The use of MRI, CT and lumbar puncture in dementia diagnostics: data from the SveDem Registry

Costs of diagnosing early Alzheimer's disease in three European memory clinic settings: Results from the precision medicine in Alzheimer's disease project

OBJECTIVES

The implementation of disease-modifying treatments for Alzheimer's Disease (AD) will require cost-effective diagnostic processes. As part of The Precision Medicine In AD consortium (PMI-AD) project, the aim is to analyze the baseline costs of diagnosing early AD at memory clinics in Norway, Slovenia, and the Netherlands.

METHODS

The costs of cognitive testing and a clinical examination, apolipoprotein E, magnetic resonance imaging (MRI), cerebrospinal fluid (CSF), positron emission tomography and blood-based biomarkers (BBM), which are used in different combinations in the three countries, were analyzed. Standardized unit costs, adjusted for GDP per capita and based on Swedish conditions were applied. The costs were expressed in euros (€) as of 2019. A diagnostic set comprising clinical examination, cognitive testing, MRI and CSF was defined as the gold standard, with MRI mainly used as an exclusion filter.

RESULTS

Cost data were available for 994 persons in Norway, 169 in Slovenia and 1015 in the Netherlands. The mean diagnostic costs were 1478 (95% confidence interval 1433-1523) € in Norway, 851 (731-970) € in Slovenia and 1184 (1135-1232) € in the Netherlands. Norway had the highest unit costs but also the greatest use of tests. With a uniform diagnostic test set applied, the diagnostic costs were 1264 (1238-1291) €, in Norway, 843 (771-914) € in Slovenia and 1184 (1156-1213) € in the Netherlands. There were no major cost differences between the final set of diagnoses.

CONCLUSIONS

The total costs for setting a diagnosis of AD varied somewhat in the three countries, depending on unit costs and use of tests. These costs are relatively low in comparison to the societal costs of AD.

Accelerated MRI using intelligent protocolling and subject-specific denoising applied to Alzheimer's disease imaging

Magnetic Resonance Imaging (MR Imaging) is routinely employed in diagnosing Alzheimer's Disease (AD), which accounts for up to 60-80% of dementia cases. However, it is time-consuming, and protocol optimization to accelerate MR Imaging requires local expertise since each pulse sequence involves multiple configurable parameters that need optimization for contrast, acquisition time, and signal-to-noise ratio (SNR). The lack of this expertise contributes to the highly inefficient utilization of MRI services diminishing their clinical value. In this work, we extend our previous effort and demonstrate accelerated MRI via intelligent protocolling of the modified brain screen protocol, referred to as the Gold Standard (GS) protocol. We leverage deep learning-based contrast-specific image-denoising to improve the image quality of data acquired using the accelerated protocol. Since the SNR of MR acquisitions depends on the volume of the object being imaged, we demonstrate subject-specific (SS) image-denoising. The accelerated protocol resulted in a 1.94 × gain in imaging throughput. This translated to a 72.51% increase in MR Value-defined in this work as the ratio of the sum of median object-masked local SNR values across all contrasts to the protocol's acquisition duration. We also computed PSNR, local SNR, MS-SSIM, and variance of the Laplacian values for image quality evaluation on 25 retrospective datasets. The minimum/maximum PSNR gains (measured in dB) were 1.18/11.68 and 1.04/13.15, from the baseline and SS image-denoising models, respectively. MS-SSIM gains were: 0.003/0.065 and 0.01/0.066; variance of the Laplacian (lower is better): 0.104/-0.135 and 0.13/-0.143. The GS protocol constitutes 44.44% of the comprehensive AD imaging protocol defined by the European Prevention of Alzheimer's Disease project. Therefore, we also demonstrate the potential for AD-imaging via automated volumetry of relevant brain anatomies. We performed statistical analysis on these volumetric measurements of the hippocampus and amygdala from the GS and accelerated protocols, and found that 27 locations were in excellent agreement. In conclusion, accelerated brain imaging with the potential for AD imaging was demonstrated, and image quality was recovered post-acquisition using DL-based image denoising models.

Structural brain imaging as a diagnostic tool in dementia, why and how?

