A rapid review exploring nurse‐led memory clinics

Abstract Aims To systematically explore the structures, functions, outcomes, roles and nursing credentials of memory clinics where nurses autonomously lead diagnosis and postdiagnostic care. Design A systematic rapid review was conducted. Data sources MEDLINE (Ovid), CINAHL Full‐Text (EBSCO) and EMBASE were systematically searched in December 2019 with no timeframe limitations imposed. Review Methods The modified PRISMA checklist was used as a guide to facilitate the review. Articles identified were screened and assessed for inclusion criteria, and screening of reference lists of included studies was also completed. Results Six articles, published between 2011–2019, including two case studies, two descriptive reports, one qualitative study and one programme evaluation were included in the review. Nurse‐led memory clinics were situated in community centres, on university campuses, hospitals and in general practitioners' offices. The services offered included assessment, diagnosis and treatment/postdiagnostic care. Nurse credentials included advanced practice nurses and a community psychiatric nurse who was a non‐medical prescriber. Overall, there was low quantity and quality of evidence to evaluate outcomes.

care is in great demand, now more than ever. Traditionally, physician-run memory clinics have been used to try and meet this need by providing early assessment, diagnosis and treatment and by facilitating dementia follow-up care (e.g. providing resources and information; teaching; coordinating care) (Jolley & Moniz-Cook, 2009); however, with the growing demands, alternatives or variations to this approach are necessary. Nurse-led memory clinics may be a complementary model to help address this growing need of care for those living with or at risk for dementia and their caregivers.

| Background
Memory clinics, led by specialist physicians and run out of academic hospitals as an outpatient-based service, were introduced in the 1980s (Jolley et al., 2006;Van der Cammen er al., 1987). The initial aim of these clinics was for research purposes; however, the memory clinic model has developed over the years including variations in settings, team members, referral processes, patient characteristics and services.
These changes have better addressed the needs of individuals living with dementia and their caregivers including timely assessment, diagnosis and follow-up care (Hansen et al., 2017;Jolley et al., 2006;Minstrell et al., 2015). While there may be differences among clinics, most memory clinics have some form of multidisciplinary team structure led by a specialist physician to provide specialized assessment and early intervention, including neuropsychological testing, neuroimaging and psychosocial evaluations (Jolley & Moniz-Cook, 2009;Lindesay et al., 2002;Ramakers & Verhey, 2011;Woodward & Woodward, 2009).
The increasing prevalence of dementia cases requiring diagnostic services, in combination with financial constraints, rising expectations among patients and a limited workforce (including a short supply of physicians), places a huge burden on our current healthcare systems (Hansen et al., 2017;Jolley et al., 2006;Laurant et al., 2005;Minstrell et al., 2015). Reves et al. (2018) suggest innovative models for dementia diagnosis and care need to be explored to improve outcomes, while being cost-effective and efficient. Nurse-led memory clinics (NLMC), sometimes referred to as nurse practitioner-led clinics, have been suggested as an alternative to the traditional memory clinic model to improve the need for access to dementia diagnosis and care (Hansen et al., 2017;Minstrell et al., 2015). It should be noted that in this instance, a "nurse-led memory clinic" does not necessarily mean a nurse working in isolation, but rather being a lead for diagnostic and postdiagnostic care for clients with dementia, in a similar fashion as the more traditional "physician-run" clinics previously mentioned. Various forms of nurse-led clinics (i.e. being led by Registered Nurses, specialist nurses and/or nurse practitioners, with varying degrees of autonomy and responsibility) have been shown to provide quality care (Carey & Courtenay, 2007;Hansen et al., 2017;Lewis et al., 2009;Minstrell et al., 2015;Morgan et al., 2013); have a positive impact on patient outcomes (Carey & Courtenay, 2007;Hansen et al., 2017;McLoughney et al., 2007;Minstrell et al., 2015;Morgan et al., 2013); and use less financial and human resources (Carey & Courtenay, 2007;Lewis et al., 2009 While nurse-led memory clinics are a novel approach that appears to have merit, little is known about nurses in this type of role in this setting (Stirling et al., 2012(Stirling et al., , 2016. To date, no systematic review has been conducted to consolidate the current approaches and practices of nurse-led memory clinics where the nurse autonomously leads both the diagnosis and postdiagnostic care for individuals with dementia. One systematic literature review did explore nurse prescribing in memory services (Emrich-Mills et al., 2019); however, most of the articles reviewed were for supplementary prescribing after a diagnosis was made by a physician. While nurse prescribing has the potential to improve efficiencies (e.g. timey access to reliable diagnosis and treatment; cost-effective care; Emrich-Mills et al., 2019;McInally, 2015), our understanding of nurses comprehensively leading the care of individuals with dementia in a memory clinic, from diagnosis through to postdiagnostic care, is limited.

