Guideline recommendations on the role of the general practitioner in the diagnosis of dementia: a protocol for a scoping review of clinical practice guidelines

Mary Cronin; Aisling Jennings; Marieke Perry; Irene Hartigan; Séan O'Dowd; Nicola Cornally; Suzanne Timmons; Kieran Walsh; Tony Foley

doi:10.12688/hrbopenres.13919.2

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Revised

Guideline recommendations on the role of the general practitioner in the diagnosis of dementia: a protocol for a scoping review of clinical practice guidelines

[version 2; peer review: 2 approved]

Mary Cronin ¹, Aisling Jennings¹, Marieke Perry², [...] Irene Hartigan³, Séan O'Dowd⁴, Nicola Cornally³, Suzanne Timmons⁵, Kieran Walsh⁶, Tony Foley¹

Mary Cronin ¹, Aisling Jennings¹, [...] Marieke Perry², Irene Hartigan³, Séan O'Dowd⁴, Nicola Cornally³, Suzanne Timmons⁵, Kieran Walsh⁶, Tony Foley¹

PUBLISHED 12 Feb 2025

Author details Author details

¹ Department of General Practice, School of Medicine, College of Medicine and Health, University College Cork, Cork, Ireland
² Department of Geriatrics, Radboud University Medical Centre, Nijmegen, The Netherlands
³ School of Nursing and Midwifery, University College Cork, Cork, Ireland
⁴ HSE National Dementia Office, Tullamore, Ireland
⁵ Centre for Gerontology and Rehabilitation, School of Medicine, College of Medicine and Health, University College Cork, Cork, Ireland
⁶ School of Pharmacy, University College Cork, Cork, Ireland

Mary Cronin
Roles: Methodology, Writing – Original Draft Preparation, Writing – Review & Editing

Aisling Jennings
Roles: Methodology, Writing – Review & Editing

Marieke Perry
Roles: Methodology, Writing – Review & Editing

Irene Hartigan
Roles: Methodology, Writing – Review & Editing

Séan O'Dowd
Roles: Conceptualization, Methodology

Nicola Cornally
Roles: Methodology, Writing – Review & Editing

Suzanne Timmons
Roles: Methodology, Writing – Review & Editing

Kieran Walsh
Roles: Methodology, Writing – Review & Editing

Tony Foley
Roles: Conceptualization, Funding Acquisition, Methodology, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

This article is included in the Dementia Trials Ireland (DTI) and Dementia Research Network Ireland (DRNI) gateway.

Abstract

Introduction

A timely diagnosis of dementia offers the opportunity of earlier intervention and activation of coordinated care plans. General Practitioners (GPs) play a key role in dementia diagnosis, from symptom recognition to clinical assessment, investigation, diagnosis and onward referral for confirmation of the diagnosis and subtyping. Dementia clinical practice guidelines (CPGs) offer clinicians guidance on dementia care but often do not specifically address the role of the GP in the diagnostic process. This protocol outlines a scoping review to identify evidence-based dementia clinical practice guidelines and map the recommended role of GPs in the diagnosis of dementia.

Method

The scoping review will be conducted using the Arksey and O'Malley framework, and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for scoping reviews (PRISMA-ScR) will be used to guide the reporting. We will search five electronic databases (PubMed, CINAHL, Embase, PsycINFO, Cochrane Library) for dementia CPGs published since 2019. CPGs are often not published in peer-reviewed journals; therefore, a parallel search of relevant grey literature will be conducted. We will also search the websites of GP professional organisations and guideline developers. Two reviewers will independently screen all articles based on inclusion criteria, with conflicts resolved by a third reviewer.

Conclusion

This scoping review will examine up-to-date dementia CPGs to determine recommendations for the role of GPs in the assessment, investigation, diagnosis and onward referral of patients with suspected dementia to secondary care.

Keywords

General practice, primary healthcare, practice guidelines, diagnosis, dementia.

Corresponding author: Mary Cronin

Competing interests: No competing interests were disclosed.

Grant information: This work is supported by a Health Research Board Applied Partnership Award [APA-2022-027]

Copyright: © 2025 Cronin M et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Cronin M, Jennings A, Perry M et al. Guideline recommendations on the role of the general practitioner in the diagnosis of dementia: a protocol for a scoping review of clinical practice guidelines [version 2; peer review: 2 approved]. HRB Open Res 2025, 7:46 (https://doi.org/10.12688/hrbopenres.13919.2) First published: 08 Jul 2024, 7:46 (https://doi.org/10.12688/hrbopenres.13919.1) Latest published: 12 Feb 2025, 7:46 (https://doi.org/10.12688/hrbopenres.13919.2)

Revised Amendments from Version 1

We thank both reviewers for their contributions, which improved the scoping review protocol considerably. We responded to each reviewer using a point-by-point response format and provided the details of the changes made. We have added to the introduction section to address the 'why' of referral, the imminent introduction of DMTs, and the critical role GPs will play in early identification, assessment, and referral to specialist services. In the introduction, we have also addressed the international context of the role of the GP. We have provided more detail in the method section about how we will contact GP professional organisations and included an update of the search before the final analysis. In the conclusion, we expanded on the potential impact of the research to include the development of a dementia diagnosis and management guidance document for GPs in Ireland and potentially to inform the development of a referral form to support referral from primary care to secondary care for patients with suspected cognitive impairment or dementia.

See the authors' detailed response to the review by Emer O'Brien
See the authors' detailed response to the review by Soo Borson

Introduction

Dementia is an acquired cognitive function loss across several domains¹ with progressive and potentially severe effects on day-to-day living for patients and their families. Globally, approximately 55 million people live with dementia, with an annual incidence of nearly 10 million cases², making dementia care a global health priority³. A timely diagnosis of dementia is important as it can improve the quality of life of people with dementia and their family caregivers⁴. Furthermore, with the emergence of disease-modifying therapies (DMTs), early identification and onward referral for further specialist evaluation is critical as DMTs are indicated for use in early disease stages due to their potential to slow progression but not reverse existing symptoms⁵.

General Practitioners (GPs), as the usual first point of contact, have a key role in symptom recognition, assessment and referral of patients with suspected dementia. This may involve the direct diagnosis of dementia by the GP or, more usually, the completion of a detailed clinical assessment, relevant investigations and the exclusion of other differential diagnoses prior to onward referral^6–8. In terms of the dementia diagnostic pathway, GPs play varying roles in healthcare systems worldwide, with a significant emphasis on a gatekeeping role in many countries. In the UK and Dutch healthcare systems, GPs serve as gatekeepers, managing patient access to specialists and ensuring efficient use of resources^9,10. Similarly, in Australia, GPs control patient referrals to specialists and diagnostic services, promoting cost-effectiveness and preventive care¹¹. Conversely, in the United States, GPs have a less centralized gatekeeping role, as patients often have direct access to specialists, depending on insurance plans¹². These varying GP roles reflect differing healthcare priorities, from cost containment to patient autonomy.

Dementia remains underdiagnosed despite the important implications for patients and their families. While GPs have been criticised for low identification and dementia diagnosis rates in primary care¹³, research has found that many GPs take a nuanced, patient-centred approach¹⁴. GPs undertake a complex, decision-making process, whereby they balance the risks and benefits of making the diagnosis¹⁵. Even in the absence of a formal diagnosis or disclosure of a diagnosis of dementia, GPs often activate a range of dementia care services and supports for their patients¹⁴. When deciding whether to initiate the formal diagnostic and referral process, GPs weigh up many different competing issues related to patient autonomy, consent, risks, patient needs, planning for the future, optimising treatments and access to dementia care services^14,15. Upon making a decision to refer to specialist services, dementia diagnostic and care pathways can be difficult to navigate for both GPs and for people living with dementia and their caregivers^16,17 leading to further diagnostic delays.

The timing of the diagnosis of dementia is important. Up until now, the absence of effective disease-modifying therapies (DMTs) has led to National Dementia Strategy recommendations for a ‘timely’ diagnosis of dementia as opposed to an ‘early’ diagnosis, i.e. at the right time for the patients, taking the risks and benefits of diagnosis into consideration¹⁸. However, the introduction of the first anti-amyloid immunotherapy DMTs for the treatment of patients with early symptomatic Alzheimer’s disease (AD) will inevitably necessitate a shift towards earlier identification and diagnosis¹⁹. The emergence of DMTs will likely increase the pressures and demands on primary care and the limited resources of healthcare systems²⁰. It will be important for GPs to identify potentially eligible patients with cognitive disorders, arrange early referral to specialist centres and coordinate care for patients during and after treatment. While the introduction of DMTs brings hope for many, evidence-informed, clear and equitable diagnostic pathways from primary care to specialist services will be urgently needed. In parallel with the introduction of DMTs, the diagnostic pathway of AD is transforming with the introduction of AD-specific biomarkers, most commonly amyloid positron emission tomography (PET) and cerebrospinal fluid (CSF) biomarkers²¹. Recent findings suggest that blood-based biomarkers (BBMs) will be introduced into clinical practice within two-three years²².

GPs often look to evidence-based clinical practice guidelines (CPGs) to facilitate decision-making in the clinical setting²³. A recent systematic review of CPGs for dementia found that many publications include information on diagnosis, treatment and monitoring, with a small number of more recent publications also including screening²⁴. The process of the development of CPGs varies internationally. In some countries, such as The Netherlands, CPGs are developed specifically for GPs25. In contrast, in other countries, guidelines are developed by national organisations, such as the National Institute for Health and Care Excellence (NICE), for a broad range of healthcare professionals, often with GPs as contributors²⁵. Recommendations around clinical assessment and onward referral from primary to secondary care are often not addressed or are unclear in CPGs. For example, the National Institute for Health and Care Excellence (NICE) guideline indicates referral to specialist services when dementia is still suspected after reversible causes of cognitive decline or cognitive impairment from medicines have been investigated⁷. In comparison, the Scottish Intercollegiate Guidelines Network (SIGN) guideline suggests several cognitive tests that may be used to identify patients who would benefit from referral to secondary care²⁶.

Despite their central position, the specific role of GPs in the diagnostic process has not been systematically examined within CPGs. To the best of our knowledge, no systematic attempts have been made to compare recommendations from existing dementia CPGs with respect to the role of the GP in the diagnosis of dementia. This review aims to identify CPGs that include a focus on the diagnosis of dementia and examine the specific role of GPs in the clinical assessment, investigation, diagnosis and referral of patients to secondary care. The review findings will inform the development of a dementia diagnosis and management guidance document for GPs in Ireland and has the potential to inform the development of a dementia referral form that may be used when referring a patient with suspected cognitive impairment or dementia from primary to secondary care.

