How is migration background considered in the treatment and care of people? A comparison of national dementia care guidelines in Europe

Background People with a migration background are vulnerable to dementia. Due to problems such as underdiagnosis or access barriers, the care of this population is a public health challenge in Europe. Many countries are issuing care guidelines, but a systematic overview of their references to migration groups is lacking. This study aims to analyze national dementia care guidelines regarding their focus on people with a migration background, what specific actions to ensure healthcare have been undertaken at the national level, and whether recommendations for action are made for this population. Methods This study is a systematic analysis of national dementia care guidelines of the EU and EFTA (European Free Trade Association) countries. Using the discourse analysis model by Keller (2011), 43 documents from 24 EU and 3 EFTA countries were systematically screened for migration references via keyword and context analysis. The content of the migration-related section was paraphrased, memos and comments were added, and the individual text passages were coded using the strategy of open coding. Results Twenty-seven of the 35 EU and EFTA countries have guidelines or similar documents on care for people with dementia, and 12 refer to migration. Norway, Sweden, and Northern Ireland refer to this topic in detail. The focus of the migration-related guidelines is on the early detection and diagnosis of dementia. The main message is that standardized diagnostic tools such as the MMSE (Mini-Mental State Examination) or the clock test are not suitable for linguistic minorities. Nine countries make recommendations for the care of people with a migration background and dementia, but only Norway, Sweden, and Denmark point to available healthcare services. A key recommendation is that the linguistic and cultural background of people should be considered when selecting diagnostic tests. Several countries refer to the validity of the RUDAS (Rowland Universal Dementia Assessment Scale) for migrants. Conclusions The topic of migration plays a subordinate role in the dementia care guidelines of European countries. Almost all countries lack appropriate diagnostic tools and healthcare services for people with a migration background. Consequently, this group is vulnerable to underdiagnosis and a lower level of care.


