What is the role of the PN in the care of people living with dementia, or cognitive impairment, and their support person(s)? : A systematic review.


 Background: The potential value of expanding the Practice Nurse role to include the recognition and management of dementia has been acknowledged and Practice Nurses are well-positioned to provide comprehensive dementia information and support so that people living with dementia are better equipped to self-manage their health and live well with dementia. The purpose of this review was to systematically examine published Australian and international literature to identify the existing and potential roles of Practice Nurse’s involvement in the delivery of care to people living with dementia or cognitive impairment and their support person(s) and also describe the characteristics and effectiveness of nurse interventions in dementia models of care in general practice. Methods: We systematically reviewed the evidence for roles and characteristics of the Practice Nurse in the delivery of dementia care. A comprehensive literature search identified relevant original research published in English between January 2000 and January 2019 and available in full text. Thirteen articles were included. Results: Characteristics of roles, undertaken by nurses working in the general practice setting, which were potentially beneficial to people living with dementia and their support person were identified. These included increased patient accessibility to the Practice Nurse, early recognition and management of cognitive changes, care management and collaboration with the General Practitioner. Limitations of the provision of dementia care by Practice Nurses included a lack of definition of the role, inadequate dementia specific training, time constraints and poor communication with General Practitioners. Conclusions Further research is required to define and evaluate the scope of practice and characteristics of the Practice Nurse role in dementia care provision. Embedding in usual general practice care an evidence-based model of care describing the role of the Practice Nurse in dementia care provision has the potential to increase early recognition of cognitive impairment and more appropriate primary care management of dementia. Systematic Review registration number PROSPERO 2018 CRD42018088191

cognitive impairment and more appropriate primary care management of dementia. Systematic Review registration number PROSPERO 2018 CRD42018088191 BACKGROUND Australian and international literature [1,2] reveals a significant gap in the delivery of dementia care in the general practice setting. In one study, 66% of participants (people with memory concerns) reported that they would like a memory test and 81% reported that they would speak with their General Practitioner (GP) if they thought they had dementia [3]. However, despite people's intent to report their concerns with their GP, there is a significant gap in the delivery of dementia care in the general practice setting [1]. Barriers to the identification, diagnosis and management of dementia are multiple and complex, and in some cases include a perception by the GP that nothing can be done and that support options are lacking [4]. Dementia is the second leading cause of death in Australia and currently more than 400 000 Australians are living with dementia (ABS, 2016). This number is expected to increase three-fold by 2056 [5]. Around 83% of all males with dementia and 71% of females with dementia live in the community [5] with 50 percent of dementia cases remaining undiagnosed [6]. When combining these figures with the approximately 200 000 unpaid care-givers involved in supporting a person living with dementia [5] a significant number of people are likely to be attending general practices and not having their health and social care needs met. Exploring new ways to improve the identification and management of dementia in the primary care setting is needed.
Approximately two thirds of Australian general practices employ a nurse [7] and nurse-led clinics are known to maximise patient health outcomes in primary care [8,9]. The Practice Nurse (PN) is a primary health care nurse employed in General Practice. As described by the Australian Primary Health Care Nurse Association (APNA) the role of the PN can include women's health, men's health, aged care, chronic disease management, immunisation, wound management, health promotion and population health. Given that co-morbidity in people living with dementia is high [8,10] the PN is likely to have established a therapeutic relationship through routine primary care treatment, over-75 health checks and chronic disease management with people with cognitive decline [11].
The potential value of expanding the PN role to include the recognition and management of dementia has been acknowledged [12,4]. However, there is limited research on the role of the PN in dementia care delivery in Australian or in international literature. A significant barrier to GP's discussing dementia with their patients is the perception that nothing can be done and that support options are lacking [4]. Developing a model of dementia care that incorporates a flexible clinical pathway to guide the PN, along with a compendium of resources that can be used to draw upon additional knowledge to assist in providing appropriate care for people with dementia, could help to overcome these barriers. The PN could offer the GP a means of providing immediate support to patients and their families, following a discussion about dementia that includes a conversation about their concerns and referral on to further supports as needed.
In summary, a PN model of dementia care has the potential to assist with the identification of cognition concerns and understanding of the impact of dementia on the health and well-being of an individual. Such a model is not only likely to lead to increased identification of dementia but also to more appropriate primary care treatment, chronic disease management, and, care planning for people with existing or emerging cognitive impairment or dementia and the people supporting them.
To date there has been no systematic review of the evidence on the role of the PN in dementia care delivery.

