The use of the integrated cognitive assessment to improve the efficiency of primary care referrals to memory services in the accelerating dementia pathway technologies study
Authors: Modarres Mohammad Hadi , Kalafatis Chris , Apostolou Panos , Tabet Naji , Khaligh-Razavi Seyed-Mahdi 
Published: September 2023

Background

Current primary care cognitive assessment tools are either crude or time-consuming instruments that can only detect cognitive impairment when it is well established. This leads to unnecessary or late referrals to memory services, by which time the disease may have already progressed into more severe stages. Due to the COVID-19 pandemic, some memory services have adapted to the new environment by shifting to remote assessments of patients to meet service user demand. However, the use of remote cognitive assessments has been inconsistent, and there has been little evaluation of the outcome of such a change in clinical practice. Emerging research has highlighted computerized cognitive tests, such as the Integrated Cognitive Assessment (ICA), as the leading candidates for adoption in clinical practice. This is true both during the pandemic and in the post-COVID-19 era as part of healthcare innovation.

Objectives

The Accelerating Dementias Pathways Technologies (ADePT) Study was initiated in order to address this challenge and develop a real-world evidence basis to support the adoption of ICA as an inexpensive screening tool for the detection of cognitive impairment and improving the efficiency of the dementia care pathway.

Methods

Ninety-nine patients aged 55–90 who have been referred to a memory clinic by a general practitioner (GP) were recruited. Participants completed the ICA either at home or in the clinic along with medical history and usability questionnaires. The GP referral and ICA outcome were compared with the specialist diagnosis obtained at the memory clinic.

Participants were given the option to carry out a retest visit where they were again given the chance to take the ICA test either remotely or face-to-face.

Results

The primary outcome of the study compared GP referral with specialist diagnosis of mild cognitive impairment (MCI) and dementia. Of those the GP referred to memory clinics, 78% were necessary referrals, with ~22% unnecessary referrals, or patients who should have been referred to other services as they had disorders other than MCI/dementia. In the same population the ICA was able to correctly identify cognitive impairment in ~90% of patients, with approximately 9% of patients being false negatives. From the subset of unnecessary GP referrals, the ICA classified ~72% of those as not having cognitive impairment, suggesting that these unnecessary referrals may not have been made if the ICA was in use. ICA demonstrated a sensitivity of 93% for dementia and 83% for MCI, with a specificity of 80% for both conditions in detecting cognitive impairment. Additionally, the test-retest prediction agreement for the ICA was 87.5%.

Conclusion

The results from this study demonstrate the potential of the ICA as a screening tool, which can be used to support accurate referrals from primary care settings, along with the work conducted in memory clinics and in secondary care. The ICA’s sensitivity and specificity in detecting cognitive impairment in MCI surpassed the overall standard of care reported in existing literature.