Fernandes et al.

BMC Fam Pract (2021) 22:166

https://doi.org/10.1186/s12875-021-01461-5

RESEARCH Open Access

Optimizing the diagnosis and management

of dementia within primary care: a systematic
review of systematic reviews
Brooklynn Fernandes1*, Zahra Goodarzi2 and Jayna Holroyd‑Leduc2

Abstract
Background: To understand how best to approach dementia care within primary care and its challenges, we exam‑
ined the evidence related to diagnosing and managing dementia within primary care.
Methods: Databases searched include: MEDLINE, Embase, PsycINFO and The Cochrane Database of Systematic
Reviews from inception to 11 May 2020. English-language systematic reviews, either quantitative or qualitative, were
included if they described interventions involving the diagnosis, treatment and/or management of dementia within
primary care/family medicine and outcome data was available. The risk of bias was assessed using AMSTAR 2. The
review followed PRISMA guidelines and is registered with Open Science Framework.
Results: Twenty-one articles are included. The Mini-Cog and the MMSE were the most widely studied cognitive
screening tools. The Abbreviated Mental Test Score (AMTS) achieved high sensitivity (100 %, 95 % CI: 70-100 %) and
specificity (82 %, 95 % CI: 72-90 %) within the shortest amount of time (3.16 to 5 min) within primary care. Five of six
studies found that family physicians had an increased likelihood of suspecting dementia after attending an educa‑
tional seminar. Case management improved behavioural symptoms, while decreasing hospitalization and emergency
visits. The primary care educational intervention, Enhancing Alzheimer’s Caregiver Health (Department of Veter‑
ans Affairs), was successful at increasing carer ability to manage problem behaviours and improving outcomes for
caregivers.
Conclusions: There are clear tools to help identify cognitive impairment in primary care, but strategies for man‑
agement require further research. The findings from this systematic review will inform family physicians on how to
improve dementia diagnosis and management within their primary care practice.
Keywords: Dementia, Primary care, Family physician, Systematic review, Diagnosis

*Correspondence: [email protected]
1
Faculty of Science, University of Calgary, Calgary, Canada
Full list of author information is available at the end of the article

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Fernandes et al. BMC Fam Pract (2021) 22:166 Page 2 of 17

Background format that would address the existing evidence to prac-

At any given time, 5–8 % of the general population aged tice gap.
60 and over are living with dementia, and it is expected
that 152 million people in the world will have demen- Data Sources
tia by 2050 [1]. The impact of dementia is far reaching, The systematic literature search was developed in con-
as it affects not only the person with dementia, but also sultation with a health sciences librarian, with the final
their family carers, the healthcare system and society as search being completed 11 May 2020. The following data-
a whole [1]. Dementia is often unrecognized, and there bases using the Ovid platform were searched without a
is an underuse of diagnostic assessment tools and a lack restriction to publication date: MEDLINE, EMBASE,
of attention to the issues faced by family caregivers [2]. PsycINFO and The Cochrane Database of Systematic
Approximately 65 % of dementia cases are undiagnosed Reviews. We searched the following clusters of search
in primary care, which negatively impacts these patients terms: Family Practice and Dementia. In each category,
by not implementing advanced care planning and man- we used controlled vocabulary such as Medical Subject
agement strategies before the dementia progresses Headings (MeSH) as well as keywords. Within each clus-
[3]. The U.S Preventative Services Task Force recom- ter, terms were combined with OR, and between the clus-
mends that clinicians assess cognitive functioning when ters with AND. We then used CADTH search terms for
a patient is suspected of cognitive impairment based on the systematic review study designs [7] (Additional file 1:
the physician’s observation or caregiver concerns [3]. Appendix 1). The reference list of a previous relevant sys-
Canadian consensus guidelines similarly do not recom- tematic review of systematic reviews published in 2014
mend asymptomatic screening, but instead suggest use was also searched [8].
of validated screening tools if there is clinical concern for
a cognitive disorder [4]. Common neuropsychological Study Selection
screening tools administered by family physicians (FPs) Systematic reviews were considered if they met the fol-
include the Mini-Mental State Examination (MMSE) and lowing inclusion criteria.
Clock Drawing Test (CDT) [3]. However, it is not clear
that these are the best screening tools for use in primary • Population: Primary care or family practice settings
care. seeing persons with dementia.
Time constraints are often an issue for family doc- • Intervention: The detection, diagnosis, treatment
tors as it relates to diagnosing and managing demen- and/or management of dementia including models of
tia. The time allocated for a typical office visit makes care, pathways and/or protocols.
it challenging to perform a cognitive assessment [5]. • Comparators: Usual care, wait-list control or other
FPs often feel uncertainty regarding the management interventions within the scope of the review.
of dementia after a diagnosis has been made [5]. This • Outcomes: The description of the detection, diagno-
highlights the current need to better optimize demen- sis, treatment or management strategies, along with
tia care within primary care. The objective of this sys- measures of their acceptability, efficacy or effective-
tematic review of systematic reviews was to determine ness in the provision of care.
the most effective evidence-based strategies to diag- • Study design: Systematic review, either quantitative
nose and manage dementia within primary care. Spe- or qualitative.
cifically, we seek to understand what practices FPs can
undertake to ensure accurate and timely testing and Articles were also selected for inclusion if they were
management. English-language articles, included relevant descriptions
of the interventions used, and outcome data was available.
Methods Two reviewers (B.F and J.H.-L.) independently screened
This systematic review was conducted in accordance the titles and abstracts for possible inclusion. If either
to PRISMA (Preferred Reporting Items for Systematic reviewer thought the citation was relevant or potentially
Reviews and Meta-analyses) guidelines [6], and the pro- relevant, the full-text article was then retrieved for fur-
tocol is registered in Open Science Framework [DOI ther evaluation. All full-text articles were assessed inde-
https://​doi.​org/​10.​17605/​OSF.​IO/​E4AW5]. All data gen- pendently for inclusion by B.F and J.H.-L. Any conflicts
erated or analysed during this study are included in this were resolved through discussion. One reviewer (B.F.)
published article in Additional file 1: Appendixes 1 and independently extracted the following information from
2. A systematic review of systematic reviews was deter- the included full-text studies using a standardized data
mined to be the past method to further summarize and extraction form: authors, year of publication, coun-
tailor the current body of literature on this topic into a try where the review was conducted, number of studies
Fernandes et al. BMC Fam Pract (2021) 22:166 Page 3 of 17

