Background
Methods
Data Sources
Study Selection
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Population: Primary care or family practice settings seeing persons with dementia.
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Intervention: The detection, diagnosis, treatment and/or management of dementia including models of care, pathways and/or protocols.
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Comparators: Usual care, wait-list control or other interventions within the scope of the review.
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Outcomes: The description of the detection, diagnosis, treatment or management strategies, along with measures of their acceptability, efficacy or effectiveness in the provision of care.
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Study design: Systematic review, either quantitative or qualitative.
Quality Assessment and Analysis
Results
Screening tools
Reference, Country | Number of studies included in systematic review | Intervention(s) | Comparator | Cognitive outcome(s) measured | Time of administration (minutes) | Sensitivity (%) | Specificity | Conclusions | Abbreviations |
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Mitchell et al, United Kingdom | 44 | Multidomain screening tests (known as a battery detection method) in primary care which assess for multiple cognitive domains. Primary care case-finding † : ▪AMTS/MSQ, ▪MSQ ▪WIND-SET ▪PCL ▪AMTS ▪PCL Primary care screening ‡ : ▪ PCL ▪AMTS/MSQ ▪MSQ ▪SPMSQ ▪GPCOG | MMSE | Dementia | Primary care case-finding: ▪AMTS/MSQ = 4 ▪MSQ = 2 ▪WIND-SET = 1 ▪PCL = 11 ▪AMTS = 2 ▪PCL = 11 Primary care screening: ▪PCL = 11 ▪AMTS/MSQ = 4 ▪MSQ = 2 ▪SPMSQ = 2 ▪GPCOG = 5 Comparator: ▪MMSE = 9 with healthy individuals and 15 with patients with dementia. | Battery detection methods: ▪84.0 (95% CI 74.2–91.8) | Battery detection methods: ▪89.9 (95% CI 78.3–97.4) | The optimal individual tools were the AMTS/MSQ and PCL. AMTS was superior to the MMSE for case finding however the MMSE was optimal for screening. | AMTS/MSQ-Abbreviated Mental Test Score/Mental Status Questionnaire, (WIND-SET)-Specific Set of items from MMSE, PCL-Prueba cognitive de leganes, AMTS-Abbreviated mental test score, GPCOG-General practitioner’s assessment of cognition, MMSE-Mini-Mental State Examination † Case-finding is defined as any tool or questionnaire which identifies a condition with minimal false negatives, measured as the positive predicative value. ‡ Screening is the ability of a test to rule out a diagnosis with minimal false positives, reported as the negative predictive value. |
Creavin et al, United Kingdom | 70 | ▪MMSE | A commonly accepted clinical (gold) reference standard. | Dementia | ▪MMSE=7 with a patient with dementia and 5 with a person with normal cognition | Carnero-Pardo 2013: ▪Cut point of 17 = 70 (95% CI 59-80) ▪Cut point of 24 = 100 (95% CI 95-100) | Carnero-Pardo 2013: ▪Cut point of 17 = 93 (95% CI 89, 96) ▪Cut point of 24 = 46 (95% CI 40-52) | Carnero-Pardo 2013 reported there were some false negatives as the sensitivity fell from 1.00 (95% CI 0.95 to 1.00) to 0.70 (95% CI 0.59 to 0.80). The summary diagnostic accuracy could not be estimated due to insufficient data. | |
