Case-finding of dementia in general practice and effects of subsequent collaborative care; design of a cluster RCT

Abstract

BackgroundIn the primary care setting, dementia is often diagnosed relatively late in the disease process. Case finding and proactive collaborative care may have beneficial effects on both patient and informal caregiver by clarifying the cause of cognitive decline and changed behaviour and by enabling support, care planning and access to services.We aim to improve the recognition and diagnosis of individuals with dementia in general practice. In addition to this diagnostic aim, the effects of case finding and subsequent care on the mental health of individuals with dementia and the mental health of their informal carers are explored.Methods and designDesign: cluster randomised controlled trial with process evaluation.Participants: 162 individuals ≥ 65 years, in 15 primary care practices, in whom GPs suspect cognitive impairment, but without a dementia diagnosis.Intervention; case finding and collaborative care: 2 trained practice nurses (PNs) invite all patients with suspected cognitive impairment for a brief functional and cognitive screening. If the cognitive tests are supportive of cognitive impairment, individuals are referred to their GP for further evaluation. If dementia is diagnosed, a comprehensive geriatric assessment takes place to identify other relevant geriatric problems that need to be addressed. Furthermore, the team of GP and PN provide information and support.Control: GPs provide care and diagnosis as usual.Main study parameters: after 12 months both groups are compared on: 1) incident dementia (and MCI) diagnoses and 2) patient and caregiver quality of life (QoL-AD; EQ5D) and mental health (MH5; GHQ 12) and caregiver competence to care (SSCQ). The process evaluation concerns facilitating and impeding factors to the implementation of this intervention. These factors are assessed on the care provider level, the care recipient level and on the organisational level.DiscussionThis study will provide insight into the diagnostic yield and the clinical effects of case finding and collaborative care for individuals with suspected cognitive impairment, compared to usual care. A process evaluation will give insight into the feasibility of this intervention.The first results are expected in the course of 2013.Trial registrationNTR3389

Patient characteristics associated with screening positive for Alzheimer’s disease and related dementia

“…Given the uncertainty regarding routine, population screening, targeted screening of people at risk for ADRD may represent an alternative to traditional population screening. 6 , 7 Patient characteristics, such as education and comorbidity burden, 8 , 9 as well as lifestyle factors, 10 have been shown to correlate with cognitive impairment screening results. For example, some research has shown that patients who score worse on cognitive assessment are more likely to be female, African-American, and have less years of formal education.…”

Exploring dementia management attitudes in primary care: a key informant survey to primary care physicians in 25 European countries

“…Some studies show that more than 50% of persons with dementia have never received a diagnosis of dementia from a physician (7). A 2012 review showed that 14-33% of mild dementia and 28-61% of moderate to severe dementia cases were diagnosed in primary care (8)(9)(10)(11). In the short-term, timely diagnosis ensures access to psychosocial and pharmacological interventions .…”

Case Finding of Mild Cognitive Impairment and Dementia and Subsequent Care; Results of a Cluster RCT in Primary Care

“…FPs performed this classification of cognition based on their recollection of clinical patient contacts and on information in the electronic medical records. As described in a previous paper, this yielded a selection of persons with a prior chance of cognitive impairment of 47.1% (according to the CAMCOG), which is substantially higher than in the general population of this age [ 46 ].…”

“…Further management of persons diagnosed with MCI and having unmet care needs, or persons diagnosed with dementia, included psychoeducation, a needs assessment, drawing up of a care plan and referral to services. More details of the intervention are provided elsewhere [ 46 ].…”

“…Quality of life with the Quality of life in Alzheimer’s Disease scale (QoL-AD) (REF). Close-relatives’ mental health was measured with the General Health Questionnaire (GHQ12),their generic health related Quality of life with the EuroQol scale (EQ5D) [ 46 ].…”