included, study designs included, databases searched, Quality Assessment and Analysis
time frame of article search, inclusion and exclusion Two reviewers (B.F and J.H.-L.) independently assessed
criteria, population (mean age, SD and dementia diag- the quality of the included studies using the AMSTAR
nosis), intervention, comparator, sample size, setting (if 2 Systematic Review Quality Appraisal Checklist 2020.
the intervention was cognitive screening, the method of Systematic reviews without a clear PICO were excluded.
administration), time of administration (if intervention Best practices for quality assessment using AMSTAR
was cognitive screening), cognitive outcome(s) meas- 2 are to consider the impact of inadequate ratings for
ured, results (meta-analysis, Sn, Sp, accuracy), and other each category rather than generate an overall score.
(Additional file 1: Appendix 2). One reviewer (B.F) cat- The AMSTAR 2 quality appraisal results for each of the
egorized each study based on the primary category of included studies is available in Additional file 1: Appen-
intervention, which was verified by another reviewer dix 3 [9]. A qualitative descriptive summary of the lit-
(J.H-L). erature is presented.

Fig. 1 PRISMA flow diagram

Fernandes et al. BMC Fam Pract (2021) 22:166 Page 4 of 17

Table 1 Screening tools and their comparators, cognitive outcomes, administration time, sensitivity and specific and conclusions from
the literature included in this systematic review
Reference, Number Intervention(s) Comparator Cognitive Time of Sensitivity (%) Specificity Conclusions Abbreviations
Country of studies outcome(s) administration
included in measured (minutes)
systematic
review

Mitchell et al, 44 Multidomain MMSE Dementia Primary care case- Battery Battery detec‑ The optimal AMTS/MSQ-Abbreviated

▪AMTS/MSQ = 4 ▪89.9 (95% CI

United screening tests finding: detection tion methods: individual tools Mental Test Score/Men‑

▪MSQ = 2 ▪84.0 (95% CI

Kingdom (known as a methods: were the AMTS/ tal Status Questionnaire,

▪WIND-SET = 1
battery detec‑ 78.3–97.4) MSQ and PCL. (WIND-SET)-Specific Set

▪PCL = 11
tion method) 74.2–91.8) AMTS was of items from MMSE,

▪AMTS = 2
in primary care superior to the PCL-Prueba cognitive

▪PCL = 11
which assess for MMSE for case de leganes, AMTS-
multiple cogni‑ finding however Abbreviated mental test
tive domains. Primary care the MMSE was score, GPCOG-General

▪PCL = 11
Primary care screening: optimal for practitioner’s assess‑

▪AMTS/MSQ, ▪AMTS/MSQ = 4
case-finding † : screening. ment of cognition,

▪MSQ ▪MSQ = 2
MMSE-Mini-Mental

▪WIND-SET ▪SPMSQ = 2
State Examination

▪PCL ▪GPCOG = 5
† Case-finding is defined

▪AMTS
as any tool or question‑

▪PCL ▪MMSE = 9
Comparator: naire which identifies a
condition with minimal
Primary care with healthy false negatives, meas‑

▪ PCL
screening ‡ : individuals and ured as the positive

▪AMTS/MSQ
15 with patients predicative value.

▪MSQ
with dementia. ‡ Screening is the ability

▪SPMSQ
of a test to rule out a

▪GPCOG
diagnosis with minimal
false positives, reported
as the negative predic‑
tive value.
Creavin et al, 70 ▪MMSE A commonly Dementia ▪MMSE=7 with Carnero-Pardo Carnero-Pardo Carnero-Pardo 2013

▪Cut point ▪Cut point of 17

United accepted a patient with 2013: 2013: reported there
Kingdom clinical (gold) dementia and were some false
reference 5 with a person of 17 = = 93 (95% CI negatives as the

▪Cut point of 24
standard. with normal 70 (95% CI 89, 96) sensitivity fell

▪Cut point of
cognition 59-80) from 1.00 (95%
= 46 (95% CI CI 0.95 to 1.00)
24 = 100 40-52) to 0.70 (95% CI
(95% CI 0.59 to 0.80). The
95-100) summary diag‑
nostic accuracy
could not be
estimated due to
insufficient data.
Fernandes et al. BMC Fam Pract (2021) 22:166 Page 5 of 17

Table 1 (continued)
Reference, Number Intervention(s) Comparator Cognitive Time of Sensitivity (%) Specificity Conclusions Abbreviations
Country of studies outcome(s) administration
included in measured (minutes)
systematic
review

▪MoCA-B; MoCA ▪MoCA-B = 15-21;

▪SPMSQ
Abd Razak 30 Comparing the Mild cognitive For detecting For detecting For detecting NR-Not Reported,