Abd Razak et al, Malaysia | 30 | ▪MoCA-B; MoCA ▪SPMSQ ▪MEFO ▪ACE-III ▪AQT-CF ▪SLUMS ▪5 Object Test ▪BNB Semantic Fluency ▪SMCC compared to MMSE and CDT ▪CASI-S ▪RCS ▪CPS ▪Literacy Independent Cognitive Assessment ▪BIMS; BCAT ▪3MS ▪Mini-Cog; MIS; MF-2 ▪VT-VSM; VR-DOT ▪CCS ▪CAMCI ▪CADi; CADi-2 ▪DRA ▪p-AD8 ▪IQCODE | Comparing the feasibility and validity between the various screening tools. | Mild cognitive impairment and dementia | ▪MoCA-B = 15-21; MoCA = 10-15 ▪SPMSQ = 10-15 ▪MEFO = 10-15 ▪ACE-III = 15 ▪AQT-CF = 3-5 ▪SLUMS = 7 ▪5 Object Test = <5 ▪BNB Semantic Fluency = 31 ▪MCC compared to MMSE and CDT = NR ▪CASI-S = NR ▪RCS = <3 ▪CPS = NR ▪Literacy Independent Cognitive Assessment = 20 ▪BIMS = 3; BCAT = 10-15 ▪3MS = 17 ▪Mini-Cog = 3; MIS = 4; MF-2 = <2 ▪VT-VSM = >12; VR-DOT = NR ▪CCS = 3 ▪CAMCI = 30 ▪CADi = 10; CADi-2 = 10-40 ▪DRA = NR ▪p-AD8 = NR ▪IQCODE = 10 | For detecting dementia: ▪ACE-III at a cut-off point of <81, Sn = 100 For detecting MCI: ▪MoCA, Sn = 91-97 | For detecting dementia: ▪ACE-III at a cut-off point of <81, Sp=96 For detecting MCI: ▪MoCA, Sp = 60-80 | For detecting dementia: Screening tools less sensitive to ACE-III but with relatively high Sn/Sp values were: SLUMS, RCS, and BCAT. For detecting MCI: The MoCA was the most commonly used tool and had the highest Sn/Sp ranges. Less specific to the MoCA but among the most sensitive tools were the (VR-DOT) and IQCODE. Tools with the highest specificity but with lower sensitivity were: The 5 Objects Test, RCS, CPS, and (VT-VSM). | NR-Not Reported, MCI-Mild Cognitive Impairment, (MoCA-B)-Montreal Cognitive Assessment-Basic, (MoCA)-Montreal Cognitive Assessment, SPMSQ-Short Portable Mental Status Questionnaire, (MEFO)-Memory, fluency and orientation, (ACE-III)-Addenbrooke's Cognitive Examination III, (AQT-CF)-A Quick Test of Cognitive Speed, (SLUMS)- Saint Louis University Mental Status, (BNB)-Brief Neuropsychological Battery Semantic Fluency, (SMCC)-The Subjective Memory Complaint Clinical, (CASI-S)-Cognitive Abilities Screening Instrument-Short, (RCS)-Rapid Cognitive Screen, (CPS)-Cognitive Performance Scale, (BIMS)-Brief Interview for Mental Status, (BCAT)-Brief Cognitive Assessment Tool, (3MS)-Modified Mini-Mental State Examination, (MIS)-Memory Impairment Screen, (MF-2)-Memory Function 2, (VT-VSM)-Virtual Reality technology: Virtual supermarket, (VR-DOT)-Virtual Reality Day-Out-Task, (CCS)-Computerized Cognitive Screening Tests, (CAMCI)-Computerized Assessment of Mild Cognitive Impairment, (CADi)-[Cognitive Assessment for Dementia, iPad version], (CADi-2)-[Revised Cognitive Assessment for Dementia, iPad version], (DRA)-Dementia Risk Assessment, (p-AD8)-Participant-rated, (IQCODE)- Informant Questionnaire on Cognitive Decline in the Elderly individuals |
Smith et al, United Kingdom | 33 | ▪Rural Older Adult Memory Evaluation ▪Mini-Cog ▪PRISM-PC ▪SAPH questionnaire ▪MMSE and clinical history/examination ▪7-minute screen ▪CIE and MMSE | Not mentioned. | Dementia | Not mentioned. | Not mentioned. | Not mentioned. | There is insufficient evidence to support the adoption of these programmes into practice. Six positive and eight negative effects of primary care screening and early diagnosis of dementia were reported. | (PRISM-PC)-Perceptions Regarding Investigational Screening for Memory in Primary Care, SAPH-Dementia Screening and Perceived Hames, CIE-The Canberra Interview for the Elderly |