Method

The method will follow the procedure outlined by Arksey and O'Malley²⁷ while incorporating additional revisions and suggestions for enhancing and strengthening the framework^28,29. Therefore, the review follows a six-step process including: (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data, (5) collating, summarising and reporting the results, (6) consultation exercise with stakeholders. Each of the six steps in the framework are outlined in detail below. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for scoping reviews (PRISMA-ScR)³⁰ will guide the reporting of the scoping review. The PRISMA-ScR provides a standardised system for researchers to report scoping reviews and includes twenty essential and two optional items in a checklist format. The checklist includes the key items considered essential for providing full transparency around the research process. The completed checklist will be provided in the scoping review publication. The quality of the included guidelines will be assessed using the AGREE II instrument³¹. This scoping review protocol was registered with Open Science Framework on 17th June, 2024.

1. Identifying the research question

The Population, Concept, Context (PCC) model^32,33, widely recommended for scoping reviews, was used to determine the focus of the research question and to formulate inclusion and exclusion criteria.

Search terms (See Table 1) were developed by the research team using a literature review and informed by previous systematic and scoping reviews related to clinical practice guidelines and dementia^24,34,35. An information specialist from University College Cork was consulted to finalise the research terms. The search terms will be refined further based on retrieved abstracts²⁸.

Table 1. Search terms.

	Search terms
Patients with cognitive impairment or dementia	dementia* OR Alzheimer* OR “cognitive impairment” OR “Cognitive decline” OR “cognitive dysfunction”
Management or diagnosis of dementia	Diagnos* OR screen* OR “best clinical practice” OR “disease management” OR manage* OR “principles of car” OR “comprehensive car”
Guideline	Guid* OR “best practice” OR procedure OR “Clinical Practice Guideline” OR recommend

Overarching research question: What is the recommended role of the GP in the diagnosis of dementia in CPGs?

Specifically, the review will focus on the following questions:

1. What CPGs on dementia care include a focus on the diagnostic process in the general practice setting?
2. What are the recommendations regarding the role of the GP in the clinical assessment, investigation, and diagnosis of dementia?
3. What is the recommended referral process outlined in CPGs when referring a patient with suspected dementia from primary to secondary care?
4. What are the CPG recommendations regarding dementia diagnostic criteria?
5. With specific reference to the introduction of biomarkers and novel disease modifying therapies for AD, what are the recommendations regarding the diagnostic process in general practice?

2. Identifying relevant studies

Searches will be carried out on databases of peer-reviewed literature (PubMed, CINAHL, Embase, PsycINFO, Cochrane Library). We will use the alerts feature on databases to keep up to date with any new publications throughout the course of the review. Given that many CPGs may not be published in peer-reviewed databases, we will primarily search the grey literature. The grey literature search will include Lenus (the Irish Health Repository), National Institute for Health and Care Excellence (NICE) and Scottish Intercollegiate Guideline Network (SIGN) websites and generic search engines, i.e. Google and Google Scholar (first 200 citations). In addition, we will search appropriate databases for guidelines including, but not limited to, Guideline Central, Guidelines International Network, UpToDate, TRIP, and the Agency for Healthcare Research and Quality, using combinations of the keywords used in the bibliographic database search. We will also search the websites of GP professional organisations nationally and internationally, as guidelines are often made available for GPs through these platforms. Where dementia guidelines are unavailable (or inaccessible) on the professional organisation websites, we will contact them via email to request a copy. Google Translate will be used to increase the likelihood of a response from international GP organisations. Where there is more than one guideline from the same author or organisation we will use the most up-to-date version. We will also search the reference lists of all included CPGs.

Searches will be limited to titles and abstracts, and all identified citations will be uploaded to Covidence for screening and data management purposes.

The literature search will be limited to publications from January 2019 to May 2024. These timelines were selected to reflect the evolution of clinical practice and to update the literature since the publication of the most recent CPG on dementia care for GPs in Ireland in 2019³⁶. To ensure the comprehensiveness and currency of our review, we will conduct an updated literature search prior to the final analysis. This search will again include the original databases PubMed, CINAHL, Embase, PsycINFO and Cochrane Library, covering the period from the last search date to the present. Any new studies meeting the inclusion criteria will be incorporated into the final synthesis.

3. Study selection

The title and abstract of papers will be screened initially, and full-text papers will then be reviewed for inclusion. Clinical practice guidelines will be translated into English when required. Full-text studies that do not meet the inclusion criteria will be excluded, and the reasons for exclusion will be provided in an appendix in the final scoping review (See Table 2 for inclusion/exclusion criteria). Where there is conflict, another member of the multidisciplinary research team will act as a third reviewer. This systematic team approach to study selection is recommended to ensure rigour²⁸.

Table 2. Eligibility criteria.

Inclusion criteria

Exclusion criteria

Papers from the past five years (2019–2024) will be included to gain
up-to-date clinical guidance.
Guidelines for the management or diagnosis of Mild Cognitive
Impairment (MCI), early Alzheimer’s Disease and related dementias.
Evidence-based guidelines produced by national and international
groups to guide clinical practice following formal procedures for
practice guideline development.
Relevant to the diagnosis of dementia in primary care. Relevance
determined by the inclusion of:
          ●  Screening to identify patients with MCI or Dementia
          ●  Clinical assessment
          ●  Diagnosis
          ●  Elimination of other possible causes of symptoms
          ●  Investigation of dementia
          ●  Recommendations for referral
Guidelines in any language.

Guidelines for specific populations, e.g. guidelines for dementia
in young adults or those with ID.
Guidelines not evidence-based or where the guideline
development is not transparent.
Regional guidelines.
Research studies, academic journal articles such as those
examining guideline adherence, compliance, development, or
evaluation.
Editorials.
Conference proceedings and theses.
Study Protocols.
Guidelines specific to genetic testing, risk factors, dementia
prevention, post-diagnosis care, palliative care, treatment or
therapies for the management of dementia.
Guidelines specific for other health professionals, i.e., nurses,
Allied Healthcare Professionals, or caregivers.
Guidelines for use in in-patient hospital settings.
National strategies or policies.
Summaries of CPGs

4. Charting of the data

Data charting involves charting the data according to key issues and themes²⁷. We will also conduct another step to charting, which involves two reviewers independently charting five to ten papers using the form and then consulting to discuss if their approach is consistent²⁸. Therefore, we will develop a draft form to include items such as 1) authors, 2) year of publication, 3) country of origin, 4) aims/ objectives, 5) type of guideline/guidance, 6) clinical history, 7) physical examination 8) cognitive screening tests 9) investigations, 10) exclusion of other diagnosis 11) communication to other healthcare professionals 12) DMTs 13) biomarkers and 14) referral to specialist services. We will review a number of papers using the form and will consult and update the form, as necessary. Following the finalisation of the charting form, we will chart the remaining papers and consult to finalise the charting in an iterative process.

5. Summarising and reporting results

Two reviewers will summarise findings from the extracted data to include a descriptive numerical summary of the characteristics of the included guidelines. The research team will produce a complete synthesis of recommendations for referral from primary care to secondary care. Results will be reported using the PRISMA-ScR guidelines³⁰. Each research question will be reported separately and presented in a tabular form and as a narrative summary.

6. Consultation exercise with stakeholders

Arksey & O’Malley suggested that a consultation exercise with stakeholders is an optional step²⁷. However, Levac et al. and Daudt et al. suggest that this should be required for a scoping review^28,29. We will engage with GPs, secondary care specialists, multidisciplinary healthcare professionals and with The Dementia Research Advisory Team (DRAT) of the Alzheimer’s Society of Ireland. DRAT is a group of people living with dementia and carers/supporters who are involved in dementia research as co-researchers.

Conclusions

The findings from this scoping review will inform the development of a dementia diagnosis and management guidance document for GPs in Ireland and will have the potential to inform the development of a referral form to support referral from primary care to secondary care for patients with suspected cognitive impairment or dementia. The imminent introduction of DMTs for Alzheimer's disease underscores the urgency and importance of the early diagnosis of Alzheimer’s disease. GPs will play a critical role in early identification, assessment, and referral to specialist services. This shift will necessitate clear, evidence-informed diagnostic pathways from primary to secondary care, to ensure patients receive equitable, appropriate and timely care. The rigorous and transparent methodology and a strong multidisciplinary team approach will ensure that the guideline and referral form is based on rich data and provides appropriate information to GPs. The research findings will also be submitted for publication in relevant peer-reviewed journals and presented at conferences.

Data availability

No data are associated with this article.

Faculty Opinions recommended

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Comments on this article Comments (0)

Version 2

VERSION 2 PUBLISHED 08 Jul 2024

Author details Author details

Mary Cronin
Roles: Methodology, Writing – Original Draft Preparation, Writing – Review & Editing

Aisling Jennings
Roles: Methodology, Writing – Review & Editing

Marieke Perry
Roles: Methodology, Writing – Review & Editing

Irene Hartigan
Roles: Methodology, Writing – Review & Editing

Séan O'Dowd
Roles: Conceptualization, Methodology

Nicola Cornally
Roles: Methodology, Writing – Review & Editing

Suzanne Timmons
Roles: Methodology, Writing – Review & Editing

Kieran Walsh
Roles: Methodology, Writing – Review & Editing

Tony Foley
Roles: Conceptualization, Funding Acquisition, Methodology, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

This work is supported by a Health Research Board Applied Partnership Award [APA-2022-027]

Article Versions (2)

version 2

Revised

Published: 12 Feb 2025, 7:46

https://doi.org/10.12688/hrbopenres.13919.2

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Published: 08 Jul 2024, 7:46

https://doi.org/10.12688/hrbopenres.13919.1

© 2025 Cronin M et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Cronin M, Jennings A, Perry M et al. Guideline recommendations on the role of the general practitioner in the diagnosis of dementia: a protocol for a scoping review of clinical practice guidelines [version 2; peer review: 2 approved]. HRB Open Res 2025, 7:46 (https://doi.org/10.12688/hrbopenres.13919.2)

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Reviewer Report 18 Feb 2025

Emer O'Brien, Department of General Practice, RCSI, Dublin, Ireland

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https://doi.org/10.21956/hrbopenres.15479.r45629

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Soo Borson, University of Southern California, Los Angeles, USA

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Reviewer Report 18 Dec 2024

Soo Borson, University of Southern California, Los Angeles, USA

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https://doi.org/10.21956/hrbopenres.15268.r43930

This paper describes a protocol for a scoping review of guidelines for GP diagnosis of dementia. While it's questionable whether a protocol paper for a scoping review requires publication on its own - rather than simply as part of the completed review when submitted - this is well done. A particular strength is the authors' intent to consult a range of relevant stakeholders as part of the scoping process.