METHODS
This paper systematically reviews international and national peer-reviewed academic literature to answer the review questions: 1.
What are the existing and potential roles performed by the PN in the care of people living with dementia or cognitive impairment and their informal caregivers in General Practice? 2.
What are the characteristics of any existing nurse interventions that provide care to people living with dementia, or cognitive impairment, and their informal caregivers in the General Practice setting?
This systematic review was guided by the PRISMA-P Checklist [13] which comprises a 27item checklist for systematic reporting. The checklist includes items deemed essential for systematic review reporting [14].

Eligibility criteria
All research and other academic literature that described a role in care of a person with dementia and/ or their caregiver performed by a nurse in a General Practice setting A review of the included paper's reference lists and citations was undertaken to identify any additional studies initially omitted from the primary search.

Search strategy
Original searches were carried out on the 24 th

Study selection
All records from searches were retrieved in Endnote reference management software, and transferred to Covidence, the on-line standard production platform for Cochrane Reviews (https://www.covidence.org/home). Using Covidence, all records were independently screened for eligibility using the identified inclusion criteria by two authors (CG and DG).
Any discrepancies were resolved by a consensus meeting with the third author (DP).
The steps taken for paper selection included: An initial screening for relevance using the titles of identified references. Papers considered to be irrelevant were removed from the selection process. A conservative approach was taken.
Abstracts of remaining titles were reviewed based on inclusion criteria. The abstracts were coded relevant/ irrelevant/ unsure. The irrelevant papers were discarded from the selection process. Full text papers were retrieved for abstracts categorised as relevant or unsure.
The full text papers were reviewed and those papers deemed relevant meeting the selection criteria were included in the systematic review.

Data Collection processes
Data extraction for all study types included: author, year, country; aim; research design; instruments; sample and size; intervention type; analysis methods and outcomes.

Risk of bias in individual studies
Two reviewers (CG, DG) independently assessed the risk of bias in included studies. Any disagreements between the reviewers were resolved by discussion, with involvement of a third reviewer (DP).
Each included study was assessed using a quality appraisal tool appropriate for the methodology used. Randomised Controlled Trial (RCT) studies were assessed for risk of bias using the Cochrane Risk of Bias Tool [15] in which bias was assessed as a judgement (high, low or unclear) in five domains; selection, performance, attrition, reporting and other. The CEBM Critical Appraisal tool [16] consists of 10 questions to assess the risk of bias in methodology, analysis and outcomes in cross-sectional studies with each question A summary of the quality appraisal for each study is presented in Tables 1, 2, 3 and 4 and any issues of potential bias for a given study are reported in the synthesis of the studies.

Synthesis of results
The data were synthesised to classify how the published academic literature addresses the research question and to identify and analyse key concepts. Data were heterogeneous and did not allow for meta-analysis.
A comparison of the studies and their findings was therefore conducted to synthesise the data into tables according to their methodological nature. Where the findings of a study have been published in more than one journal, the data have been grouped as the primary source together with the publication with the most detailed analysis. The other papers describing the same study were described as supplementary papers.
Data were extracted from the studies and tabulated under the headings: research aim; study design; instruments; sample characteristics; intervention type; analysis and outcomes. (Tables 5,6,7 and 8). This approach provided an analysis of the published academic literature and enabled the exploration of relationships within and between studies and a description of themes across the included studies.

