Adherence to Clinical Practice Guidelines during Dementia Work-Up in a Real-World Setting: A Study from the Registry of Dementias of Girona

Abstract

Background:

There are several position statements and clinical practice guidelines (CPG) for diagnosing dementia.

Objective:

Our aims were to evaluate the adherence to CPG among specialists in the 7 memory clinics included in the Registry of Dementias of Girona (ReDeGi), and to compare the results between 2007–2011 and 2012–2015. We also determined the time and number of visits required to achieve a diagnosis, the supplementary tests ordered, and the drugs prescribed according to dementia subtypes.

Methods:

Medical charts of a stratified random sample of 475 ReDeGi cases were reviewed. Basic dementia work-up was evaluated using as a reference evidence-based CPG. An Index of Adherence (AI) was calculated using the following items in the medical chart: cognitive symptomatology; functional disability evaluation; physical examination; neurological examination; psychiatric examination; brief cognitive examination; activities of daily living performance examination; blood test; structural neuroimaging (CT-scan or MRI).

Results:

The mean AI to CPG among specialists was of 8.2 points, and it improved from 7.9 points in 2007–2011 to 8.5 points in 2012–2015 (Cohen’s d = 0.46). A lower adherence was detected in the most severe cases. A dementia diagnosis required 3.5 visits, regardless of the subtype of dementia, although milder cases required more time, more visits, and more supplementary tests than severe cases.

Conclusion:

The adherence to CPG in the catchment area of the ReDeGi is high, and an epidemiological surveillance system such as the ReDeGi may help in improving it. Dementia guidelines should establish procedures adapted to clinical practice, with simplified recommendations for most severe cases.

Keywords

Dementia diagnosis practice guideline registries

INTRODUCTION

The increasing prevalence of dementia is a challenge for healthcare systems, since it increases the health-care costs and the need for resources [1]. Diagnosing and treating dementia, as well as developing appropriate care plans, is essential to make the most of the available resources, and to diminish as much as possible the disease burden [2 –4].

Several national and international evidence-based clinical practice guidelines (CPG) and position statements have been developed in order to assist in the diagnosis and management of dementia [5]. Proposed tests for dementia work-up vary depending on the CPG, and although some of them are widely recommended (i.e., cognitive testing using standardized tools, structural imaging using either computed tomography scan or magnetic resonance imaging, physical, neurological, and psychiatric examination, etc.), others are recommended by some guidelines only, or in cases with clinical features suggestive of specific dementia subtypes (i.e., cerebrospinal fluid analyses, electroencephalogram, HIV, syphilis, vitamin B12 or folate testing, genetic studies, etc.) [5]. However, to date, only a few studies have analyzed the physicians’ adherence to CPGs during dementia work-up in a real-world setting [6 –9].

Since 2007, the Registry of Dementias of Girona (ReDeGi) records all the incident cases of dementia in the Health Region of Girona (Catalonia, NE Spain). In our region, a statement issued in 1997 indicated that acetylcholinesterase inhibitors (AChEIs) could only be prescribed in secondary care settings. Thus, primary care specialists refer the patients with suspected dementia to the memory clinics, and as a result, all the cases included in the ReDeGi have been diagnosed by secondary healthcare specialists.

The procedures of the ReDeGi [10] require that specialist physicians collect and note down a set of clinical and demographic characteristics into the medical chart of the patients. These notes are further reviewed and collected by the technician of the ReDeGi to register all incident cases of dementia.

Thus, the aims of this paper were to evaluate the adherence to CPGs among the specialists performing the diagnoses of dementia registered in the 7 memory clinics in the catchment area of the ReDeGi, and to compare this adherence between two periods of time, 2007–2011 and 2012–2015. Our hypothesis was that the establishment of the ReDeGi in our area may have contributed to a standardization of the diagnostic procedures, so that we would detect an improvement of the adherence to CPGs during dementia work-up in 2012–2015. We determined the supplementary tests ordered, and the drugs prescribed to the patients at the moment the diagnosis was made, depending on the subtype of dementia. Finally, we also provide information on the time to diagnosis and on the number of visits required to achieve a diagnosis.

METHODS

Geographical area of reference, study population, and sample size

This study used data from the ReDeGi, which registers demographic and clinical data of all the incident cases of dementia diagnosed in the 7 hospitals of the public health care system of the Health Region of Girona (HRG). The HRG is located in the North-East of Catalonia, which is, in turn, in the North-East part of Spain. It has an area of 5,517 km², a population of 753,024 inhabitants (according to the Citizens Municipal Registry 2015), and a population density of 136.5 inhabitants/km². The ReDeGi collects the information of the patients in the year of the diagnosis, and 6,530 cases were registered between 2007 and 2015.