| Aims
The aim of this rapid review was to systematically explore the structures, functions and outcomes of nurse-led memory clinics, and the nursing roles and credentials of nurses leading memory clinics to inform nursing practice; enlighten discussions about interventions and innovations to improve the diagnosis and treatment of dementia; and identify areas for future research. This was accomplished through the systematic exploration of the questions: (a) what are the structures, functions and outcomes of nurse-led memory clinics ?; and (b) what are the roles and credentials of nurses leading memory clinics? For the purposes of this review, "nurse-led memory clinic" was defined as a memory clinic/service or specialized geriatric clinic/service, with a nurse working autonomously leading both the diagnosis and postdiagnostic care for clients with dementia.

| Design
A rapid review approach was chosen given the limited time and resources available to the authors to produce consolidated evidence to inform local practice, policy and research discussions on NLMC, while maintaining quality and credibility (Haby et al., 2016;O'Leary et al., 2017). The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist (Moher et al., 2009) was modified (including the risk of bias checklist item) and used as a guide to facilitate a rapid review of the published research on this topic.
Review modifications, which were aligned with rapid review methodology, included the following: (a) a targeted research question; (b) fewer searched databases; (c) reduced time frame; (d) exclusion of grey literature; and (e) use of one reviewer (Haby et al., 2016).
According to Stevens et al. (2018), while PRISMA is a reporting guideline intended for systematic reviews and meta-analysis, many published rapid reviews have used this as a guide due to the lack of rapid review specific guidelines. These authors are currently addressing this gap through developing a protocol to develop PRISMA-RR for rapid reviews. Rapid reviews have been demonstrated as a practical approach to informing healthcare decisions, nursing policy and nursing practice (O'Leary et al., 2017).

| Search methods
An initial limited search of MEDLINE (Ovid), CINAHL Full-Text (EBSCO) and EMBASE (Elsevier) was undertaken to identify search terms and articles on this topic. In collaboration with a librarian (AG), a full search strategy was developed by using text words and index terms gathered from relevant articles. Each identified search term was tested in each database (i.e. MEDLINE, CINAHL, EMBASE), and only those producing unique results were included in the final strategy. The search strategy was peer reviewed by a second librarian (RW) using the Peer Review of Electronic Search Strategies (PRESS) guidelines (CADTH, 2016). Since rapid reviews use fewer search databases (Haby et al., 2016), these three databases were identified in partnership with two health-science librarians (AG and RW) to ensure they would produce the best search result on the topic of interest. Full search strategies for all databases, conducted in December 2019, are available in Table 1. The reference list of all studies selected for critical appraisal was also searched for additional studies.
Articles focused on nurse-led memory clinics in dementia care were considered for inclusion if they met the following criteria: (a) published in a peer-reviewed journal; (b) either a primary study (including qualitative, quantitative and mixed methods), a review, or a descriptive report (professional/clinical articles or cases); (c) written in the English language; and (d) met the definition of "nurse-led memory clinic" previously described. There were no geographical or publication timeframe limitations imposed.

