PROJECT SUMMARY / ABSTRACT Efficient and user-friendly paradigms to detect cognitive impairment, including dementia are needed in primary care. The UCSF Brain Health Assessment accurately detects cognitive impairment via an appealing tablet interface with automated scoring and EMR integration. With the first round of funding, we validated the paradigm in English and Spanish speakers, developed regression-based norms that accurately classify patients by their likelihood of impairment, identified racial and ethnic disparities and barriers to brain health care, and at UCSF primary care the paradigm increased diagnosis rates by 40%. The primary goals of the proposed work are to evaluate the effectiveness of the paradigm for improving brain health care via a large pragmatic trial, to address challenges to implementation, and to pioneer precision medicine approaches to reference group adjustments. In Aim 1, we will conduct a pragmatic cluster randomized trial in 26 Kaiser Southern California primary care clinics to determine the effectiveness of the paradigm on detection rates and other brain health outcomes. In Aim 2, we will identify and address challenges to implementation and sustainability. In Aim 3, we will further diversify our well-characterized reference group and refine our detection algorithms to adjust for social determinants of brain health (not race), which is novel and also critical for a paradigm to be appropriate for all members of the increasingly diverse U.S. older adult population. If successful, this work will produce a validated paradigm that is available to address the unmet need to detect cognitive impairment, including dementia, in large and diverse populations seen in primary care, and provide useful information about wide scale implementation of the paradigm to mitigate healthcare disparities and improve brain health care.