The sample size was calculated based on an estimated prevalence of 50% of adherence to CGP for each period with an alpha level of 0.05 and a precision level of±6%. The final sample size was a stratified random sample of 494 patients (247 for each period: 2007–2011 and 2012–2015) representative of the cases included in the ReDeGi. This sample size had a statistical power of 88.6% to detect a minimum difference of 10% in the prevalence of the adherence to CGP between the two periods. Of the initial sample of 494 patients, 19 (3.8%) were excluded due to the impossibility to access to their medical charts. No differences were detected between these 19 cases and the rest of the sample regarding age, gender, diagnosis, or severity of the dementia. Thus, the medical charts of a final sample of 475 patients with dementia were reviewed in order to obtain the diagnostic-related variables used in this study. Specifically, a sample of 229 cases was reviewed from the period 2007–2011, and 246 from the period 2012–2015.

ReDeGi procedure

The ReDeGi uses standardized criteria for case definition, and follows the guidelines proposed by the Center for Disease Control and Prevention for a surveillance system [11]. The methodological principles and the functional structure of the ReDeGi have been previously described [10]. Dementia diagnoses in the ReDeGi are performed on the basis of the DSM-IV-TR [12] criteria. In a complementary fashion, clinical research criteria are used for dementia subtypes [13 –18]. A specialist technician of the ReDeGi periodically reviews the medical chart of the new cases of dementia notified in each of the 7 hospitals of the HRG, and registers the information in a clinical research form. The collected information of the ReDeGi meets the confidentiality requirements stated by the Spanish legislation.

Dementia diagnoses and antidementia drugs prescription

Information on dementia diagnoses was obtained from the ReDeGi, and further classified as follows: 1) Alzheimer’s disease (AD); 2) vascular dementia (VaD); 3) mixed dementia (MxD); 4) dementia with Lewy bodies (DLB); 5) other degenerative dementias (ODD), which included Parkinson’s disease dementia, Huntington’s disease dementia, frontotemporal dementia, progressive supranuclear palsy, and corticobasal syndrome dementia; 6) other dementias (OD), which included non-specified dementia, multiple etiology dementia, alcoholic-related dementia, HIV-associated dementia, traumatic brain injury-related dementia, and Creutzfeldt-Jakob disease.

The severity of the dementia, assessed using the Clinical Dementia Rating (CDR) [19] was recorded. The specialty of the physician performing the diagnosis was recorded. The time for diagnosis was calculated as the number of months between the initial assessment date and the final diagnosis date. The number of visits required to make a diagnosis was also recorded.

AChEIs and N-Methyl-D-aspartate receptor antagonists (NMDA-antagonists) prescribed at the moment of diagnosis were also extracted from the medical charts of the patients.

Adherence evaluation procedure

International clinical CPGs for AD and dementia were reviewed [20 –24], as well as the Spanish Clinical CPGs [25]. We also took into consideration a recent review of the main moderate-to-high quality dementia guidelines using the Appraisal of Guidelines Research and Evaluation II (AGREE-II) as a tool for quality appraisal [5]. After reviewing the main CPGs, and using as a reference the evaluation performed in another report by other authors [6], we used the main and most common parameters in the medical chart to evaluate the basic dementia work-up: 1) history of cognitive symptoms; 2) history of functional disability; 3) physical examination; 4) neurological examination; 5) psychiatric examination (assessment of behavioral and psychological symptoms of dementia); 6) brief cognitive examination; 7) ADL performance examination; 8) blood test; and 9) structural neuroimaging (either CT scan or MRI).

The medical charts were reviewed by two specialists (OTG and JGO) using a predefined methodology. The documentation degree of each variable was rated according to the categories shown in Table 1. Thus, in the case of the evaluation of the history of cognitive symptoms, history of functional disability, physical examination, neurological examination, and psychiatric examination, the information included in the medical chart was rated as being well documented, sufficiently documented, insufficiently documented, or not documented. Regarding cognitive examination (brief and extended) and ADL performance examination, the presence or absence of results from standardized tests and scales was recorded. Similarly, in the case of blood tests, computed tomography (CT) scan, magnetic resonance imaging (MRI), single photon emission computed tomography (SPECT), positron emission tomography (PET), cerebrospinal fluid (CSF) analysis, electroencephalogram (EEG), and genetic testing, the presence or absence of results in the medical chart was recorded (Table 1).