Suggestions:
1. I would strongly urge the authors to frame the 'why' of GP dementia diagnosis, i.e. how making a dementia diagnosis in primary care informs patient (not just disease) management; what do GPs need to know about the individual and the family in order to provide primary care for people with dementia - regardless of specialist involvement?
2. I recommend similar attention to the 'why' of specialist referrals for diagnosis. We know that patterns of diagnosis and management of dementia are heavily dependent on national, local, and specific practice-based opportunities, which are not equitably distributed. There has been a longterm mismatch between recognition that GPs do most of the diagnosing and managing of patients with dementia and the 'knee-jerk' expectation that all patients with possible cognitive disorders need to see specialists; we know this is both infeasible, invalid when considered from a global perspective, and likely wasteful of scarce specialist resources (no offense to specialists; I am one). It would be most welcome to have a critical, evidence-based review of decision points regarding who, when, and why specialist referral is important and useful.
3. There will need to be some attention to another scarce resource - the availability of high-specificity diagnostic testing for etiology of dementia, and of disease-modifying treatments for Alzheimer's disease, which varies with country, region, population, health system, and many other ecological determinants. Identifying candidates for such therapies is a major driver of specialist referral in some sectors of US health care; it would be valuable to consider this from a transnational perspective.

Is the rationale for, and objectives of, the study clearly described?

Partly
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Yes
Are the datasets clearly presented in a useable and accessible format?

Not applicable

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Dementia in primary care; early detection of dementia; complex care approaches.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Author Response 13 Feb 2025

Mary Cronin, Department of General Practice, School of Medicine, College of Medicine and Health, University College Cork, Cork, Ireland

13 Feb 2025

Author Response

Many thanks for the very helpful, constructive comments around the ‘why’ of GP diagnosis, the ‘why’ of referral to specialists for diagnosis and also the introduction of DMTs and the ... Continue reading Many thanks for the very helpful, constructive comments around the ‘why’ of GP diagnosis, the ‘why’ of referral to specialists for diagnosis and also the introduction of DMTs and the scarcity of resources. We have added two paragraphs to the Introduction section to address these important points. We feel this has strengthened the paper significantly, adding a real-world context to the diagnostic debate. In the full scoping review, we will further elaborate on these important points

Point by point response:

Comment 1:
Reviewer’s Comment
“I would strongly urge the authors to frame the ‘why’ of GP dementia diagnosis, i.e. how making a dementia diagnosis in primary care informs patient (not just disease) management; what do GPs need to know about the individual and the family in order to provide primary care for people with dementia – regardless of specialist involvement?”
RESPONSE: Thank you for this comment. We acknowledge that there is a complexity to the ‘why’ of GP dementia diagnosis and how it informs patient care. We have added the following text to address this point.
‘While GPs have been criticised for low identification and dementia diagnosis rates in primary care(13).Research has found that many GPs take a nuanced, patient-centred approach(14). GPs undertake a complex, decision-making process, whereby they balance the risks and benefits of making the diagnosis (15). GPs compare competing patient priorities, when deciding when to initiate the formal diagnostic process and when to refer onwards to secondary care for confirmation of a suspected diagnosis of dementia. Even in the absence of a formal diagnosis or disclosure of a diagnosis of dementia, GPs activate a range of dementia care services and supports for their patients(14).’(Introduction Paragraph 2).

Comment 2:
Reviewer’s Comment:
“I recommend similar attention to the ‘why’ of specialist referrals for diagnosis. We know that patterns of diagnosis and management of dementia are heavily dependent on national, local, and specific practice-based opportunities, which are not equitably distributed. There has been a long-term mismatch between recognition that GPs do most of the diagnosing and managing of patients with dementia and the ‘knee-jerk’ expectation that all patients with possible cognitive disorders need to see specialists; we know this is both infeasible, invalid when considered from a global perspective, and likely wasteful of scarce specialist resources (no offense to specialists; I am one). It would be most welcome to have a critical, evidence-based review of decision points regarding who, when, and why specialist referral is important and useful.”
RESPONSE: We appreciate your comment and agree that the rationale for specialist referrals needs to be clearly articulated. We have added the text below and expanded further in response to comment no.3.
‘When deciding whether to initiate the formal diagnostic and referral process, GPs weigh up many different competing issues related to patient autonomy, consent, risks, patient needs, planning for the future, optimising treatments and access to dementia care services (14, 15). Upon making a decision to refer to specialist services, dementia diagnostic and care pathways can be difficult to navigate for both GPs and for people living with dementia and their carers,(16, 17) leading to further diagnostic delays.’ (Introduction Paragraph 3)

Comment 3:
Reviewer’s Comment:
"There will need to be some attention to another scarce resource - the availability of high-specificity diagnostic testing for etiology of dementia, and of disease-modifying treatments for Alzheimer's disease, which varies with country, region, population, health system, and many other ecological determinants. Identifying candidates for such therapies is a major driver of specialist referral in some sectors of US health care; it would be valuable to consider this from a transnational perspective."
RESPONSE: Thank you for this comment regarding disease modifying therapies and limited resources. We have added the following text to address this point.
‘Up until now, the absence of effective disease modifying therapies (DMTs) has led to national dementia strategy recommendations for a ‘timely’ diagnosis of dementia as opposed to an ‘early’ diagnosis i.e. at the right time for the patients, taking the risks and benefits of diagnosis into consideration (Vinay). However, the move towards a biological diagnosis of Alzheimer’s disease and the introduction of the first anti-amyloid immunotherapy DMTs for the treatment of patients with early symptomatic Alzheimer’s disease will inevitably necessitate a shift towards earlier identification and diagnosis (Dobson). Healthcare systems are poorly prepared for this paradigm shift in diagnosis and treatment. The emergence of DMTs will likely increase the pressures and demands on primary care and on the limited resources of healthcare systems too (Smith). It will be important for GPs to identify potentially eligible patients with cognitive disorders, arrange early referral to specialist centres and coordinate care for patients during and after treatment. While the introduction of DMTs brings hope for many, evidence-informed, clear and equitable diagnostic pathways from primary care to specialist services will be urgently needed.’(Introduction paragraph 3)
Many thanks for the very helpful, constructive comments around the ‘why’ of GP diagnosis, the ‘why’ of referral to specialists for diagnosis and also the introduction of DMTs and the scarcity of resources. We have added two paragraphs to the Introduction section to address these important points. We feel this has strengthened the paper significantly, adding a real-world context to the diagnostic debate. In the full scoping review, we will further elaborate on these important points

Point by point response:

Comment 1:
Reviewer’s Comment
“I would strongly urge the authors to frame the ‘why’ of GP dementia diagnosis, i.e. how making a dementia diagnosis in primary care informs patient (not just disease) management; what do GPs need to know about the individual and the family in order to provide primary care for people with dementia – regardless of specialist involvement?”
RESPONSE: Thank you for this comment. We acknowledge that there is a complexity to the ‘why’ of GP dementia diagnosis and how it informs patient care. We have added the following text to address this point.
‘While GPs have been criticised for low identification and dementia diagnosis rates in primary care(13).Research has found that many GPs take a nuanced, patient-centred approach(14). GPs undertake a complex, decision-making process, whereby they balance the risks and benefits of making the diagnosis (15). GPs compare competing patient priorities, when deciding when to initiate the formal diagnostic process and when to refer onwards to secondary care for confirmation of a suspected diagnosis of dementia. Even in the absence of a formal diagnosis or disclosure of a diagnosis of dementia, GPs activate a range of dementia care services and supports for their patients(14).’(Introduction Paragraph 2).

Comment 2:
Reviewer’s Comment:
“I recommend similar attention to the ‘why’ of specialist referrals for diagnosis. We know that patterns of diagnosis and management of dementia are heavily dependent on national, local, and specific practice-based opportunities, which are not equitably distributed. There has been a long-term mismatch between recognition that GPs do most of the diagnosing and managing of patients with dementia and the ‘knee-jerk’ expectation that all patients with possible cognitive disorders need to see specialists; we know this is both infeasible, invalid when considered from a global perspective, and likely wasteful of scarce specialist resources (no offense to specialists; I am one). It would be most welcome to have a critical, evidence-based review of decision points regarding who, when, and why specialist referral is important and useful.”
RESPONSE: We appreciate your comment and agree that the rationale for specialist referrals needs to be clearly articulated. We have added the text below and expanded further in response to comment no.3.
‘When deciding whether to initiate the formal diagnostic and referral process, GPs weigh up many different competing issues related to patient autonomy, consent, risks, patient needs, planning for the future, optimising treatments and access to dementia care services (14, 15). Upon making a decision to refer to specialist services, dementia diagnostic and care pathways can be difficult to navigate for both GPs and for people living with dementia and their carers,(16, 17) leading to further diagnostic delays.’ (Introduction Paragraph 3)

Comment 3:
Reviewer’s Comment:
"There will need to be some attention to another scarce resource - the availability of high-specificity diagnostic testing for etiology of dementia, and of disease-modifying treatments for Alzheimer's disease, which varies with country, region, population, health system, and many other ecological determinants. Identifying candidates for such therapies is a major driver of specialist referral in some sectors of US health care; it would be valuable to consider this from a transnational perspective."
RESPONSE: Thank you for this comment regarding disease modifying therapies and limited resources. We have added the following text to address this point.
‘Up until now, the absence of effective disease modifying therapies (DMTs) has led to national dementia strategy recommendations for a ‘timely’ diagnosis of dementia as opposed to an ‘early’ diagnosis i.e. at the right time for the patients, taking the risks and benefits of diagnosis into consideration (Vinay). However, the move towards a biological diagnosis of Alzheimer’s disease and the introduction of the first anti-amyloid immunotherapy DMTs for the treatment of patients with early symptomatic Alzheimer’s disease will inevitably necessitate a shift towards earlier identification and diagnosis (Dobson). Healthcare systems are poorly prepared for this paradigm shift in diagnosis and treatment. The emergence of DMTs will likely increase the pressures and demands on primary care and on the limited resources of healthcare systems too (Smith). It will be important for GPs to identify potentially eligible patients with cognitive disorders, arrange early referral to specialist centres and coordinate care for patients during and after treatment. While the introduction of DMTs brings hope for many, evidence-informed, clear and equitable diagnostic pathways from primary care to specialist services will be urgently needed.’(Introduction paragraph 3)
Competing Interests: No competing interests were disclosed. Close
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COMMENTS ON THIS REPORT