The demands for more people to be investigated due to cognitive failure and suspected dementia are increasing as increasing numbers of us get older and the incidence of dementia increases. An important part of a dementia study includes the structural imaging of the brain. Two imaging techniques, Computed Tomography (CT) and Magnetic Resonance Imaging (MRI), are used in this context. They differ in many ways and one question is which of the methods should be used in the first instance. Considering the large number of investigations to be expected in the future it is vital that they be cost-effective. Structural imaging aims partly to find secondary causes of cognitive failure and partly to provide support in the differential diagnostic reasoning. The methods differ; CT is significantly cheaper but exposes the patient to radiation, MRI is expensive but does not use X-rays. MRI provides better imaging of cerebrovascular lesions than CT as well as better imaging of structures near the skull base. The difference in diagnostic accuracy is small and it is doubtful whether that difference justifies the large difference in cost.

Combining diagnostic memory clinic with rehabilitation follow-up after hip fracture

PURPOSE

Cognitive impairment and dementia are common in older hip fracture patients. We describe new diagnoses of cognitive disorders (NDCDs) and associated factors in a two-year post-hip fracture follow-up including the use of the diagnostic facilities of a memory clinic.

METHODS

Data were collected on admission and at outpatient assessment 4-6 months post-hip fracture. Diagnoses of cognitive disorders followed the evidence-based Finnish national care guideline including internationally accepted criteria. NDCDs up to 2 years post-hip fracture were extracted manually from the patient files. Logistic regression models were computed to examine the associations between the pre-fracture factors and the domains of the outpatient geriatric assessment and NDCDs.

RESULTS

Of the 1165 hip fracture patients aged ≥ 65 years, 831 had no previous diagnosis of cognitive disorder. Of these, NDCD was documented in 23.3%. Alzheimer's disease (AD) with or without vascular cognitive impairment (VCI) was the most common diagnosis. Cognitive disorder was usually at a moderate stage. Age, higher ASA score and poor nutritional status on admission were associated with new cognitive disorders. At the outpatient follow-up, poorer activities of daily living and mobility disability were associated with NDCD. Patients with a NDCD were more likely to suffer greater mobility impairment, poorer nutritional status and to have more supported living arrangements at follow-up than in the pre-fracture situation.

CONCLUSION

NDCDs are common after hip fracture and associated with impaired rehabilitation outcomes and poor nutritional status. A post-hip fracture assessment co-organized in the form of a memory clinic seems to be feasible to detect previously undiagnosed cognitive disorders. Earlier diagnosis of cognitive disorders is warranted.

An investigation of the correlation between the S-glutathionylated GAPDH levels in blood and Alzheimer's disease progression

Alzheimer’s disease (AD) is a progressive neurodegenerative disease characterized by two aggregates, namely, amyloid-β (Aβ) plaques and neurofibrillary tangles (NFTs) of hyperphosphorylated tau protein (tau-p), which are released into the blood in a very small amount and cannot be easily detected. An increasing number of recent studies have suggested that S-glutathionylated glyceraldehyde 3-phosphate dehydrogenase (GAPDH) is highly correlated with Aβ in patients with AD and that S-glutathionylated GAPDH plays a role as a proapoptotic factor in AD. We found that S-glutathionylated GAPDH is abundant in the blood of AD patients, which is unusual because S-glutathionylated GAPDH cannot exist in the blood under normal conditions. The aim of this study was to further explore the correlation between the S-glutathionylated GAPDH levels in blood plasma and AD progression. As controls, we recruited 191 people without AD, which included 111 healthy individuals and 37 patients with depression and insomnia, in the psychosomatic clinic. Moreover, 47 patients with AD (aged 40–89 years) were recruited at the neurology clinic. The blood S-glutathionylated GAPDH levels in the AD patients were significantly (p < 0.001) higher (752.7 ± 301.7 ng/dL) than those in the controls (59.92 ± 122.4 ng/dL), irrespective of gender and age. For AD diagnosis, the criterion blood S-glutathionylated GAPDH level > 251.62 ng/dL exhibited 95.74% sensitivity and 92.67% specificity. In fact, the individuals aged 70–89 years, namely, 37 patients from the psychosomatic clinic and 42 healthy individuals, showed significant blood S-glutathionylated GAPDH levels (230.5 ± 79.3 and 8.05 ± 20.51 ng/dL, respectively). This finding might indicate neurodegenerative AD progression in psychosomatic patients and suggests that the degree of neuronal apoptosis during AD progression might be sensitively evaluated based on the level of S-glutathionylated GAPDH in blood.

Incidental Findings Identified on Head MRI for Investigation of Cognitive Impairment: A Retrospective Review

INTRODUCTION

Incidental findings are common in presumed healthy volunteers but are infrequently studied in patients in a clinical context.