Table 1

Variables obtained from the medical charts and categories used in this study

Variables	Type of measure and categories
	1. Well documented	2. Sufficiently documented	3. Insufficiently documented	4. Not documented
History of cognitive symptoms	detailed history including onset, progression and characteristics of cognitive symptoms	sufficient history to document progressive cognitive impairment	cognitive symptoms noted in the medical chart without further elaboration	no information
History of functional disability	detailed history including onset, progression and characteristics of functional impairment	sufficient history to document progressive functional impairment	functional impairment noted in the medical chart without further elaboration	no information
Physical examination	full physical examination documented	abnormal findings summarized	scarcely documented, insufficient to rule out systemic causes of cognitive and functional impairment	no information
Neurological examination	full neurological examination documented	abnormal findings summarized	scarcely documented, insufficient to help determine the neurological condition underlying dementia	no information
Psychiatric examination	full psychiatric examination documented	abnormal findings summarized	scarcely documented, insufficient to rule out psychiatric illness such as depression	no information
Brief cognitive examination	Results from a standardized screening neuropsychological test (MMSE, MOCA, TAM, others). (Yes/No)
Extended cognitive examination	Results from a standardized extended neuropsychological test (CAMCOG, ADAS-Cog, WMS, STROOP, WCSR, others). (Yes/No)
ADL performance examination	Results from a standardized scale or questionnaire of ADL (BDRS, DAD, others. (Yes/No)
Blood test	(Yes/No): Complete blood count; Vitamin B12 and folate; T4 and TSH; Creatinine or Creatinine clearance; Albumin; Glucose; C reactive protein;
Sedimentation rate; HIV antibodies; Syphilis serology; Cholesterol; Acid uric
CT scan	(Yes/No)
MRI
SPECT
PET
Cerebrospinal fluid
EEG
Genetic testing

ADL, Activities of Daily Living; CT scan, computed tomography scan; MRI, magnetic resonance imaging; SPECT, single photon emission computed tomography; CSF analysis, cerebrospinal fluid analysis; EEG, electroencephalogram; PET, positron emission tomography.

Basic dementia work-up was considered to be satisfactory and thus, with a high adherence to CPGs, when the medical chart contained the history of cognitive symptoms, history of functional disability, physical examination, neurological examination, psychiatric examination, brief cognitive examination well documented or sufficiently documented, and when the medical chart contained the results of ADL performance examination, blood test, and structural neuroimaging (either CT scan or MRI). When these parameters were not documented or were insufficiently documented, the dementia work-up was considered to be unsatisfactory and with poor adherence to CPGs. A final Adherence to clinical practice guidelines Index (AI) was calculated as the sum of the 9 parameters scored as satisfactory. This AI ranged from 0 to 9 points, with higher scores indicating better adherence to CPGs recommendations.

Although most of the CPGs support ordering basic blood tests— including complete blood count, blood glucose, and liver and renal functions— the main differences are related to the recommendations regarding vitamin B12 and folate levels, thyroid function, syphilis serology, and HIV antibodies. Since these tests are used to rule out comorbidities that may cause cognitive disorders, and they may be ordered only when there is a specific clinical suspicion, we did not include them as required in the blood tests. The same occurs with the use of techniques such as SPECT or PET, CSF analysis, EEG, extended neuropsychological assessment, and genetic testing, which are ordered depending on the clinical characteristics of the patient and/or on the subtype of dementia suspected. Therefore, we provide descriptive information on these variables, but have not included them to calculate the adherence to CPG.

Data analysis

A descriptive analysis of the variables was performed using central tendency measures and dispersion for quantitative variables. Absolute and relative frequencies were calculated for qualitative variables. Normality was checked using Shapiro-Wilk test. Bivariate analyses were performed using Fisher’s exact tests for categorical variables and Kruskal-Wallis tests for continuous variables. The effect size of the differences between the AI means of the two periods studied here was analyzed using the Cohen’s d, by calculating the mean difference between the two groups, and then dividing the result by the pooled standard deviation. The effect sizes of the differences between the frequencies of tests performed in the two periods of time were analyzed using odds ratios. Results are expressed as absolute numbers and percentages, means, standard deviations (SD), odds ratios (OR), and 95% confidence intervals (CI). Statistical tests were considered to be significant with a two-tailed p value < 0.05. Processing and analysis of the data were performed using thestatistical package SPSS v15.0 for Windows (SPSS, Inc., Chicago, IL).