Background
Caring for people with dementia, especially those who also have a migration background, is a major challenge for public health in Europe. Due to demographic changes, the number of people with dementia in Europe is expected to increase [1] from 9.95 million in 2010 to 13.95 million in 2030 [2]. The prevalence of dementia in people with a migration background (PwM) will increase particularly strongly because the number of older PwM is rising significantly [3] and the risk of dementia increases at a higher age [4]. In the EU, the number of PwM who are over 64 years of age rose from 4.73 million in 2000 to 7.37 million in 2017 [5]. The members of this group are distributed very unevenly across the individual EU countries. More than half of them live in France, Germany, and the UK. Spain, Poland, Italy, Austria, the Netherlands, and Sweden have also large populations of older PwM (2017) [5].
The older migrant population of most European countries and Europe as a whole is characterized by a high degree of linguistic and cultural diversity. There are considerable differences among the EU countries regarding the internal structure of the migrant population. Many European countries, such as France [6], Germany [7], the UK [8], and Spain [9], have a heterogeneous migrant population with large diversity in terms of countries of origin of the largest migrant groups. A few countries, such as Sweden and Poland, have a slightly more homogeneous migrant population. Many countries of origin have geographical proximity, a related national language, and many cultural similarities with the host country [10,11].
Limited data are available to validly estimate the number of PwM with dementia in Europe. For example, a recent analysis for Germany estimates their number to be 96,500 [12], indicating the need to further examine this group.
Another major problem is the lack of a common definition of migration background at the European level. While the United Nations defines PwM as people who are living in countries other than their country of birth, in Germany, the concept of migration background is based on one's own and their parents' citizenship (PwM are not born with German citizenship or have at least one parent who was not born with German citizenship) [13].
There is some evidence indicating that PwM are a vulnerable group in terms of dementia diagnosis and healthcare. Various barriers to seeking help, such as different views and perceptions regarding dementia and care among people with different cultural backgrounds, lack of familiarity of PwM with the respective health care system, stigmatization, and discrimination, are apparent. With respect to stigmatization, the World Alzheimer Report 2019 has described significant countryspecific differences. For example, according to the ADI (Alzheimer Disease International) global survey on attitudes toward dementia, 69% of Romanians consider people with dementia to be dangerous, while this figure is 29% in Greece, 20% in Poland, 15% in Germany, and 2 % in Portugal. Almost 67% of the participants from Russia and approximately 58% of Polish people said they wanted to keep dementia a secret. This was the intention of approximately 20% of respondents in Germany and only approximately 3 % of participants in Iran and Kenya [14]. These and other identified country-specific differences in perceptions of dementia are likely to have an impact on the care requirements and utilization of care services by people who emigrated from these countries. Lack of information about the healthcare system and lack of knowledge about existing healthcare services are also often an obstacle to formal care. The organization of healthcare systems and the healthcare concepts of the countries of origin and the host countries often differ considerably [15,16]. The lack of familiarity with the healthcare system, different perceptions, and stigmatization, together with other factors (convictions and beliefs about dementia (e.g., in some ethnic groups, the widespread perception that dementia is contagious or due to spiritual forces or punishment from God), cultural and language barriers, and inappropriate services [3,17,18]), result in underdiagnosis of dementia in PwM [19] and lower use of dementia-related healthcare services among this group [20][21][22][23][24]. Studies have shown that due to the migration background, the validity of the dementia diagnosis is often less accurate and reliable among PwM than in the general population [19]. Thus, different cultural backgrounds must be taken into account to avoid the risk that the growing numbers of PwM with dementia are treated insufficiently or do not use adequate health services [3].
PwM with dementia are in most cases, and even more frequently than people with dementia without a migration background, cared for at home by family members. In many migrant communities, the care of older relatives, who previously cared for them, is a cultural, religious, and emotional norm [25]. The norm of the family-oriented model can lead to exhaustion and stress, especially for female caregivers who do not have the support of an extended family and simultaneously have other important tasks and obligations (job, child care), which can have a negative impact on the care situation. This is particularly the case when care is provided in a country with other cultural norms [26]. Several studies have shown that the psychological burden of family caregivers with a migration background is even higher than for people without a migration background [27][28][29]. Although there is a great need [30], family caregivers with migration backgrounds take advantage of fewer support services than the majority population [31,32]. A central cause could be a lack of language and culturally sensitive support services for family caregivers with migration backgrounds or a lack of information about these services [30,33].
There are efforts in different countries to remedy these problems. On the European level, Alzheimer Europe provides information on established initiatives and materials for the care of PwM with dementia [34]. In the UK, a project exists for people with dementia and their caregivers from black, Asian, and ethnic minorities (The Dementia Alliance for Culture and Ethnicity) [35]. There is also the ETNIMU initiative in Finland for people from the Roma population and people with a Russian, Estonian, or Somali background [36]. Switzerland has initiated the project 'Doppelt fremd', which refers to Italian migrants [37]. However, a Europe-wide analysis of existing strategies is lacking.
On the broader level of dementia care in general, several European countries have issued dementia strategies or national dementia plans (NDPs) [38]. While these plans are targeted at the population as a whole, the topic of migration plays a subordinate role in most NDPs [17,39]. Only 10 of the 35 EU and EFTA countries (28%) have issued an NDP that refers to migration, and one single NDP (the Austrian Dementia Report) contains a separate chapter addressing this topic. Eight NDPs have planned actions to improve care for PwM with dementia, but specific healthcare services for this population exist only in Norway, Northern Ireland, and the Netherlands. Almost all European countries seem to have large gaps in care provision to PwM with dementia on the national level [39]. However, in treatment and care, there are other forms of national guidelines, policies, and recommendations issued by professional medical and nursing associations and health care organizations. Their aim is usually to guide, standardize, and/or increase the quality of treatment and care delivery. A large number of such documents exist, but to our knowledge, there is no systematic analysis of their consideration of migrant-related characteristics. A systematic overview could identify common topics and provide information about approaches in different parts of Europe from which other countries could benefit.
This study aims to analyze national treatment and care guidelines, policies, and recommendations on dementia with regard to PwM. The topics of interest are the guidelines' focus, what specific actions to ensure healthcare have been undertaken and to what extent at the national level, and whether recommendations for action are made specifically for this target group.