RESULTS
The search strategy identified 1875 references ( Figure 1). After removal of duplicates 1799 abstracts were examined for relevance and 68 full text references were obtained for full text screening. Hand-searching of references lists of included articles yielded an additional three articles. In total 71 articles were assessed for eligibility, of which 13 articles were selected for data extraction and analysis.
Fifty-eight studies assessed for eligibility were excluded. Eighteen were grey literature, 17 did not include the primary health care nurse, six were not available in full text, seven papers were removed as they were multiple publications reporting on the same intervention, five were published outside of the time-frame for inclusion, three were duplicate studies [19][20][21] and two studies [22,23] were excluded as the outcomes had not been published. Bryans et al., [22] did not publish the outcomes of a survey study on primary health care nurses and dementia care due to significant loss to follow-up. For similar reasons, Perry et al., [23] did not publish the outcomes of the dementia training programme on diagnostic assessment and management of dementia by primary care nurses.

Study characteristics
Of the 13 included studies, three were RCTs, three utilised survey questionnaires, four were mixed-method studies with one of these a Rand-Delphi study, and three were qualitative studies using interviews.
The studies were conducted in the Netherlands (n=1), Germany (n=1), United States of America (n=1), The United Kingdom (n=5), Australia (n=4) and one was conducted across the Netherlands and the United Kingdom (n=1).
All the studies were published between 2000 and 2019.
Exploring dementia care knowledge and attitudes of primary health care practitioners was the focus of three studies [11,12,3]. Two studies [27,28] explored participant experiences of dementia care delivery in primary health care and one study [29] explored service use and reported unmet needs of people with dementia and support person(s). Investigating the implications of early recognition of dementia for the roles of the primary health care team was the focus of one study [30] The authors of one study [31] developed quality indicators for dementia care in primary health care settings and one study investigated the value and useability of an online dementia management tool for health professionals [32]. The study characteristics are described in Tables 5, 6, 7 and 8.