▪MEFO ▪SPMSQ = 10-15 ▪ACE-III at a ▪ACE-III at a cut-

et al, feasibility impair‑ MoCA = 10-15 dementia: dementia: dementia: MCI-Mild Cognitive

▪ACE-III ▪MEFO = 10-15

Malaysia and validity ment and Screening tools Impairment, (MoCA-

▪AQT-CF ▪ACE-III = 15
between dementia cut-off point off point of less sensitive to B)-Montreal Cognitive

▪SLUMS ▪AQT-CF = 3-5

the various of <81, Sn <81, Sp=96 ACE-III but with Assessment-Basic,

▪5 Object Test ▪SLUMS = 7

screening = 100 For detecting relatively high (MoCA)-Montreal

▪BNB Semantic ▪5 Object Test ▪MoCA, Sp =

tools. For detecting MCI: Sn/Sp values Cognitive Assessment,

▪MoCA, Sn =
MCI: were: SPMSQ-Short Portable

▪SMCC compared ▪BNB Semantic

Fluency = <5 60-80 SLUMS, RCS, and Mental Status Question‑
91-97 BCAT. naire, (MEFO)-Memory,

▪MCC compared
to MMSE and Fluency = 31 For detecting fluency and orientation,

▪CASI-S
CDT MCI: The MoCA (ACE-III)-Addenbrooke’s

▪RCS
to MMSE and was the most Cognitive Examination

▪CPS ▪CASI-S = NR
CDT = NR commonly used III, (AQT-CF)-A Quick

▪Literacy Inde‑ ▪RCS = <3

tool and had the Test of Cognitive Speed,

▪CPS = NR
highest Sn/Sp (SLUMS)- Saint Louis

▪Literacy Inde‑
pendent Cogni‑ ranges. University Mental

▪BIMS; BCAT​
tive Assessment Less specific to Status, (BNB)-Brief

▪3MS
pendent Cogni‑ the MoCA but Neuropsychological Bat‑

▪Mini-Cog; MIS;
tive Assessment among the tery Semantic Fluency,

▪BIMS = 3; BCAT =
= 20 most sensitive (SMCC)-The Subjective

▪VT-VSM; VR-DOT
MF-2 tools were the Memory Complaint

▪CCS ▪3MS = 17
10-15 (VR-DOT) and Clinical, (CASI-S)-Cogni‑

▪CAMCI ▪Mini-Cog = 3;
IQCODE. Tools tive Abilities Screening

▪CADi; CADi-2
with the highest Instrument-Short,

▪DRA
MIS = 4; MF-2 specificity but (RCS)-Rapid Cognitive

▪p-AD8 ▪VT-VSM = >12;

= <2 with lower Screen, (CPS)-Cognitive

▪IQCODE
sensitivity were: Performance Scale,

▪CCS = 3
VR-DOT = NR The 5 Objects (BIMS)-Brief Interview

▪CAMCI = 30
Test, RCS, CPS, for Mental Status,

▪CADi = 10;
and (VT-VSM). (BCAT)-Brief Cognitive
Assessment Tool, (3MS)-

▪DRA = NR
CADi-2 = 10-40 Modified Mini-Mental

▪p-AD8 = NR
State Examination,

▪IQCODE = 10
(MIS)-Memory
Impairment Screen,
(MF-2)-Memory Func‑
tion 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 ver‑
sion], (DRA)-Dementia
Risk Assessment,
(p-AD8)-Participant-
rated, (IQCODE)- Inform‑
ant Questionnaire on
Cognitive Decline in the
Elderly individuals
Smith et al, 33 ▪Rural Older Adult Not mentioned. Dementia Not mentioned. Not men‑ Not mentioned. There is insufficient (PRISM-PC)-Perceptions
United Memory Evalu‑ tioned. evidence to sup‑ Regarding Investiga‑

▪Mini-Cog
Kingdom ation port the adop‑ tional Screening for

▪PRISM-PC
tion of these Memory in Primary

▪SAPH question‑
programmes into Care, SAPH-Dementia
practice. Six posi‑ Screening and Per‑

▪MMSE and clinical

naire tive and eight ceived Hames, CIE-The
negative effects Canberra Interview for
history/exami‑ of primary care the Elderly

▪7-minute screen
nation screening and

▪CIE and MMSE

early diagnosis of
dementia were
reported.
Fernandes et al. BMC Fam Pract (2021) 22:166 Page 6 of 17

Table 1 (continued)
Reference, Number Intervention(s) Comparator Cognitive Time of Sensitivity (%) Specificity Conclusions Abbreviations
Country of studies outcome(s) administration
included in measured (minutes)
systematic
review

▪AMT = 3:16
▪Camnridge Cog‑
Brodaty et al, 83 Instruments MMSE Dementia Screening tests Screening tests Screening tests MAT-Mental Alterna‑
Australia Validated in validated validated validated in tion Test. *- (Based
General Practice, nitive Examina‑ in general in general general practice, on Diagnostic and

▪CDT = 2:16
Community tion = 20 practice, practice, community Statistical Manual

▪GPCOG = 4.5
or Population community community or population of Mental Disorders,

▪AMT ▪Mini-Cog = 2-4

Samples: or popula‑ or population samples: Fourth Edition criteria

▪Cambridge ▪MIS = 4 ▪AMT-100 (95% ▪AMT-82 (95%

tion samples: samples: AMT had a requiring that instru‑

▪MMSE = 4
PPV=0.42 (95% ments test memory

▪Short and Sweet ▪Cambridge ▪Cambridge

Cognitive CI 70-100) CI 72-90) CI), NPV=1.00 and at least one other

▪CDT
Examination (95% CI), misclas‑ cognitive domain).