Methods
This study is a systematic analysis of the public national (political and medical) discourse on the care of PwM with dementia in EU and EFTA countries, represented by written statements in national documents on dementia care.

Data Sources
In this study, healthcare services at the national level are defined as all services involving healthcare, such as information, support, advice, diagnosis, or treatment plans, which are not limited to specific regions, companies or institutions and are referred to in official national documents by country representatives (e.g., representatives of health ministries, other members of government or representatives of national professional societies).
The following organizations were contacted for information about the existence of national guidelines, policies, and recommendations: national Alzheimer societies (n = 28), national health or social ministries (n = 32), and national professional societies for geriatrics, gerontology or neurology (n = 27) of 31 EU and four EFTA countries. The Alzheimer societies were contacted first (on 02 and 03 May 2019), the health ministries second (on 20 and 21 May 2019), and the professional societies third (on 10 and 11 July 2019). These organizations were asked whether care or treatment guidelines for people with dementia exist at the national level and how these documents could be accessed. The response rate was just over 39% (33 of 87 organizations responded). It was particularly high in the national health or social ministries (almost 72% (23 of 32)) but significantly lower in the national Alzheimer societies (approximately 21% (6 of 28)) and the national professional societies for geriatrics, gerontology or neurology (almost 15% (4 of 27)). The ministries and professional societies were identified by a Google search, while the Alzheimer Europe website served as the basis for the contact data of the Alzheimer societies [40]. In the case of nonresponse by the three organizations contacted, a Google search was carried out to find research institutions, university faculties, medical facilities, clinics, or NGOs, and a PubMed search was conducted to find researchers dealing with the topic of dementia in the individual countries, who were then written to. In two cases (Slovakia and Poland), the respective embassies in Germany and the German embassies in the respective capital were also contacted. Finally, we received responses from 47 organizations of 35 countries and were thus able to perform an analysis for each EU and EFTA country. The list of responding organizations is attached in the appendix (Table 3). To integrate documents from as many countries as possible, no definitions or restrictions were made. All documents mentioned by these organizations were included in this study. The organizations either sent the documents themselves or referred to online platforms where they were accessible. Accordingly, the websites of the national Alzheimer societies, the health ministries, and various professional societies (geriatrics, neurology, psychology) and associations (medical association) served as sources of data. In addition, a Google search was conducted. The corpus of documents for this study was 43 documents. These documents were published in the EU and EFTA countries listed in Table 2. The distribution of the 43 documents among these countries is shown in Table 1.

Procedures
The documents were heterogeneous and contained different document types with different definitions of policies, guidelines, and recommendations (Table 1). To structure this corpus, the documents were assigned to the following standardized categories.

Policies
Instructions for action published by legally legitimated institutions that must be followed in a binding manner and that reflect the state of knowledge of medical science at a certain point in time [41][42][43].

Guidelines
Systematically developed and scientifically based, legally nonbinding decision-making assistance on the appropriate procedure for specific health problems [44,45].

