’s, and backwards counting. Cognitive impairment was defined as a score of 11 or less. Four self-reported preventive services were examined: flu shot, cholesterol test, prostate exam (for male only), and mammogram (for female only). Logistic regression was used to test the association of cognitive impairment in 2010 and preventive services use two years later (in 2012). Covariates included age, gender, race/ethnicity, marital status, current smoking status, BMI, depression, physical activity, health insurance, and chronic disease diagnoses including diabetes, cancer, stroke, heart disease, arthritis, and chronic lung disease. HRS sampling design was incorporated in all estimates.

Results: Adults with cognitive impairment were 35% less likely to report cholesterol test two years later (OR=0.65, 95% CI=[0.55-0.77], p<.001). Men with cognitive impairment were 28% less likely to report prostate exam (OR=0.72, 95% CI=[0.61-0.85], p<.001). Cognitive impairment was associated with nearly 20% reduced odds of receiving mammograms among women (OR=0.82, CI=[0.72-0.95], p<.05,). However, cognitive impairment was not significantly associated with utilization of flu shot.

Conclusion: Cognitive impairment may be a significant barrier to utilization of preventive services among middle-aged and older adults. Currently, utilization of several preventive services in the elderly population is not meeting Healthy People 2020 goals. The recent health care reform provides tremendous opportunities to improve preventive services utilization among older adults as Medicare increasingly focuses on prevention. This study suggests that older adults with cognitive impairment may be a vulnerable group at heighted risk for underutilization of preventive services even with nearly universal health insurance coverage in this population. Future studies should examine barriers to preventive services specific to this population.