Development of Clinical Pathway for Mild Cognitive Impairment and Dementia to Quantify Cost of Age-Related Cognitive Disorders in Malaysia
Last reviewed: March 2026
Key Findings
- A clinical pathway for MCI and dementia was successfully developed using expert group discussion (EGD) methods with Malaysian health practitioners.
- The pathway covers a 60-year-old reference patient from initial memory clinic referral through diagnosis over three outpatient visits spanning one year.
- Approximately 80% of dementia patients were expected to require antidepressant medications alongside primary treatment, and around 20% would need inpatient care in end-of-life stages.
- The clinical pathway identified all key clinical activities and resource requirements needed for comprehensive cost estimation of MCI and dementia management in Malaysia.
Background and Context
Malaysia is undergoing a rapid demographic transition. The nation is projected to become an aged society by 2030, with an increasingly large proportion of older adults living with age-related cognitive disorders, including mild cognitive impairment (MCI) and dementia. Globally, more than 55 million people were estimated to live with dementia, a figure expected to rise to 139 million by 2050. In the Malaysian context, available evidence suggests that the prevalence of dementia among the older population is influenced by multiple factors, including age, ethnicity, educational attainment, and the presence of vascular risk factors such as hypertension and diabetes.
Despite these growing concerns, health economic data on the cost of managing cognitive disorders in Malaysia have remained scarce. Without reliable cost estimates, policymakers lack the evidence needed to allocate resources effectively, plan specialised services, or evaluate the cost-effectiveness of prevention strategies. The study by Aljunid and colleagues, published in the Malaysian Journal of Public Health Medicine (MJPHM) in 2014, was designed to address this critical gap by developing a standardised clinical pathway that captures the full spectrum of care activities for MCI and dementia patients within the Malaysian healthcare system.
Study Design and Methodology
This study employed an expert group discussion (EGD) approach to develop clinical pathways for MCI and dementia. The EGD brought together a multidisciplinary panel of practitioners, including geriatricians, neurologists, psychiatrists, pharmacists, occupational therapists, and health economists, all with experience in managing cognitive disorders within Malaysian public hospitals. The study received ethics approval from the Ministry of Health Malaysia.
The reference case for the pathway was a 60-year-old patient referred to a memory clinic with a chief complaint of forgetfulness. Through a structured consensus process, the expert panel mapped out all clinical activities, diagnostic evaluations, pharmacological interventions, non-pharmacological therapies, and nursing care requirements across the entire disease trajectory. The pathway distinguished between outpatient management, inpatient care, and community-based support, recognising that the needs of patients change considerably as the condition progresses from MCI through mild, moderate, and severe dementia stages.
Clinical Pathway Structure
The resulting clinical pathway covered a systematic sequence of care episodes. Following initial referral, the patient undergoes three outpatient visits at the memory clinic, during which a clinical diagnosis of either MCI or dementia is established. The pathway detailed the diagnostic workup, which typically includes neuropsychological assessments, blood investigations, and neuroimaging studies. It also specified the medications commonly used, including cholinesterase inhibitors for confirmed Alzheimer’s disease and antidepressant medications, which the expert panel estimated would be needed by approximately 80% of patients at some stage of their illness.
| Phase | Setting | Key Activities | Typical Duration |
|---|---|---|---|
| Referral & Screening | Primary care / Memory clinic | Initial cognitive assessment, history taking, basic blood workup | Visit 1 (Day 1) |
| Diagnostic Workup | Memory clinic | Neuropsychological testing, neuroimaging, differential diagnosis | Visits 2–3 (Weeks 4–12) |
| Outpatient Management | Memory clinic | Pharmacotherapy, occupational therapy, caregiver counselling | Ongoing (1 year+) |
| Inpatient Care | Hospital | Acute behavioural management, end-of-life care (~20% of patients) | Variable |
| Community Support | Home / Community | Home nursing, social support, carer respite | Ongoing |
An important feature of the pathway was its consideration of lifetime resource requirements. The expert panel identified additional resources needed to manage patients across the full spectrum of their remaining life expectancy, including home nursing services, occupational therapy, and carer support. This lifetime perspective is essential for health economic evaluations, as the costs of dementia care escalate considerably as patients progress to more severe stages and lose the ability to live independently.
Types of Cognitive Impairment Addressed
The clinical pathway distinguished between several subtypes of cognitive impairment. Mild cognitive impairment was categorised as either amnestic (characterised primarily by memory deficits) or non-amnestic. Dementia was further classified into neurodegenerative types (including Alzheimer’s disease, frontotemporal dementia, dementia with Lewy bodies, and Parkinson’s disease dementia), vascular dementia, and medical dementia attributable to other systemic conditions. This classification scheme is consistent with international diagnostic frameworks and was considered essential for accurate cost estimation, as different dementia subtypes require different treatment approaches and have different resource utilisation patterns.