OBJECTIVE

To determine the prevalence, nature, and management implications of incidental findings on head MRI in patients presenting with cognitive symptoms, and to quantify and describe unexpected MRI abnormalities that are of uncertain relevance to the patient's cognitive symptoms.

METHODS

A single-centre retrospective review of patients attending a regional early-onset cognitive disorders clinic between March 2012 and October 2018. Medical records of consecutive patients who underwent head MRI were reviewed. Unexpected MRI findings were classified according to their severity and likelihood of being incidental. Markers of small vessel disease and cerebral atrophy were excluded.

RESULTS

Records of 694 patients were reviewed (median age 60 years, 49.9% female), of whom 514 (74.1%) underwent head MRI. 54% of the patients received a diagnosis of a neurodegenerative disorder. Overall 111 incidental findings were identified in 100 patients of whom 18 patients (3.5%, 95% CI 2.2-5.6%) had 18 incidental findings classified as requiring additional medical evaluation. 82 patients (16%, 95% CI 13.0-19.5%) had 93 incidental findings without clearly defined diagnostic consequences. 17 patients (3.3%) underwent further investigations, 14 patients (2.7%) were referred to another specialist clinic and 3 patients (0.6%) were treated surgically. Two patients had MRI findings of uncertain relevance to their cognitive symptoms, necessitating prolonged clinic follow-up.

CONCLUSION

Incidental findings are common in patients with cognitive impairment from this large clinic-based series; however, few required additional medical evaluation. These data could help inform discussions between clinicians and people with cognitive symptoms regarding the likelihood and potential implications of incidental imaging findings.

AVRA: Automatic visual ratings of atrophy from MRI images using recurrent convolutional neural networks

Quantifying the degree of atrophy is done clinically by neuroradiologists following established visual rating scales. For these assessments to be reliable the rater requires substantial training and experience, and even then the rating agreement between two radiologists is not perfect. We have developed a model we call AVRA (Automatic Visual Ratings of Atrophy) based on machine learning methods and trained on 2350 visual ratings made by an experienced neuroradiologist. It provides fast and automatic ratings for Scheltens' scale of medial temporal atrophy (MTA), the frontal subscale of Pasquier's Global Cortical Atrophy (GCA-F) scale, and Koedam's scale of Posterior Atrophy (PA). We demonstrate substantial inter-rater agreement between AVRA's and a neuroradiologist ratings with Cohen's weighted kappa values of κw = 0.74/0.72 (MTA left/right), κw = 0.62 (GCA-F) and κw = 0.74 (PA). We conclude that automatic visual ratings of atrophy can potentially have great scientific value, and aim to present AVRA as a freely available toolbox.

Clinical validity of medial temporal atrophy as a biomarker for Alzheimer's disease in the context of a structured 5-phase development framework

Research criteria for Alzheimer's disease recommend the use of biomarkers for diagnosis, but whether biomarkers improve the diagnosis in clinical routine has not been systematically assessed. The aim is to evaluate the evidence for use of medial temporal lobe atrophy (MTA) as a biomarker for Alzheimer's disease at the mild cognitive impairment stage in routine clinical practice, with an adapted version of the 5-phase oncology framework for biomarker development. A literature review on visual assessment of MTA and hippocampal volumetry was conducted with other biomarkers addressed in parallel reviews. Ample evidence is available for phase 1 (rationale for use) and phase 2 (discriminative ability between diseased and control subjects). Phase 3 (early detection ability) is partly achieved: most evidence is derived from research cohorts or clinical populations with short follow-up, but validation in clinical mild cognitive impairment cohorts is required. In phase 4, only the practical feasibility has been addressed for visual rating of MTA. The rest of phase 4 and phase 5 have not yet been addressed.

Monitoring disease progression in mild cognitive impairment: Associations between atrophy patterns, cognition, APOE and amyloid

BACKGROUND

A disease severity index (SI) for Alzheimer's disease (AD) has been proposed that summarizes MRI-derived structural measures into a single score using multivariate data analysis.

OBJECTIVES

To longitudinally evaluate the use of the SI to monitor disease progression and predict future progression to AD in mild cognitive impairment (MCI). Further, to investigate the association between longitudinal change in the SI and cognitive impairment, Apolipoprotein E (APOE) genotype as well as the levels of cerebrospinal fluid amyloid-beta 1-42 (Aβ) peptide.