▪GPCOG
Screening Cognitive Cognitive sification of 16%, CDT-Clock Drawing

▪Mini-Cog
Instrument Examina‑ Examina‑ had internal Test. GPCOG-General

▪MIS ▪Short IQCODE

= 10 tion-88 (95% tion-75 (95% consistency and Practitioner Assessment

▪MMSE ▪CDT-76 (95% ▪CDT-81 (95% CI

CI 64-99) CI 67-83) face validity. of Cognition.

▪Short and Sweet

= 30s Mini-Cog had a

▪GPCOG-85 ▪GPCOG-86
CI 60-88) 77-84) PPV=0.34 (95%
Screening CI), NPV=0.98

▪Short IQCODE
Instrument (95% CI (95% CI (95% CI), 12%

▪Mini-Cog-76 ▪Mini-Cog-89
76-92) 81-91) misclassification,
no education
(95% CI (95% CI bias or language/

▪MIS-80 (95% ▪MIS-96 (95% CI

65-85) 87-91) cultural bias,
and had face

▪MMSE-69 ▪MMSE-89 (95%

CI 66-90) 94-98) validity*.
The AMT, CDT,

▪Short and
(95% CI CI 87-92) GPCOG, Short

▪Short and
66-73) IQCODE, Mini-
Sweet Screen‑ Cog, and MIS all
Sweet ing Instru‑ had a NPV =<
Screening ment-91 (95% MMSE (0.92).

▪Short
Instru‑ CI 90-92) The GPCOG,
ment-94 Mini-Cog and
(95% CI IQCODE-82 MIS had a

▪Short
88-96) (95% CI misclassification
79-85) rate =< MMSE
IQCODE-79 (15%) and had a
(95% CI high sensitivity
65-90) and specificity
(>=80%) and
were therefore
chosen as the
most suitable
instruments for
use in general
practice.
Seitz et al, 4 The Mini-Cog Standard diag‑ Alzheimer’s Mini-Cog = 3-5 in Carnero- Carnero-Pardo Presently there

▪40 (95% CI
Canada performed in nostic criteria disease routine practice Pardo 2013 2013: is insufficient
insolation or for the clinical dementia dementia evidence to
scored based on diagnosis of and related prevalence 30-50) support the use

▪100 (95% CI ▪85 (95% CI

results on the dementia dementias was 34.5%: Fuchs 2012: of Mini-Cog in
CDT or three- primary care.
word recall 93-100) 81-89) Studies mentioned

▪73 (95% CI
Fuchs 2012 Holsinger 2012: are primary
5.0% journal articles
dementia 68-77) (cross-sectional

▪100 (95% CI ▪27 (95% CI

prevalence: McCarten 2012: studies).

84-100) 16-41)
Holsinger 2012
(highest
quality
study) 5.5%
dementia

▪76 (95% CI
prevalence:

53-92)
McCarten
2012 90.3%
dementia

▪84 (95% CI
prevalence:

81-87)
Fernandes et al. BMC Fam Pract (2021) 22:166 Page 7 of 17

Table 1 (continued)
Reference, Number Intervention(s) Comparator Cognitive Time of Sensitivity (%) Specificity Conclusions Abbreviations
Country of studies outcome(s) administration
included in measured (minutes)
systematic
review

▪3MS ▪3MS = 10-15 ▪3MS = 83-94 ▪3MS = 85-90

▪CASI ▪CASI = 15-20 ▪CASI = 91-95 ▪CASI = 37-97
Cullen et al, 36 Gold standard Cognitive These tests were (ACE-R)-Addenbrooke’s

▪MMSE ▪MMSE = 8-13 ▪MMSE = ▪MMSE = 87-99

United diagnostic impairment selected as brief Cognitive Examination

▪SASSI ▪SASSI = 10-15 ▪SASSI = 81-91

Kingdom criteria or any type assessment tools Revised, STMS-Short Test

▪STMS ▪STMS = 5 ▪SASSI = 94 ▪STMS = 88-94

(based on of dementia 69-91 in the doctor’s of Mental Status, CCSE-

▪CAST ▪CAST = 15 ▪STMS = 86-95 ▪CAST = 88-100

international office due to Cognitive Capacity

▪GPCOG ▪GPCOG = 5 ▪CAST = 88-95 ▪GPCOG = 86

diagnostic their reported Screening Examination,

▪7MS ▪7MS = 7-15 ▪GPCOG = 85 ▪7MS = 94

guidelines or sensitivity and (R-CAMCOG)-Rotter‑

▪AMT ▪AMT = 5 ▪7MS = 91 ▪AMT = 71-100

clinical judge‑ specificity values dam Version of the

▪Mini-Cog ▪Mini-Cog = 3-4 ▪AMT = 73-100 ▪Mini-Cog =

ment fol‑ that were >85% Cambridge Cognitive

▪SIS ▪SIS = 5 ▪Mini-Cog =

lowing a full for all dementia Examination

▪T&C ▪T&C = 1 ▪SIS = 88-91

assessment 89-93 types together

▪ACE-R ▪ACE-R = 16 ▪SIS = 81-89 ▪T&C = 54-96

battery). 76-99 or for more than

▪DemTect ▪DemTect = 8-10 ▪T&C = 63-95 ▪ACE-R =

one particular

▪ACE-R =
subtype alone,

▪DemTect = 92
89-100 and/or they

▪DemTect
84-94 covered at
(Alzheimer’s least three key
= 100 dementia) domains.
(Alzheimer’s The 3MS and CASI
dementia) are the only tests
which cover all
six key abilities
(Attention/work‑
ing memory,
verbal recall,
expressive
language, verbal
fluency, visual
construction,
reasoning/judge‑
ment).
▪MIS ▪MIS, IST = 4 ▪MIS, IST = 74 ▪MIS = 84, IST
▪IST, BVRT ▪IST, BVRT = 1 ▪IST, BVRT -
Lischka et al, 12 A full clinical Dementia, MCI, Tools with the high‑ (IST,BVRT)-Isaacs Set Test,