Randomised Controlled Trials
Three studies utilised an RCT [21,25,26]  In all three models of care the nurse was the care manager who worked in collaboration with the primary care doctor. All care management models followed a structured assessment and care planning protocol. Care management ranged in duration from six [26] to twelve months [21,25] [20]. The study was designed to apply the shared elements of current treatment guidelines for patients with Alzheimer's disease [21]. The essential components of the model of care were a comprehensive screening and diagnosis protocol [33], a multi-disciplinary team approach to care coordinated by a geriatric nurse practitioner and a proactive longitudinal tracking system [20]. The primary outcome measurement was the identification and treatment of behavioural and psychological symptoms of dementia, with an emphasis on non-pharmacological management.
Intervention patients received care management by an interdisciplinary team led by the nurse working with the patient's family caregiver and integrated within primary care [20,34]. There was one nurse in each of the two study primary care practices, with each site including multiple clinics. This nurse was a geriatric nurse practitioner who had received specific training in communicating the diagnosis of Alzheimer's disease to patients and families. In addition to training, the nurse participated in weekly support meeting with a geriatrician, geriatric psychiatrist and a psychologist who reviewed the care provided. Caregivers and patients were seen by the nurse in the primary care clinic fortnightly, then monthly for one year. At each contact caregivers completed the Memory and Behaviour Problems Checklist which activated a specific behavioural intervention protocol [20]. The nurse managed non pharmacological interventions independently and if the intervention was unsuccessful then collaborated with GP to institute drug therapy.
Advice on communication skills; strategies for managing support person(s) stress; legal and financial advice; physical activity guidelines and the Alzheimer's Association Caregiver Guide was the minimum intervention that all treatment group caregivers received included [20]. Caregivers were also invited to participate in a monthly support group with a concurrent exercise program for the person with dementia [19].
The intervention group had fewer behavioural problems and reduced support person(s) stress, but there was no significant impact on depression or function. There was no evidence that the intervention improves or worsens cognition, activities of daily living or the rate of nursing home placement.
The results of this study indicate that this type of model of care can be implemented in primary care, particularly with the involvement of geriatric advanced practice nurses, who can effectively manage the complex nature of Alzheimer's disease. Callahan et al., [21] report that the effectiveness of the intervention depended on the key role played by the nurse. The model of care was acceptable to patients and primary care physicians [19] improving primary care efficiency. Factors important to nurses' success included establishing good relations with primary care physician, effective communication with the primary care physician and familiarity with primary care settings [20]. The intervention strength is credited to its comprehensive and integrated approach in line with effective chronic disease management models [21]. This model of care is potentially more health care intensive as the patients receiving care management had higher cumulative doctor or nurse visits compared with usual care, however these costs may be off-set by a reduction in pharmacological management of behavioural and psychological symptoms of dementia [21].
Callahan et al., [21] describe the main limitation of the study as the inability to identify The intervention included five hours of face-to-face family practitioner training to increase knowledge to diagnose dementia, a practice guideline and a trained PN to facilitate the diagnostic process and collaborative care. There were two study nurses covering seven participating practices. Collaborative care included the PN prioritising problems and preparing a care plan using the results of the administration of the Residential Assessment Instrument [36] and in collaboration with the individual with dementia or MCI, the caregiver and the GP.
The study outcomes were a non-significant increase in MCI and dementia diagnoses resulting from a combined educational, case finding and care intervention. Collaborative care did not seem to have impact on mental health and quality of life for study participants. The family practitioners and PNs described case-finding and the provision of collaborative care as a positive experience, however the PN did describe the process of inviting people for an assessment as time-consuming.
Limitations to the study included low response rates limiting the external validity of the study. The rates of MCI or dementia were lower than expected. The reasons for this may have included a type 2 error with a low sensitivity of the cognitive tests performed by PN.
In addition, there was sub-optimal implementation of the intervention with the family practitioner not always performing further diagnostic assessments on all persons referred by the PN. The potential impact of the intervention on rate of new diagnosis may have been mitigated by these factors.
Thyrian et al., [26] tested the effectiveness of dementia care management (DCM) in the treatment and care of people with dementia living at home and on caregiver burden [37].
DCM is a collaborative care model that uses a computer-assisted program to determine a personalised array of intervention modules and subsequent success monitoring that will provide optimal treatment and care for people with dementia and support caregivers. A RCT involving 634 people with dementia was conducted with six nurses who had completed a dementia care-specific qualification to provide the DCM intervention [38]. The intervention was provided for 6 months in the homes of the people with dementia. This study found that DCM was a safe intervention significantly decreasing behavioural and psychological symptoms of dementia and care giver burden. People with dementia with DCM had an increased chance of receiving anti-dementia drug treatment. DCM significantly increased QOL for patients not living alone but did not increase QOL overall.
There was no effect on the potential administration of inappropriate medication.
It was recommended that DCM provided by trained nurses was an effective collaborative care model improving patient and caregiver outcomes and should be incorporated into routine primary health care. However, the DCM qualification piloted in Dreier et al., [38] is time intensive with 35 modules over 18 months, which would not be easily accessible for all primary care nurses.
Thyrian et al., [26] describe limitations of the study including potential selection bias as screening and recruitment were part of routine care. The intervention and control groups had an uneven number of participants; the GPs in the control group had fewer patients. In addition, the GPs may have become aware of their assignment to the control or intervention group. The study was embedded into routine care resulting in high external validity.

