Implementing post diagnostic dementia care in primary care: a mixed-methods systematic review
Open accessAbstract
OBJECTIVES: Concentrating post-diagnostic dementia care in primary care may lead to better and more cost-effective care closer to home. We aimed to assess which intervention components and contextual factors may contribute to the successful delivery and implementation of primary care-led post-diagnostic dementia care. METHODS: Mixed-methods systematic review. We searched five databases (inception-March 2019) with reference list screening and citation tracking. We included studies evaluating post-diagnostic dementia care interventions where primary care had a significant role in dementia care, which assessed one or more implementation elements (acceptability, feasibility, adoption, sustainability, reach, costs, appropriateness or fidelity). Two authors independently critically appraised studies. RESULTS: Out of 4528 unique references, we screened 380 full texts and included 49 evaluations of services collecting implementation process data. Most services had high acceptability ratings. The most acceptable components were information provision, social and emotional support and links to community organisations. Feasibility was chiefly influenced by provider engagement and leadership, building dementia care capacity, sufficient resources/funding and collaboration. Care quality was maximised through adding capacity from a dementia-specific health professional. On the basis of limited data, costs for various primary care-led models did not substantially differ from each other. CONCLUSION: A range of primary care-led dementia care models appear feasible and acceptable. Future services should: add dementia-focussed health professionals into primary care, develop primary care leadership and provide sufficient funding and collaboration opportunities. Information, community service links and social and ongoing support should be part of services. Further exploration of service reach and formalised fidelity assessment are needed.
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Several decades of research supports the value of collaborative primary care models that bring different health professionals together to care for people living with dementia.
“Several decades of research supports the value of collaborative primary care models that bring these different health professionals together to care for people living with dementia.650,651”
From 2023 Alzheimer's disease facts and figures (2023) · cites this paper as [651]
The Collaboration section says close cooperation among primary care, specialists, and case managers was essential to making dementia services work. The Discussion also finds that adding other disciplines appeared to improve care quality. The review supports the value of collaborative models, but the cited passages do not establish the claim’s “several decades” timeframe. (LLM, conf=0.78)
Experimental — accuracy not yet measuredThese collaborative primary care models have been associated with reduced behavioral symptoms, improved function and quality of life, decreased caregiver burden, and lower health care costs related to hospitalizations, emergency department visits and other outpatient visits.
“These models have been associated with a range of benefits including reduced behavioral symptoms, improved function and quality of life, decreased caregiver burden, and lower health care costs related to hospitalizations, emergency department visits and other outpatient visits.651,652”
From 2023 Alzheimer's disease facts and figures (2023) · cites this paper as [651]
Section 3.10 (page not provided) reports that non-randomised studies suggested cost savings for some primary care-led dementia models, which supports the cost-benefit portion in general. It does not attribute those savings specifically to fewer hospitalizations, emergency department visits, or outpatient visits. The passages found on behavioral symptoms, function, and caregiver support concern monitoring, assessment, or satisfaction rather than the claimed improvements in patient outcomes or reduced caregiver burden. (LLM, conf=0.84)
Experimental — accuracy not yet measuredThese collaborative and comprehensive models have been associated with a range of benefits including reduced behavioral symptoms, improved function and quality of life, decreased caregiver burden, and lower health care costs related to hospitalizations, emergency department visits and other outpatient visits.
“These collaborative and comprehensive models have been associated with a range of benefits including reduced behavioral symptoms, improved function and quality of life, decreased caregiver burden, and lower health care costs related to hospitalizations, emergency department visits and other outpatient visits.”
From 2024 Alzheimer's disease facts and figures (2024) · cites this paper as [751]
Section 3.10 (page not specified) reports that some non-randomised studies suggested cost savings for primary care-led dementia care, while two randomised trials found no significant cost differences. The passages do not establish reduced behavioural symptoms, improved function or quality of life, decreased caregiver burden, or that the reported savings specifically arose from hospitalisations, emergency department visits and outpatient visits. (LLM, conf=0.86)
Experimental — accuracy not yet measuredSeveral decades of research support the value of collaborative models that bring different health professionals together, such as social workers, registered nurses and non‐clinical care managers, physicians and advanced practice providers, and direct care workers, including nurse aides, nursing assistants, home health aides and personal care aides.
“As mentioned in the Workforce section, several decades of research support the value of collaborative models that bring different health professionals together, such as social workers, registered nurses and non‐clinical care managers, physicians and advanced practice providers, and direct care workers, including nurse aides, nursing assistants, home health aides and personal care aides. 750 , 751”
From 2024 Alzheimer's disease facts and figures (2024) · cites this paper as [751]
Section 3.5.4, Collaboration, says close collaboration among primary care, specialists and case managers was essential to making dementia services work. Section 3.1 describes models involving physicians, nurses, case managers and other care staff. The review does not establish the claim for the full listed workforce, particularly direct care aides, or for collaborative models beyond post-diagnostic dementia care in primary care. (LLM, conf=0.85)
Experimental — accuracy not yet measuredSeveral decades of research supports the value of collaborative primary care models that bring different health professionals together to care for people living with dementia.