Recommendations
Suggestions, advice, hints, or consensual solution strategies for selected questions. Recommendations have lower scientific evidence and a lower normative character than guidelines [42,43].
Subsequently, the content of the documents was described. First, the tables of contents were examined for an existing migration chapter. Then, the continuous text was screened for the following key terms: minorities, minority, migration, culture, ethnic, background, migrant, sensitive, cultural, diverse, diversity, language, origin, nonwestern, characteristic, communities, religious, native and guest. If a migration reference could be identified, the content of the respective section was subjected to a detailed analysis. The fine analysis was based on Keller's model of qualitative discourse analysis (2011). This knowledge-sociological approach aims to reveal the processes and practices of knowledge production at the level of institutional fields. This method can be used to reconstruct whether and to what extent discourses establish or organize relations between phenomena. Thus, this model is a suitable approach to reveal the extent to which the relationship between dementia and migration is considered in official documents at the national level and what knowledge about the care situation of PwM with dementia exists or is communicated [46].
The data were analyzed according to the following scheme: 1. the relevant text passages were read repeatedly; 2. the contents were paraphrased; 3. the individual text passages were assigned memos and comments; 4. the text passages were coded; 5. the statement contents were recorded and reconstructed in an interpretativeanalytical way; 6. the empirical results were interpreted and assessed; 7. the results were presented in tabular and text form. The comments described which criteria were used to formulate the respective codes and assign them to a text passage, and the memos documented what further considerations and hypotheses arose regarding the specific text passage. For the coding of the text passages, the strategy of open coding was used. The categories were derived from the contents of the texts [46]. Table 2 shows the categories derived from the documents that were analyzed. The data coding was carried out by the first author. In this study, the data were first interpreted individually for each country, then short country profiles were produced, and finally, the findings were compared.

Language of national dementia care guidelines
The country-specific institutions and experts were mainly contacted in English, while the German-speaking countries were contacted in German. In some (mainly Eastern European) countries, follow-up contact was made in the respective national language. For this purpose, the translation program DeepL and Google Translator were used. The 43 documents sent in by the institutions and experts were mostly (28) written in the respective national language. Eight documents (1 each from England, Wales, Scotland, Ireland, Malta, Flanders, Spain, and the Netherlands) were available in English and 7 documents (3 from Switzerland, 2 from Austria, 1 each from Germany and Luxembourg) in German. Of  (Table 2). Most other countries refer only briefly, with individual sentences or short sections, to specific aspects of this topic. In addition to country-specific differences, there are document type-specific differences. While none of the three reports/strategies refers to migration, two of seven recommendations, 11 of 30 guidelines, and two of three policies have a reference.

Overview of country-specific guidelines
This section presents the results for the individual countries that have national guidelines with a migration reference. The results are structured according to the respective themes and subthemes and are presented descriptively. In Table 4 attached in the appendix, supporting quoted text excerpts are presented.
Austria Document: "Medical guideline for integrated care for dementia patients" from 2011. Theme: Dementia diagnosis; key message: Neuropsychological tests for differential diagnosis must take into account a person's sociocultural background and language skills. Subtheme: Diagnostic tools; key message: The significance of the Mini-Cog-Screening-Test is not affected by linguistic and cultural differences [47].  [56]. This brochure provides information on the tasks, requirements, and guidelines for professional interpreters and gives an overview of the rights, duties, and information/compliance bodies for people who use the services of an interpreter [57].  [60], people born abroad [61]). The content focus of the sections on the care of PwM with dementia in the migration-related documents is on early detection and diagnosis. Only Belgium (Flanders) does not take this topic into account. The main problem identified is that the cultural background and language skills of PwM can influence the results of dementia diagnostic tests [52-54, 56, 59]. Consequently, the focus in most countries (9 out of 12) is on the suitability of cognitive screening tools for minority groups. Norway, Northern Ireland, England, Wales, and Spain report that standardized cognitive tests such as the MMSE or the clock test are not suitable for people with a different linguistic or cultural background [52,55,56,59]. Ireland and Austria refer to cognitive screening tests such as the MIS and the Mini-Cog Screening Test, which are less prone to linguistic and cultural influences [47,54]. Norway, Sweden, and Denmark point to the validity of RUDAS for people with a different linguistic or cultural background [51,56,60]. The second central topic is the existence of care inequalities between ethnic minorities and the majority population (in 8 of 12 countries). Norway and Sweden note that PwM use fewer formal healthcare services (primary healthcare services, community support services, inpatient care services) [56,61]. In seven countries, the access of PwM with dementia to healthcare services is discussed. Some countries report that PwM or ethnic minorities have less access to adequate healthcare services [52,56], and they have lower chances of early detection and appropriate drug treatment [61]. Six countries point to care barriers such as stereotyping or linguistic, cultural, and ethnic barriers. As a result, PwM are mentioned by several countries as a risk group for underdiagnosis and lower use of care [52,55,61]. Seven countries identify that PwM with dementia have special needs. They refer to a different perspective on dementia, different preferences for care, and other ideals, ideas, and desires regarding information and self-determination [55, 56,59,60].