| Search outcome
All retrieved articles were inputted into Covidence online software, and duplicates were removed ( Figure 1). Titles, key words and abstracts were screened by a single reviewer (KL) for their relevance to the research question and inclusion criteria. It should be noted that for articles to be included, they needed to clearly convey the nurse was autonomously diagnosing dementia. Many studies reviewed discussed nurse prescribing, but they did not give enough details to determine whether nurses were also making an autonomous diagnosis or whether the diagnosis was predetermined before the prescribing happened. In these cases, the articles were not included based on missing information. Studies that were questionable for inclusion were reviewed by a second reviewer (SD).
Of the 206 retrieved articles, 75 were identified for full review. These articles were read and evaluated against the inclusion criteria. Five articles were included in the final review, and data were then extracted (Clibbens et al., 2019;Hain et al., 2011;McInally, 2015;Minstrell et al., 2015;Stirling et al., 2016). One additional article was added from screening the reference lists of included studies (Hansen et al., 2017). The final number of included papers was six ( Figure 1).

| Quality appraisal
Due to the methodological heterogeneity of the included articles (e.g. no randomized control trials, no systematic reviews, no inferential statistics) and the descriptive nature of this review, a formal quality appraisal or risk of bias assessment could not be conducted. However, quality and risk of bias was considered and commented on for each article (Garritty et al., 2020). Table 2 summarizes the articles included in this review, including the following: type of article, purpose and quality/limitations. As suggested by Grant and Booth (2009), to accommodate for this, additional time was devoted to developing the research questions, synthesizing and exploring the data and reflecting on overall limitations to help counterbalance the lack of a formal quality appraisal in a rapid review. The decision to not reject articles based solely on hierarchical standards of quality is supported by Pawson (2007), where he advocates there are often "nuggets of wisdom in methodologically weak studies" and an appraisal tool should be secondary to the explanatory pursuit of the question one is trying to answer (p. 127). In light of the descriptive nature of the questions in this review, and the limited peer-reviewed literature on this topic, the authors included all articles that met the inclusion criteria, while acknowledging their limitations and weakness.

| Data abstraction
One reviewer carried out the data extraction (KL) using a data collection form to support the search strategy. In keeping with the guidance of PRISMA (Moher et al., 2009), a data collection form was created to identify variables needed to answer the review questions. 4 TI "nurse-led" OR AB "nurse-led" 3,919 5 TI "nurse practitioner*" OR AB "nurse practitioner*" 12,886 6 TI "advanced practice* nurs*" OR AB "advanced practice* nurs*" 3,807 7 TI "nurs* prescri*" OR AB "nurs* prescri*" 1,592

| Synthesis
Due to the descriptive nature of the review questions, methodological heterogeneity among each included study and the low quality of quantitative evidence to statistically evaluate outcomes, the extracted data were synthesized narratively in

| Study selection and characteristics
A PRISMA flow diagram illustrating the screening and selection of studies for inclusion of this rapid review is presented in Figure 1.
The review comprised six articles in total, originating from the F I G U R E 1 Flowchart of search outcomes (Moher et al., 2009)

| Structure
The settings described in each article for NLMC included the fol- had an open referral system where individuals with memory concerns could refer themselves, or be referred by another community agency (Hain et al., 2011;Minstrell et al., 2015). The NLMCs included multidisciplinary teams, which could include psychologists, social workers, occupational therapists and/or physiotherapists (Clibbens et al., 2019;Hain et al., 2011;Hansen et al., 2017); teams consisting of just the nurse and consulting physician

Formative Program Evaluation
To describe the development and evaluation of a nurse practitioner-led interprofessional geriatric outpatient clinic called "Inter-D Clinic" Lack of standardized outcome measures were reported as a limitation due to the retrospective and observational nature of the evaluation. Low response rate on surveys: patient/caregiver (N = 10), PCPs (12); may not be representative of 293 patients seen. Key areas identified for transferability to other locations would be expertise of team members (i.e. comprehensive knowledge of systems and supports) and access to key medical resources, including laboratory and imaging services, pharmacist, physician for restricted medications McInally (2015) Case Study To review and evaluate the effectiveness of a nurse-led mental health clinic for older adults with a focus on the nurse as a prescriber of 'memory drugs' Qualitative feedback was collected from GPs only. No formal evaluation was conducted with patients or carers. Feedback was collected at random and some outcomes reported were anecdotal (e.g. more cost effective, yet nowhere was this analysis shown). Accuracy of diagnosis was compared with prevalence reported by the Alzheimer's society, not with control.