“Several decades of research supports the value of collaborative primary care models that bring different health professionals together, such as social workers, registered nurses and non‐clinical care managers, in addition to physicians and advanced practice providers, to care for people living with dementia.”
From 2024 Alzheimer's disease facts and figures (2024) · cites this paper as [751]
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Self-citationCaring for People With Dementia: Mapping the Experience and Journey From Diagnosis
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Living With Dementia: Care Partner Needs and Outcomes of a Dementia Support Program in Primary Care
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PIRMINĖS SVEIKATOS PRIEŽIŪROS SLAUGYTOJO KOMPETENCIJOS ANKSTYVOJE DEMENCIJOS DIAGNOSTIKOJE
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Additional file 2 of Mapping the evidence on dementia care pathways – A scoping review
Saragosa, M., MacEachern, E., Chiu, M., Weylie, S., Schneider, K., Maloney, E. R., Holland, J., Kuluski, K., Orchanian‐Cheff, A., & Nelson, M. L. (2024) · Figshare · doi:10.6084/m9.figshare.26771747
Additional file 1 of Mapping the evidence on dementia care pathways – A scoping review
Saragosa, M., MacEachern, E., Chiu, M., Weylie, S., Schneider, K., Maloney, E. R., Holland, J., Kuluski, K., Orchanian‐Cheff, A., & Nelson, M. L. (2024) · Figshare · doi:10.6084/m9.figshare.26771733
Henein, M., Arsenault‐Lapierre, G., Sourial, N., Godard‐Sebillotte, C., Bergman, H., & Vedel, I. (2022) · Figshare · doi:10.6084/m9.figshare.19802420
Inside the black box: Refining programme theory in the PriDem dementia care study
Griffiths, S., Spencer, E., Robinson, L., Rait, G., & on behalf of Glasgow Royal Infirmary HFpEF team (2026) · PLoS ONE · doi:10.1371/journal.pone.0333154
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Hu, J., Niu, R., Du, Q., Xiang, C., Zuo, Y., Jeung, J., & Ma, X. (2026) · International Journal of Human-Computer Studies · doi:10.1016/j.ijhcs.2026.103892
From bilingual dementia screening to equitable clinical action in primary care
Fujiwara, Y. (2026) · Journal of Alzheimer s Disease · doi:10.1177/13872877261491982
- Authors
- Frost, R., Rait, G., Aw, S., Brunskill, G., Wilcock, J., Robinson, L., Knapp, M., Hogan, N., Harrison Dening, K., Allan, L., Manthorpe, J., Walters, K., & on behalf of the PriDem team
- Affiliations
- University College London (GB)
- National University of Singapore (SG)
- Newcastle University (GB)
- London School of Economics and Political Science (GB)
- Dementia UK, London, UK
- University of Exeter (GB)
- King's College London (GB)
- Corresponding author
- Frost, Rachael
- ORCID
- Venue
- Aging & Mental Health
- Publisher
- Informa UK Limited
- Published
- 2020-09-10
- Volume
- 25
- Issue
- 8
- Pages
- 1381-1394
- ISSN
- 1360-7863 (ISSN-L)
- 1364-6915
- OpenAlex
- W3082029180
- Cited by
- 39
- References
- 67
- Citations by year
- 2026: 5 · 2025: 8 · 2024: 11 · 2023: 4 · 2022: 8 · 2021: 3
- FWCI
- 0.62
- Type
- journal article
- Language
- en
- Open access
- green
- doi.org
- Locations
- Aging & Mental Health (publishedVersion)
- PubMed (publishedVersion)
- London School of Economics and Political Science Research Online (London School of Economics and Political Science) (acceptedVersion)
- London School of Economics and Political Science Theses Online (London School of Economics and Political Science) (acceptedVersion)
- Open Research Exeter (University of Exeter) (acceptedVersion)
- National University of Singapore (submittedVersion)
- UCL Discovery (University College London) (submittedVersion)
- Figshare (submittedVersion)
- Research Portal (King's College London) (submittedVersion)
- Newcastle University ePrints (Newcastle Univesity)
- Funders
- Alzheimer’s Society (331)
- Topics
- Health Sciences › Medicine › Psychiatry and Mental health › Dementia and Cognitive Impairment Research
- Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
- Health Sciences › Health Professions › General Health Professions › Geriatric Care and Nursing Homes
- Keywords
- primary care, implementation, acceptability, feasibility, community organizations, socioemotional support, care costs, service sustainability, provider engagement
- MeSH terms
- Cost-Benefit Analysis, Dementia, Health Personnel, Humans, Primary Health Care, Quality of Health Care
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