Survey Questionnaire studies
Three studies reported survey results [11,12,29]. Manthorpe et al., [12] and Trickey et al., [11] investigated dementia knowledge and attitudes of primary health care nurses (CN), health visitors, community mental health care nurses (CMHN) and PNs in the provision of care for people living with dementia. The third study [29] explored service use and unmet needs of people with dementia recruited a decade apart.
Manthorpe et al., [12] reported all groups of primary health care nurses had similar knowledge related to the early signs and symptoms of dementia. However, PNs were less confident in providing advice and support than community mental health care nurses. In the study undertaken by Trickey et al., [11], PNs completing the Over-75 year health check were less likely than other nurse groups to take any action, other than to refer to the GP, when presented with a person living with dementia and their support person.
Gilbert et al., [29] reported that support person(s) were increasingly contacting a PN for support with less evident use of CN, health visitors and CMHN. This may in part be attributed to greater access to a PN and the changing nature of the PN role with an increased focus on chronic disease management. Support person(s) reported that they were still not getting the advice and support they needed.
Authors of all three studies identified a need to improve PN knowledge of dementia and its management. In the study by Trickey et al., [11] participants reported guidelines would be helpful to address gaps in knowledge and to standardise practice.
The survey outcomes and study limitations are described in detail below.
Manthorpe et al., [12] administered a questionnaire to 268 nurses; comprising 79 CMHNs, 153 CNs and 36 PNs, to explore whether there had different perspectives on early diagnosis of dementia and to consider the effects of any variation. These questionnaires were completed by nurses who attended one-day workshops offered on 24 occasions in 21 settings across the UK over a three month period. The workshops were open to all health practitioners who worked in the community setting and were part of a training program on early diagnosis of dementia [39].
All of the nurse groups were in regular contact with people with dementia and were able to respond to early signs of dementia and identify potential sources of support. However, both PNs and CNs felt less confident in the provision of dementia care and service coordination than community mental health care nurses. Once a diagnosis had been given approximately half of the PN respondents reported that they found it challenging to provide advice and support about behavioural or psychological problems. About one third of PNs found providing information about support services and obtaining support services "considerably difficult" with slightly more reporting "considerable difficulty" in the coordination of services. Dementia support in the community was seen by all nurse groups as a specialist function with the key worker role best fulfilled by community mental health care nurses. A limitation in drawing generalizable conclusions from this study was that the nurse participants volunteered to attend a 1-day training course on dementia in their own time. Therefore, the sample group was likely a group of interested and perhaps atypical practitioners. However, when considering the role of the PN in the provision of dementia care the authors conclude that despite PNs being in contact with the population likely to benefit from early recognition of dementia, work is needed to increase PN confidence, knowledge and skills in recognising dementia and supporting people undergoing referral or assessment.
Trickey et al., [11] utilised a postal questionnaire survey that was completed by 127 primary care nurses in the UK (a response rate of 65%) of which 71% were practice based nurses. The study aimed to examine the knowledge, attitudes and inter-professional working practices among nurses who undertake the Over-75 Check towards assessing and managing patients with symptoms of dementia. The survey also assessed the level of support for a clinical practice guideline.
The outcomes of the study revealed there was little evidence of a systematic approach within practices. Twenty-five percent of survey respondents indicated they would take no action other than to refer to a GP in response to a case vignette describing a consultation with an older couple; the wife showing signs of dementia and the husband anxious about the future. Of the remaining participants, there was a mixed response to the action they would take, with little evidence of holistic assessment and care. Just under one third reported they would make an informal or formal assessment of cognition, 5% would explore the husband's mood and 1% would look at specific support needs for the husband.
The extent of action nurses indicated they would take was dependant on their skills and perception of autonomy, with most intended action reported by highly trained nurses with more confidence and perceived autonomy. Trickey et al., [11] concluded that many professionals undertaking the Over-75 health check are not sufficiently trained to assess patients with potentially early signs of cognitive impairment. The majority of respondents recognised the need to standardise care and the need for early intervention and indicated that guidelines would be helpful in their practice to address gaps in knowledge. This was a small survey conducted in a limited geographical area which restricts drawing generalizable conclusions. Additionally, using a vignette may more correctly be exploring current practice rather than knowledge and attitudes. However, given the prevalence of PNs undertaking the Over-75 Check in General Practice it is reasonable to conclude that education to support recognition of cognitive impairment and the provision of consistent and adequate care for people with dementia is warranted.
Gilbert et al., [29] report the results of a UK study comparing service use and unmet needs by people with dementia and their support person(s) in two samples a decade apart using the same survey instrument. The participants in this study were recruited in two earlier RCTs [40,41] testing the effectiveness of the EVIDEM dementia educational intervention [41] and support person(s) accounts of their encounters with family practice [40].
Recruitment was part of an educational intervention study and those taking part in such trials are not representative of the wider community of people with dementia and their caregivers. Despite this limitation the two samples were largely similar in demographics.
There were statistically significant differences in service use and unmet needs between the two samples, with a reduction in unmet need in the second sample. However, managing physical and verbal aggression remained a significant challenge. Gilbert et al., [29] report this reduction may be related to changes in service use and national policy promoting earlier recognition, improved access to treatment, specialist services and social supports and better identification and recognition of support person(s). In the second sample, the role of PNs was more evident, especially for non-spouse support person(s), and the use of CNs, CMHNs and home visitors was less apparent. It is not known if these contacts were to review dementia or were encounters for management of co-morbidities.  [24].
The small scale of the study means that conclusions drawn from it must be tentative. The limitations of this study included less than expected dyad recruitment for all practices.