RESULTS

Sample characteristics

A stratified random sample of 475 patients with dementia was used in this study. Specifically, there were 255 cases (53.8%; 95% CI = 49.1–58.3) with AD, 24 cases (5.1%; 95% CI = 2.9–7.1) with VaD, 86 cases (18.1%; 95% CI = 14.5–21.7) with MxD, 22 cases (4.6%; 95% CI = 3.0–7.0) with DLB, 32 cases (6.7%; 95% CI = 4.7–9.5) with ODD (of which, 10 cases (18.5%; 95% CI = 7.2–29.8) had Parkinson’s disease dementia, 2 cases (3.7%; 95% CI = 0.5–12.7) had Huntington’s disease dementia, 18 cases (33.3%; 95% CI = 19.8–46.8) had frontotemporal dementia, 1 case (1.9; 95% CI = 0.1–9.9) had progressive supranuclear palsy, and 1 case (1.9; 95% CI = 0.1–9.9) had corticobasal syndrome dementia), and 56 cases (11.7%; 95% CI = 8.8–14.8) had OD [of which, 37 cases (66.1%; 95% CI = 52.8–79.4) had non-specified dementia, 15 cases (26.7%; 95% CI = 14.3–39.3) had multiple etiology dementia, 1 case (1.8%; 95% CI = 0.1–9.6) had alcoholic-related dementia, 1 case (1.8%; 95% CI = 0.1–9.6) had HIV-associated dementia, 1 case (1.8%; 95% CI = 0.1–9.6) had traumatic brain injury-related dementia, and 1 case (1.8%; 95% CI = 0.1–9.6) had Creutzfeldt-Jakobdisease].

In the sample, there were 277 women (58.3%; 95% CI = 53.8–62.9), and the mean age at baseline was 79.9 years (SD = 7.0). At the moment the diagnosis was made, the mean MMSE score was of 17.9 points (SD = 5.3), and there were 314 patients at CDR = 1 (66.2%; 95% CI = 61.7–70.5), 114 patients at CDR = 2 (24.1%; 95% CI = 20.1–27.9), and 46 patients at CDR = 3 (9.7%; 95% CI = 6.9–12.4). The time to diagnosis was 5.9 months (SD = 11.3), and the mean number of visits to achieve a diagnosis was 3.5 (SD = 2.5). Among the different dementia subtypes, there were no differences regarding the time to diagnosis, or the number of visits to achieve the diagnosis. However, more severe cases were diagnosed faster than milder cases [mild: 7.0 months (SD = 12.3); moderate: 4.1 months (SD = 7.6); severe: 3.2 months (SD = 10.6); K-W = 23.224; df = 2; p < 0.001] and required less visits [mild: 3.8 visits (SD = 2.6); moderate: 3.1 visits (SD = 2.3); severe: 2.3 visits (SD = 1.5); K-W = 31.087; df = 2; p < 0.001].

There were no differences between the two periods of time regarding gender ratio, age, education level, civil status, and dementia subtype. However, in 2012–2015 a higher proportion of diagnoses were made at a mild phase (69.9% versus 62.3%; F = 7.893; p = 0.019), and the patients were less often institutionalized (3.7% versus 7.3%; F = 11.942; p = 0.002).

All dementia diagnoses in the HRG are outpatient diagnoses, since when inpatients display symptoms of dementia they are further referred to memory clinics or to geriatrics/neurology units. Most of the patients were referred from Primary Care (81.6%; n = 381), while the rest (18.4%; n = 94) were mainly referred from nursing homes, and other Hospital services. No dementia-specific referral protocols exist in our area. In our sample, almost all the diagnoses (98.9%; n = 470) were performed by dementia specialists: psychiatrists (11.4%; n = 54), geriatricians (23.2%; n = 110) or neurologists (64.4%; n = 306). The rest of the cases (1.1%; n = 5) were diagnosed by internal medicine specialists.

Adherence to clinical practice guidelines

The general AI was 8.2 points (SD = 1.3) out of 9, and there were no differences depending on the dementia subtype. Table 2 shows the rates of satisfactory parameters detected in the medical charts, and the AI for each dementia subtype. No significant differences were detected between dementia subtypes, with the exception of the psychiatric examination, which was satisfactory in 95.8% (95% CI = 78.9–99.9) of the cases in VaD, and in 73.2% (95% CI = 60.7–85.7) of the cases in OD (F = 13.240; p = 0.017) (Table 2).