▪CAMCI ▪CAMCI = 15 ▪IST, BVRT -

Canada examina‑ amnestic = 81 est specificity Benton’s Visual Reten‑

▪ACE ▪ACE = 15 ▪MMSE

tion as the MCI, mild Cutoff level 1 rates: tion Test. CAMCI-Chi‑

▪ADAS-Cog ▪ADAS-Cog = NR ▪CAMCI = 83.4 ▪S-MMSE

reference demen‑ = 90.8 Cutoff level 1 nese Abbreviated Mild

▪CAMCOG ▪CAMCOG = 20 ▪ACE - Cutoff ▪CAMCI = 78.5

standard. tia, and = 52.2 Cognitive Impairment

▪MoCA ▪MoCA = 10-12 ▪ACE - Cutoff

questionable Tests with the Test, (ADAS-Cog)-

▪S-MMSE ▪S-MMSE = 10
dementia. <88/100 = highest sensitivi‑ Alzheimer Disease

▪IQCODE ▪IQCODE = 10-20 ▪ADAS-Cog ▪HDS-R

100 <88/100 ties: Assessment Scale-

▪STMS ▪STMS = 5 ▪ADAS-Cog ▪ACE, which

= 43 Cognitive Subscale,

▪MMSE ▪MMSE = 5-10

- Cutoff (S-MMSE)-Standardized

▪HDS-R ▪HDS-R = NR
<75/100 - Cutoff decreased Mini-Mental State

▪CCSE ▪CCSE = 10-12 ▪CAMCOG

= 85 <75/100 depending on Examination, (HDS-R)-

▪CAMCOG = 96 ▪MoCA for the

= 83 cut-off value Hasegawa Dementia
= 76 for Scale-Revised, CCSE-
memory for memory dementia group Cognitive Capacity

▪MoCA = 94 ▪MoCA = 50
section section and 83% for the Screening Examination,

▪S-MMSE = 14 ▪S-MMSE = 100 ▪CAMCI

MCI group CAMCOG-Cambridge

▪IQCODE = 41 ▪IQCODE = 67 ▪CCSE

Cognitive Examination

▪STMS = ≤ 80 ▪STMS = ≤ 80 ▪The combination

▪MMSE = 31 ▪MMSE = 96
▪HDS-R = ▪HDS-R = 74 for
of the MMSE,
IST, and BVRT at
92 for the the dementia 90.8% for the first
dementia diabetic cut-off level.

▪CCSE - Cutoff
diabetic group The ACE demon‑

▪CCSE - Cutoff
group strated good
26/25 = 83.5 diagnostic
26/25 = accuracy with
88.1 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 sen‑
sitivity (88.1%)
and specificity
(83.5%).
Fernandes et al. BMC Fam Pract (2021) 22:166 Page 8 of 17

Table 1 (continued)
Reference, Number Intervention(s) Comparator Cognitive Time of Sensitivity (%) Specificity Conclusions Abbreviations
Country of studies outcome(s) administration
included in measured (minutes)
systematic
review

▪MMSE ▪MMSE = ▪MMSE = 56-96

▪FAQ ▪FAQ = 90
Boustani et al, 61 DSM-IV Dementia Not mentioned. The MMSE has BIMC-Blessed Information

▪BIMC ▪FAQ = 90 ▪BIMC = 65-90

United 71-92 limited Sp when Memory Concentration;

▪BOMC ▪BIMC = 90 ▪BOMC = 90

States the cut-point is BOMC-Blessed Orienta‑

▪STMS ▪BOMC = 69 ▪STMS = 90

set for higher Sn. tion Memory Concen‑

▪STMS = 81
Accuracy of the tration; FAQ-Functional
MMSE changes Activities Question‑
based upon the naire; STMS-Short
patients age, Test of Mental Status;
education level DSM-IV-Diagnostic and
and ethnicity Statistical Manual of
and therefore Mental Disorders, fourth
requires adjust‑ edition
ment when
used.
Fernandes et al. BMC Fam Pract (2021) 22:166 Page 9 of 17

Results in three primary care samples studied [11, 20−22].