Belgium (Flanders)
Nine countries provide recommendations for the care of PwM with dementia. Norway, Sweden, Germany, England, and Wales recommend that the linguistic and cultural background of people should be taken into account when selecting diagnostic test procedures [52,53,56,61]. Norway, Sweden, Northern Ireland, and Spain recommend that care providers offer specific support and information to people with dementia and their ethnic minority relatives, taking into account their cultural, religious, and linguistic needs [55, 56,59,60]. Norway, Northern Ireland, and Spain note that information in the preferred language and an independent interpreter should be offered to people with dementia and their caregivers in case of language barriers [55, 56,59]. Currently, only Norway, Sweden, and Denmark have specific healthcare services at the national level for PwM with dementia (Fig. 1). Norway has published informational material on dementia in four different languages (Norwegian, English, Polish, and Urdu) and a brochure with information on rights, requirements, and guidelines concerning the provision and use of professional interpretation services [56]. Sweden has adapted RUDAS to people with different linguistic and cultural backgrounds and developed a training program for health professionals regarding the application of this tool [61]. Denmark has validated RUDAS for PwM [51]. Sweden, Denmark, England, Wales, and Belgium (Flanders) follow an integrative care model. They adapt the mainstream services of the healthcare system to people with different linguistic or cultural backgrounds [49,51,52,60,61]. Northern Ireland recommends that healthcare providers develop specialized services for ethnic minorities [55]. The Norwegian Directive pursues a segregative care strategy with specialized services for cognitive assessment, dementia diagnosis, and follow-up, while subsequent treatment and care are provided as part of general medical care [56]. This study has shown that some models of good practice exist in individual countries, but in Europe, as a whole, there is a significant gap in care for PwM with dementia.
Relationship between population size of older migrants in individual countries and migration reference in national dementia care guidelines According to this analysis, there is a relationship between the absolute size of the population of PwM who are at an age that is associated with a higher risk of dementia (65 years or older) and the consideration of migration in dementia care guidelines. If countries with a large older migrant population (over 200,000) publish national guidelines on dementia care, the likelihood of a migration reference is much higher than if countries with a small migrant population (under 100,000) publish such documents. The example of France (largest older migrant population, no migration-related guidelines) shows that a large older migrant population does not automatically lead countries to include the topic of migration in national dementia care guidelines [5].