Table 2

Rate of satisfactory parameters in the medical chart (well or sufficiently documented for the history of cognitive symptoms, history of functional disability, and physical, neurological and psychiatric examinations, and results documented for the brief cognitive examination, ADL performance examination, blood test and structural imaging test) depending on the subtype of dementia

	AD	VaD	MxD	DLB	ODD	OD
	(n = 255)	(n = 24)	(n = 86)	(n = 22)	(n = 32)	(n = 56)
History of cognitive symptoms, n (%)	241	24	83	20	32	52
	(94.5)	(100.0)	(96.5)	(90.9)	(100.0)	(92.9)
History of functional disability, n (%)	240	24	82	20	30	53
	(94.1)	(100)	(95.3)	(90.9)	(93.8)	(94.6)
Physical examination, n (%)	227	23	81	19	31	52
	(89.0)	(95.8)	(94.2)	(86.4)	(96.9)	(92.9)
Neurological examination, n (%)	239	23	83	21	32	54
	(93.7)	(95.8)	(96.5)	(95.5)	(100.0)	(96.4)
Psychiatric examination, n (%)^*	228	23	69	19	28	41
	(89.4)	(95.8)	(80.2)	(86.4)	(87.5)	(73.2)
Brief cognitive examination, n (%)	252	24	84	22	32	55
	(98.8)	(100.0)	(97.7)	(100.0)	(100.0)	(98.2)
ADL performance examination, n (%)	247	24	84	21	29	54
	(96.9)	(100.0)	(79.7)	(95.5)	(90.6)	(96.4)
Blood test, n (%)	206	20	66	17	22	36
	(80.8)	(83.3)	(76.7)	(77.3)	(68.8)	(64.3)
Structural image (CT scan/MRI), n (%)	218	24	76	18	27	47
	(85.5)	(100.0)	(88.4)	(81.8)	(84.4)	(83.9)
Adherence Index, mean (SD)	8.2	8.7	8.2	8.0	8.2	7.9
	(1.4)	(0.6)	(1.3)	(1.4)	(1.3)	(1.5)

ADL, Activities of Daily Living; CT scan, computed tomography scan; MRI, magnetic resonance imaging. AD, Alzheimer’s disease; VaD, vascular dementia; MxD, mixed dementia; ODD, other degenerative dementias; OD, other dementias. ^*p < 0.05.

There were differences on the AI depending on the severity of the dementia, with lower adherencein severe cases (AI = 8.3 (SD = 1.2) in mild cases; AI = 8.0 (SD = 1.5) in moderate cases; AI = 7.8 (SD = 1.8) in severe cases; K-W = 8.636; df = 2; p = 0.013). The parameters less frequently documented in severe cases were the brief cognitive examination (99.7% in mild cases and 97.8% in severe cases; F = 7.065; p = 0.029), the examination of ADL performance (98.4% in mild cases and 93.5% in severe cases; F = 9.142; p = 0.007), the blood test (80.9% in mild cases and 60.9% in severe cases; F = 9.732; p = 0.007), and structural imaging (89.5% in mild cases and 71.7% in severe cases; F = 10.831; p = 0.004).

Adherence in the periods 2007–2011 and 2012–2015

Table 3 shows the rates of satisfactory parameters detected in the medical charts, and the AI for the two periods of time. The AI shows an increase over the last few years, from 7.9 points (SD = 1.4) in 2007–2011, to 8.5 points (SD = 1.2) in 2012–2015 (Mann-Whitney’s U = 20,432.500; p < 0.001), with a medium effect size (Cohen’s d = 0.46). Specifically, this increase is due to a higher ratio of patients containing in their medical charts a satisfactory history of cognitive symptomatology (OR = 3.2; 95% CI = 1.2–8.3), physical (OR = 2.6; 95% CI = 1.3–5.1), neurological (OR = 2.6; 95% CI = 1.0–6.4) and psychiatric (OR = 1.8; 95% CI = 1.1–3.1) examinations, blood test (OR = 3.0; 95% CI = 1.9–4.7), and structural imaging results (OR = 2.0; 95% CI = 1.2–3.5).

