Case-finding of mild cognitive impairment and dementia and subsequent collaborative care: Design of a cluster RCT.

In the primary care setting, dementia is often diagnosed relatively late in the disease process and care for individuals with cognitive impairment is often guided by demand, rather then being proactive. There are indications that casefinding and proactive collaborative care are beneficial to both patient and informal caregiver in terms of clarifying the cause of changed behaviour and cognition and by enabling planning of care and access to services. We hypothesize that active case finding in individuals in whom FPs suspect cognitive impairment increases incident MCI and dementia diagnoses. In addition, we explore the validity of these diagnoses and the effects of casefinding and collaborative care on the mental health of individuals with MCI or dementia and their informal carers.



Methods and design:

Design Cluster Randomised Controlled Trial.
Participants 162 individuals ≥ 65 years, in 15 primary care practices, in whom FPs suspect cognitive impairment, but without a dementia diagnosis.



Intervention:

Case finding and collaborative care. Two trained practice nurses (PNs) invite all patients with suspected cognitive impairment for a brief functional and cognitive screening. If the cognitive tests underpin the suspicion of cognitive impairment, individuals are referred to their FP for further evaluation. If MCI or dementia are diagnosed the team of FP and PN provide information and support. Furthermore, a comprehensive geriatric assessment takes place to identify other relevant geriatric problems that need to be addressed.

Control FPs provide care and diagnosis as usual.



Main study parameters After 12 months both groups are compared on: 1) Incident MCI and dementia 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 first results are expected medio 2013.

We hypothesize that active case finding in individuals in whom FPs suspect cognitive impairment increases incident MCI and dementia diagnoses. In addition we explore the validity of these diagnoses and the effects of collaborative care on the mental health of individuals diagnosed with MCI or dementia and their informal carers.

T0 = baseline, T1 = 6 mnths, T2 = 12 mnths.

The intervention in this study was developed by our project team comprising several FPs and in close collaboration with three FPs participating in the study. It is aimed at individuals classified as having 'possible cognitive impairment or dementia' by their FP and contains the following elements:



Training of FPs and practice nurses:

In order to improve recognition, diagnosis and management of MCI and dementia in primary care, FPs and PNs will undergo a training adapted from the training provided by Perry et al. in their study on case finding of dementia in primary care(Perry et al. 2008). The training focuses on collaboration between FPs and practice nurses in diagnosing and managing dementia. FPs will consider barriers to dementia diagnosis and will learn how to diagnose dementia according to current guidelines (particularly the dementia guideline of the Dutch College of General Practitioners)( 2003b). Additionally, differential diagnosis and pharmacological treatment of behavioural problems are addressed.

Practice nurses are trained to administer cognitive tests, to interpret the results and to formulate a hypothesis about the cognitive status of the individual tested. In addition, practice nurses are trained to administer the Resident Assessment Instrument (RAI), a standardised instrument for broad functional assessment of elderly patients and their informal caregiver. They learn to make a care plan based on the RAI results and evaluate it periodically.



Case finding of MCI and dementia:

1. Cognitive classification of all individuals aged 65 or older.
FPs in both conditions are asked to estimate the cognitive function of all individuals aged 65 or older in their practices;

2. Screening and diagnosis in individuals classified 'possible cognitive impairment or dementia' In the intervention practices two PNs are deployed who will perform the additional tests. They will focus exclusively on individuals with suspected cognitive impairment. They offer a brief screen of cognition (Mini Mental State Examination[MMSE] and Visual Association Test[VAT]), mood (Prime-MD), sensory functions and need for home care to all study participants. Individuals with an MMSE score > 1 SD below the average MMSE of healthy individuals of comparable age and education and/or a VAT score ≤ 4 are referred to the FP for further evaluation according to the dementia guideline of the Dutch College of General Practitioners(Kempen, Brilman, & Ormel 1995;Lindeboom et al. 2002). Figure 2 provides an overview of the intervention.



If the cognitive tests indicate cognitive performance is worse than normal for age and education, individuals are seen by their FP. The FP evaluates whether dementia, or if the criteria for dementia are not met, MCI is present. If dementia or MCI are diagnosed, the team of FP and PN provide information and support for the individual with cognitive impairment and, if present, for the informal caregiver. Subsequently they will offer a RAI assessment. Based on the results of this assessment they prioritise problems and prepare a care plan in consultation with the individual with MCI or dementia, the informal caregiver and the FP.

Additionally, the PNs will gain expert knowledge on dementia services in the region and establish close collaboration with secondary care providers. to the team of FP and PN will make agreements on collaboration with these providers based on the outlines for this in the National Collaboration Agreement for primary dementia care. These include for example agreements on information exchange, prescription of drugs, consultation and referral, crisis situations, (crisis-) admission.
The practice nurses will serve patients of several PCPs. Patient contacts will take place according to a predefined schedule. FPs remain responsible for all medical care, including crisis management during the study.



Control FPs provide care and diagnosis as usual.