Discussion
Similar to the study on the focus of NDPs in the care of PwM with dementia [39], this analysis shows that migration plays a subordinate role in national documents on dementia care. More than half of the countries with national guidelines, policies, or recommendations do not refer to this topic. Most of the documents from the 12 countries with a migration reference address it only briefly. There is broad consensus in the migration-related documents that standardized cognitive test procedures are not suitable for linguistic and cultural minorities. The Alzheimer Europe report "The development of intercultural care and support for people with dementia from minority ethnic groups" confirms this finding and concludes that most standardized tools used in European countries to diagnose dementia are not suitable for use with people from ethnic minority groups. According to the report, there is not yet an instrument that is perfectly tailored to the needs of this group. The MMSE, which is one of the most widely used cognitive screening tools in Europe, has a cultural, social, ethnic, and educational bias [3]. In addition, in many countries, reference is made to inequalities in care, such as the lower utilization of formal healthcare services by PwM and the lower offering of appropriate services compared to the majority population. Several studies also report that PwM or people from minority ethnic groups are underrepresented in dementia services [21,22,62,63], and ethnic minority caregivers use fewer formal services than the majority population [31,32]. Causes discussed are language problems, cultural views on dementia and care, lack of information on available care services, and lack of culturally and linguistically appropriate care services [15,24,25,64,65]. Furthermore, in several studies, PwM report negative encounters with healthcare providers and experiences of discrimination and racism by health professionals [66][67][68][69]. Some of these care barriers are also identified in the national dementia care guidelines analyzed in this study. In most of the guidelines with a migration reference, PwM are identified as a risk group for underdiagnosis and a lower level of care. This result is important as it shows for the first time which national care guidelines of EU and EFTA countries identify the vulnerability of PwM in terms of diagnosis and care. Since the problem identification is the basis for the adoption of measures, policy-makers in dementia care are given an indication of which European countries are expected to focus PwM in future care planning. In this way, possible models of good practice can be identified and transnational networking of care providers can be promoted.
In the care guidelines of countries such as Northern Ireland, which identify PwM or ethnic minorities as a risk group for underdiagnosis or a lower level of care, recommendations are already given for the care of PwM with dementia. A total of nine countries provide such recommendations. They recommend, inter alia, that care providers should provide people with dementia and their relatives from ethnic minorities with specific information and support services that take their cultural and linguistic background into account. Various studies also identify a large need for relief and support services for family caregivers of PwM with dementia, which must be oriented toward the individual and cultural needs of PwM and their relatives [26,[70][71][72][73][74]. In particular, the importance of mother-tongue education about dementia and culturally sensitive treatment and support services [73], for example, through dementia hotlines [26], specific counseling centers, or printed information materials [74], is emphasized. Furthermore, the need for help with physical care activities, support in the household, and, especially, more emotional and mental support is pointed out [70,71]. Another finding of this study relevant for identifying models of good practice is that only the documents from Norway, Sweden, and Denmark refer to currently available specific healthcare services for PwM with dementia. Norway provides multilingual information material on dementia. Sweden and Denmark have adapted the cognitive screening tool RUDAS to people with different linguistic and cultural backgrounds. Similar to some of the guidelines analyzed [51,56], RUDAS is recommended in further reports and articles for the diagnosis of dementia in people from ethnic minority groups [3,26] because the different tests are not influenced by gender, cultural background, and language [3]. This study confirms the findings of the study on NDPs of the EU and EFTA states [39] that in almost all European countries, a lack of culturally and linguistically appropriate healthcare services for PwM with dementia exists at the national level.
In addition, document type-specific differences with regard to migration references become apparent. While none of the reports considers the topic of dementia in PwM, two of seven recommendations, 11 of 30 guidelines and two of three policies refer to this topic. Thus, the proportion of migration-related documents increases with their scientific evidence, normative character, and legal relevance. Furthermore, documents with a large scope refer to migration in more detail than documents with a medium size, while documents with a small scope do not take this topic into account. These findings illustrate that the topic of dementia and migration is not at the top of the political agenda in European states. It is only considered when the documents have a larger scope, stronger scientific input, and greater legal relevance, as illustrated by the fact that most of the policies, but only a quarter of the recommendations, consider migration. The country-specific differences can also be explained by the different thematic focuses of the documents and the different relevance of migration in the individual countries. A further influencing factor may be the different terms used regarding PwM (e.g., Ireland: ethnic minorities [54]; Spain: people from different cultural or religious groups [59]; Sweden: people born abroad [61]). These terms are based on various definitions and a different understanding of constructs such as "ethnicity" [3]. The different use and understanding of terms regarding PwM by different countries and experts represents a major challenge for healthcare policymakers and scientists [75]. For a more exact determination of the importance of the topic of dementia and migration in Europe, a better comparability of country-specific data, and the provision of migrant-specific recommendations for action a uniform use and definition of a term regarding PwM would be essential [3].
Overall, this study provides the first overview of country-specific and transnational guidelines for the care of PwM with dementia. It offers an indication of the countries in which national dementia-specific care strategies have a focus on PwM and in which countries this group does not play a special role in care planning. This information can be used by researchers for further country-specific analyses regarding the focus of care strategies on PwM and by care planners for the initiation of targeted cooperation with care providers from countries that are planning or have already implemented specific measures to care for PwM with dementia.