Table 3

	2007–2011	2012–2015
	(n = 229)	(n = 246)
History of cognitive symptoms, n (%)*	212 (92.6)	240 (97.6)
History of functional disability, n (%)	212 (92.6)	237 (96.3)
Physical examination, n (%)^*	200 (87.3)	233 (94.7)
Neurological examination, n (%)^*	213 (93.0)	239 (97.2)
Psychiatric examination, n (%)^*	188 (82.1)	220 (89.4)
Brief cognitive examination, n (%)	227 (99.1)	242 (98.4)
ADL performance examination, n (%)	222 (96.9)	237 (96.3)
Blood test, n (%)^**	155 (67.7)	212 (86.2)
Structural image (CT scan/MRI), n (%)^*	188 (82.1)	222 (90.2)
Adherence Index, mean (SD)^**	7.9 (1.4)	8.5 (1.2)

ADL, Activities of Daily Living; CT scan, computed tomography scan; MRI, magnetic resonance imaging. ^*p < 0.05; ^**p < 0.001.

Table 4

Pharmaceuticals prescribed according to dementia subtype at the moment the diagnosis is made. Some patients were prescribed both pharmaceuticals together, AChEIs and NMDA-antagonists: AD: 27 cases; VaD: 1 case; MxD: 5 cases; ODD: 2 cases; OD: 3 cases. [n (%)]

	AD	VaD	MxD	DLB	ODD	OD
	(n = 255)	(n = 24)	(n = 86)	(n = 22)	(n = 32)	(n = 56)
AChEIs^*	193 (76.0)	8 (33.3)	61 (70.9)	16 (72.7)	16 (50.0)	22 (39.3)
NMDA-antagonists^**	57 (22.4)	2 (8.3)	13 (15.1)	3 (13.6)	0 (0.0)	6 (10.7)

AChEIs, acetylcholinesterase inhibitors; NMDA-antagonists, N-Methyl-D-Aspartate receptor antagonists; AD, Alzheimer’s disease; VaD, vascular dementia; MxD, mixed dementia; ODD, other degenerative dementias; OD, other dementias; ^*p < 0.001; ^**p < 0.05.

Pharmaceuticals prescription at the moment of diagnosis and supplementary tests ordered

Antidementia drugs were mainly prescribed to patients with AD (87.8%; 95% CI = 83.6–92.0), with MxD (80.2%; 95% CI = 71.2–89.2), and with DLB (77.3%; 95% CI=56.6–89.9). Half of the patients with ODD were also prescribed antidementia drugs (50.0%; 95% CI = 33.6–66.4), while the frequency was 37.5% (95% CI = 16.0–58.9) in patients with VaD, and 44.6% (95% CI = 30.7–58.6) in patients with OD. AChEIs were more frequently prescribed in patients at the mild stage of the disease (CDR 1: n = 238, 75.8%; CDR 2: n = 65, 57.5%; CDR 3: n = 13, 28.3%; F = 44.644; p < 0.001), while NMDA-antagonists were more frequently prescribed in patients with severe dementias (CDR 1: n = 43, 13.7%; CDR 2: n = 26, 23.0%; CDR 3: n = 12, 26.1%; F = 7.991; p = 0.017). Table 4 shows the AChEIs and NMDA-antagonists prescribed at the moment of diagnosis according to dementia subtype. No differences were detected in the prescription of antidementia drugs between the periods 2007–2011 and 2012–2015.

The frequencies of supplementary tests ordered in our sample are shown in Table 5, stratified by the subtype of dementia and by the period of time 2007–2011 and 2012–2015.

Table 5

Supplementary tests ordered by dementia subtype and in the two periods of time studied (2007–11/2012–15) [n (%)]

	Dementia subtype (2007–2015)						All dementia subtypes
	AD	VaD	MxD	DLB	ODD	OD	2007–2011	2012–2015
	(n = 255)	(n = 24)	(n = 86)	(n = 22)	(n = 32)	(n = 56)	(n = 229)	(n = 246)
HIV antibodies	18 (7.1)	4 (16.7)	6 (7.2)	3 (13.6)	4 (12.5)	6 (10.7)	14 (6.3)	27 (11.0)
Syphilis serology^a,b	62 (24.5)	5 (20.8)	10 (12.0)	5 (22.7)	8 (25.0)	3 (5.4)	35 (15.6)	58 (23.6)
Vitamin B12^b	149 (58.9)	13 (54.2)	45 (54.2)	14 (63.6)	17 (53.1)	22 (39.3)	108 (48.2)	152 (61.8)
Thyroid^b	157 (62.1)	14 (58.3)	46 (55.4)	14 (63.6)	17 (53.1)	27 (48.2)	116 (51.8)	159 (64.6)
SPECT^a	9 (3.5)	0 (0.0)	7 (8.1)	2 (9.1)	8 (25.0	5 (8.9)	19 (8.3)	12 (4.9)
CSF analysis^a,b	12 (4.7)	1 (4.2)	0 (0.0)	1 (4.5)	3 (9.4)	0 (0.0)	1 (0.4)	16 (6.5)
EEG^a	4 (1.6)	0 (0.0)	1 (1.2)	0 (0.0)	5 (15.6)	2 (3.6)	3 (1.3)	9 (3.7)
Genetic testing^a,b	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	3 (9.4)	0 (0.0)	2 (0.9)	1 (0.4)
Extended cognitive exam^a,b	182 (71.4)	21 (87.5)	52 (60.5)	16 (72.7)	25 (78.1)	31 (55.4)	145 (63.3)	182 (74.0)

