Adaptive pathways for multimodal community-based detection of cognitive impairment: the CogScreen I study

Early detection of cognitive impairment is essential for dementia prevention and timely care. However, implementation in primary care and community settings remains limited. Building dementia-prepared health systems requires scalable and adaptive pathways that integrate subjective, digital and biological indicators, while accounting for heterogeneity in risk, education and age. CogScreen I was a cluster-randomized trial conducted in Munich senior centers from March 2023 to March 2024. Recruitment focused on community-dwelling adults aged ≥ 60 years reporting subjective cognitive concerns. Centers were randomized to: (A) the Subjective Cognitive Decline Questionnaire (SCD-Q) only, (B) SCD-Q plus digital cognitive testing, or (C) SCD-Q plus digital testing plus blood biomarkers (Aβ1-42/1-40, pTau181, GFAP, NfL). The primary endpoints were feasibility and acceptability, assessed through structured questionnaires and follow-up interviews with participants and general practitioners. Secondary endpoints examined latent cognitive structures and biomarker associations. Exploratory factor and clustering analyses revealed multimodal subgroups across subjective, digital, and biological measures, which informed a hypothesis-generating three-tier adaptive detection framework (low, medium, high intensity). Among the 473 participants (mean age 74.1 ± 7.6 years; 66% female; 63% with tertiary education), both feasibility and acceptability were high: Participants described the assessments as personally relevant, clearly communicated, and medically meaningful, and appreciated the added value of digital testing and biomarkers. Digital cognitive testing and biomarkers captured distinct latent dimensions of learning/working memory, psychomotor attention, and glial and amyloid pathology. Exploratory multimodal clustering identified three dementia risk profiles-low concern, intermediate, and at risk-which informed an adaptive, tiered detection model. Notably, subjective cognitive concerns assessed by the SCD-Q were strongly associated with overall subjective symptom burden, supporting the use of brief self-report questionnaires as a pragmatic and scalable first-step stratification approach in community-based dementia detection. Community-based, tiered detection pathways for cognitive decline are feasible, acceptable, and meaningful to older adults. Exploratory multimodal profiling suggests that combining subjective, digital, and biological measures may support individualized assessment strategies. However, limited GP engagement highlights the need for stronger integration with primary care to ensure downstream diagnostics and prevention pathways. The proposed framework remains hypothesis-generating and requires prospective validation.Clinical trials registeredCogScreen has been registered at clinical trials (NCT06191952, 2023-12-20).