Limitations
Except for Belgium/Flanders, this study refers only to national policies, guidelines, and recommendations on dementia care published by national organizations or authorities such as the Alzheimer societies, professional societies, or ministries of health. Therefore, only those documents were taken into account that were sent on request by the respective organizations or ministries. We cannot rule out the possibility that organizations and documents exist that were not identified or contacted by the authors. However, the organizations involved in this study were asked to refer to appropriate information or informants, which we then included. Nevertheless, there were also organizations that did not give any response. Accordingly, in the individual EU and EFTA countries, there are other documents on the care of people with dementia (e.g., at the local level) that were not included in this study. However, this was not the aim of the study, and the inclusion of these documents would have compromised the standardization of the procedure and would have reduced comparability.
In addition, due to the level of comparison (across nations, countries, and languages), there are differences in the definition of the target group (e.g., immigrants, minority ethnic groups) and thus different terms used in the context of migration in the analyzed documents. Furthermore, there is a certain heterogeneity in terms of content focus, aims, scope, publisher, publication dates, and type of documents. These difference limit comparability; however, these limitations are well known in international comparison research and must be weighed against the new knowledge generated. This new knowledge needs to be taken into account in further research.

Conclusions
This study supplements the existing literature with a systematic analysis of the migration reference in the EU and EFTA countries' national dementia treatment and care guidelines, policies, and recommendations. The topics of interest were the migration-related content focus, the specific actions taken to ensure healthcare provision and the recommendations made for the care of this vulnerable population. Currently, migration plays a subordinate role in national documents on dementia care. Only 3 of 35 EU and EFTA countries (Norway, Sweden (both with their own chapters), and Northern Ireland) refer in their guidelines, policies, or recommendations in detail to the topic of migration. The focus of the migration-related documents is on early detection and diagnosis of dementia. The main message of these documents is that standardized cognitive test procedures such as the MMSE or the clock test are not suitable for linguistic and cultural minorities. To tackle this problem, several countries recommend that the linguistic and cultural background of PwM should be taken into account when selecting diagnostic test procedures. While Ireland and Austria point out that the cognitive screening tests MIS and Mini-Cog are less prone to linguistic and cultural influences, Norway, Sweden, and Denmark refer to the validity of RUDAS for people with a different linguistic or cultural background. In most countries with migration-related national documents on dementia care, PwM are identified as a risk group for a lower level of care and underdiagnosis. To address this problem, policy-makers, researchers, and care providers should pay more attention to the translation, validation, and nationwide availability of multicultural dementia diagnostic tools such as RUDAS for PwM. In addition, specialized tools for PwM with language, cultural, and/or educational barriers should be developed and tested. We assume that the current lack of migrant-specific diagnostic tools at the national level, if not remedied in a timely manner, may lead to a growing population being excluded from care.  Care -Impact of Culture and Language 1. "The cognitive assessment tests used have a low positive predictive value and the disadvantage of not being able to many patients due to the limitations of these tests, which may be influenced by the patient's age, sex, culture and education." 2. "The risk of abuse is multifactorial, combining personal, family, social and cultural elements." Sweden Evaluated version of the policy: Health and social care at Dementia Healthcare services -Availability "Utvärderingen tyder på att det finns brister i vården och omsorgen för personer från andra länderbåde när det gäller möjligheten till tidig upptäckt, adekvat läkemedelsbehandling och vilka insatser som ges när någon har fått en demensdiagnos." The evaluation indicates that there are deficiencies in health and social care for people from other countries -both in terms of opportunity for early detection, adequate drug treatment, and what efforts are made when someone has a dementia diagnosis.