The initial search identified 417 unique citations for possible inclusion after duplicates were removed. After searching the reference list of a relevant previous systematic review of systematic reviews6, three additional citations were collected and screened for eligibility. After screening the 420 citations, 369 were excluded because they did not meet the inclusion criteria. From the 51 full-text articles screened, 30 articles were excluded. Reasons for exclusion include not being a systematic review (n = 20), describing a setting other than primary care (n = 1), failing to describe the intervention (n = 3), or a poor AMSTAR 2 rating (n = 6). This resulted in the inclusion of 21 articles for qualitative synthesis. The included studies were published between June 2003 and July 2019.
Nine7–15 out of the 21 included systematic reviews describe screening tools for use in primary care (Table 1). Various screening tools, assessing cognitive impairment or dementia, were compared in terms of cognitive outcomes assessed, time to administer, and sensitivity and specificity. The MMSE was used as a reference standard in the majority of the included studies. The Mini-Cog (n = 5) and the MMSE (n = 7) were the most widely studied tools among the included reviews. The Mini-Cog takes approximately 3 minutes to administer, and sensitivity ranges from 76%-100% and specificity from 27%-93%7,9,11,14 depending upon the cut-off value used.
Five systematic reviews examining the MMSE found that it took between 4 to 15 minutes to administer depending upon the severity of dementia9–13. One study found a cut point of 17 had a higher specificity (93%, 95% CI: 89%-96%) than a cut point of 24 (46%, 95% CI: 40%-52%), while the sensitivity fell from 100% (95% CI: 95%-100%) to 70% (95% CI: 59%-80%) respectively13.
The Abbreviated Mental Test Score (AMTS) achieved high sensitivity (100%, 95% CI: 70%-100%) and specificity (82%, 95% CI: 72%-90%)9 compared to a clinical reference standard, and took the shortest amount of time (3.16 to 5 minutes)9,11 within primary care. The AMTS was validated for use in general practice9.
Diagnostic accuracy and physician education
The diagnosis of dementia by FPs varies but is generally low, as reported in 3 different systematic reviews8,13,16. In an (urban/rural) study, when following usual practice, only half of cases of mild dementia were diagnosed by the FP16. In a separate review, un-diagnosed dementia accounted for 50% − 66% of all cases of dementia in three primary care samples studied8,17−19. Another review reported that the recognition of cognitive impairment in usual practice achieved a detection sensitivity of 62.8% (95% CI: 38.0%-84.4%) and specificity of 87.3% (n = 3; 95% CI: 84.9%-89.4%)13. However, medical record notations mentioning dementia were present in only 37.9% (95% CI: 26.8%-49.6%) and FPs recorded a definitive dementia diagnosis in the medical record in only 10.9% (95% CI: 6.8%-15.7%) of mild cognitive impairment (MCI) cases13.
Five of six studies found that FPs had an increased likelihood of suspecting dementia after attending an educational seminar20,21. One study found that the length of the educational seminar impacted the degree of knowledge about dementia management21.
Management of dementia
Decision aids, advanced care planning (ACP), collaboration with a case manager (CM) and practice guidelines are all interventions with variable impact on helping facilitate the management of dementia in primary care20,22−26 (Table 2). A CM in particular, such as a nurse specialized in care of older adults, can be an asset to a primary care team with the collective goal of collaborating towards meeting the needs of the patient-caregiver dyad28. In the case management intervention group of a randomized controlled trial, neuropsychiatric symptoms of dementia decreased (Mean Effect Size (MES) = 0.88), as well as the numbers of hospital (MES = 0.66) and emergency department admissions (MES = 0.17)23. However, it was found that there was a lack of successful implementation of a CM into care teams within primary care because of the absence of CMs within the primary care setting, and 52% of CMs reported ineffective communication between the CM and FPs23.
Only one systematic review looked at pharmacological treatments in the context of primary care8. There was no clinically important difference observed on neuropsychiatric symptoms between patients with mild to moderate Alzheimer’s disease taking cholinesterase inhibitors versus placebo8.
Supporting caregivers of people with dementia
FPs reported feeling highly involved in dementia care29. However, family caregivers reported that communication with the FPs was unsatisfactory, specifically around awareness of daily care problems (e.g. neuropsychiatric symptoms)29. The primary care educational intervention, Resources for Enhancing Alzheimer’s Caregiver Health (Department of Veterans Affairs) (REACH VA), involves a trained coach who provides sessions to the caregiver on topics relating to self-care, problem solving, mood management and stress management30. REACH VA was successful at increasing carer ability to manage problem behaviours and improved outcomes for caregivers, such as decreased burden, depression and caregiving frustrations28,29. A meta-analysis showed that 58% (95% CI: 43%-72%) of family caregivers were in favor of early dementia diagnosis, 50% (95% CI: 35%-65%) needed education on dementia, and 23% (95% CI: 17%-31%) needed in-home support31.