What elements are important in current treatment and care guidelines to provide culturally sensitive care for people with a migration background and dementia? A systematic analysis

Among people with a migration background, problems such as underdiagnosis of dementia and underprovision are more widespread than in people without a migration background. The development of guidelines for culturally sensitive care of this population can be the first important action to address these inequalities. This article aims to provide a systematic overview of the key elements and measures regarding culturally sensitive care referred to in papers, reports, and guidelines.


Introduction
Throughout Europe, the care of people with a migration background with dementia (PwM) poses a major challenge. In the EU, the number of PwM over 64 years of age rose considerably from 4.73 million in 2000 to 7.37 million in 2017 (United Nations Department of Economic and Social Affairs 2017) and will continue to grow. There is limited data on how many PwM are affected by dementia in Europe. Estimates are available for some countries, such as Germany (Monsees et al. 2018), but these have severe limitations for a European perspective.
One key problem is the absence of a common definition of the term "migrant". While the United Nations defines PwM based on their country of birth [PwM are living in countries other than their country of birth, (United Nations Department of Economic and Social Affairs 2016)], in Germany, the status is based on their own and their parents' citizenship (PwM are those not born with German citizenship or who have at least one parent who was not born with German citizenship (Statistisches Bundesamt 2017)). The subject matter encounters definitional problems on many levels. In this study, we focus on people with a migration background (PwM) or synonymously migrants. We do not use the term "minority ethnic groups" as used in many international studies and reports. Our emphasis is on measures to improve the care situation of people who have immigrated to the country they currently live in. This specificity is associated with specific challenges that differ from the challenges faced by people from minority ethnic groups who might already have been living in the respective country for generations. While there are many similarities and intersections between these groups, not every member of a minority ethnic group is a migrant (Alzheimer Europe 2018). In some European countries, certain minority ethnic groups have specific rights (for example, concerning linguistic and culturally sensitive information) that PwM currently do not have in most countries. For these reasons, the authors believe that specific consideration of PwM in the context of dementia care is indicated. A detailed discussion on the definition of the term "migrant" and common concepts such as a "minority ethnic group" can be found in the Alzheimer Europe report "The development of intercultural care and support for people with dementia from minority ethnic groups" (Alzheimer Europe 2018). Another key problem is diagnosis. On top of the general problem of diagnosing dementia in the general population, underdiagnosis and late diagnosis of dementia are more widespread among PwM than in people without a migration background (Seven 2015). Particularly due to the lack of language-and culture-sensitive diagnostic tools, early and valid diagnosis of dementia is a major challenge for general practitioners (GPs) and specialists (Alzheimer Europe 2018).
However, PwM with dementia are a group facing specific problems. There are reports that age-associated diseases such as dementia occur at a younger age and require care at an earlier stage (Gronemeyer et al. 2017;Kaiser 2009). In addition, dementia is often associated with an early loss of the language of the country of residence (Bundesministerium für Gesundheit 2011). While families and social networks have been described as important resources for PwM with dementia, the psychological burden on their families is often higher than that on families without a migration background (Kücük 2010;Montoro-Rodriguez and Gallagher-Thompson 2009;Piechotta-Henze and Matter 2008). This constitutes a high demand for support services (Jutlla 2015), and there is an evident need for sensitization, information, and networking among migrant communities and care providers. For example, dementia is considered to be a part of normal aging or attributed to religious or spiritual elements in some migrant communities (Chaouni et al. 2020;Deutsche Alzheimer Gesellschaft 2019;Xiao et al. 2015). Simultaneously, many service providers have limited knowledge about the specific care situation of PwM (Höfler et al. 2015).
There is growing evidence that PwM with dementia are underrepresented in dementia-specific healthcare services (Giebel et al. 2015;Mukadam et al. 2011;Mukadam et al. 2015;Parveen and Oyebode 2018) and that family caregivers use fewer formal support services than people without a migration background (Dilworth-Anderson et al. 2002;Dunlop et al. 2003). This has been explained as resulting from language problems, cultural beliefs about dementia and care, stigma and shame, lack of information about available healthcare services, and lack of culturally, religiously, and linguistically appropriate services (Alzheimer Europe 2018; Bermejo et al. 2012;Bowes and Wilkinson 2003;Braun et al. 1996;Chaouni et al. 2020;Greenwood et al. 2015;Jett 2006;Mogar and von Kutzleben 2015). These factors lead to care inequalities, which should be addressed in treatment guidelines. However, a recent analysis of national guidelines on dementia care in the EU and EFTA (European Free Trade Association) countries has shown that the topic of migration plays a subordinate role in these guidelines. Moreover, no European country provides a separate, specific guideline for culturally sensitive care (Schmachtenberg et al. 2020b).
Therefore, this study aims to provide a systematic overview of the key elements and measures with regard to culturally sensitive care referred to in scientific articles and statements, political documents, and medical guidelines. First, we identify which thematic and content-related priorities are set in the documents and statements examined. Subsequently, we describe some measures recommended to improve the care situation of PwM with dementia. These are not necessarily specific to migrant groups, and have a general and transnational character. This article is addressed to policymakers, health system leaders, and further decision-makers and care planners at national and international levels. It is intended to show them which elements are important for the holistic orientation of healthcare systems and structures towards culturally sensitive care. In a further paper by Monsees et al. (submitted but not published), intercultural care as a model for the implementation of culturally sensitive care by healthcare professionals and providers of healthcare services is described in detail (Monsees et al. 2021).
Thus, the article aims to provide an answer to the following question: what elements play key roles in ensuring culturally sensitive care for PwM with dementia?