The initial search identified 417 unique citations for Another review reported that the recognition of cogni-
possible inclusion after duplicates were removed. tive impairment in usual practice achieved a detection
After searching the reference list of a relevant previ- sensitivity of 62.8 % (95 % CI: 38.0-84.4 %) and specific-
ous systematic review of systematic reviews [8], three ity of 87.3 % (n = 3; 95 % CI: 84.9-89.4 %) [16]. However,
additional citations were collected and screened for medical record notations mentioning dementia were
eligibility. After screening the 420 citations, 369 were present in only 37.9 % (95 % CI: 26.8-49.6 %) and FPs
excluded because they did not meet the inclusion cri- recorded a definitive dementia diagnosis in the medical
teria. From the 51 full-text articles screened, 30 articles record in only 10.9 % (95 % CI: 6.8-15.7 %) of mild cogni-
were excluded. Reasons for exclusion include not being tive impairment (MCI) cases [16].
a systematic review (n = 20), describing a setting other Five of six studies found that FPs had an increased
than primary care (n = 1), failing to describe the inter- likelihood of suspecting dementia after attending an
vention (n = 3), or a poor AMSTAR 2 rating (n = 6). educational seminar [23, 24]. One study found that the
This resulted in the inclusion of 21 articles (Fig. 1). The length of the educational seminar impacted the degree
included studies were published between June 2003 and of knowledge about dementia management [24].
July 2019.
Management of dementia
Screening tools Decision aids, advanced care planning (ACP), collabora-
Nine [10–18] out of the 21 included systematic reviews tion with a case manager (CM) and practice guidelines
describe screening tools for use in primary care are all interventions with variable impact on helping
(Table 1). Various screening tools, assessing cognitive facilitate the management of dementia in primary care
impairment or dementia, were compared in terms of [23, 25−29] (Table 2). A CM in particular, such as a nurse
cognitive outcomes assessed, time to administer, and specialized in care of older adults, can be an asset to a pri-
sensitivity and specificity. The MMSE was used as a ref- mary care team with the collective goal of collaborating
erence standard in the majority of the included studies. towards meeting the needs of the patient-caregiver dyad
The Mini-Cog (n = 5) and the MMSE (n = 7) were the [30]. In the case management intervention group of a
most widely studied tools among the included reviews. randomized controlled trial, neuropsychiatric symptoms
The Mini-Cog takes approximately 3 min to administer, of dementia decreased (Mean Effect Size (MES) = 0.88),
and sensitivity ranges from 76 to 100 % and specificity as well as the numbers of hospital (MES = 0.66) and
from 27 to 93 % [10, 12, 14, 17] depending upon the cut- emergency department admissions (MES = 0.17) [26].
off value used. However, it was found that there was a lack of successful
Five systematic reviews examining the MMSE implementation of a CM into care teams within primary
found that it took between 4 and 15 min to adminis- care because of the absence of CMs within the primary
ter depending upon the severity of dementia [12–16]. care setting, and 52 % of CMs reported ineffective com-
One study found a cut point of 17 had a higher speci- munication between the CM and FPs [26].
ficity (93 %, 95 % CI: 89-96 %) than a cut point of 24 Only one systematic review looked at pharmacological
(46 %, 95 % CI: 40-52 %), while the sensitivity fell from treatments in the context of primary care [11]. There was
100 % (95 % CI: 95-100 %) to 70 % (95 % CI: 59-80 %) no clinically important difference observed on neuropsy-
respectively [16]. chiatric symptoms between patients with mild to moder-
The Abbreviated Mental Test Score (AMTS) achieved ate Alzheimer’s disease taking cholinesterase inhibitors
high sensitivity (100 %, 95 % CI: 70-100 %) and specific- versus placebo [11].
ity (82 %, 95 % CI: 72-90 %) [12] compared to a clinical
reference standard, and took the shortest amount of Supporting caregivers of people with dementia
time (3.16 to 5 min) [12, 14] within primary care. The FPs reported feeling highly involved in dementia care
AMTS was validated for use in general practice [12]. [31]. However, family caregivers reported that com-
munication with the FPs was unsatisfactory, specifically
Diagnostic accuracy and physician education around awareness of daily care problems (e.g. neuropsy-
The diagnosis of dementia by FPs varies but is generally chiatric symptoms) [31]. The primary care educational
low, as reported in 3 different systematic reviews [11, intervention, Resources for Enhancing Alzheimer’s Car-
16, 19]. In an (urban/rural) study, when following usual egiver Health (Department of Veterans Affairs) (REACH
practice, only half of cases of mild dementia were diag- VA), involves a trained coach who provides sessions to
nosed by the FP [19]. In a separate review, un-diagnosed the caregiver on topics relating to self-care, problem solv-
dementia accounted for 50 − 66 % of all cases of dementia ing, mood management and stress management [32].
Fernandes et al. BMC Fam Pract (2021) 22:166 Page 10 of 17

Table 2 Case management interventions and corresponding comparators and outcomes from the literature included in this
systematic review
Authors, Country Number of studies Intervention Comparator Outcomes
included in systematic
review

Sivananthan et al, Canada 12 7 dementia care processes Clinical services provided by ▪8 out of 12 studies reported
recommended by best physicians to older adults that <60% of physicians

▪Formal memory testing

practice guidelines: diagnosed with dementia. conducted formal memory

▪Imaging
testing, while 3 studies

▪Laboratory testing
reported <15%, and 1 study

▪Interventions ▪33% to 91% of family physi‑

<4%

▪Counseling
▪Community service
cian’s prescribed medica‑

▪Specialist referrals
tions for dementia and
consequent behavioral

▪33-80% of physicians
problems

reported the use of CT or

MRI as a diagnostic tool, and

▪2 studies reported that >80%

>75% used blood work

of physicians provided

▪Only 63% of case managers

counseling.
Khanassov et al, Canada 23 Case Management inter‑ No comparator
ventions comprising all clearly explained their role
components identified to the patient-caregiver
by the Case Management dyads while 25% did not

▪Case finding and screening

Society of America: give any detail during

▪Assessment ▪52% of case managers

assessment

▪Care planning
▪Implementation and
indicated that poor com‑
munication with health‑

▪Monitoring
management care providers negatively

▪Review ▪Limiting factors to case

affected their work

management implemen‑
tation were: insufficient
knowledge of diagnostic
tools, absence of training,
and the absence of the case
manager in the primary care
setting.
Fernandes et al. BMC Fam Pract (2021) 22:166 Page 11 of 17