Author Response 13 Feb 2025

Mary Cronin, Department of General Practice, School of Medicine, College of Medicine and Health, University College Cork, Cork, Ireland

13 Feb 2025

Author Response

Many thanks for the very helpful, constructive comments around the ‘why’ of GP diagnosis, the ‘why’ of referral to specialists for diagnosis and also the introduction of DMTs and the ... Continue reading Many thanks for the very helpful, constructive comments around the ‘why’ of GP diagnosis, the ‘why’ of referral to specialists for diagnosis and also the introduction of DMTs and the scarcity of resources. We have added two paragraphs to the Introduction section to address these important points. We feel this has strengthened the paper significantly, adding a real-world context to the diagnostic debate. In the full scoping review, we will further elaborate on these important points

Point by point response:

Comment 1:
Reviewer’s Comment
“I would strongly urge the authors to frame the ‘why’ of GP dementia diagnosis, i.e. how making a dementia diagnosis in primary care informs patient (not just disease) management; what do GPs need to know about the individual and the family in order to provide primary care for people with dementia – regardless of specialist involvement?”
RESPONSE: Thank you for this comment. We acknowledge that there is a complexity to the ‘why’ of GP dementia diagnosis and how it informs patient care. We have added the following text to address this point.
‘While GPs have been criticised for low identification and dementia diagnosis rates in primary care(13).Research has found that many GPs take a nuanced, patient-centred approach(14). GPs undertake a complex, decision-making process, whereby they balance the risks and benefits of making the diagnosis (15). GPs compare competing patient priorities, when deciding when to initiate the formal diagnostic process and when to refer onwards to secondary care for confirmation of a suspected diagnosis of dementia. Even in the absence of a formal diagnosis or disclosure of a diagnosis of dementia, GPs activate a range of dementia care services and supports for their patients(14).’(Introduction Paragraph 2).

Comment 2:
Reviewer’s Comment:
“I recommend similar attention to the ‘why’ of specialist referrals for diagnosis. We know that patterns of diagnosis and management of dementia are heavily dependent on national, local, and specific practice-based opportunities, which are not equitably distributed. There has been a long-term mismatch between recognition that GPs do most of the diagnosing and managing of patients with dementia and the ‘knee-jerk’ expectation that all patients with possible cognitive disorders need to see specialists; we know this is both infeasible, invalid when considered from a global perspective, and likely wasteful of scarce specialist resources (no offense to specialists; I am one). It would be most welcome to have a critical, evidence-based review of decision points regarding who, when, and why specialist referral is important and useful.”
RESPONSE: We appreciate your comment and agree that the rationale for specialist referrals needs to be clearly articulated. We have added the text below and expanded further in response to comment no.3.
‘When deciding whether to initiate the formal diagnostic and referral process, GPs weigh up many different competing issues related to patient autonomy, consent, risks, patient needs, planning for the future, optimising treatments and access to dementia care services (14, 15). Upon making a decision to refer to specialist services, dementia diagnostic and care pathways can be difficult to navigate for both GPs and for people living with dementia and their carers,(16, 17) leading to further diagnostic delays.’ (Introduction Paragraph 3)

Comment 3:
Reviewer’s Comment:
"There will need to be some attention to another scarce resource - the availability of high-specificity diagnostic testing for etiology of dementia, and of disease-modifying treatments for Alzheimer's disease, which varies with country, region, population, health system, and many other ecological determinants. Identifying candidates for such therapies is a major driver of specialist referral in some sectors of US health care; it would be valuable to consider this from a transnational perspective."
RESPONSE: Thank you for this comment regarding disease modifying therapies and limited resources. We have added the following text to address this point.
‘Up until now, the absence of effective disease modifying therapies (DMTs) has led to national dementia strategy recommendations for a ‘timely’ diagnosis of dementia as opposed to an ‘early’ diagnosis i.e. at the right time for the patients, taking the risks and benefits of diagnosis into consideration (Vinay). However, the move towards a biological diagnosis of Alzheimer’s disease and the introduction of the first anti-amyloid immunotherapy DMTs for the treatment of patients with early symptomatic Alzheimer’s disease will inevitably necessitate a shift towards earlier identification and diagnosis (Dobson). Healthcare systems are poorly prepared for this paradigm shift in diagnosis and treatment. The emergence of DMTs will likely increase the pressures and demands on primary care and on the limited resources of healthcare systems too (Smith). It will be important for GPs to identify potentially eligible patients with cognitive disorders, arrange early referral to specialist centres and coordinate care for patients during and after treatment. While the introduction of DMTs brings hope for many, evidence-informed, clear and equitable diagnostic pathways from primary care to specialist services will be urgently needed.’(Introduction paragraph 3)
Many thanks for the very helpful, constructive comments around the ‘why’ of GP diagnosis, the ‘why’ of referral to specialists for diagnosis and also the introduction of DMTs and the scarcity of resources. We have added two paragraphs to the Introduction section to address these important points. We feel this has strengthened the paper significantly, adding a real-world context to the diagnostic debate. In the full scoping review, we will further elaborate on these important points

Point by point response:

Comment 1:
Reviewer’s Comment
“I would strongly urge the authors to frame the ‘why’ of GP dementia diagnosis, i.e. how making a dementia diagnosis in primary care informs patient (not just disease) management; what do GPs need to know about the individual and the family in order to provide primary care for people with dementia – regardless of specialist involvement?”
RESPONSE: Thank you for this comment. We acknowledge that there is a complexity to the ‘why’ of GP dementia diagnosis and how it informs patient care. We have added the following text to address this point.
‘While GPs have been criticised for low identification and dementia diagnosis rates in primary care(13).Research has found that many GPs take a nuanced, patient-centred approach(14). GPs undertake a complex, decision-making process, whereby they balance the risks and benefits of making the diagnosis (15). GPs compare competing patient priorities, when deciding when to initiate the formal diagnostic process and when to refer onwards to secondary care for confirmation of a suspected diagnosis of dementia. Even in the absence of a formal diagnosis or disclosure of a diagnosis of dementia, GPs activate a range of dementia care services and supports for their patients(14).’(Introduction Paragraph 2).

Comment 2:
Reviewer’s Comment:
“I recommend similar attention to the ‘why’ of specialist referrals for diagnosis. We know that patterns of diagnosis and management of dementia are heavily dependent on national, local, and specific practice-based opportunities, which are not equitably distributed. There has been a long-term mismatch between recognition that GPs do most of the diagnosing and managing of patients with dementia and the ‘knee-jerk’ expectation that all patients with possible cognitive disorders need to see specialists; we know this is both infeasible, invalid when considered from a global perspective, and likely wasteful of scarce specialist resources (no offense to specialists; I am one). It would be most welcome to have a critical, evidence-based review of decision points regarding who, when, and why specialist referral is important and useful.”
RESPONSE: We appreciate your comment and agree that the rationale for specialist referrals needs to be clearly articulated. We have added the text below and expanded further in response to comment no.3.
‘When deciding whether to initiate the formal diagnostic and referral process, GPs weigh up many different competing issues related to patient autonomy, consent, risks, patient needs, planning for the future, optimising treatments and access to dementia care services (14, 15). Upon making a decision to refer to specialist services, dementia diagnostic and care pathways can be difficult to navigate for both GPs and for people living with dementia and their carers,(16, 17) leading to further diagnostic delays.’ (Introduction Paragraph 3)

Comment 3:
Reviewer’s Comment:
"There will need to be some attention to another scarce resource - the availability of high-specificity diagnostic testing for etiology of dementia, and of disease-modifying treatments for Alzheimer's disease, which varies with country, region, population, health system, and many other ecological determinants. Identifying candidates for such therapies is a major driver of specialist referral in some sectors of US health care; it would be valuable to consider this from a transnational perspective."
RESPONSE: Thank you for this comment regarding disease modifying therapies and limited resources. We have added the following text to address this point.
‘Up until now, the absence of effective disease modifying therapies (DMTs) has led to national dementia strategy recommendations for a ‘timely’ diagnosis of dementia as opposed to an ‘early’ diagnosis i.e. at the right time for the patients, taking the risks and benefits of diagnosis into consideration (Vinay). However, the move towards a biological diagnosis of Alzheimer’s disease and the introduction of the first anti-amyloid immunotherapy DMTs for the treatment of patients with early symptomatic Alzheimer’s disease will inevitably necessitate a shift towards earlier identification and diagnosis (Dobson). Healthcare systems are poorly prepared for this paradigm shift in diagnosis and treatment. The emergence of DMTs will likely increase the pressures and demands on primary care and on the limited resources of healthcare systems too (Smith). It will be important for GPs to identify potentially eligible patients with cognitive disorders, arrange early referral to specialist centres and coordinate care for patients during and after treatment. While the introduction of DMTs brings hope for many, evidence-informed, clear and equitable diagnostic pathways from primary care to specialist services will be urgently needed.’(Introduction paragraph 3)
Competing Interests: No competing interests were disclosed. Close
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Reviewer Report 25 Nov 2024

Emer O'Brien, Department of General Practice, RCSI, Dublin, Ireland

Approved with Reservations

https://doi.org/10.21956/hrbopenres.15268.r42855

Thank you for the opportunity to review this scoping review protocol on evidence relating to GP care of patients with dementia.

Below are some comments for consideration by the authors.

Overall
The rational for the review is clearly outlined. The aim is to map the role of the GP in the diagnosis of dementia. I would suggest it might be sufficient to search International GP professional organisations specifically to determine best practice relating to the role of the GP in this process. This may require modification of the search strategy to include primary care/general practice and a specific focus on searching/contacting GP professional organisations, as these guidelines are not always available through database searches, as outlined by the authors.

More specifically this review wishes to explore ‘the specific role of the GP in… referral of patients to secondary care. CPGs may outline recommendations for referral between primary and secondary care but this interface will be different depending on the role of the GP in the healthcare system - the gatekeeper role. Another consideration might be who within the health system develops guidelines for use in general practice. For example, in the UK NICE hold this central function and there may be GP representatives on the guideline working group. In comparison in the Netherlands, it is the role of the GP professional organisation (NHG) to develop guidelines. I would suggest further exploration of these issues would be valuable in the introduction.

Further considerations
The third objective is to determine what is the recommended referral process – I wonder will these details relating to the referral process be included in CPGs, this information may be available via international GP professional organisations.

