Missed and Delayed Diagnosis of Dementia in Primary Care

Abstract

Dementia is a growing public health problem for which early detection may be beneficial. Currently, the diagnosis of dementia in primary care is dependent mostly on clinical suspicion based on patient symptomsor caregivers' concerns and is prone to be missed or delayed. We conducted a systematic review of the literature to ascertain the prevalence and contributing factors for missed and delayed dementia diagnoses in primary care. Prevalence of missed and delayed diagnosis was estimated by abstracting quantitative data from studies of diagnostic sensitivity among primary care providers. Possible predictors and contributory factors were determined from the text of quantitative and qualitative studies of patient-, caregiver-, provider-, and system-related barriers. Overall estimates of diagnostic sensitivity varied among studies and appeared to be in part a function of dementia severity, degree of patient impairment, dementia subtype, and frequency of patient-provider contact. Major contributory factors included problems with attitudes and patient-provider communication, educational deficits, and system resource constraints. The true prevalence of missed and delayed diagnoses of dementia is unknown but appears to be high. Until the case for dementia screening becomes more compelling, efforts to promote timely detection should focus on removing barriers to diagnosis.

Spurious Inferences about Long-Term Outcomes

“…Many survivor outcomes of interest may be systematically underdiagnosed in routine practice (47,65,66). As such, an intervention to improve such an outcome after critical illness might yield a positive trial, even if the critical illness does not cause the outcome-but instead because critical illness serves as a marker for a large burden of an underdiagnosed problem or propensity to develop that problem.…”

Education to Improve Dementia Care:

“…perceive that specialists are most appropriate for making dementia diagnoses, 3,15 yet national consensus guidelines have recommended that the diagnosis and management of patients with dementia should largely be the responsibility of primary care. 16 Enhanced training in clinical assessment and access to diagnostic tools have been identified as critical to improving the diagnosis of dementia.…”

“…16 Enhanced training in clinical assessment and access to diagnostic tools have been identified as critical to improving the diagnosis of dementia. 1,3,15 To build capacity for dementia care, a continuing medical education (CME) workshop was developed by family physicians for family physicians with the support of the Ontario College of Family Physicians, Canada. The workshop was adapted from the curriculum of a comprehensive 5-day interprofessional training program designed to develop primary care-based collaborative memory clinics.…”

“…1,3 Studies have also found that physicians have difficulty differentiating types of dementia, 12 lack knowledge of early signs and symptoms of cognitive impairment, 13 and lack confidence in their diagnostic skills. 14,15 They may…”

“…1,2 As many as two-thirds of persons in the community with dementia remain undiagnosed 3 ; the global prevalence rate of undiagnosed dementia has been estimated to be 61%. 4 Delayed diagnosis results in a higher burden of suffering, excessive emergency department (ED) visits and hospitalizations, higher rates of care in hospitals while waiting for more appropriate alternate levels of care (ALC), premature institutionalization, and higher avoidable health care costs.…”