Minstrell et al. (2015)
Case Study To identify the demographics, assessment scores and diagnostic profiles of those attending an open referral nurse-led memory clinic (NLMC) and to assess how it differs from other memory clinic profiles Descriptive statistics for demographics, assessments and diagnoses were compared to other quantitative studies; however due to variability between studies, no quantitative analysis was done. This also made it difficult to determine the contribution of each process towards the outcomes identified. Sample size was also relatively low. Results are descriptive patterns and thus did not report statistical significance

| Functions, roles and credentials
The services offered by all NLMC included assessment, diagnosis and treatment/postdiagnostic care, which could include prescribing, Another clinic in Scotland, situated in a small community, employed a community practice nurse with over 20 years of experience with a non-medical prescribing licence (McInally, 2015).
A result summary table (see Table 3) features additional details for each NLMC in terms of functions (i.e. clinic details, details of assessment) and roles (i.e. the role of the lead nurse, practice guidelines/policies).

| D ISCUSS I ON
The goal of this review was to explore the existing peer-reviewed Access to the clinics varied between requiring a referral by their primary care provider and allowing individuals with concerns to refer themselves or be referred by another community agency. Minstrell et al. (2015) suggest open referral policies that allow individuals to self-refer to a memory clinic when they have concerns about their own cognitive function can remove obstacles that might delay access to early diagnosis of dementia. From the operational details provided, it appeared most clinics operated one day per week and initial assessments ranged from one-three visits and could last between 45 min-2.5 hr. All six clinics had the nurse leading the diagnosis and care planning for individuals with dementia; however, all nurses had some form of medical support, either in a consultatory or collaborative structure, with a doctor (i.e. GP, geriatrician or old age psychiatrist). The structure of the NLMC reviewed is quite like more traditional memory clinics described in the literature (Braekhus et al., 2011;Jolley et al., 2006;Jolley & Moniz-Cook, 2009;Van der Cammen et al., 1987). Jolley et al. (2006) identified the essential attributes of a memory clinic, which includes dedicated time and space, a core team, links to other agencies including the Alzheimer's society and expertise of other disciplines. The latter attribute, expertise of other disciplines, varied the most among the clinics, where some worked in a multidisciplinary team (Clibbens et al., 2019;Hain et al., 2011;Hansen et al., 2017) and others had only a team consisting of the nurse and specialist (Minstrell et al., 2015;Stirling et al., 2016). In these situations, it is unknown if this was in fact the case, or if other team members were just not mentioned in the article.
The main functions of the NLMC appeared similar across all clinics, irrespective of location, including assessment, diagnosis and treatment/postdiagnostic care. These services did not appear to differ from the essential activities identified by Jolley et al. (2006), or from those in traditional memory clinics that are led by specialized medical staff (Braekhus et al., 2011;Jolley et al., 2006;Jolley & Moniz-Cook, 2009;Van der Cammen et al., 1987), including assessment/investigation, diagnosis (including differential diagnosis), communication of findings with patients/caregivers, connecting with other community agencies, providing treatment, monitoring progress, patient/caregiver education and health promotion. Even when compared with another primary care-based memory clinic models (Dodd et al., 2016;Lee et al., 2014;Wells & Smith, 2017), the central functions of assessment, diagnosis, treatment and postdiagnostic care were similar to what was described in the NLMC reviewed. One essential area mentioned by Jolley et al. (2006) that was not directly commented on in the articles included in this review was research and auditing; however, one might assume research and auditing, to some degree, were being implemented since all six of these clinics published articles on their NLMC.
The roles of the nurses leading the care in each of the memory clinics were comparable. Nurses were involved with leading the assessments (e.g. medical examination, cognitive assessment), ordering investigations (e.g. bloodwork, CT/MRI as required), diagnosing, prescribing medications and developing a plan of care (including resources and referrals). It should be noted, however, that in Australia only medical specialists can prescribe for cholinesterase inhibitors and order MRI testing (Minstrell et al., 2015). In these situations, the nurse practitioner would have to consult with an old age psychiatrist to get these test/prescriptions ordered; yet, they had full autonomy to assess, diagnose and prescribe other medications for the individuals they cared for.
The credentials of nurses with a lead role in NLMC were similar in most cases. The majority were APNs (Clibbens et al., 2019;Hain et al., 2011;Hansen et al., 2017;Minstrell et al., 2015;Stirling et al., 2016), and one was a community psychiatric nurse and non-medical prescriber (McInally, 2015). Nurses licensed as independent prescribers in the United Kingdom are able to assess, diagnose and independently prescribe medications and some controlled substances (Courtenay et al., 2011). In contrast, nurses that are supplementary prescribers can only prescribe medications as set out in a clinical management plan after an assessment and diagnosis is made by a physician. While the specific details for the full scope of practice and licensure of the nurses in each clinic were not always provided, the numerous nursing titles used for the nurses working in similar NLMC highlight the confusion that can be created for the various roles and skills of APNs (Bishop, 2014 (Flynn, 2005), kidney disease (Coleman et al., 2017), community medicine (Kant et al., 2018) and arthritis care (Garner et al., 2017). This review highlights the need for research with thorough methodologies, focused on outcomes, to inform evidence-based decisions.
This review provides insight into how current NLMC are structured and how they function, including the roles and credentials of the nurses leading the memory clinic processes to inform nursing practice. Additional implications for practice based on the outcomes reported suggest APNs can be a potential solution for improving dementia care. It is expected that as the role of APNs in memory clinics continue to expand and more high-quality research is conducted and published, the value of APNs in dementia care will be substantiated. Additional topics that would also enhance our understanding in this area would include exploration of the barriers to implementing such a nurse-led memory clinic model, and what health disciplines are most critical to offering optimal care.
A systematic process was followed to conduct this rapid review; however, there were still several limitations. This rapid review only used three databases to search for peer-reviewed articles; therefore, some articles may have been missed for inclusion in this review. Due to time and resource limitations, articles were reviewed by only one reviewer, except for studies deemed questionable for inclusion by that reviewer. Having a second reviewer independently review all the articles may have resulted in additional articles for inclusion. The heterogeneity of articles reviewed and the lack of systematic review evidence or randomized control trials was a limitation for doing a formal quality appraisal as part of the review process. This heterogeneity and the various levels of details described in each article also made it challenging to paint a holistic picture of the structures and functions of each clinic for comparison.