In the methods section - it might be useful if the authors provide a definition for the word 'published’ eg. available on GP professional organisations websites (which can include national or international guidelines endorsed by professional organisations). As above and in addition, given the 2023 SR by Monfared et al, it may be sufficient for the authors to review recommendations specific to general practice.

Identifying relevant studies – ‘we will also search the websites of GP professional organisations both nationally and internationally’ Consideration will need to be given to access – if the guidelines are not open access will these be excluded or will the summary (which often is open access) be included. Will the authors contact the organisation directly to gain access to the required CPGs.

Inclusion criteria – appropriate for use in primary care – if not including general practice/primary care in the search terms, the word appropriate will need to be clearly defined. Exclusion – guidelines for use in hospital settings – suggest clarify if hospital setting and secondary care are synonymous

Guideline/guidance – the inclusion criteria is specific to 'guideline’ therefore suggest remove guidance or include an explanation for the word 'guidance' in the inclusion criteria.

Consultation – this is a most welcome step as will ensure both healthcare professional and patient involvement which should increase the likelihood of implementation."

Is the rationale for, and objectives of, the study clearly described?

Partly
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Yes
Are the datasets clearly presented in a useable and accessible format?

Not applicable

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: general practice, scoping review, systematic review, evidence based practice

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Author Response 12 Feb 2025

Mary Cronin, Department of General Practice, School of Medicine, College of Medicine and Health, University College Cork, Cork, Ireland

12 Feb 2025

Author Response

Many thanks for this helpful review, which raised valid points about the availability and development of Clinical Practice Guidelines and the international context, all of which add value to the ... Continue reading Many thanks for this helpful review, which raised valid points about the availability and development of Clinical Practice Guidelines and the international context, all of which add value to the protocol paper. We have added information to the introduction and method to address these points, and they will be further explored in the discussion of our findings in the scoping review paper.
Point-by-point response:
Comment 1
Reviewer’s comment:
“The rational for the review is clearly outlined. The aim is to map the role of the GP in the diagnosis of dementia. I would suggest it might be sufficient to search International GP professional organisations specifically to determine best practice relating to the role of the GP in this process. This may require modification of the search strategy to include primary care/general practice and a specific focus on searching/contacting GP professional organisations, as these guidelines are not always available through database searches, as outlined by the authors.”
RESPONSE: Thank you for this observation. This was carefully considered during our preliminary searches to refine the search terms. Our initial searches indicated that CPGs for dementia care were published by both national organisations and GP professional organisations. Therefore, to ensure a rigorous approach, we will search the websites of GP professional organisations, both nationally and internationally, as well as the peer-review databases and other sources of grey literature. Where no guidelines are available on the website, we will email the organisations to request copies. We have now amended the protocol method section to reflect this. The following text has been added.

We will also search the websites of GP professional organisations both nationally and internationally as guidelines are often made available for GPs through these platforms. Where dementia guidelines are unavailable (or inaccessible) on the professional organisation websites, we will contact them via email to request a copy. Google Translate will be used to increase the likelihood of a response from international GP organisations.

Comment 2
Reviewer’s comment:
“More specifically, this review wishes to explore ‘the specific role of the GP in… referral of patients to secondary care. CPGs may outline recommendations for referral between primary and secondary care but this interface will be different depending on the role of the GP in the healthcare system - the gatekeeper role. Another consideration might be who within the health system develops guidelines for use in general practice. For example, in the UK NICE hold this central function and there may be GP representatives on the guideline working group. In comparison in the Netherlands, it is the role of the GP professional organisation (NHG) to develop guidelines. I would suggest further exploration of these issues would be valuable in the introduction.”
RESPONSE: Thank you. In the introduction, we have now mentioned the complexity of differing health systems internationally, which will also be addressed in more detail in the scoping review paper. We have also acknowledged that different organisations may be responsible for guideline development, and similarly, we aim to address this further based on our findings. The following text has been added to the introduction.

In terms of the dementia diagnostic pathway, GPs play varying roles in healthcare systems worldwide, with a significant emphasis on a gatekeeping role in many countries. In the UK and Dutch healthcare systems, GPs serve as gatekeepers, managing patient access to specialists and ensuring efficient use of resources (9, 10). Similarly, in Australia, GPs control patient referrals to specialists and diagnostic services, promoting cost-effectiveness and preventive care(11). Conversely, in the United States, GPs have a less centralized gatekeeping role, as patients often have direct access to specialists, depending on insurance plans(12). These varying GP roles reflect differing healthcare priorities, from cost containment to patient autonomy. (Introduction paragraph 2)

The development of CPGs can vary with some countries, such as The Netherlands, developing practice guidelines specifically for GPs. In contrast, in other countries such as the UK, guidelines are developed by national organisations (Introduction paragraph 5)

Comment 3
Reviewer’s comment:
“The third objective is to determine the recommended referral process. I wonder if these details relating to the referral process will be included in CPGs. This information may be available via international GP professional organisations.”
RESPONSE: Thank you; this is a very valid point. However, this review examines Clinical Practice Guidelines (CPGs) to establish the recommended role of the GP across diagnostic and referral processes. Therefore, it was felt that considering other sources of referral information would be outside the scope. We have amended the third research objective to clarify this. We will also revisit this point in the discussion section of our scoping review paper. The third objective now includes the following text:

What is the recommended referral process outlined in CPGs when referring a patient with suspected dementia from primary to secondary care?

Comment 4
Reviewer’s comment:
“In the methods section, it might be useful if the authors provide a definition for the word 'published’, e.g., available on GP professional organisations' websites (which can include national or international guidelines endorsed by professional organisations). As above, and in addition, given the 2023 SR by Monfared et al., it may be sufficient for the authors to review recommendations specific to general practice.”
RESPONSE: Thank you we appreciate that this needs clarifying. We have added some additional information to clarify what is meant by ‘published’. You make an interesting observation about the review by Monfared et al. (2023), and we did consider this. Although the authors reviewed screening and diagnosis recommendations, it was not within the scope of their review to consider the recommended role of the GP. In addition, many of the included CPGs in the Monfared et al. review were published in 2018, and we felt it important to gain more up-to-date data if possible. We have now added the following text to the section ‘identifying relevant studies’:

We will also search the websites of GP professional organisations nationally and internationally as guidelines are often made available for GPs through these platforms.

Comment 5
Reviewer’s comment:
“Identifying relevant studies – ‘we will also search the websites of GP professional organisations both nationally and internationally’ Consideration will need to be given to access – if the guidelines are not open access will these be excluded or will the summary (which often is open access) be included. Will the authors contact the organisation directly to gain access to the required CPGs”.
RESPONSE: Yes, thank you. We will contact the organisations to gain access, which has now been clarified in the method section. We do not intend to include open-access summaries, and we have now clarified this in the exclusion criteria. The following text indicates these changes:
Where dementia guidelines are unavailable (or inaccessible) on the professional organisation websites, we will contact them via email to request a copy. Google Translate will be used to increase the likelihood of a response from international GP organisations.
(Method section: Identifying relevant studies)

Summaries of CPGs (added to exclusion criteria)

Comment 6
Reviewer’s comment:
“Inclusion criteria – appropriate for use in primary care – if not including general practice/primary care in the search terms, the word appropriate will need to be clearly defined. Exclusion – guidelines for use in hospital settings – suggest clarify if hospital setting and secondary care are synonymous“
RESPONSE: We appreciate that this may be unclear; therefore, we have removed the criteria ‘appropriate for use in primary care’. The next point ‘relevant for the diagnosis of dementia in primary care’ indicates our approach to inclusion and outlines what is meant by ‘relevant’. We have amended the exclusion criteria section to clarify what is meant by hospital settings. The revised text reads:

Guidelines for use in hospital in-patient settings.(Exclusion criteria)

Comment 7
Reviewer’s comment
“Guideline/guidance – the inclusion criteria is specific to 'guideline’ therefore suggest remove guidance or include an explanation for the word 'guidance' in the inclusion criteria”.
RESPONSE: Thank you. For clarity, we have removed the word guidance.
Many thanks for this helpful review, which raised valid points about the availability and development of Clinical Practice Guidelines and the international context, all of which add value to the protocol paper. We have added information to the introduction and method to address these points, and they will be further explored in the discussion of our findings in the scoping review paper.
Point-by-point response:
Comment 1
Reviewer’s comment:
“The rational for the review is clearly outlined. The aim is to map the role of the GP in the diagnosis of dementia. I would suggest it might be sufficient to search International GP professional organisations specifically to determine best practice relating to the role of the GP in this process. This may require modification of the search strategy to include primary care/general practice and a specific focus on searching/contacting GP professional organisations, as these guidelines are not always available through database searches, as outlined by the authors.”
RESPONSE: Thank you for this observation. This was carefully considered during our preliminary searches to refine the search terms. Our initial searches indicated that CPGs for dementia care were published by both national organisations and GP professional organisations. Therefore, to ensure a rigorous approach, we will search the websites of GP professional organisations, both nationally and internationally, as well as the peer-review databases and other sources of grey literature. Where no guidelines are available on the website, we will email the organisations to request copies. We have now amended the protocol method section to reflect this. The following text has been added.

We will also search the websites of GP professional organisations both nationally and internationally as guidelines are often made available for GPs through these platforms. Where dementia guidelines are unavailable (or inaccessible) on the professional organisation websites, we will contact them via email to request a copy. Google Translate will be used to increase the likelihood of a response from international GP organisations.

Comment 2
Reviewer’s comment:
“More specifically, this review wishes to explore ‘the specific role of the GP in… referral of patients to secondary care. CPGs may outline recommendations for referral between primary and secondary care but this interface will be different depending on the role of the GP in the healthcare system - the gatekeeper role. Another consideration might be who within the health system develops guidelines for use in general practice. For example, in the UK NICE hold this central function and there may be GP representatives on the guideline working group. In comparison in the Netherlands, it is the role of the GP professional organisation (NHG) to develop guidelines. I would suggest further exploration of these issues would be valuable in the introduction.”
RESPONSE: Thank you. In the introduction, we have now mentioned the complexity of differing health systems internationally, which will also be addressed in more detail in the scoping review paper. We have also acknowledged that different organisations may be responsible for guideline development, and similarly, we aim to address this further based on our findings. The following text has been added to the introduction.

