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      Prevalence and determinants of undetected dementia in the community: a systematic literature review and a meta-analysis

      systematic-review

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          Abstract

          Objectives

          Detection of dementia is essential for improving the lives of patients but the extent of underdetection worldwide and its causes are not known. This study aimed to quantify the prevalence of undetected dementia and to examine its correlates.

          Methods/setting/participants

          A systematic search was conducted until October 2016 for studies reporting the proportion of undetected dementia and/or its determinants in either the community or in residential care settings worldwide. Random-effects models calculated the pooled rate of undetected dementia and subgroup analyses were conducted to identify determinants of the variation.

          Primary and secondary outcome measures

          The outcome measures of interest were the prevalence and determinants of undetected dementia.

          Results

          23 studies were eligible for inclusion in this review. The pooled rate of undetected dementia was 61.7% (95% CI 55.0% to 68.0%). The rate of underdetection was higher in China and India (vs Europe and North America), in the community setting (vs residential/nursing care), age of <70 years, male gender and diagnosis by general practitioner. However, it was lower in the studies using Mini-Mental State Examination (MMSE) diagnosis criteria.

          Conclusions

          The prevalence of undetected dementia is high globally. Wide variations in detecting dementia need to be urgently examined, particularly in populations with low socioeconomic status. Efforts are required to reduce diagnostic inequality and to improve early diagnosis in the community.

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          Most cited references31

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          Neural mechanisms of ageing and cognitive decline.

          Nicholas A. Bishop, Tao Lu, Bruce A. Yankner (2010)
          During the past century, treatments for the diseases of youth and middle age have helped raise life expectancy significantly. However, cognitive decline has emerged as one of the greatest health threats of old age, with nearly 50% of adults over the age of 85 afflicted with Alzheimer's disease. Developing therapeutic interventions for such conditions demands a greater understanding of the processes underlying normal and pathological brain ageing. Recent advances in the biology of ageing in model organisms, together with molecular and systems-level studies of the brain, are beginning to shed light on these mechanisms and their potential roles in cognitive decline.
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            Underdiagnosis of dementia in primary care: variations in the observed prevalence and comparisons to the expected prevalence.

            Amanda Connolly, Ella Gaehl, Helen Martin … (2011)
            Dementia is a major and growing health problem. Diagnosis is an important step in the access to care, but many dementia patients remain undiagnosed. This study investigated the magnitude and variation in the difference between 'observed' and 'estimated' prevalence of dementia in general practices. We also explored practice characteristics associated with observed prevalence rates. Six Primary Care Trusts (PCTs) provided data on all general practices (N = 351) in their area in terms of number of doctors, patient list size, number of patients over 65 years of age, socio-economic deprivation status of practices and number of patients on dementia registers. The average observed prevalence overall of dementia amongst patients 65 years and over was 3.0% [95CI 2.8, 3.2]. The observed prevalence was 54.5% [95CI 49.2, 58.9] lower than the prevalence observed in the epidemiological studies in the UK. For an average size general practice (list size of 5269 patients) approximately 27 [95CI 22, 32] patients with dementia may remain undiagnosed. Statistically significant differences in prevalence rates were found between the different PCTs (Wald chi-square = 103.8 p < 0.001). The observed prevalence of dementia was significantly lower among practices run by one GP compared to multiple GPs (p = 0.003), and in more affluent areas (p < 0.001). Just under a half of the expected numbers of patients with dementia are recognised in GP dementia registers. The underdiagnosis of dementia varies with practice characteristics, socio-economic deprivation and between PCTs, which has implications for the local implementation of the National Dementia Strategy.
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              The detection of dementia in the primary care setting.

              J. David Curb, P. Blanchette, V Valcour … (2000)
              Recognition and medical record documentation of dementia in the primary care setting are thought to be poor. To our knowledge, previous studies have not examined these issues in private practice office settings within the United States. To determine the rate of unrecognized and undocumented dementia in a primary care internal medicine private practice. This was a cross-sectional study of 297 ambulatory persons aged 65 years and older attending an internal medicine private group practice within an Asian American community of Honolulu, Hawaii. Of the subjects, 95% had been with their current primary care physician for at least 1 year. Each subject's primary care physician noted the presence or absence of dementia by questionnaire at the time of an office visit. An investigating physician (V.G.V.) subsequently assessed cognitive function using the Cognitive Abilities Screening Instrument, and confirmed the presence of dementia and its severity, if present, using Benson and Cummings' criteria and the Clinical Dementia Rating Scale, respectively. A trained research assistant completed telephone interviews to proxy informants for collateral information concerning cognition, behavior, and occupational or social function. Subjects' outpatient medical records were reviewed for documentation of problems with cognition. Twenty-six cases of dementia were identified. Of these 26, 17 (65%) (95% confidence interval, 44.3-82.8) were not documented in outpatient medical records; of 18 patients, 12 (67%) (95% confidence interval, 40.9-86.7) were not thought to have dementia by their physicians at the time of the office visit. Recognition and documentation rates increased with advancing stage of disease. Dementia is often unrecognized and undocumented in private practice settings. Arch Intern Med. 2000;160:2964-2968
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                Author and article information

                Journal
                Journal ID (nlm-ta): BMJ Open
                Journal ID (iso-abbrev): BMJ Open
                Journal ID (hwp): bmjopen
                Journal ID (publisher-id): bmjopen
                Title: BMJ Open
                Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                ISSN (Electronic): 2044-6055
                Publication date Collection: 2017
                Publication date (Electronic): 3 February 2017
                Volume: 7
                Issue: 2
                Electronic Location Identifier: e011146
                Affiliations
                [1 ]Faculty of Education, Health and Wellbeing University of Wolverhampton , Wolverhampton, UK
                [2 ]Post Graduate Academic Institute of Medicine, University of Wolverhampton , Wolverhampton, UK
                [3 ]Department of Practice and Policy, University College London , London, UK
                [4 ]School of Health Administration, Anhui Medical University , China
                [5 ]New Cross Hospital, The Royal Wolverhampton NHS Trust , UK
                [6 ]Department of Public Health, Wolverhampton City Council , Wolverhampton, UK
                [7 ]Department of Psychiatry, University of Liverpool , Liverpool, UK
                [8 ]Dementia Collaborative Research Centre-Early Diagnosis and Prevention, Centre for Research on Ageing, Health and Wellbeing, Research School of Population Health, The Australian National University , Canberra, Australia
                Author notes
                [Correspondence to ] Dr Ruoling Chen, r.chen@ 123456wlv.ac.uk ; Dr Li Wei, l.wei@ucl.ac.uk and Dr Dongmei Zhang (for Chinese), zdmd@sina.com

                AC is co-first author.

                Article
                Publisher ID: bmjopen-2016-011146
                DOI: 10.1136/bmjopen-2016-011146
                PMC ID: 5293981
                PubMed ID: 28159845
                SO-VID: 95d7f30a-f726-4079-ad98-2e0e669eb1d2
                Copyright © Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/
                License:

                This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

                History
                Date received : 18 January 2016
                Date revision received : 7 December 2016
                Date accepted : 11 January 2017
                Categories
                Subject: Public Health
                Subject: Research
                Subject: 1506
                Subject: 1724
                Subject: 1698
                Subject: 1692
                Subject: 1699

                ScienceOpen disciplines: Medicine
                Keywords: geriatric medicine
                Data availability:
                ScienceOpen disciplines: Medicine
                Keywords: geriatric medicine

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