Table 2 (continued)
Authors, Country Number of studies Intervention Comparator Outcomes
included in systematic
review

Decision-making interven‑ ▪The majority of studies

▪DECIDE decreased decisional
Davies et al, United King‑ 10 Place of care:

▪One study used solely

dom tions with decision aids in used a control group

▪GOLD showed less of an

dementia care (i.e. audio conflict in caregivers
guided booklet, a printed listening to a verbal narra‑
decision aids about tive of the disease. increase in burden and
dementia and feeding; greater increase in the
a living with dementia knowledge of caregivers

▪A video decision aid

Guiding Options for Living Goals of care:
with Dementia (GOLD)
book; DECIDE interven‑ combined with a struc‑
tion: a guided decision tured meeting improved
aid participants read and communication between
complete with support caregivers and professionals
of decision coach to and improved the concord‑
assist in making decisions ance on the goals of care
regarding care home after 9 months

▪Two RCTs (N=72) included.

placement, video decision Meta-analysis:

▪Decision aids are effective

aid and structured meet‑
ing between surrogate
decision maker and in decreasing decisional
interdisciplinary care plan conflict in caregivers (stand‑
team; a video decision aid ardized MD=− 0.50, 95%
and audio description of CI [ − 0.97, − 0.02]). This
advanced dementia) suggests increased confi‑
dence in decision-making
and understanding of the

▪Decisional conflict was

decisions.

measured using the Deci‑

sion Conflict Scale at 3
months post intervention.

▪An early start while cognitive

Tilburgs et al, Australia 16 Advanced care planning No comparator Facilitators for ACP:
(ACP)

▪Inclusion of all stakeholders

decline is mild.

and a good relationship

between the GP, patient,

▪Discussion of social and

and family carers.

medical issues aimed at

▪Decision aids that provide

maintaining a normal life.

information and structure

which contribute to deci‑
sion making.

▪Uncertainty about the tim‑

Barriers for ACP:

▪How to plan for an uncertain

ing of ACP.

▪Lack of knowledge about

future.

dementia and patient’s lack

▪Bad relationships among

of knowledge of diagnosis.

▪Stress/fear caused by ACP.

stakeholders.

▪Who should take initiative

▪Difficulties assessing the

for ACP.

dementia patient’s deci‑

▪Changing preferences.
sional capacities.
Fernandes et al. BMC Fam Pract (2021) 22:166 Page 12 of 17

Table 2 (continued)
Authors, Country Number of studies Intervention Comparator Outcomes
included in systematic
review

▪2 of 3 RCTs of physician
▪Control groups.
Mukadam et al, United 13 Interventions intended to RCT:

▪Dementia
Kingdom increase the detection of : education found group

▪Suspected dementia
Non-randomized studies educational interventions

▪People presenting with

and pre-post study increased the likelihood

▪Comparison groups.
designs: of physicians suspecting

▪Non-randomized study find‑

memory complaints dementia.

ings suggest that clinician

education in primary care
interventions can increase
the proportion of patients
in whom physicians suspect
dementia; untargeted com‑
munity leaflet campaigns
did not increase dementia

▪Pre-post comparison
diagnosis rates.

studies showed no posi‑

tive 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.
Fernandes et al. BMC Fam Pract (2021) 22:166 Page 13 of 17

Table 2 (continued)
Authors, Country Number of studies Intervention Comparator Outcomes
included in systematic
review

▪Assessment ▪Control group ▪4/10 trials showed a

Khanassov et al, Canada 43 Case management (CM): RCT: RCT evidence:

▪Care planning
▪Implementation ▪No control
Qualitative studies: decrease in the frequency

▪Management
of behavioral symptoms

▪Regular follow-up
of dementia in the CM
intervention group (mean
effect size 0.88), while 2/7
reported a decrease in

▪No effect on cognition

depression symptoms.

and perceived health was

▪8/11 trials found no effect on

observed.

▪Hospital admissions
institutionalization.

decreased (MES=0.66) in

▪Decreased ER admission
2/5 studies.

was observed in 1/3 stud‑

ies (effect size: 0.17) and
a decrease in length of
hospital stay was shown
in both of the studies that
evaluated this outcome

▪For caregivers, 5/10 studies

(MES=1.06).

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

▪Intervention durations being

matching:

▪Need for high-intensity CM.

too short.

▪Scarce communication.
▪Case manager and physician

▪Lack of healthcare providers

in different locations.

with geriatric training.

Addressing these barriers
correlated with better out‑
comes, as studies address‑
ing more barriers resulted
in more positive outcomes
(agreement κ=0.94; CI,
0.82-1.1).
Fernandes et al. BMC Fam Pract (2021) 22:166 Page 14 of 17

Table 2 (continued)
Authors, Country Number of studies Intervention Comparator Outcomes
included in systematic
review
▪Intervention clinics demon‑
appointment of dementia ▪Clinical practice guidelines
Perry et al, Netherlands 6 Series of seminars and the Control groups in studies:
strated better health-related
care managers. for dementia received quality of life (QoL), overall

▪No training
by mail quality of health care in

▪No seminars
patients, family caregiving

▪No training and no

quality, social support and
more family caregivers

▪Short, partly interactive

dementia care managers reported receiving all the

▪The health-related QoL

help they needed.
seminar on dementia
diagnostics (3 hours). of the caregiver did not

▪Higher proportions of
increase.

patients were newly

diagnosed with dementia
following educational work‑
shops and computerized
Decision Support System
(DSS) group compared to

▪After a 2-h seminar for

the control group.

physicians there were

higher rates of ’suspected
dementia’ and lower rates
of both ’uncertain’ and ’non-
suspected’ diagnoses when
compared to the control

▪Both the mean compliance

group.

