© Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
EDITORIAL
Crucial role of primary healthcare professionals in the
assessment and diagnosis of dementia
Hao Xue, PhD; Jingchun Nie, PhD; Yaojiang Shi, PhD
Center for Experimental Economics in Education,
Shaanxi Normal University, PR China
Corresponding author: Dr Yaojiang Shi (shiyaojiang7@gmail.com)
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Worldwide, dementia is one of the major causes of
disability and dependency among elderly populations. Globally, there are
approximately 50 million people with dementia, and nearly 10 million new
cases are diagnosed every year.1
The global costs and economic impacts of dementia to the society are
huge—an amount equivalent to about 1 trillion dollars in 2019.2 China accounts for approximately 25% of the worldwide
population of patients with dementia.3
The overall prevalence of dementia in Chinese people aged ≥60 years is
5.3% (95% confidence interval=4.3%-6.3%).4
Both the annual cost per person and the proportion of the national gross
domestic product that dementia accounts for exceeds the global averages,
imposing a substantial economic burden on China.5
In addition, other conditions that are common in elderly populations, such
as frailty, hip fractures, and cancer6
7 8
9 may further compound the
consequences of dementia.
In this issue of the Hong Kong Medical Journal,
Lam and colleagues report findings with important implications for the
assessment and diagnosis of dementia.10
They review recent approaches for its diagnosis and highlighted their
applications in primary healthcare settings. They summarise the importance
and definition of dementia, categorise the differential diagnosis of
cognitive impairment, and explain the diagnostic approach, including the
history and physical examination, cognitive assessment, laboratory tests,
and neuroimaging. Most importantly, Lam et al10
provide background information and advice for healthcare professionals on
how they should utilise recent approaches in diagnosing dementia in
clinical practice. Recent studies have used standardised patients who were
recruited from local communities and extensively trained to present the
same set of standard symptoms to multiple providers to assess quality of
clinical care in China, India, and Kenya. They have shown that the quality
of primary care in low-and-middle-income countries was poor.11 12 13 14 15 16 Most
cases were incorrectly diagnosed based on a very lenient definition, and
simple medical conditions were improperly managed in the majority of
cases. Antibiotics were usually inappropriately overprescribed, and it was
less likely for primary care providers to refer patients to higher-level
hospitals for specialist care when needed. Although the large “know-do
gap”—the gap between healthcare providers’ knowledge and their performance
in clinical practice—can explain part of the low quality, the lack of
essential and updated knowledge to handle this medical condition is still
one of the major reasons for substandard care.17
18 19
According to the National Institute for Health and Care Excellence
guideline on dementia issued in 2018, primary care professionals are
expanding their roles in the diagnosis and assessment of dementia, which
highlights the need for updated education and training for healthcare
professionals on dementia diagnosis and treatment.20
Lam et al10
provide background information for the diagnosis of dementia; however,
there are caveats that require caution when we are using these methods.
First, the costs of each type of diagnostic method should be considered.
For example, neuroimaging can be very expensive and is not without hazard.
It may not be suitable for extensive use in primary care. Second, the
sensitivity and specificity of the tools should be explored to minimise
misdiagnosis due to false positive or false negative results. Third,
individuals with a high risk of cognitive impairment and dementia should
also be identified. Patients with a profile of cardiovascular risk factors
(ie, hypertension, diabetes, or dyslipidaemia) are more likely to have
dementia.21 Diagnosis and
screening may be more efficient if primary care professionals could
recognise these patients earlier.
Not only should primary care providers be trained
in management of dementia, but a national level project should be
implemented to train specialists on dementia so as to enhance capacity to
devise interventions in the community, such as establishment of more
memory clinics. Training modules are suggested to be based on most recent
research findings, including systematic reviews and meta-analysis. For
instance, the 2018 National Institute on Aging–Alzheimer’s Association
Research Framework could be adopted in the design of training materials.22 23
Moreover, the prevalence of dementia and updated clinical management
guidelines in China should be incorporated. Recent studies in Hong Kong
have also highlighted some novel findings that could be applicable for
care of dementia.24 25 26 27 28 In
addition to training professionals, building an appropriately structured
partnership, which takes incentives for both primary care providers and
specialists, the welfare of patients and caregivers, and the cost of
government and society into consideration, is also a challenge for
policymakers in redesigning healthcare policy. It is also essential to
enhance public awareness so that dementia patients and their caregivers
are encouraged to seek help from professional care facilities for reducing
their physical and mental burden.5
Author contributions
All authors contributed to the concept or design,
acquisition of data. analysis or interpretation of data, drafting of the
article, and critical revision for important intellectual content. All
authors had full access to the data, contributed to the study, approved
the final version for publication, and take responsibility for its
accuracy and integrity.
Conflicts of interest
The authors have declared no conflict of interest.
Funding/support
The authors are supported by the 111 Project (Grant
No. B16031).
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