In 2015, the Indonesian Neurologist Association/Perhimpunan Dokter Spesialis Saraf Indonesia (PERDOSSI) issued a clinical practice guideline on dementia diagnosis and management. The document outlined diagnostic paths in the different levels of healthcare services (PERDOSSI, 2015).

In primary care, patients coming with subjective complaints, change of activities of daily living (ADL), or brought to the clinic due to the family/carer’s concern on their cognitive changes will be considered for assessment. The physician should interview the patient and/or the carer about the history of the complaint and then perform physical examination of the patient, especially of the cardiovascular and neurological system. The patient’s cognitive function will then be assessed using the Mini Mental State Examination (MMSE). The physician should also document changes on the patient’s activities and cognitive function using the AD8 instrument based on the carer’s report. Patients with abnormalities in clinical or neurological examinations, MMSE score of less than 24, or AD8 score of 2 or more should be referred to a neurologist (in the second level of healthcare services) or to a memory clinic (in the third level of healthcare services). If these criteria are not met, the patient is advised to return for a check-up in 6 months (PERDOSSI, 2015).

In hospital (secondary level of healthcare), patients presenting with complaints suggestive of dementia or referred by the primary care will undergo a similar process to that of primary care. In an addition the Geriatric Depression Scale should be performed to exclude depression as well as a clock-drawing test (CDT), and the Montreal Cognitive Assessment (MoCA). Blood sample should be taken to check the patient’s lipid profile, renal and liver function, glucose level, and electrolytes. A CT-scan should be done to aid diagnosis. Patients with abnormalities in physical examination, AD8 > 2/MMSE < 24/CDT < 24/MoCA < 24 are advised to be referred to a memory clinic (PERDOSSI, 2015).

In the memory clinic (tertiary healthcare level), additional exams performed include other neuropsychological tests, the Neuropsychiatric Inventory (NPI), other blood tests (fasting blood glucose, folic acid, and vitamin B12 levels, thyroid function) and an electrocardiogram. Other specific tests according to indication can also be ordered, such as VDRL for syphilis or a HIV test. An MRI (preferable) or CT should be performed, followed by electroencephalogram or lumbar puncture if indicated. These additional exams are expected to aid diagnosis of dementia and its causes (PERDOSSI, 2015).

During our interview for WP3 with a general practitioner managing a geriatric clinic of a primary care centre, we learnt that dementia screening practice is not routine practice. The physician informed us that most of the dementia cases documented in that centre already received a diagnosis in the hospital and then reported back to the centre for documentation and administrative requirements (Source: WP3 FGD info from GP). However, this is contradictory to another statement by the physician. The GP explained that based on the new Ministry of Health’s regulation no. 4/2019 on the Minimum Standard of Service, the centre has now routinely started to screen older people with several tools that include a cognitive instrument (Abbreviated Mental Test) (Ministry of Health Regulation No. 4/2019 on Technical Standard to Fulfill Quality of Basic Service in Minimum Standard of Healthcare Service (Permenkes No. 4/2019 Tentang Standar Teknis Pemenuhan Mutu Pelayanan Dasar Pada Standar Pelayanan Minimal Bidang), 2019). More about this regulation will be discussed in this document in Part 7, Dementia Care System Organisation, Community-based Services for Dementia, and Diagnostic services (in primary care)).

The stratified screening and diagnosis pathway outlined above seems to be typical of patients using the National Health Insurance. However, the pathways of patients with self-funded access to healthcare vary greatly depending on the patient’s economic status and geographical area. Some patients decide to go directly to the secondary or tertiary healthcare providers, or even undertake tests abroad. Some secondary health centres have sufficient resources to perform the examinations outlined for tertiary health care providers and thus can provide the level of diagnosis at secondary level. It is also important to note that a lot of patients receive their diagnosis of dementia whilst being treated for other issues (WP3 FGD info from neurologist and GP).

References:

Ministry of Health Regulation no. 4/2019 on Technical Standard to Fulfill Quality of Basic Service in Minimum Standard of Healthcare Service (Permenkes no. 4/2019 tentang Standar Teknis Pemenuhan Mutu Pelayanan Dasar pada Standar Pelayanan Minimal Bidang , (2019) (testimony of Ministry of Health Republic of Indonesia).

PERDOSSI. (2015). Panduan Praktik Klinik: Diagnosis dan Penatalaksanaan Demensia. PERDOSSI.