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

▪Physicians gained more

control clinics.

knowledge after a 5-h semi‑

▪After 9-months, more physi‑

nar than a 3-h seminar.

cians 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.

REACH VA was successful at increasing carer ability to Discussion

manage problem behaviours and improved outcomes This systematic review of systematic reviews identified
for caregivers, such as decreased burden, depression and evidence to inform processes for diagnosis and manage-
caregiving frustrations [30, 31]. A meta-analysis showed ment of dementia within primary care. While the diag-
that 58 % (95 % CI: 43-72 %) of family caregivers were in nostic accuracy of a tool may be high, the time taken to
favor of early dementia diagnosis, 50 % (95 % CI: 35-65 %) administer the tool and copyright limitation for tool use
needed education on dementia, and 23 % (95 % CI: are also important to consider in the context of a busy
17-31 %) needed in-home support [33]. primary care office. The MMSE, which is copyrighted,
Fernandes et al. BMC Fam Pract (2021) 22:166 Page 15 of 17

may not be the best test for use in general practice. this context. One systematic review found no clinically
Instead, the AMTS appears to be the most suitable tool important differences between groups receiving cho-
for use in a busy primary care office, as it has good diag- linesterase inhibitors and those receiving a placebo in the
nostic accuracy, does not appear to be copyright pro- development of behavioral and neuropsychiatric symp-
tected and takes less time to administer than the MMSE toms of Alzheimer’s disease [11]. Similarly, cholinesterase
[12, 14, 15]. The Mini-Cog is also quick to administer, and inhibitor use was found to have uncertain clinical benefit
a Cochrane systematic review evaluating the Mini-Cog in a recent systematic review that explored the benefits
across care settings recommended that the Mini-Cog and harms of prescription drugs for the treatment of Alz-
be used initially as a case finding test to identify patients heimer disease, regardless of care setting [36]. This recent
who would benefit from additional cognitive evaluations review also found limited benefit for memantine.
for dementia [34]. However, the sensitivity of the Mini-
Cog may not be high enough to be considered useful in
primary care [17], as too many cases would be missed. Conclusions
The current literature suggests that the implementation The AMTS is suitable for detecting dementia within pri-
of case management directly into the primary care set- mary care given its high sensitivity and short adminis-
ting can be of great benefit to the patient-caregiver dyad, tration time. To improve dementia identification, FPs
as well as to the health care system. The CM can help should participate in educational interventions. Incor-
facilitate the advanced care planning process [29], as well poration of CMs into the primary care team can help
as decrease the frequency of neuropsychiatric symptoms with dementia management and result in improved out-
of dementia, symptoms of depression, hospital admis- comes. There is limited evidence supporting the benefit
sions and length of stay in hospital; caregivers can also for pharmacological treatments in the context of pri-
benefit by experiencing decreased burden and depression mary care.
[26]. A Cochrane review evaluating the effectiveness of
case management in community settings lends support
to dementia case management, finding that carer bur- Limitations and Future Research
den decreased and fewer patients where institutional- A limitation of this systematic review of systematic
ized after 6 months [35]. Further, there was a reduction in reviews includes the exclusion of possibly relevant phar-
residential home and hospital use after 6 months of case macological reviews, given the fact that we focused on
management implementation [35]. There is however a studies conducted in the primary care setting. Future
lack of evidence related to cost effectiveness of case man- pharmacological studies conducted in the specific con-
agement. Facilitating successful case management and text of primary care are needed. Additionally, the results
advanced care planning includes early implementation from our review are limited to literature from countries
while cognitive decline is mild, involving all stakeholders that clearly distinguish primary care from specialist
(caregiver, patient, family and FP), and fostering a good care, given the focus of the search strategy. Lastly, many
relationship between the FP and patient-caregiver dyad of the studies included within the identified systematic
[29]. The CM should be physically present in the primary reviews inappropriately used the MMSE as a reference
care setting, clearly explain their role to all stakeholders, tool when determining the sensitivity and specificity of
implement high-intensity case management, and com- various screening tools. Further studies should compare
municate frequently to all stakeholders in order to ensure commonly used screening tools within primary care to a
positive outcomes for the patient-caregiver dyad [26, 27]. recognized gold standard.
Combining educational seminars for FPs with dementia
case management may be the best management strategy Abbreviations
FPs: Family physicians; PRISMA: Preferred Reporting Items for Systematic
[23, 24]. Educational interventions focused on demen- Reviews and Meta-analyses; MMSE: Mini-Mental State Examination; AMTS:
tia diagnosis and management in the context of primary Abbreviated Mental Test Score; ACP: Advanced Care Planning; CM: Case Man‑
care increased the likelihood of FPs suspecting dementia, ager; MES: Mean Effect Size; REACH VA: Resources for Enhancing Alzheimer’s
Caregiver Health (Department of Veterans Affairs).
while also improving the experience of the family car-
egiver and the patient [23, 24].
There was limited evidence concerning the use of phar- Supplementary Information
macological interventions for the treatment of demen- The online version contains supplementary material available at https://​doi.​
tia within the primary care setting. Unfortunately, many org/​10.​1186/​s12875-​021-​01461-5.
pharmacologic studies do not focus on primary care or
FPs, making it difficult to draw conclusions about the Additional file 1.
approach to take regarding the use of medications in
Fernandes et al. BMC Fam Pract (2021) 22:166 Page 16 of 17

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practitioner towards the family caregiver of a community-dwelling

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