METHODS

The dataset included 195 AD, 145 MCI and 228 control subjects with annual follow-up for three years, where 70 MCI subjects progressed to AD (MCI-p). For each subject the SI was generated at baseline and follow-ups using 55 regional cortical thickness and subcortical volumes measures that extracted by the FreeSurfer longitudinal stream.

RESULTS

MCI-p subjects had a faster increase of the SI over time (p < 0.001). A higher SI at baseline in MCI-p was related to progression to AD at earlier follow-ups (p < 0.001) and worse cognitive impairment (p < 0.001). AD-like MCI patients with the APOE ε4 allele and abnormal Aβ levels had a faster increase of the SI, independently (p = 0.003 and p = 0.004).

CONCLUSIONS

Longitudinal changes in the SI reflect structural brain changes and can identify MCI patients at risk of progression to AD. Disease-related brain structural changes are influenced independently by APOE genotype and amyloid pathology. The SI has the potential to be used as a sensitive tool to predict future dementia, monitor disease progression as well as an outcome measure for clinical trials.

Differences in diagnostic process, treatment and social Support for Alzheimer's dementia between primary and specialist care: resultss from the Swedish Dementia Registry

Background

the increasing prevalence of Alzheimer's dementia (AD) has shifted the burden of management towards primary care (PC). Our aim is to compare diagnostic process and management of AD in PC and specialist care (SC).

Design

cross-sectional study.

Subjects

a total of, 9,625 patients diagnosed with AD registered 2011–14 in SveDem, the Swedish Dementia Registry.

Methods

descriptive statistics are shown. Odds ratios are presented for test performance and treatment in PC compared to SC, adjusted for age, sex, Mini-Mental State Examination (MMSE) and number of medication.

Results

a total of, 5,734 (60%) AD patients from SC and 3,891 (40%) from PC. In both, 64% of patients were women. PC patients were older (mean age 81 vs. 76; P < 0.001), had lower MMSE (median 21 vs. 22; P < 0.001) and more likely to receive home care (31% vs. 20%; P < 0.001) or day care (5% vs. 3%; P < 0.001). Fewer diagnostic tests were performed in PC and diagnostic time was shorter. Basic testing was less likely to be complete in PC. The greatest differences were found for neuroimaging (82% in PC vs. 98% in SC) and clock tests (84% vs. 93%). These differences remained statistically significant after adjusting for MMSE and demographic characteristics. PC patients received less antipsychotic medication and more anxiolytics and hypnotics, but there were no significant differences in use of cholinesterase inhibitors between PC and SC.

Conclusion

primary and specialist AD patients differ in background characteristics, and this can influence diagnostic work-up and treatment. PC excels in restriction of antipsychotic use. Use of head CT and clock test in PC are areas for improvement in Sweden.

Dementia Diagnosis, Treatment, and Care in Specialist Clinics in Two Scandinavian Countries: A Data Comparison between the Swedish Dementia Registry (SveDem) and the Danish Dementia Registry

BACKGROUND

Two dementia quality registries have been developed in Denmark and Sweden with the aim to assess quality of dementia care based on adherence to national guidelines.

OBJECTIVE

To compare patient characteristics, diagnostics, treatment, and quality indicators of dementia care among patients referred to specialist units in Sweden and Denmark.

METHODS

Data from the Swedish Dementia Registry (SveDem) and the Danish Dementia Registry were merged. Newly diagnosed dementia cases referred to memory clinics during 2007-2012 were included (19,629 Swedish and 6,576 Danish patients).

RESULTS

The median duration between initial assessment and confirmed diagnosis was 56 and 57 days in Sweden and Denmark, respectively. Brain imaging using MRI was twice as common in Sweden. A diagnosis of dementia was established at an average MMSE of 21. An etiological diagnosis was concluded in 89.6% of the Swedish and 87.3% of the Danish cases. Alzheimer's disease (AD) was the most common disorder (47.7% in Denmark and 36.6% in Sweden); however, more cases were diagnosed as mixed AD in Sweden (24.7% versus 10.6% ). More than 80% of patients with AD, dementia with Lewy bodies, and Parkinson's disease with dementia were treated with anti-dementia drugs.

CONCLUSION

The targets of several quality indicators in both registries were met, such that structural brain imaging and MMSE were performed in >90% and an etiological diagnosis was concluded in >80% of the patients. However, there were also results of concern. The diagnosis of dementia was established at a mean MMSE of 21, which is already late in the course of most dementia disorders. A higher chance of vascular findings following the higher rate of MRI in Sweden may have resulted in more mixed AD diagnosis, which could be one explanation for diagnostic differences but also highlights the need to harmonize diagnostic criteria.

