Dementia management in European primary care

Abstract: Background: Around 50 million people worldwide have dementia and the prevalence is expected to increase to 152 million by 2050. According to the WHO, dementia is a priority health policy issue. The role of primary care physicians (PCPs) for timely dementia management can be cost-effective, yet PCP involvement in the management of patients with presumed or diagnosed dementia vary across Europe.Aim: Exploring dementia identification and management in European primary care. Methods: Paper I is a key informant survey across 25 countries based on self-administered questionnaires from 445 PCPs. Paper II is an adaptation into Italian of the cognitive test - A Quick Test of cognitive speed (AQT). Paper III is an explorative analysis inspired by grounded theory examining dementia case reports from 106 key informant PCPs (same study as paper I). Paper IV examined if brief cognitive tests used in primary care could identify mild cognitive impairment (MCI) in 466 primary care patients referred to a memory clinic due to cognitive complaints. The examined tests were the Mini-Mental State Examination (MMSE), the Clock Drawing Test and AQT.Results: In paper I we found that in some countries, PCPs were allowed to establish a diagnosis of dementia and start specific drug treatment reimbursed by health insurance. In most countries only neurologists, geriatricians, and psychiatrists were allowed to diagnose and treat dementia. A positive association found between the right to prescribe dementia drugs and pursuing dementia diagnostic work-up (OR 3.4; 95% CI 2.3–5.2) implied that dementia diagnostic activities were higher for PCPs who were entitled to prescribe dementia drugs. In paper II Italian reference norms for AQT were successfully established. In paper III we analysed 155 dementia case stories (81 women, 74 men, median age 80 years) from 106 PCPs from 23 countries. In 89 of 155 cases (57%) memantine or acetylcholinesterase inhibitors were prescribed; appropriate according to guidelines in 60% and questionable/inappropriate in 40%, showing a broadening of guideline indications. Unburdening dementia, especially by drugs, was a core pattern of dementia management by many physicians. In paper IV we showed that no single or combination of tests had sufficient accuracy to identify patients with MCI and differentiate them from those with only subjective and benign symptoms. Conclusions: Differing regulations about who does what in dementia management affected PCP’s activities in dementia investigations and assessment. The cognitive test AQT has now been adapted to Italian speakers. Real world dementia drug treatment was characterised by a broadening of guideline indications in order to unburden dementia patients and family members. Since the currently used tests in primary care lack accuracy for identifying MCI better cognitive tests are needed.