Undetected Cognitive Impairment in Saudi Arabia: A National Analysis of Screening Coverage, Diagnostic Yield, and Equity Gaps in Primary Healthcare

BACKGROUND AND OBJECTIVES: Dementia and mild cognitive impairment represent a growing neurological burden in Saudi Arabia, driven by population aging and a high concentration of modifiable risk factors. Most affected individuals remain undiagnosed, yet no national analysis of cognitive screening coverage, diagnostic yield, or equity gaps has been conducted within the primary healthcare system. To quantify cognitive impairment screening coverage among adults aged ≥60 years, characterize diagnostic yield and tool utilization patterns, identify equity gaps, and assess alignment with the World Health Organization (WHO) Global Action Plan on Dementia 2017-2025 targets. METHODS: This descriptive study used a serial (repeated) cross-sectional design with trend analysis, analyzing annual secondary surveillance and survey data from 2016 to 2023 drawn from the WHO Global Dementia Observatory, Saudi Ministry of Health Annual Statistical Yearbooks, the Saudi Health Interview Survey 2018, and a regional dementia prevalence study. Descriptive statistics characterized screening and diagnostic patterns over time; regional and urban-rural comparisons were assessed cross-sectionally at single time points (2023 and 2018). RESULTS: National cognitive screening coverage increased from 8.3% in 2016 to 21.7% in 2023. The Mini-Mental State Examination was the most utilized instrument (62.4% of screening encounters), followed by the Montreal Cognitive Assessment (28.1%). Among screened individuals, 34.2% received a new clinically confirmed diagnosis of mild cognitive impairment or dementia, and 71.3% of these new diagnoses had no prior documented cognitive concern. Screening coverage ranged from 31.4% (Central region) to 9.2% (border regions) and was roughly twice as high in urban areas (26.8%) as in rural areas (13.1%). The dementia diagnosis documentation rate-the indicator most directly aligned with the WHO Global Action Plan's Target 4 for dementia diagnosis-improved from 18.4% in 2016 to 41.6-64.6% of estimated prevalent cases in 2023. CONCLUSIONS: Cognitive impairment screening coverage in Saudi Arabia's primary healthcare system remains critically low, and this shortfall in case-finding capacity is the most likely driver of continued underdiagnosis. Whether the WHO Global Action Plan's dementia diagnosis target has been met remains uncertain given the wide prevalence-estimate range, underscoring the need for better prevalence data alongside systematic screening integration, standardized tool adoption, and equity-focused outreach.