AD, Alzheimer’s disease; VaD, vascular dementia; MxD, mixed dementia; ODD, other degenerative dementias; OD, other dementias; SPECT, single photon emission computed tomography; CSF analysis, cerebrospinal fluid analysis; EEG, electroencephalogram. No positron emission tomography (PET) was ordered in any dementia subtype between 2007 and 2015; Dementia subtype Fisher’s exact test: ^ap < 0.05; Period of time Fisher’s exact test: ^bp < 0.05.

DISCUSSION

In this paper, we use a representative sample of the cases included in the ReDeGi to evaluate the adherence to CPGs among the specialists performing the diagnoses of dementia. We also provide information on the time to diagnosis and on the number of visits required to achieve a diagnosis, as well as on the antidementia drugs prescribed at the moment the diagnosis is made, and on the supplementary tests ordered to perform the diagnosis of the different dementia subtypes. We also compare the adherence between two periods of time, 2007–2011 and 2012–2015. Our findings support the quality of the diagnoses registered by the ReDeGi.

According to our results, the mean adherence to CPGs in the ReDeGi was 8.2 points out of 9, which means that 91.1% of the parameters of the dementia work-up recommended by the CPGs were satisfactorily documented in the medical charts. Moreover, according to our hypothesis, the adherence improved in the last years, from 7.9 points in 2007–2011 to 8.5 points in 2012–2015 (moderate effect size).

We used international and national CPGs as a reference, and the variables used to evaluate the adherence were selected in accordance with a study previously performed by other authors in Denmark [6] in order to ease the comparison of our results. This Danish study reported a satisfactory/acceptable adherence to CPGs only in 51.3% of the cases, which is much lower than our 91.1%. This difference is probably due to the fact that in their case, 25% of the patients were diagnosed by non-dementia specialists, while in our case this occurred only in 5 cases (1.1%). Other studies in Italy, Germany, and USA [7 –9] detected differences among the diverse medical specialties regarding the performance of the tests recommended by the CPGs. Besides, in contrast with our study, almost all of the patients diagnosed by non-dementia specialists in the Danish study were inpatients. Patients with advanced and not previously diagnosed dementias are more likely to display increased dementia symptomatology when they are hospitalized, which facilitates the work-up to make a diagnosis with less tests. Nevertheless, these cases are then recorded as being performed with a low adherence toCPGs.

When analyzing the frequency of performance of each recommended test and examination depending on the subtype of dementia, the only difference we detected was related to psychiatric examination. A lower rate of psychiatric examinations was detected in the cases with OD. This result may be due to the increased heterogeneity of the cases included in this group of dementias, which often present with symptoms suggestive of a specific dementia subtype, leading to a diagnosis performed without all the tests and examinations recommended by the guidelines. Also, these patients may have been transferred more often from other medical specialties, and some of the required tests may have been already conducted, but were not included in thisstudy.

Concerning antidementia drugs prescribed at the moment the diagnosis is made, according to some quality indicators defined by the National Swedish Board of Health and welfare [26] to evaluate the Swedish registry (SveDem) dementia care [27, 28], above 80% of the patients with AD, dementia with Lewy bodies, and Parkinson’s disease dementia should be treated with antidementia medication. Our results show that the ReDeGi fits into this quality indicator, since 87.8% of the patients with AD were prescribed antidementia pharmaceuticals at the moment of diagnosis. Also, 50.0% of the patients with ODD were prescribed an antidementia drug, and most of these cases correspond to patients diagnosed with Parkinson’s disease dementia [29]. However, our results indicate that 33.3% of the cases with VaD were prescribed an AChEI, which is not recommended in most CPGs. Yet, it may be due to the therapeutic effect on cognitive and non-cognitive abilities that AChEIs may have been prescribed to this group ofpatients [30].