Brodaty et al, Australia | 83 | Instruments Validated in General Practice, Community or Population Samples: ▪AMT ▪Cambridge Cognitive Examination ▪CDT ▪GPCOG ▪Mini-Cog ▪MIS ▪MMSE ▪Short and Sweet Screening Instrument ▪Short IQCODE | MMSE | Dementia | ▪AMT = 3:16 ▪Camnridge Cognitive Examination = 20 ▪CDT = 2:16 ▪GPCOG = 4.5 ▪Mini-Cog = 2-4 ▪MIS = 4 ▪MMSE = 4 ▪Short and Sweet Screening Instrument = 10 ▪Short IQCODE = 30s | Screening tests validated in general practice, community or population samples: ▪AMT-100 (95% CI 70-100) ▪Cambridge Cognitive Examination-88 (95% CI 64-99) ▪CDT-76 (95% CI 60-88) ▪GPCOG-85 (95% CI 76-92) ▪Mini-Cog-76 (95% CI 65-85) ▪MIS-80 (95% CI 66-90) ▪MMSE-69 (95% CI 66-73) ▪Short and Sweet Screening Instrument-94 (95% CI 88-96) ▪Short IQCODE-79 (95% CI 65-90) | Screening tests validated in general practice, community or population samples: ▪AMT-82 (95% CI 72-90) ▪Cambridge Cognitive Examination-75 (95% CI 67-83) ▪CDT-81 (95% CI 77-84) ▪GPCOG-86 (95% CI 81-91) ▪Mini-Cog-89 (95% CI 87-91) ▪MIS-96 (95% CI 94-98) ▪MMSE-89 (95% CI 87-92) ▪Short and Sweet Screening Instrument-91 (95% CI 90-92) ▪Short IQCODE-82 (95% CI 79-85) | Screening tests validated in general practice, community or population samples: AMT had a PPV=0.42 (95% CI), NPV=1.00 (95% CI), misclassification of 16%, had internal consistency and face validity. Mini-Cog had a PPV=0.34 (95% CI), NPV=0.98 (95% CI), 12% misclassification, no education bias or language/cultural bias, and had face validity*. The AMT, CDT, GPCOG, Short IQCODE, Mini-Cog, and MIS all had a NPV =< MMSE (0.92). The GPCOG, Mini-Cog and MIS had a misclassification rate =< MMSE (15%) and had a high sensitivity and specificity (>=80%) and were therefore chosen as the most suitable instruments for use in general practice. | MAT-Mental Alternation Test. *- (Based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria requiring that instruments test memory and at least one other cognitive domain). CDT-Clock Drawing Test. GPCOG-General Practitioner Assessment of Cognition. |
Seitz et al, Canada | 4 | The Mini-Cog performed in insolation or scored based on results on the CDT or three-word recall | Standard diagnostic criteria for the clinical diagnosis of dementia | Alzheimer's disease dementia and related dementias | Mini-Cog = 3-5 in routine practice | Carnero-Pardo 2013 dementia prevalence was 34.5%: ▪100 (95% CI 93-100) Fuchs 2012 5.0% dementia prevalence: ▪100 (95% CI 84-100) Holsinger 2012 (highest quality study) 5.5% dementia prevalence: ▪76 (95% CI 53-92) McCarten 2012 90.3% dementia prevalence: ▪84 (95% CI 81-87) | Carnero-Pardo 2013: ▪40 (95% CI 30-50) Fuchs 2012: ▪85 (95% CI 81-89) Holsinger 2012: ▪73 (95% CI 68-77) McCarten 2012: ▪27 (95% CI 16-41) | Presently there is insufficient evidence to support the use of Mini-Cog in primary care. Studies mentioned are primary journal articles (cross-sectional studies). | |
Cullen et al, United Kingdom | 36 | ▪3MS ▪CASI ▪MMSE ▪SASSI ▪STMS ▪CAST ▪GPCOG ▪7MS ▪AMT ▪Mini-Cog ▪SIS ▪T&C ▪ACE-R ▪DemTect | Gold standard diagnostic criteria (based on international diagnostic guidelines or clinical judgement following a full assessment battery). | Cognitive impairment or any type of dementia | ▪3MS = 10-15 ▪CASI = 15-20 ▪MMSE = 8-13 ▪SASSI = 10-15 ▪STMS = 5 ▪CAST = 15 ▪GPCOG = 5 ▪7MS = 7-15 ▪AMT = 5 ▪Mini-Cog = 3-4 ▪SIS = 5 ▪T&C = 1 ▪ACE-R = 16 ▪DemTect = 8-10 | ▪3MS = 83-94 ▪CASI = 91-95 ▪MMSE = 69-91 ▪SASSI = 94 ▪STMS = 86-95 ▪CAST = 88-95 ▪GPCOG = 85 ▪7MS = 91 ▪AMT = 73-100 ▪Mini-Cog = 76-99 ▪SIS = 81-89 ▪T&C = 63-95 ▪ACE-R = 84-94 ▪DemTect = 100 (Alzheimer's dementia) | ▪3MS = 85-90 ▪CASI = 37-97 ▪MMSE = 87-99 ▪SASSI = 81-91 ▪STMS = 88-94 ▪CAST = 88-100 ▪GPCOG = 86 ▪7MS = 94 ▪AMT = 71-100 ▪Mini-Cog = 89-93 ▪SIS = 88-91 ▪T&C = 54-96 ▪ACE-R = 89-100 ▪DemTect = 92 (Alzheimer's dementia) | These tests were selected as brief assessment tools in the doctor's office due to their reported sensitivity and specificity values that were >85% for all dementia types together or for more than one particular subtype alone, and/or they covered at least three key domains. The 3MS and CASI are the only tests which cover all six key abilities (Attention/working memory, verbal recall, expressive language, verbal fluency, visual construction, reasoning/judgement). | (ACE-R)-Addenbrooke's Cognitive Examination Revised, STMS-Short Test of Mental Status, CCSE-Cognitive Capacity Screening Examination, (R-CAMCOG)-Rotterdam Version of the Cambridge Cognitive Examination |