In terms of the dementia diagnostic pathway, GPs play varying roles in healthcare systems worldwide, with a significant emphasis on a gatekeeping role in many countries. In the UK and Dutch healthcare systems, GPs serve as gatekeepers, managing patient access to specialists and ensuring efficient use of resources (9, 10). Similarly, in Australia, GPs control patient referrals to specialists and diagnostic services, promoting cost-effectiveness and preventive care(11). Conversely, in the United States, GPs have a less centralized gatekeeping role, as patients often have direct access to specialists, depending on insurance plans(12). These varying GP roles reflect differing healthcare priorities, from cost containment to patient autonomy. (Introduction paragraph 2)

The development of CPGs can vary with some countries, such as The Netherlands, developing practice guidelines specifically for GPs. In contrast, in other countries such as the UK, guidelines are developed by national organisations (Introduction paragraph 5)

Comment 3
Reviewer’s comment:
“The third objective is to determine the recommended referral process. I wonder if these details relating to the referral process will be included in CPGs. This information may be available via international GP professional organisations.”
RESPONSE: Thank you; this is a very valid point. However, this review examines Clinical Practice Guidelines (CPGs) to establish the recommended role of the GP across diagnostic and referral processes. Therefore, it was felt that considering other sources of referral information would be outside the scope. We have amended the third research objective to clarify this. We will also revisit this point in the discussion section of our scoping review paper. The third objective now includes the following text:

What is the recommended referral process outlined in CPGs when referring a patient with suspected dementia from primary to secondary care?

Comment 4
Reviewer’s comment:
“In the methods section, it might be useful if the authors provide a definition for the word 'published’, e.g., available on GP professional organisations' websites (which can include national or international guidelines endorsed by professional organisations). As above, and in addition, given the 2023 SR by Monfared et al., it may be sufficient for the authors to review recommendations specific to general practice.”
RESPONSE: Thank you we appreciate that this needs clarifying. We have added some additional information to clarify what is meant by ‘published’. You make an interesting observation about the review by Monfared et al. (2023), and we did consider this. Although the authors reviewed screening and diagnosis recommendations, it was not within the scope of their review to consider the recommended role of the GP. In addition, many of the included CPGs in the Monfared et al. review were published in 2018, and we felt it important to gain more up-to-date data if possible. We have now added the following text to the section ‘identifying relevant studies’:

We will also search the websites of GP professional organisations nationally and internationally as guidelines are often made available for GPs through these platforms.

Comment 5
Reviewer’s comment:
“Identifying relevant studies – ‘we will also search the websites of GP professional organisations both nationally and internationally’ Consideration will need to be given to access – if the guidelines are not open access will these be excluded or will the summary (which often is open access) be included. Will the authors contact the organisation directly to gain access to the required CPGs”.
RESPONSE: Yes, thank you. We will contact the organisations to gain access, which has now been clarified in the method section. We do not intend to include open-access summaries, and we have now clarified this in the exclusion criteria. The following text indicates these changes:
Where dementia guidelines are unavailable (or inaccessible) on the professional organisation websites, we will contact them via email to request a copy. Google Translate will be used to increase the likelihood of a response from international GP organisations.
(Method section: Identifying relevant studies)

Summaries of CPGs (added to exclusion criteria)

Comment 6
Reviewer’s comment:
“Inclusion criteria – appropriate for use in primary care – if not including general practice/primary care in the search terms, the word appropriate will need to be clearly defined. Exclusion – guidelines for use in hospital settings – suggest clarify if hospital setting and secondary care are synonymous“
RESPONSE: We appreciate that this may be unclear; therefore, we have removed the criteria ‘appropriate for use in primary care’. The next point ‘relevant for the diagnosis of dementia in primary care’ indicates our approach to inclusion and outlines what is meant by ‘relevant’. We have amended the exclusion criteria section to clarify what is meant by hospital settings. The revised text reads:

Guidelines for use in hospital in-patient settings.(Exclusion criteria)

Comment 7
Reviewer’s comment
“Guideline/guidance – the inclusion criteria is specific to 'guideline’ therefore suggest remove guidance or include an explanation for the word 'guidance' in the inclusion criteria”.
RESPONSE: Thank you. For clarity, we have removed the word guidance.
Competing Interests: No competing interests were disclosed. Close
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COMMENTS ON THIS REPORT

Author Response 12 Feb 2025

Mary Cronin, Department of General Practice, School of Medicine, College of Medicine and Health, University College Cork, Cork, Ireland

12 Feb 2025

Author Response

Many thanks for this helpful review, which raised valid points about the availability and development of Clinical Practice Guidelines and the international context, all of which add value to the ... Continue reading Many thanks for this helpful review, which raised valid points about the availability and development of Clinical Practice Guidelines and the international context, all of which add value to the protocol paper. We have added information to the introduction and method to address these points, and they will be further explored in the discussion of our findings in the scoping review paper.
Point-by-point response:
Comment 1
Reviewer’s comment:
“The rational for the review is clearly outlined. The aim is to map the role of the GP in the diagnosis of dementia. I would suggest it might be sufficient to search International GP professional organisations specifically to determine best practice relating to the role of the GP in this process. This may require modification of the search strategy to include primary care/general practice and a specific focus on searching/contacting GP professional organisations, as these guidelines are not always available through database searches, as outlined by the authors.”
RESPONSE: Thank you for this observation. This was carefully considered during our preliminary searches to refine the search terms. Our initial searches indicated that CPGs for dementia care were published by both national organisations and GP professional organisations. Therefore, to ensure a rigorous approach, we will search the websites of GP professional organisations, both nationally and internationally, as well as the peer-review databases and other sources of grey literature. Where no guidelines are available on the website, we will email the organisations to request copies. We have now amended the protocol method section to reflect this. The following text has been added.

We will also search the websites of GP professional organisations both nationally and internationally as guidelines are often made available for GPs through these platforms. Where dementia guidelines are unavailable (or inaccessible) on the professional organisation websites, we will contact them via email to request a copy. Google Translate will be used to increase the likelihood of a response from international GP organisations.

Comment 2
Reviewer’s comment:
“More specifically, this review wishes to explore ‘the specific role of the GP in… referral of patients to secondary care. CPGs may outline recommendations for referral between primary and secondary care but this interface will be different depending on the role of the GP in the healthcare system - the gatekeeper role. Another consideration might be who within the health system develops guidelines for use in general practice. For example, in the UK NICE hold this central function and there may be GP representatives on the guideline working group. In comparison in the Netherlands, it is the role of the GP professional organisation (NHG) to develop guidelines. I would suggest further exploration of these issues would be valuable in the introduction.”
RESPONSE: Thank you. In the introduction, we have now mentioned the complexity of differing health systems internationally, which will also be addressed in more detail in the scoping review paper. We have also acknowledged that different organisations may be responsible for guideline development, and similarly, we aim to address this further based on our findings. The following text has been added to the introduction.

In terms of the dementia diagnostic pathway, GPs play varying roles in healthcare systems worldwide, with a significant emphasis on a gatekeeping role in many countries. In the UK and Dutch healthcare systems, GPs serve as gatekeepers, managing patient access to specialists and ensuring efficient use of resources (9, 10). Similarly, in Australia, GPs control patient referrals to specialists and diagnostic services, promoting cost-effectiveness and preventive care(11). Conversely, in the United States, GPs have a less centralized gatekeeping role, as patients often have direct access to specialists, depending on insurance plans(12). These varying GP roles reflect differing healthcare priorities, from cost containment to patient autonomy. (Introduction paragraph 2)

The development of CPGs can vary with some countries, such as The Netherlands, developing practice guidelines specifically for GPs. In contrast, in other countries such as the UK, guidelines are developed by national organisations (Introduction paragraph 5)

Comment 3
Reviewer’s comment:
“The third objective is to determine the recommended referral process. I wonder if these details relating to the referral process will be included in CPGs. This information may be available via international GP professional organisations.”
RESPONSE: Thank you; this is a very valid point. However, this review examines Clinical Practice Guidelines (CPGs) to establish the recommended role of the GP across diagnostic and referral processes. Therefore, it was felt that considering other sources of referral information would be outside the scope. We have amended the third research objective to clarify this. We will also revisit this point in the discussion section of our scoping review paper. The third objective now includes the following text:

What is the recommended referral process outlined in CPGs when referring a patient with suspected dementia from primary to secondary care?

Comment 4
Reviewer’s comment:
“In the methods section, it might be useful if the authors provide a definition for the word 'published’, e.g., available on GP professional organisations' websites (which can include national or international guidelines endorsed by professional organisations). As above, and in addition, given the 2023 SR by Monfared et al., it may be sufficient for the authors to review recommendations specific to general practice.”
RESPONSE: Thank you we appreciate that this needs clarifying. We have added some additional information to clarify what is meant by ‘published’. You make an interesting observation about the review by Monfared et al. (2023), and we did consider this. Although the authors reviewed screening and diagnosis recommendations, it was not within the scope of their review to consider the recommended role of the GP. In addition, many of the included CPGs in the Monfared et al. review were published in 2018, and we felt it important to gain more up-to-date data if possible. We have now added the following text to the section ‘identifying relevant studies’:

We will also search the websites of GP professional organisations nationally and internationally as guidelines are often made available for GPs through these platforms.

Comment 5
Reviewer’s comment:
“Identifying relevant studies – ‘we will also search the websites of GP professional organisations both nationally and internationally’ Consideration will need to be given to access – if the guidelines are not open access will these be excluded or will the summary (which often is open access) be included. Will the authors contact the organisation directly to gain access to the required CPGs”.
RESPONSE: Yes, thank you. We will contact the organisations to gain access, which has now been clarified in the method section. We do not intend to include open-access summaries, and we have now clarified this in the exclusion criteria. The following text indicates these changes:
Where dementia guidelines are unavailable (or inaccessible) on the professional organisation websites, we will contact them via email to request a copy. Google Translate will be used to increase the likelihood of a response from international GP organisations.
(Method section: Identifying relevant studies)

Summaries of CPGs (added to exclusion criteria)

Comment 6
Reviewer’s comment:
“Inclusion criteria – appropriate for use in primary care – if not including general practice/primary care in the search terms, the word appropriate will need to be clearly defined. Exclusion – guidelines for use in hospital settings – suggest clarify if hospital setting and secondary care are synonymous“
RESPONSE: We appreciate that this may be unclear; therefore, we have removed the criteria ‘appropriate for use in primary care’. The next point ‘relevant for the diagnosis of dementia in primary care’ indicates our approach to inclusion and outlines what is meant by ‘relevant’. We have amended the exclusion criteria section to clarify what is meant by hospital settings. The revised text reads:

Guidelines for use in hospital in-patient settings.(Exclusion criteria)

Comment 7
Reviewer’s comment
“Guideline/guidance – the inclusion criteria is specific to 'guideline’ therefore suggest remove guidance or include an explanation for the word 'guidance' in the inclusion criteria”.
RESPONSE: Thank you. For clarity, we have removed the word guidance.
Many thanks for this helpful review, which raised valid points about the availability and development of Clinical Practice Guidelines and the international context, all of which add value to the protocol paper. We have added information to the introduction and method to address these points, and they will be further explored in the discussion of our findings in the scoping review paper.
Point-by-point response:
Comment 1
Reviewer’s comment:
“The rational for the review is clearly outlined. The aim is to map the role of the GP in the diagnosis of dementia. I would suggest it might be sufficient to search International GP professional organisations specifically to determine best practice relating to the role of the GP in this process. This may require modification of the search strategy to include primary care/general practice and a specific focus on searching/contacting GP professional organisations, as these guidelines are not always available through database searches, as outlined by the authors.”
RESPONSE: Thank you for this observation. This was carefully considered during our preliminary searches to refine the search terms. Our initial searches indicated that CPGs for dementia care were published by both national organisations and GP professional organisations. Therefore, to ensure a rigorous approach, we will search the websites of GP professional organisations, both nationally and internationally, as well as the peer-review databases and other sources of grey literature. Where no guidelines are available on the website, we will email the organisations to request copies. We have now amended the protocol method section to reflect this. The following text has been added.