Regarding the time to diagnosis, and the number of visits required, in our area, a dementia diagnosis required approximately 3 visits in 6 months, regardless of the subtype of dementia. Nevertheless, milder cases required more time and an increased number of visits than severe cases (mild cases: 3.8 visits in 7.0 months versus severe cases: 2.3 visits in 3.2 months), which is in line with the lower adherence to guidelines’ recommendations we detected in severe cases. This may be due to the impossibility to perform some tests (i.e., some neuropsychological tests) to severely cognitively impaired patients, or to the fact that they may be unnecessary to perform a diagnosis.

Regarding the differences on adherence between 2007–2011 and 2012–2015, in the most recent period of time the cases were diagnosed at milder phases, which may explain this improvement of the adherence to CPGs. Besides, and in agreement with this, more additional tests were ordered in the last period, which was probably caused by the deeper study milder cases require to achieve a diagnosis of dementia, and to identify a specific subtype. Other authors previously reported that clinical guidelines for the management of patients with dementia should provide different recommendations for older patients with comorbidities [31]. In light of our results, and as an extension of the suggestion to improve the guidelines according to age and comorbidities, we think that dementia guidelines may also establish separate procedures for dementia work-up, depending on the severity of the dementia. However, the improvement of the adherence to CPG in the last years cannot be attributed only to the milder severity of the dementias diagnosed. The presence of the ReDeGi and the internal data analysis, together with the dissemination of this information have favored the development of standardized procedures, and have provided all dementia specialists in our area with a common environment. We believe that the implementation and settlement of the ReDeGi may have played a key role in the observed increase of the adherence to CPG.

Several limitations should be taken into account when interpreting our results. First, we calculated the AI by rating each of the 9 parameters used for the evaluation with 1 point, although not all of them may have the same importance in dementia work-up. Second, in this study we used the information included in the medical charts of the patients during the dementia work-up visits in the memory clinics, and some information registered in other visits or in other medical departments might have not been included. Third, we clustered low-frequency dementias into groups, which prevented studying the adherence to dementia work-up recommendations specific for these dementias. Fourth, our sample contained only a few dementias diagnosed by non-dementia specialists (n = 5; 1.1%), which is representative of the ReDeGi, but prevented studying the differences on adherence between dementia-specialists and non dementia-specialists. Fifth, PET was not available in the HRG hospitals during all the period analyzed, which may have caused a decreased use of this test in our study.

Conclusion

Our results indicate that, among the specialists in the ReDeGi, the adherence to CPGs is high, and that it has increased in the last years. This increase may be due to patients being diagnosed at milder phases, but it may also be due to the presence of an epidemiological surveillance system (the ReDeGi) in our geographical area, which promotes the standardization of procedures and unites dementia specialists in a joint project. Dementia guidelines can be implemented with high fidelity in the clinical setting, although they should be adjusted to fit with current clinical practice, especially regarding the work-up required in cases with severe dementias.

Footnotes

ACKNOWLEDGMENTS

The ReDeGi is founded by the Health Region of Girona from the Department of Health of the Generalitat de Catalunya (Spain). This work was funded by Eli Lilly and Company. The funding source had no involvement in the decision to submit the paper for publication.

Authors’ disclosures available online ().

THE REDEGI GROUP consists of the following investigators:

Department of Neurology, Hospital Universitari Josep Trueta: Jordi Gich; Albert Molins; Lluís Ramió; Joaquín Serena; Yolanda Silva, Mikel Terceño, René Robles.

Dementia Unit, Hospital Santa Caterina: Marta Hernández; Manuela Lozano; Immaculada Pericot; Joan Vilalta-Franch; Antoni Turon Estrada; Jordi Llinás; Secundino López-Pousa, Berta Solano, Mikel Terceño.

Dementia Unit, Serveis de Salut Integrats del Baix Empordá: Elisabet Alsina; Rosa de Eugenio; Erélido Hernández; Margarita Flaqué.

Neurology Department, Hospital de Figueres: Olga Carmona; Marta Cullell; Teresa Osuna; M^a del Mar Fernández.

Neurology and Geriatrics Departments, Hospital d’Olot: Josep Bisbe; Marta Linares; Fabian Marquez Daniel; Natalia Vallmajó.

Neurology and Geriatrics Departments, Hospital de Blanes: Héctor Perkal; Marta Viñas.

Neurology Department; Hospital de Campdevánol: Isabel Casas; Josefa Turbau; Josep M^a Cuy; Anna Manzano.

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