Lischka et al, Canada | 12 | ▪MIS ▪IST, BVRT ▪CAMCI ▪ACE ▪ADAS-Cog ▪CAMCOG ▪MoCA ▪S-MMSE ▪IQCODE ▪STMS ▪MMSE ▪HDS-R ▪CCSE | A full clinical examination as the reference standard. | Dementia, MCI, amnestic MCI, mild dementia, and questionable dementia. | ▪MIS, IST = 4 ▪IST, BVRT = 1 ▪CAMCI = 15 ▪ACE = 15 ▪ADAS-Cog = NR ▪CAMCOG = 20 ▪MoCA = 10-12 ▪S-MMSE = 10 ▪IQCODE = 10-20 ▪STMS = 5 ▪MMSE = 5-10 ▪HDS-R = NR ▪CCSE = 10-12 | ▪MIS, IST = 74 ▪IST, BVRT - Cutoff level 1 = 90.8 ▪CAMCI = 83.4 ▪ACE - Cutoff <88/100 = 100 ▪ADAS-Cog - Cutoff <75/100 = 85 ▪CAMCOG = 76 for memory section ▪MoCA = 94 ▪S-MMSE = 14 ▪IQCODE = 41 ▪STMS = ≤ 80 ▪MMSE = 31 ▪HDS-R = 92 for the dementia diabetic group ▪CCSE - Cutoff 26/25 = 88.1 | ▪MIS = 84, IST = 81 ▪IST, BVRT - Cutoff level 1 = 52.2 ▪CAMCI = 78.5 ▪ACE - Cutoff <88/100 = 43 ▪ADAS-Cog - Cutoff <75/100 = 83 ▪CAMCOG = 96 for memory section ▪MoCA = 50 ▪S-MMSE = 100 ▪IQCODE = 67 ▪STMS = ≤ 80 ▪MMSE = 96 ▪HDS-R = 74 for the dementia diabetic group ▪CCSE - Cutoff 26/25 = 83.5 | Tools with the highest specificity rates: ▪MMSE ▪S-MMSE Tests with the highest sensitivities: ▪HDS-R ▪ACE, which decreased depending on cut-off value ▪MoCA for the dementia group and 83% for the MCI group ▪CAMCI ▪CCSE ▪The combination of the MMSE, IST, and BVRT at 90.8% for the first cut-off level. The ACE demonstrated good diagnostic accuracy with AUC=0.98. Xu et al. (2002) found that the CCSE was the best predictive screen in MCI participants for diagnosing all dementia due to its high sensitivity (88.1%) and specificity (83.5%). | (IST,BVRT)-Isaacs Set Test, Benton's Visual Retention Test. CAMCI-Chinese Abbreviated Mild Cognitive Impairment Test, (ADAS-Cog)-Alzheimer Disease Assessment Scale-Cognitive Subscale, (S-MMSE)-Standardized Mini-Mental State Examination, (HDS-R)-Hasegawa Dementia Scale-Revised, CCSE-Cognitive Capacity Screening Examination, CAMCOG-Cambridge Cognitive Examination |
Boustani et al, United States | 61 | ▪MMSE ▪FAQ ▪BIMC ▪BOMC ▪STMS | DSM-IV | Dementia | Not mentioned. | ▪MMSE = 71-92 ▪FAQ = 90 ▪BIMC = 90 ▪BOMC = 69 ▪STMS = 81 | ▪MMSE = 56-96 ▪FAQ = 90 ▪BIMC = 65-90 ▪BOMC = 90 ▪STMS = 90 | The MMSE has limited Sp when the cut-point is set for higher Sn. Accuracy of the MMSE changes based upon the patients age, education level and ethnicity and therefore requires adjustment when used. | BIMC-Blessed Information Memory Concentration; BOMC-Blessed Orientation Memory Concentration; FAQ-Functional Activities Questionnaire; STMS-Short Test of Mental Status; DSM-IV-Diagnostic and Statistical Manual of Mental Disorders, fourth edition |
Diagnostic accuracy and physician education
Management of dementia
Authors, Country | Number of studies included in systematic review | Intervention | Comparator | Outcomes |
