Improving the Referral of Patients With Suspected Cognitive Impairment and Early Dementia

The pilot study has an exploratory quasi-experimental design. It is single blinded in the perspective of the Neurology consultation, regarding the origin and method of referral of each patient with a suspected diagnosis of MCI or early dementia from primary care.

The study will be implemented at six Portuguese FHU from Matosinhos. FHU will be similar in size, demographic composition, annual average of patients with cognitive complaints suspected of a diagnosis of MCI or early dementia, and annual average of referrals of patients with suspected MCI or early dementia to specialized care. FHU will be randomly allocated to the three study groups, existing two FHU in each group.

In each FHU, all PCCs will be invited to participate and all eligible patients will be proposed to be included in the study. The PCCs will assess the patient during a normal consultation and, whenever considered relevant, will decide to apply the referral strategy based on the support tools available. This will be a non-probabilistic consecutive sampling process of the general population, carried out by PCCs. An average of 20 to 30 patients are expected to be referred to the specialized care, after one year of recruitment, in each group.

The study groups are characterized as the following:

i) Group MoCA/MMSE: a training session about dementia management and standardized criteria for referral will be provided to the participant PCCs, complemented with training in the administration of MMSE and MoCA, provided also to resident clinicians responsible for administration of the tests. MMSE will be administered if the patient has three to four years of schooling, and the MoCA will be used if the patient has more than four years of schooling. Patients with less than three years of education will be evaluated through regular clinical practice.

ii) Group Brain on Track/MoCA/MMSE: a training session about dementia management and standardized criteria for referral will be provided to the participant PCCs, complemented with training in the administration of Brain on Track, MMSE, and MoCA, provided also to resident clinicians responsible for administration of the tests. Brain on Track is a class I digital medical device web-based, used to remotely monitor cognitive function: https://neuroinova.com/brain-on-track/. There will be a first assessment that will have the aim of providing training to patients by a resident clinician. One week later, a second assessment will be performed. Depending on the score obtained in the second session, patients will be immediately referred to a specialized consultation, will not be referred or will be followed up during a period of 12 months with remote self monitorization, every three months. Concerning the patients followed-up, according to the total score from the four self-assessments, PCCs will decide whether to refer or not. Patients who are illiterate will be evaluated through regular clinical practice, or MMSE or MoCA tests, according to years of schooling, if they are literate, but do not gather the inclusion criteria for the administration of Brain on Track.

iii) Control group: regular clinical practice complemented with the provision of standardized criteria for referring patients with a suspected diagnosis of MCI or early dementia to PCCs.

In each study group, the participating health professionals will receive adequate training from the research team.

All referred patients will undergo a comprehensive neuropsychological assessment and a complete etiological study, performed by Neurologists from the reference hospital associated with the participating FHU. This assessment will validate the PCCs´ clinical decision of referral as correct or incorrect, in all three groups. Concerning the validation of the clinical decision of non-referral, all the patients not referred will be contacted by phone, one year after the participation in the study, to check if the diagnosis changed during that period of time and the patient is being followed up or will start to be followed up by a Neurologist.

Additionally, Focus Groups will be performed at the end of the period of patients´ recruitment of one year, with health professionals from FHU allocated to interventional groups, and at the end of the one-year follow-up period with Brain on Track, with patients who were allocated to this follow-up. The aim of this qualitative study is to perceive the experience of health professionals and patients on using the respective interventional cognitive strategies.

The success of the implementation of the study will be quantified by quality indicators of two types, indicators of adhesion and indicators of referral, which will be constructed upon data collected by PCCs in specific forms designed by the research team and integrated into the local computer network of FHU, as well as data collected by Neurologists in specific forms also created by the research team.

The statistical analysis of will be performed using SPSS statistical software and will consist of a comparison of the primary endpoints between the three study groups, using an adequate statistical test for independent samples, namely a Qui-Square test or a T-test. The significance level will be fixed at 5%. Concerning the secondary endpoint related to the adhesion to the interventional strategies implemented, models of logistic regression will be used to assess the associations between patients and health professionals sociodemographic and professional characteristics, and the level of adhesion to the intervention. Odds ratio with 95% confidence intervals will be computed using logistic regression. The qualitative data obtained from Focus Groups will be analyzed using NVivo software and all the information collected will be transcribed verbatim, and a thematic analysis and data triangulation will be performed subsequently.

• Adhesion to interventional strategies by health professionals [Срок оценки: At one-year of recruitment]
• Adhesion to Brain on Track by patients allocated to remote follow-up [Срок оценки: At the end of the remote monitoring period of 12 months with Brain on Track]