Qualitative studies
All three qualitative studies [27,28,30] [27]. The memory nurses were from secondary care dementia services, located centrally and provided expert consultancy to GPs around dementia medications. All the service users who were interviewed for this study had only been seen by their GP and not by memory nurses working in either primary or secondary care memory services.
The interviews revealed four main themes related to the relocation of part of the memory service from secondary care to primary care: 'the journey'; 'what next'; 'the benefits and limits of primary care'; and, 'are GPs getting it right'. Two consistently expressed concerns by all groups of participants were: lack of post-diagnostic co-ordination and GPled or multidisciplinary assessment. The process of assessment and diagnosis was described by the GPs and memory nurses as a collaborative or multi-disciplinary exercise, but with clear boundaries between roles, with the nurse carrying out the assessment and the doctor making the final diagnosis.
Training and education was repeatedly identified as a means to develop collaborative, consistent approaches to dementia care. The memory nurses described how informal learning with experience and talking with their colleagues was particularly important in enhancing competence.
The study did not aim to be generalizable, but to generate ideas for further research.
Limitations included the small sample size (n=7) and the use of peer interviewers.
Manthorpe et al., [30] conducted a focus group study with the same sample group attending a series of 24 multidisciplinary dementia workshops over 21 cities across UK over a three month period as reported in Manthorpe et al., [12] and Illiffe et al., [24]. Four categories of paired themes were identified; opportunistic screening versus population screening, referral and responsibility, key working and team working, and generalist versus specialist roles. Collaborative working in dementia care, particularly around early recognition, was seen as essential, with the PN identified as the practitioner most appropriate to take on routine screening for dementia in primary care. There was a contradiction between the perception that recognising dementia could be in the remit of all professionals, and the clear delegation of assessment to nurses. A perception that screening is a core skill that can be assimilated and incorporated into everyday practice by any nurse, although not necessarily by GPs, reflected the unresolved tension between opportunistic identification (which all could do) and a more systematic approach to screening, where nurses are seen by doctors as the most appropriate professional. A common theme was the need for education and training for screening. However that routine screening for dementia is controversial and not recommended due to the high rate of false positives [43]. There were concerns about the time required to provide more comprehensive dementia care in primary health care. Communication between professionals, increased requests for screening and assessment, the pressure of earlier reviews from those who enter the dementia systems at ever earlier stages and the higher expectations from older people and their families were seen to be costly and timeconsuming.
The study outcomes are limited in generalisability because the sample was likely a group of interested and perhaps atypical practitioners who volunteered to attend a one day training course on dementia in their own time.