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Sivananthan et al, Canada | 12 | 7 dementia care processes recommended by best practice guidelines: ▪Formal memory testing ▪Imaging ▪Laboratory testing ▪Interventions ▪Counseling ▪Community service ▪Specialist referrals | Clinical services provided by physicians to older adults diagnosed with dementia. | ▪8 out of 12 studies reported that <60% of physicians conducted formal memory testing, while 3 studies reported <15%, and 1 study <4% ▪33% to 91% of family physician's prescribed medications for dementia and consequent behavioral problems ▪33-80% of physicians reported the use of CT or MRI as a diagnostic tool, and >75% used blood work ▪2 studies reported that >80% of physicians provided counseling. |
Khanassov et al, Canada | 23 | Case Management interventions comprising all components identified by the Case Management Society of America: ▪Case finding and screening ▪Assessment ▪Care planning ▪Implementation and management ▪Monitoring ▪Review | No comparator | ▪Only 63% of case managers clearly explained their role to the patient-caregiver dyads while 25% did not give any detail during assessment ▪52% of case managers indicated that poor communication with healthcare providers negatively affected their work ▪Limiting factors to case management implementation were: insufficient knowledge of diagnostic tools, absence of training, and the absence of the case manager in the primary care setting. |
Davies et al, United Kingdom | 10 | Decision-making interventions with decision aids in dementia care (i.e. audio guided booklet, a printed decision aids about dementia and feeding; a living with dementia Guiding Options for Living with Dementia (GOLD) book; DECIDE intervention: a guided decision aid participants read and complete with support of decision coach to assist in making decisions regarding care home placement, video decision aid and structured meeting between surrogate decision maker and interdisciplinary care plan team; a video decision aid and audio description of advanced dementia) | ▪The majority of studies used a control group ▪One study used solely listening to a verbal narrative of the disease. | Place of care: ▪DECIDE decreased decisional conflict in caregivers ▪GOLD showed less of an increase in burden and greater increase in the knowledge of caregivers Goals of care: ▪A video decision aid combined with a structured meeting improved communication between caregivers and professionals and improved the concordance on the goals of care after 9 months Meta-analysis: ▪Two RCTs (N=72) included. ▪Decision aids are effective in decreasing decisional conflict in caregivers (standardized MD=− 0.50, 95% CI [ − 0.97, − 0.02]). This suggests increased confidence in decision-making and understanding of the decisions. ▪Decisional conflict was measured using the Decision Conflict Scale at 3 months post intervention. |
Tilburgs et al, Australia | 16 | Advanced care planning (ACP) | No comparator | Facilitators for ACP: ▪An early start while cognitive decline is mild. ▪Inclusion of all stakeholders and a good relationship between the GP, patient, and family carers. ▪Discussion of social and medical issues aimed at maintaining a normal life. ▪Decision aids that provide information and structure which contribute to decision making. Barriers for ACP: ▪Uncertainty about the timing of ACP. ▪How to plan for an uncertain future. ▪Lack of knowledge about dementia and patient's lack of knowledge of diagnosis. ▪Bad relationships among stakeholders. ▪Stress/fear caused by ACP. ▪Who should take initiative for ACP. ▪Difficulties assessing the dementia patient's decisional capacities. ▪Changing preferences. |
