title: Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) for the diagnosis of dementia within a secondary care setting.
abstract: BACKGROUND
  The diagnosis of dementia relies on the presence of new-onset cognitive impairment affecting an individual's functioning and activities of daily living. The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) is a questionnaire instrument, completed by a suitable 'informant' who knows the patient well, designed to assess change in functional performance secondary to cognitive change; it is used as a tool to identifying those who may have dementia.In secondary care there are two specific instances where patients may be assessed for the presence of dementia. These are in the general acute hospital setting, where opportunistic screening may be undertaken, or in specialist memory services where individuals have been referred due to perceived cognitive problems. To ensure an instrument is suitable for diagnostic use in these settings, its test accuracy must be established.
  
  
  OBJECTIVE
  To determine the diagnostic accuracy of the informant-based questionnaire IQCODE, for detection of all-cause (undifferentiated) dementia in adults presenting to secondary-care services.
  
  
  METHODS
  We searched the following sources on the 28th of January 2013: ALOIS (Cochrane Dementia and Cognitive Improvement Group), MEDLINE (Ovid SP), EMBASE (Ovid SP), PsycINFO (Ovid SP), BIOSIS Previews (Thomson Reuters Web of Science), Web of Science Core Collection (includes Conference Proceedings Citation Index) (Thomson Reuters Web of Science), CINAHL (EBSCOhost) and LILACS (BIREME). We also searched sources specific to diagnostic test accuracy: MEDION (Universities of Maastricht and Leuven); DARE (Database of Abstracts of Reviews of Effects - via the Cochrane Library); HTA Database (Health Technology Assessment Database via the Cochrane Library) and ARIF (Birmingham University). We also checked reference lists of relevant studies and reviews, used searches of known relevant studies in PubMed to track related articles, and contacted research groups conducting work on IQCODE for dementia diagnosis to try to find additional studies. We developed a sensitive search strategy; search terms were designed to cover key concepts using several different approaches run in parallel and included terms relating to cognitive tests, cognitive screening and dementia. We used standardised database subject headings such as MeSH terms (in MEDLINE) and other standardised headings (controlled vocabulary) in other databases, as appropriate.
  
  
  METHODS
  We selected those studies performed in secondary-care settings, which included (not necessarily exclusively) IQCODE to assess for the presence of dementia and where dementia diagnosis was confirmed with clinical assessment. For the 'secondary care' setting we included all studies which assessed patients in hospital (e.g. acute unscheduled admissions, referrals to specialist geriatric assessment services etc.) and those referred for specialist 'memory' assessment, typically in psychogeriatric services.
  
  
  METHODS
  We screened all titles generated by electronic database searches, and reviewed abstracts of all potentially relevant studies. Two independent assessors checked full papers for eligibility and extracted data. We determined quality assessment (risk of bias and applicability) using the QUADAS-2 tool, and reporting quality using the STARD tool.
  
  
  RESULTS
  From 72 papers describing IQCODE test accuracy, we included 13 papers, representing data from 2745 individuals (n = 1413 (51%) with dementia). Pooled analysis of all studies using data presented closest to a cut-off of 3.3 indicated that sensitivity was 0.91 (95% CI 0.86 to 0.94); specificity 0.66 (95% CI 0.56 to 0.75); the positive likelihood ratio was 2.7 (95% CI 2.0 to 3.6) and the negative likelihood ratio was 0.14 (95% CI 0.09 to 0.22).There was a statistically significant difference in test accuracy between the general hospital setting and the specialist memory setting (P = 0.019), suggesting that IQCODE performs better in a 'general' setting.We found no significant differences in the test accuracy of the short (16-item) versus the 26-item IQCODE, or in the language of administration.There was significant heterogeneity in the included studies, including a highly varied prevalence of dementia (10.5% to 87.4%). Across the included papers there was substantial potential for bias, particularly around sampling of included participants and selection criteria, which may limit generalisability. There was also evidence of suboptimal reporting, particularly around disease severity and handling indeterminate results, which are important if considering use in clinical practice.
  
  
  CONCLUSIONS
  The IQCODE can be used to identify older adults in the general hospital setting who are at risk of dementia and require specialist assessment; it is useful specifically for ruling out those without evidence of cognitive decline. The language of administration did not affect test accuracy, which supports the cross-cultural use of the tool. These findings are qualified by the significant heterogeneity, the potential for bias and suboptimal reporting found in the included studies.
authors.affiliation: Department of Cardiovascular Sciences, University of Leicester, Leicester Royal Infirmary, Leicester, UK, LE1 5WW.
authors.forename: Jennifer K
authors.initials: JK
authors.lastname: Harrison
authors.forename: Patricia
authors.initials: P
authors.lastname: Fearon
authors.forename: Anna H
authors.initials: AH
authors.lastname: Noel-Storr
authors.forename: Rupert
authors.initials: R
authors.lastname: McShane
authors.forename: David J
authors.initials: DJ
authors.lastname: Stott
authors.forename: Terry J
authors.initials: TJ
authors.lastname: Quinn
mesh_terms: D000203:Activities of Daily Living; D000328:Adult; D000368:Aged; D003072:Cognition Disorders / Q000175:diagnosis; D016001:Confidence Intervals; D003704:Dementia / Q000175:diagnosis*; D003937:Diagnosis, Differential; D006761:Hospitals; D006801:Humans; D007802:Language; D008875:Middle Aged; D019727:Proxy; D063127:Secondary Health Care; D012680:Sensitivity and Specificity; D011795:Surveys and Questionnaires