Risk of bias
The methodological quality varied across the studies (Tables 1, 2 The only clearly defined role that was examined was that of the primary care based nurse as a care manager [21,[24][25][26]. There were mixed findings regarding the effectiveness of the nurse-led case management model of care in improving quality of life measures for people living with dementia and their support person(s). However, no studies dismissed the potential of this model, with further research recommended. Callahan et al., [21] was assessed as the highest quality RCT study. The authors reported that a case management model of care can be implemented in primary care and that the effectiveness of the intervention depended on the key role of the nurse. All the nurses in these care management studies were registered nurses with dementia specific training, however in the Callahan et al., [21] study the case manager was a geriatric nurse practitioner. All health practitioners in the care manager studies described the experience as positive and perceived there to be benefits to the patient. Nurses did describe the role as time consuming and liaising with the primary care medical practitioner as cumbersome.
However, the care manager role was considered resource intensive, which could prove a challenge in its integration with practice routines that often operate, with limited time for consultations and budgetary constraints. The case management model described in Callahan et al., [21] was particularly resource intensive with one year of case management, weekly mentoring for the case manager, weekly then monthly patient contacts, and monthly care-giver support groups with concurrent exercise groups for the person living with dementia.
The other studies [3,11,12,[27][28][29][30][31][32]] explored characteristics of the role of the primary care based nurse in the care of people living with dementia and the support person. These studies were of variable quality but consistent in their outcomes. The PN was described as having an increasing profile in primary health care and being more accessible to patients, partly as a result of their changing role to include chronic disease management. There was recognition of the primary care nurse as the appropriate professional to take on the role of screening for cognitive impairment and monitoring, with the medical practitioner being responsible for diagnosis. The PN is usually responsible for the Over 75 health check which is currently underutilised and provides an opportunity to identify people with cognitive impairment. A common issue in the studies was the poor recording of diagnosis or outcome of cognitive testing in electronic medical records. Several studies identified that post-diagnostic support and carer support were lacking in current dementia care provision in primary health care. Patients with memory concerns reported that they would welcome the opportunity to discuss dementia risk reduction with the GP however the GP was not meeting this need [3]. This responsibility was reported as potentially within the scope of the primary care nurse role [3].
Developing good working relationships with the medical practitioner, familiarity with the primary care setting, perception of autonomy, dementia specific education and the embedding dementia care provision in primary health care were seen as essential to the success of the primary care nurse in dementia care provision. A consistent finding across the studies was that primary care nurses reported a lack of confidence in dementia care provision and the rating of their knowledge and skills as inadequate. This is despite the perception that nurses include themselves as an appropriate professional to discuss dementia with a patient. The need for education and training was stressed in all studies as necessary for successful dementia care provision. The use of guidelines was perceived as valuable by nurses to improve knowledge and standardise practice. Nurses in the care management models used detailed standardised protocols for dementia care provision.
The heterogeneity of studies' purpose, design and outcomes measures make it difficult to synthesise the findings and draw conclusions.

Implications for practice and research
There is justification for the involvement of the PN in the recognition and care of people

Consent for publication
Not applicable

Availability of data and materials
Not applicable

Competing interests
The authors declared no conflicts of interest.

Funding
This research received no funding.

Author contributions
CG, DG and DP developed the review question, designed the review and developed the search strategy. CG and DG conducted the selection, undertook the data extraction and conducted the quality assessment. DP helped resolve any discrepancies in the quality assessment. CG and DG wrote the manuscript and DP provided critical commentary on initial versions of the manuscript. All authors have read and approved the final submitted manuscript.        The worksho open to all community h professionals paid a small enrolment fe local Alzheim Society or equivalent. Figure 1 study selection