Mukadam et al, United Kingdom | 13 | Interventions intended to increase the detection of : ▪Dementia ▪Suspected dementia ▪People presenting with memory complaints | RCT: ▪Control groups. Non-randomized studies and pre-post study designs: ▪Comparison groups. | ▪2 of 3 RCTs of physician education found group educational interventions increased the likelihood of physicians suspecting dementia. ▪Non-randomized study findings suggest that clinician education in primary care interventions can increase the proportion of patients in whom physicians suspect dementia; untargeted community leaflet campaigns did not increase dementia diagnosis rates. ▪Pre-post comparison studies showed no positive effects for individual clinician training, group training with a routine screening programme or a targeted leaflet campaign. An increased number of memory clinics correlated with an increased number of dementia diagnoses. |
Khanassov et al, Canada | 43 | Case management (CM): ▪Assessment ▪Care planning ▪Implementation ▪Management ▪Regular follow-up | RCT: ▪Control group Qualitative studies: ▪No control | RCT evidence: ▪4/10 trials showed a decrease in the frequency of behavioral symptoms of dementia in the CM intervention group (mean effect size 0.88), while 2/7 reported a decrease in depression symptoms. ▪No effect on cognition and perceived health was observed. ▪8/11 trials found no effect on institutionalization. ▪Hospital admissions decreased (MES=0.66) in 2/5 studies. ▪Decreased ER admission was observed in 1/3 studies (effect size: 0.17) and a decrease in length of hospital stay was shown in both of the studies that evaluated this outcome (MES=1.06). ▪For caregivers, 5/10 studies showed a decrease in depression (MES=0.68) and 4/11 showed a decrease in burden (MES=0.5). Barriers to implementation of CM using outcome matching: ▪Intervention durations being too short. ▪Need for high-intensity CM. ▪Scarce communication. ▪Case manager and physician in different locations. ▪Lack of healthcare providers with geriatric training. Addressing these barriers correlated with better outcomes, as studies addressing more barriers resulted in more positive outcomes (agreement κ=0.94; CI, 0.82-1.1). |
Perry et al, Netherlands | 6 | Series of seminars and the appointment of dementia care managers. | Control groups in studies: ▪Clinical practice guidelines for dementia received by mail ▪No training ▪No seminars ▪No training and no dementia care managers ▪Short, partly interactive seminar on dementia diagnostics (3 hours). | ▪Intervention clinics demonstrated better health-related quality of life (QoL), overall quality of health care in patients, family caregiving quality, social support and more family caregivers reported receiving all the help they needed. ▪The health-related QoL of the caregiver did not increase. ▪Higher proportions of patients were newly diagnosed with dementia following educational workshops and computerized Decision Support System (DSS) group compared to the control group. ▪After a 2-h seminar for physicians there were higher rates of 'suspected dementia' and lower rates of both 'uncertain' and 'non-suspected' diagnoses when compared to the control group. ▪Both the mean compliance per patient to the total set of 23 quality indicators, and the compliance per indicator for 21 of 23 quality indicators, were better in intervention clinics than in control clinics. ▪Physicians gained more knowledge after a 5-h seminar than a 3-h seminar. ▪After 9-months, more physicians in the intervention group correctly answered 2 questions about decision-making compared to the control group. Those in the intervention group more strongly agreed that 'Older patients with dementia are difficult to manage in primary care' than the PCPs in the control group. |