High tau levels in cerebrospinal fluid predict nursing home placement and rapid progression in Alzheimer's disease

Background

Increased concentrations of cerebrospinal fluid (CSF) total tau (t-tau) and phosphorylated tau, as well as decreased amyloid-β 42 peptide, are biomarkers of Alzheimer’s disease (AD) pathology, but few studies have shown an association with AD progression rate. We hypothesized that high CSF tau, as a marker of ongoing neurodegeneration, would predict a more aggressive course of AD, using time to nursing home placement (NHP) as the main outcome.

Methods

Our sample inlcuded 234 patients with mild cognitive impairment (MCI) due to AD (n = 134) or mild to moderate AD (n = 100) who underwent lumbar puncture at a memory clinic and were followed for 2–11 years (median 4.9 years).

Results

Individuals with CSF t-tau in the highest quartile (≥900 ng/L) had a higher ratio of NHP, both in the total cohort and in patients with MCI only (adjusted HR 2.17 [95 % CI 1.24–3.80]; HR 2.37 [95 % CI 1.10–5.09], respectively), than the lowest quartile. The association between high t-tau levels and future steep deterioration was confirmed in analyses with conversion to moderate dementia (HR 1.66; 95 % CI 1.08–2.56), rapid decline in Mini Mental State Examination score (≥4-point drop/12 months), and dying in severe dementia as outcomes.

Conclusions

To our knowledge, this is the first study to show that high CSF t-tau levels predict early NHP and conversion to moderate dementia in an AD cohort. Selecting patients with high CSF t-tau, indicating more aggressive neurodegeneration and steeper decline, for AD immunotherapy trials might increase the possibility of showing contrast between active treatment and placebo.

Electronic supplementary material

The online version of this article (doi:10.1186/s13195-016-0191-0) contains supplementary material, which is available to authorized users.

Manual Planimetry of the Medial Temporal Lobe Versus Automated Volumetry of the Hippocampus in the Diagnosis of Alzheimer's Disease

Introduction:

Though a disproportionate rate of atrophy in the medial temporal lobe (MTA) represents a reliable marker of Alzheimer’s disease (AD) pathology, measurement of the MTA is not currently widely used in daily clinical practice. This is mainly because the methods available to date are sophisticated and difficult to implement in clinical practice (volumetric methods), are poorly explored (linear and planimetric methods), or lack objectivity (visual rating). Here, we aimed to compare the results of a manual planimetric measure (the yearly rate of absolute atrophy of the medial temporal lobe, 2D-yrA-MTL) with the results of an automated volumetric measure (the yearly rate of atrophy of the hippocampus, 3D-yrA-H).

Methods:

A series of 1.5T MRI studies on 290 subjects in the age range of 65–85 years, including patients with AD (n = 100), mild cognitive impairment (MCI) (n = 100), and matched controls (n = 90) from the AddNeuroMed study, were examined by two independent subgroups of researchers: one in charge of volumetric measures and the other in charge of planimetric measures.

Results:

The means of both methods were significantly different between AD and the other two diagnostic groups. In the differential diagnosis of AD against controls, 3D-yrA-H performed significantly better than 2D-yrA-MTL while differences were not statistically significant in the differential diagnosis of AD against MCI.

Conclusion:

Automated volumetry of the hippocampus is superior to manual planimetry of the MTL in the diagnosis of AD. Nevertheless, the 2D-yrAMTL is a simpler method that could be easily implemented in clinical practice when volumetry is not available. 

Measuring Global Brain Atrophy with the Brain Volume/Cerebrospinal Fluid Index: Normative Values, Cut-Offs and Clinical Associations

BACKGROUND

Global brain atrophy is present in normal aging and different neurodegenerative disorders such as Alzheimer's disease (AD) and is becoming widely used to monitor disease progression.

SUMMARY

The brain volume/cerebrospinal fluid index (BV/CSF index) is validated in this study as a measurement of global brain atrophy. We tested the ability of the BV/CSF index to detect global brain atrophy, investigated the influence of confounders, provided normative values and cut-offs for mild, moderate and severe brain atrophy, and studied associations with different outcome variables. A total of 1,009 individuals were included [324 healthy controls, 408 patients with mild cognitive impairment (MCI) and 277 patients with AD]. Magnetic resonance images were segmented using FreeSurfer, and the BV/CSF index was calculated and studied both cross-sectionally and longitudinally (1-year follow-up). Both AD patients and MCI patients who progressed to AD showed greater global brain atrophy compared to stable MCI patients and controls. Atrophy was associated with older age, larger intracranial volume, less education and presence of the ApoE ε4 allele. Significant correlations were found with clinical variables, CSF biomarkers and several cognitive tests.