Cost Estimation Framework
One of the primary objectives of developing this clinical pathway was to provide a foundation for a subsequent costing study. The pathway was designed to capture all clinically important activities and interventions that would be included in a step-down costing methodology. Related work by the same research group, subsequently published as a provider cost study, examined data from 128 patients randomly selected from seven public hospitals across seven states in Malaysia. That follow-up study found that 49.2% of patients were male, with an average age of 71 years (standard deviation 7.01 years), and approximately 51.6% were of Chinese ethnicity, 22.7% Malay, 13.3% Indian, and 12.5% other ethnic groups. Household expenditure data from caregiver studies estimated that the average monthly cost of informal caregiving for dementia patients was approximately RM 3,500.
Relevance to Malaysian Healthcare Policy
The significance of this study extends beyond its immediate contribution to cost estimation. Malaysia’s healthcare system faces mounting pressure from population ageing, and cognitive disorders represent one of the most resource-intensive conditions in geriatric medicine. The clinical pathway developed in this study provides a standardised framework that can inform service planning, guide the allocation of specialist staff, and support the development of integrated care models that bridge hospital-based and community-based services.
Furthermore, the study aligns with international trends in dementia care that emphasise early identification, structured diagnostic pathways, and comprehensive care coordination. The Malaysian Clinical Practice Guidelines on Management of Dementia, while not recommending routine screening in the general elderly population, do support targeted evaluation of individuals with subjective memory complaints. The clinical pathway from this study provides operational detail on how such targeted assessments can be structured within existing healthcare infrastructure.
Dementia Burden in Malaysia
The broader context of dementia in Malaysia reinforces the importance of this research. Multiple risk factors have been identified among the Malaysian population, including advancing age, lower educational attainment, Indian ethnicity, hypertension, and social isolation. Education has been highlighted as the principal modifiable risk factor among the psychosocial determinants linked to dementia in Malaysia, underscoring the importance of cognitive stimulation and training programmes for older adults who may not have had access to higher education earlier in life. Approximately 12% of individuals with MCI progress to dementia each year, typically Alzheimer’s disease, making early identification and intervention critical.
Implications for Practice
The clinical pathway offers several practical implications for healthcare providers in Malaysia. It provides a structured template that memory clinics can adopt or adapt for their own practice settings. It also highlights the importance of multidisciplinary care, recognising that effective management of MCI and dementia requires input from geriatricians, psychiatrists, pharmacists, occupational therapists, nurses, and social workers. The emphasis on caregiver support is particularly relevant in the Malaysian context, where informal caregivers—typically family members—bear a significant proportion of the care burden.
For health economists and policymakers, the pathway provides the necessary clinical detail to conduct robust cost-of-illness studies, cost-effectiveness analyses, and budget impact assessments. Such evidence is critical for informing decisions about the allocation of resources to cognitive disorder services and for evaluating the potential return on investment of early intervention programmes.
Limitations
Several limitations should be acknowledged. The clinical pathway was developed through expert consensus, which inherently reflects the views and practice patterns of the participating clinicians. While the use of a multidisciplinary panel strengthens the validity of the pathway, it is possible that the resource utilisation patterns described may not be fully generalisable to all healthcare settings in Malaysia, particularly smaller or more remote facilities with limited specialist services. Additionally, the pathway was designed for the Malaysian public health system; private sector practice patterns may differ considerably. The reference case of a 60-year-old patient may not capture the full diversity of presentations, particularly among patients with early-onset dementia or those with complex comorbidities.
Conclusion
The development of this clinical pathway for MCI and dementia represents an important step toward building an evidence base for health economic evaluation of age-related cognitive disorders in Malaysia. By systematically mapping the care activities and resource requirements across the disease trajectory, the study provides a foundation for cost estimation that is grounded in the realities of Malaysian clinical practice. As Malaysia approaches its transition to an aged nation, such evidence will be indispensable for planning sustainable and equitable health services for the growing population of older adults living with cognitive impairment.
Citation
Aljunid SM, Maimaiti N, Ahmed Z, Muhammad Nur A, Mohamed Nor N, Ismail N, Haron SA, Shafie AA, Salleh M, Yusuf S, Mat Saher Z, Drahman I, Saring ARM, Harun NA, Koris R. Development of clinical pathway for mild cognitive impairment and dementia to quantify cost of age-related cognitive disorders in Malaysia. Malaysian Journal of Public Health Medicine. 2014;14(3):88–96.
Licensed under Creative Commons Attribution-NonCommercial 4.0 (CC BY-NC 4.0)