| CON CLUS IONS
The prevalence of dementia is on the rise. Maintaining the status quo in how we currently diagnose and treat dementia could be troublesome, not only for those with dementia and their caregivers, but for the healthcare system and our communities as a whole.
Innovative approaches are needed today and for the future, to address this issue and to ensure individuals with dementia can access timely diagnostic and postdiagnostic care. Nurses with advanced training (i.e. NPs, non-medical prescribers) have the skill set to offer a viable solution to improve access to diagnosis and needed care for those with, or at risk, for dementia. The paucity of published peerreviewed literature on NLMC makes it difficult to come to any firm conclusions; however, the existing evidence and the trends identified in the literature suggest NLMC could be an innovative solution to enhancing dementia care and warrants further exploration.

ACK N OWLED G EM ENTS
We would like to thank Alex Goudreau (AG), Librarian at the University of New Brunswick, for her support in developing the search strategy, Richelle Witherspoon (RW), Librarian at the University of New Brunswick, for peer reviewing the search strategy for this rapid review, and Dr. Alison Luke (AL), Research Associate at the University of New Brunswick, for her editorial contributions.

CO N FLI C T O F I NTE R E S T
No conflict of interest has been declared by the author(s).

E TH I C A L A PPROVA L
Research ethics committee approval was not required for this review.

PATI E NT CO N S E NT S TATE M E NT
This review did not need to seek patient consent.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this review are noted in the body of the article and identified in the reference list.