We will also search the websites of GP professional organisations both nationally and internationally as guidelines are often made available for GPs through these platforms. Where dementia guidelines are unavailable (or inaccessible) on the professional organisation websites, we will contact them via email to request a copy. Google Translate will be used to increase the likelihood of a response from international GP organisations.

Comment 2
Reviewer’s comment:
“More specifically, this review wishes to explore ‘the specific role of the GP in… referral of patients to secondary care. CPGs may outline recommendations for referral between primary and secondary care but this interface will be different depending on the role of the GP in the healthcare system - the gatekeeper role. Another consideration might be who within the health system develops guidelines for use in general practice. For example, in the UK NICE hold this central function and there may be GP representatives on the guideline working group. In comparison in the Netherlands, it is the role of the GP professional organisation (NHG) to develop guidelines. I would suggest further exploration of these issues would be valuable in the introduction.”
RESPONSE: Thank you. In the introduction, we have now mentioned the complexity of differing health systems internationally, which will also be addressed in more detail in the scoping review paper. We have also acknowledged that different organisations may be responsible for guideline development, and similarly, we aim to address this further based on our findings. The following text has been added to the introduction.

In terms of the dementia diagnostic pathway, GPs play varying roles in healthcare systems worldwide, with a significant emphasis on a gatekeeping role in many countries. In the UK and Dutch healthcare systems, GPs serve as gatekeepers, managing patient access to specialists and ensuring efficient use of resources (9, 10). Similarly, in Australia, GPs control patient referrals to specialists and diagnostic services, promoting cost-effectiveness and preventive care(11). Conversely, in the United States, GPs have a less centralized gatekeeping role, as patients often have direct access to specialists, depending on insurance plans(12). These varying GP roles reflect differing healthcare priorities, from cost containment to patient autonomy. (Introduction paragraph 2)

The development of CPGs can vary with some countries, such as The Netherlands, developing practice guidelines specifically for GPs. In contrast, in other countries such as the UK, guidelines are developed by national organisations (Introduction paragraph 5)

Comment 3
Reviewer’s comment:
“The third objective is to determine the recommended referral process. I wonder if these details relating to the referral process will be included in CPGs. This information may be available via international GP professional organisations.”
RESPONSE: Thank you; this is a very valid point. However, this review examines Clinical Practice Guidelines (CPGs) to establish the recommended role of the GP across diagnostic and referral processes. Therefore, it was felt that considering other sources of referral information would be outside the scope. We have amended the third research objective to clarify this. We will also revisit this point in the discussion section of our scoping review paper. The third objective now includes the following text:

What is the recommended referral process outlined in CPGs when referring a patient with suspected dementia from primary to secondary care?

Comment 4
Reviewer’s comment:
“In the methods section, it might be useful if the authors provide a definition for the word 'published’, e.g., available on GP professional organisations' websites (which can include national or international guidelines endorsed by professional organisations). As above, and in addition, given the 2023 SR by Monfared et al., it may be sufficient for the authors to review recommendations specific to general practice.”
RESPONSE: Thank you we appreciate that this needs clarifying. We have added some additional information to clarify what is meant by ‘published’. You make an interesting observation about the review by Monfared et al. (2023), and we did consider this. Although the authors reviewed screening and diagnosis recommendations, it was not within the scope of their review to consider the recommended role of the GP. In addition, many of the included CPGs in the Monfared et al. review were published in 2018, and we felt it important to gain more up-to-date data if possible. We have now added the following text to the section ‘identifying relevant studies’:

We will also search the websites of GP professional organisations nationally and internationally as guidelines are often made available for GPs through these platforms.

Comment 5
Reviewer’s comment:
“Identifying relevant studies – ‘we will also search the websites of GP professional organisations both nationally and internationally’ Consideration will need to be given to access – if the guidelines are not open access will these be excluded or will the summary (which often is open access) be included. Will the authors contact the organisation directly to gain access to the required CPGs”.
RESPONSE: Yes, thank you. We will contact the organisations to gain access, which has now been clarified in the method section. We do not intend to include open-access summaries, and we have now clarified this in the exclusion criteria. The following text indicates these changes:
Where dementia guidelines are unavailable (or inaccessible) on the professional organisation websites, we will contact them via email to request a copy. Google Translate will be used to increase the likelihood of a response from international GP organisations.
(Method section: Identifying relevant studies)

Summaries of CPGs (added to exclusion criteria)

Comment 6
Reviewer’s comment:
“Inclusion criteria – appropriate for use in primary care – if not including general practice/primary care in the search terms, the word appropriate will need to be clearly defined. Exclusion – guidelines for use in hospital settings – suggest clarify if hospital setting and secondary care are synonymous“
RESPONSE: We appreciate that this may be unclear; therefore, we have removed the criteria ‘appropriate for use in primary care’. The next point ‘relevant for the diagnosis of dementia in primary care’ indicates our approach to inclusion and outlines what is meant by ‘relevant’. We have amended the exclusion criteria section to clarify what is meant by hospital settings. The revised text reads:

Guidelines for use in hospital in-patient settings.(Exclusion criteria)

Comment 7
Reviewer’s comment
“Guideline/guidance – the inclusion criteria is specific to 'guideline’ therefore suggest remove guidance or include an explanation for the word 'guidance' in the inclusion criteria”.
RESPONSE: Thank you. For clarity, we have removed the word guidance.
Competing Interests: No competing interests were disclosed. Close
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Version 2

VERSION 2 PUBLISHED 08 Jul 2024

Open Peer Review

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Reviewer Reports

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	1	2
Version 2 (revision) 12 Feb 25	read	read
Version 1 08 Jul 24	read	read

Emer O'Brien, Department of General Practice, RCSI, Dublin, Ireland
Soo Borson, University of Southern California, Los Angeles, USA

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Reviewer Report

6 Views

18 Feb 2025 | for Version 2

Emer O'Brien, Department of General Practice, RCSI, Dublin, Ireland

6 Views Cite this report Responses(0)

Approved

Thank you for your detailed responses. I think this version of the protocol is ready to be approved. All the best with the scoping review.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

general practice, scoping review, systematic review, evidence based practice

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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Reviewer Report

9 Views

13 Feb 2025 | for Version 2

Soo Borson, University of Southern California, Los Angeles, USA

9 Views Cite this report Responses(0)

Approved

The authors have been responsive to previous reviews.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Dementia in primary care; early detection of dementia; complex care approaches.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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Reviewer Report

14 Views

18 Dec 2024 | for Version 1

Soo Borson, University of Southern California, Los Angeles, USA

14 Views Cite this report Responses(1)

Approved With Reservations

Is the rationale for, and objectives of, the study clearly described?

Partly
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Yes
Are the datasets clearly presented in a useable and accessible format?

Not applicable

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Dementia in primary care; early detection of dementia; complex care approaches.

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Responses (1)

Author Response

13 Feb 2025

Mary Cronin, Department of General Practice, School of Medicine, College of Medicine and Health, University College Cork, Cork, Ireland

Many thanks for the very helpful, constructive comments around the ‘why’ of GP diagnosis, the ‘why’ of referral to specialists for diagnosis and also the introduction of DMTs and the scarcity of resources. We have added two paragraphs to the Introduction section to address these important points. We feel this has strengthened the paper significantly, adding a real-world context to the diagnostic debate. In the full scoping review, we will further elaborate on these important points

Point by point response:

Comment 1:
Reviewer’s Comment
“I would strongly urge the authors to frame the ‘why’ of GP dementia diagnosis, i.e. how making a dementia diagnosis in primary care informs patient (not just disease) management; what do GPs need to know about the individual and the family in order to provide primary care for people with dementia – regardless of specialist involvement?”
RESPONSE: Thank you for this comment. We acknowledge that there is a complexity to the ‘why’ of GP dementia diagnosis and how it informs patient care. We have added the following text to address this point.
‘While GPs have been criticised for low identification and dementia diagnosis rates in primary care(13).Research has found that many GPs take a nuanced, patient-centred approach(14). GPs undertake a complex, decision-making process, whereby they balance the risks and benefits of making the diagnosis (15). GPs compare competing patient priorities, when deciding when to initiate the formal diagnostic process and when to refer onwards to secondary care for confirmation of a suspected diagnosis of dementia. Even in the absence of a formal diagnosis or disclosure of a diagnosis of dementia, GPs activate a range of dementia care services and supports for their patients(14).’(Introduction Paragraph 2).