KEY MESSAGES

The BV/CSF index may be useful for staging individuals according to the degree of global brain atrophy, and for monitoring disease progression. It also shows potential for predicting clinical changes and for being used in the clinical routine.

The Effect of Age Correction on Multivariate Classification in Alzheimer's Disease, with a Focus on the Characteristics of Incorrectly and Correctly Classified Subjects

The similarity of atrophy patterns in Alzheimer’s disease (AD) and in normal aging suggests age as a confounding factor in multivariate models that use structural magnetic resonance imaging (MRI) data. To study the effect and compare different age correction approaches on AD diagnosis and prediction of mild cognitive impairment (MCI) progression as well as investigate the characteristics of correctly and incorrectly classified subjects. Data from two multi-center cohorts were included in the study [AD = 297, MCI = 445, controls (CTL) = 340]. 34 cortical thickness and 21 subcortical volumetric measures were extracted from MRI. The age correction approaches involved: using age as a covariate to MRI-derived measures and linear detrending of age-related changes based on CTL measures. Orthogonal projections to latent structures was used to discriminate between AD and CTL subjects, and to predict MCI progression to AD, up to 36-months follow-up. Both age correction approaches improved models’ quality in terms of goodness of fit and goodness of prediction, as well as classification and prediction accuracies. The observed age associations in classification and prediction results were effectively eliminated after age correction. A detailed analysis of correctly and incorrectly classified subjects highlighted age associations in other factors: ApoE genotype, global cognitive impairment and gender. The two methods for age correction gave similar results and show that age can partially masks the influence of other aspects such as cognitive impairment, ApoE-e4 genotype and gender. Age-related brain atrophy may have a more important association with these factors than previously believed.

Benchmarking biomarker-based criteria for Alzheimer's disease: Data from the Swedish Dementia Registry, SveDem

INTRODUCTION

New research guidelines for the diagnosis of Alzheimer's disease (AD) include biomarker evidence of amyloid-β (Aβ) and tau pathology. The aim of this study was to investigate what proportion of AD patients diagnosed in clinical routine in Sweden that had an AD-indicative cerebrospinal fluid (CSF) biomarker profile.

METHODS

By cross-referencing a laboratory database with the Swedish Dementia Registry (SveDem), 2357 patients with data on CSF Aβ and tau biomarkers and a clinical diagnosis of AD with dementia were acquired.

RESULTS

Altogether, 77.2% had pathologic Aβ42 and total tau or phosphorylated tau in CSF. These results were stable across age groups. Female sex and low mini-mental state examination score increased the likelihood of pathologic biomarkers.

DISCUSSION

About a quarter of clinically diagnosed AD patients did not have an AD-indicative CSF biomarker profile. This discrepancy may partly reflect incorrect (false positive) clinical diagnosis or a lack in sensitivity of the biomarker assays.

SveDem, the Swedish Dementia Registry - a tool for improving the quality of diagnostics, treatment and care of dementia patients in clinical practice

BACKGROUND

The Swedish Dementia Registry (SveDem) was developed with the aim to improve the quality of diagnostic work-up, treatment and care of patients with dementia disorders in Sweden.

METHODS

SveDem is an internet based quality registry where several indicators can be followed over time. It includes information about the diagnostic work-up, medical treatment and community support (www.svedem.se). The patients are diagnosed and followed-up yearly in specialist units, primary care centres or in nursing homes.

RESULTS

The database was initiated in May 2007 and covers almost all of Sweden. There were 28 722 patients registered with a mean age of 79.3 years during 2007-2012. Each participating unit obtains continuous online statistics from its own registrations and they can be compared with regional and national data. A report from SveDem is published yearly to inform medical and care professionals as well as political and administrative decision-makers about the current quality of diagnostics, treatment and care of patients with dementia disorders in Sweden.

CONCLUSION

SveDem provides knowledge about current dementia care in Sweden and serves as a framework for ensuring the quality of diagnostics, treatment and care across the country. It also reflects changes in quality dementia care over time. Data from SveDem can be used to further develop the national guidelines for dementia and to generate new research hypotheses.