Comment 2:
Reviewer’s Comment:
“I recommend similar attention to the ‘why’ of specialist referrals for diagnosis. We know that patterns of diagnosis and management of dementia are heavily dependent on national, local, and specific practice-based opportunities, which are not equitably distributed. There has been a long-term mismatch between recognition that GPs do most of the diagnosing and managing of patients with dementia and the ‘knee-jerk’ expectation that all patients with possible cognitive disorders need to see specialists; we know this is both infeasible, invalid when considered from a global perspective, and likely wasteful of scarce specialist resources (no offense to specialists; I am one). It would be most welcome to have a critical, evidence-based review of decision points regarding who, when, and why specialist referral is important and useful.”
RESPONSE: We appreciate your comment and agree that the rationale for specialist referrals needs to be clearly articulated. We have added the text below and expanded further in response to comment no.3.
‘When deciding whether to initiate the formal diagnostic and referral process, GPs weigh up many different competing issues related to patient autonomy, consent, risks, patient needs, planning for the future, optimising treatments and access to dementia care services (14, 15). Upon making a decision to refer to specialist services, dementia diagnostic and care pathways can be difficult to navigate for both GPs and for people living with dementia and their carers,(16, 17) leading to further diagnostic delays.’ (Introduction Paragraph 3)

Comment 3:
Reviewer’s Comment:
"There will need to be some attention to another scarce resource - the availability of high-specificity diagnostic testing for etiology of dementia, and of disease-modifying treatments for Alzheimer's disease, which varies with country, region, population, health system, and many other ecological determinants. Identifying candidates for such therapies is a major driver of specialist referral in some sectors of US health care; it would be valuable to consider this from a transnational perspective."
RESPONSE: Thank you for this comment regarding disease modifying therapies and limited resources. We have added the following text to address this point.
‘Up until now, the absence of effective disease modifying therapies (DMTs) has led to national dementia strategy recommendations for a ‘timely’ diagnosis of dementia as opposed to an ‘early’ diagnosis i.e. at the right time for the patients, taking the risks and benefits of diagnosis into consideration (Vinay). However, the move towards a biological diagnosis of Alzheimer’s disease and the introduction of the first anti-amyloid immunotherapy DMTs for the treatment of patients with early symptomatic Alzheimer’s disease will inevitably necessitate a shift towards earlier identification and diagnosis (Dobson). Healthcare systems are poorly prepared for this paradigm shift in diagnosis and treatment. The emergence of DMTs will likely increase the pressures and demands on primary care and on the limited resources of healthcare systems too (Smith). It will be important for GPs to identify potentially eligible patients with cognitive disorders, arrange early referral to specialist centres and coordinate care for patients during and after treatment. While the introduction of DMTs brings hope for many, evidence-informed, clear and equitable diagnostic pathways from primary care to specialist services will be urgently needed.’(Introduction paragraph 3)

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No competing interests were disclosed.

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Reviewer Report

25 Views

25 Nov 2024 | for Version 1

Emer O'Brien, Department of General Practice, RCSI, Dublin, Ireland

25 Views Cite this report Responses(1)

Approved With Reservations

Is the rationale for, and objectives of, the study clearly described?

Partly
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Yes
Are the datasets clearly presented in a useable and accessible format?

Not applicable

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

general practice, scoping review, systematic review, evidence based practice

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Responses (1)

Author Response

12 Feb 2025

Mary Cronin, Department of General Practice, School of Medicine, College of Medicine and Health, University College Cork, Cork, Ireland

Many thanks for this helpful review, which raised valid points about the availability and development of Clinical Practice Guidelines and the international context, all of which add value to the protocol paper. We have added information to the introduction and method to address these points, and they will be further explored in the discussion of our findings in the scoping review paper.
Point-by-point response:
Comment 1
Reviewer’s comment:
“The rational for the review is clearly outlined. The aim is to map the role of the GP in the diagnosis of dementia. I would suggest it might be sufficient to search International GP professional organisations specifically to determine best practice relating to the role of the GP in this process. This may require modification of the search strategy to include primary care/general practice and a specific focus on searching/contacting GP professional organisations, as these guidelines are not always available through database searches, as outlined by the authors.”
RESPONSE: Thank you for this observation. This was carefully considered during our preliminary searches to refine the search terms. Our initial searches indicated that CPGs for dementia care were published by both national organisations and GP professional organisations. Therefore, to ensure a rigorous approach, we will search the websites of GP professional organisations, both nationally and internationally, as well as the peer-review databases and other sources of grey literature. Where no guidelines are available on the website, we will email the organisations to request copies. We have now amended the protocol method section to reflect this. The following text has been added.

We will also search the websites of GP professional organisations both nationally and internationally as guidelines are often made available for GPs through these platforms. Where dementia guidelines are unavailable (or inaccessible) on the professional organisation websites, we will contact them via email to request a copy. Google Translate will be used to increase the likelihood of a response from international GP organisations.

Comment 2
Reviewer’s comment:
“More specifically, this review wishes to explore ‘the specific role of the GP in… referral of patients to secondary care. CPGs may outline recommendations for referral between primary and secondary care but this interface will be different depending on the role of the GP in the healthcare system - the gatekeeper role. Another consideration might be who within the health system develops guidelines for use in general practice. For example, in the UK NICE hold this central function and there may be GP representatives on the guideline working group. In comparison in the Netherlands, it is the role of the GP professional organisation (NHG) to develop guidelines. I would suggest further exploration of these issues would be valuable in the introduction.”
RESPONSE: Thank you. In the introduction, we have now mentioned the complexity of differing health systems internationally, which will also be addressed in more detail in the scoping review paper. We have also acknowledged that different organisations may be responsible for guideline development, and similarly, we aim to address this further based on our findings. The following text has been added to the introduction.

In terms of the dementia diagnostic pathway, GPs play varying roles in healthcare systems worldwide, with a significant emphasis on a gatekeeping role in many countries. In the UK and Dutch healthcare systems, GPs serve as gatekeepers, managing patient access to specialists and ensuring efficient use of resources (9, 10). Similarly, in Australia, GPs control patient referrals to specialists and diagnostic services, promoting cost-effectiveness and preventive care(11). Conversely, in the United States, GPs have a less centralized gatekeeping role, as patients often have direct access to specialists, depending on insurance plans(12). These varying GP roles reflect differing healthcare priorities, from cost containment to patient autonomy. (Introduction paragraph 2)

The development of CPGs can vary with some countries, such as The Netherlands, developing practice guidelines specifically for GPs. In contrast, in other countries such as the UK, guidelines are developed by national organisations (Introduction paragraph 5)

Comment 3
Reviewer’s comment:
“The third objective is to determine the recommended referral process. I wonder if these details relating to the referral process will be included in CPGs. This information may be available via international GP professional organisations.”
RESPONSE: Thank you; this is a very valid point. However, this review examines Clinical Practice Guidelines (CPGs) to establish the recommended role of the GP across diagnostic and referral processes. Therefore, it was felt that considering other sources of referral information would be outside the scope. We have amended the third research objective to clarify this. We will also revisit this point in the discussion section of our scoping review paper. The third objective now includes the following text:

What is the recommended referral process outlined in CPGs when referring a patient with suspected dementia from primary to secondary care?

Comment 4
Reviewer’s comment:
“In the methods section, it might be useful if the authors provide a definition for the word 'published’, e.g., available on GP professional organisations' websites (which can include national or international guidelines endorsed by professional organisations). As above, and in addition, given the 2023 SR by Monfared et al., it may be sufficient for the authors to review recommendations specific to general practice.”
RESPONSE: Thank you we appreciate that this needs clarifying. We have added some additional information to clarify what is meant by ‘published’. You make an interesting observation about the review by Monfared et al. (2023), and we did consider this. Although the authors reviewed screening and diagnosis recommendations, it was not within the scope of their review to consider the recommended role of the GP. In addition, many of the included CPGs in the Monfared et al. review were published in 2018, and we felt it important to gain more up-to-date data if possible. We have now added the following text to the section ‘identifying relevant studies’:

We will also search the websites of GP professional organisations nationally and internationally as guidelines are often made available for GPs through these platforms.

Comment 5
Reviewer’s comment:
“Identifying relevant studies – ‘we will also search the websites of GP professional organisations both nationally and internationally’ Consideration will need to be given to access – if the guidelines are not open access will these be excluded or will the summary (which often is open access) be included. Will the authors contact the organisation directly to gain access to the required CPGs”.
RESPONSE: Yes, thank you. We will contact the organisations to gain access, which has now been clarified in the method section. We do not intend to include open-access summaries, and we have now clarified this in the exclusion criteria. The following text indicates these changes:
Where dementia guidelines are unavailable (or inaccessible) on the professional organisation websites, we will contact them via email to request a copy. Google Translate will be used to increase the likelihood of a response from international GP organisations.
(Method section: Identifying relevant studies)

Summaries of CPGs (added to exclusion criteria)

Comment 6
Reviewer’s comment:
“Inclusion criteria – appropriate for use in primary care – if not including general practice/primary care in the search terms, the word appropriate will need to be clearly defined. Exclusion – guidelines for use in hospital settings – suggest clarify if hospital setting and secondary care are synonymous“
RESPONSE: We appreciate that this may be unclear; therefore, we have removed the criteria ‘appropriate for use in primary care’. The next point ‘relevant for the diagnosis of dementia in primary care’ indicates our approach to inclusion and outlines what is meant by ‘relevant’. We have amended the exclusion criteria section to clarify what is meant by hospital settings. The revised text reads:

Guidelines for use in hospital in-patient settings.(Exclusion criteria)

Comment 7
Reviewer’s comment
“Guideline/guidance – the inclusion criteria is specific to 'guideline’ therefore suggest remove guidance or include an explanation for the word 'guidance' in the inclusion criteria”.
RESPONSE: Thank you. For clarity, we have removed the word guidance.

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Competing Interests

No competing interests were disclosed.

Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

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Guideline recommendations on the role of the general practitioner in the diagnosis of dementia: a protocol for a scoping review of clinical practice guidelines

Abstract

Introduction

Method

Conclusion

Keywords

Revised Amendments from Version 1

Introduction

Method

1. Identifying the research question

Table 1. Search terms.

2. Identifying relevant studies

3. Study selection

Table 2. Eligibility criteria.

4. Charting of the data

5. Summarising and reporting results

6. Consultation exercise with stakeholders

Conclusions

Data availability

References

Comments on this article Comments (0)

Open Peer Review

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Open Peer Review

Reviewer Status

Reviewer Reports

Comments on this article

Are you a HRB-funded researcher?

Thank you!

Guideline recommendations on the role of the general practitioner in the diagnosis of dementia: a protocol for a scoping review of clinical practice guidelines

Abstract

Introduction

Method

Conclusion

Keywords

Revised Amendments from Version 1

Introduction

Method

1. Identifying the research question

Table 1. Search terms.

2. Identifying relevant studies

3. Study selection

Table 2. Eligibility criteria.

4. Charting of the data

5. Summarising and reporting results

6. Consultation exercise with stakeholders

Conclusions

Data availability

References

Comments on this article Comments (0)

Open Peer Review

Comments on this article Comments (0)

Open Peer Review

Reviewer Status

Reviewer Reports

Comments on this article

Competing Interests Policy

Stay Updated

Are you a HRB-funded researcher?

Thank you!