Methods
This study is a systematic analysis of the special discourses held in articles from peer-reviewed scientific journals, in scientifically oriented oral statements from conference presentations, in politically determined dementia plans and international reports, and in medically oriented guidelines on the care of PwM with dementia. Thereby, three models were combined (triangulation): (1) for the collection of statements from scientific articles, the systematic literature analysis by Becker (2018) was used, (2) for the analysis of the data, the discourse analysis by Keller (2011) was implemented, and (3) for the coding, the qualitative content analysis model proposed by Mayring (2014) was applied.

Data collection
1. To identify relevant articles in scientific journals, the databases PsycARTICLES, Psychology and Behavioral Sciences Collection, and PsycINFO on the platform EBSCOhost and the PubMed database were screened. In doing this, the key terms 'care', 'Versorgung', 'dementia', 'Demenz', 'migration', and 'Migration' were used. These terms were chosen because they represent the key elements of the research question of this study, and in previous research, these terms have generated the most hits for articles that explicitly report results from studies on the care of PwM with dementia. For example, analyses of national dementia plans and care guidelines have shown that entering the term 'migration/Migration' in the search function of the documents generates a significantly higher number of hits regarding the reference to PwM than other search terms such as 'minority', 'culture', or 'ethnic'. In this study, only articles in German and English were considered, as these represent the mother tongue and second language, respectively, of the authors. Most of the studies were published in English, but there are also relevant articles on the care of PwM with dementia that were published exclusively in German. For a qualitative content analysis of articles in other languages, the language skills of the authors are insufficient. The study covers the period from 1 January 2009 to 1 November 2019. This period is based on the validity of recommendations for action from guidelines and dementia plans of various European countries. In most EU and EFTA countries, the validity of guidelines and dementia plans is 5 years. Since the recommendations for action in two successive documents often differ only slightly, and since clear discrepancies only occur between recommendations from guidelines or dementia plans whose publication is more than 10 years apart, this period was used as a basis for this analysis. The database search was limited to abstracts and titles because the study should only consider articles that focus on the care of PwM with dementia.
The formal search criteria were as follows: language: German and English, After excluding four articles due to the date of publication (before 11 November 2009) and four articles due to the implementation of material quality criteria (inclusion of elements/measures on the care of PwM with dementia), the corpus comprised n = 17 articles.
2. Afterwards, the following documents were integrated into the corpus: the dementia plans of the EU and EFTA countries, which were available via the website of Alzheimer Europe or the search engine Google on 1 November 2019; the dementia care guidelines, which were sent after a mail request (between 2 May and 11 July 2019) until 1 November 2019 by the national Alzheimer societies, health ministries, and professional societies (for geriatrics, gerontology, and neurology) of the EU and EFTA countries; articles referenced in the systematically derived articles; and international reports, books, databases, and websites that were available online on 1 November 2019, and where elements or measures regarding the care of PwM with dementia could be derived. For this purpose, a Google search was carried out. The search engine was searched for several keywords such as report/book/database/website and dementia and migration, dementia care, or migrants and health.
3. Finally, oral statements were derived from conference presentations, workshops, and discussion panels in EU countries on the topic of dementia and migration. Only contributions from events attended by the authors were considered. The authors evaluated the programs of various events organized at the EU level, and attended those that highlighted topics that the authors identified as relevant in the context of caring for PwM with dementia. In addition, an event of the German Alzheimer Society with contributions from scientists, practitioners, and family caregivers on the topic of dementia and migration was considered.

Basis of the data
The search resulted in the following hits: N = 113 documents, books, databases, and websites, and n = 4 events. After screening the content of these texts and events, the following discourse fragments remained: N = 64 documents, books, databases, and websites ,and n = 4 events. These are divided as follows: 28 scientific articles, 15 national guidelines, 11 national dementia plans, six international reports on dementia, health, and migration, two books on dementia and migration, one database with initiatives on intercultural care, one website on health and migration, the North Sea Dementia Group Meeting 2019, the Alzheimer Europe Conference 2019, the European Public Health Conference 2019, and the Symposium Dementia and Migration of the German Alzheimer Society 2019. These texts, publications, and events represent the database for the results of this study.

Data evaluation
The relevant text sections and oral contributions were paraphrased, memos and comments were added, and the text was coded (Keller 2011). A combination of deductive and inductive categorization was used. First, categories were derived from other guidelines on dementia care (DGPPN and DGN 2016;Dorner et al. 2011;Fröschl et al. 2015; Schweizerische Akademie der Medizinischen Wissenschaften 2017; Schweizerische Alzheimervereinigung 2014). These categories were assigned to the individual text sections. From data material that could not be coded in this way, content categories were aggregated. Then, the category set shown in Table 1 was structured by formulating main categories. Afterward, a rough structure was generated from the main categories, and the content was placed in order (Mayring 2014). A consensus was built, central statements were derived, and deviating or singular statements were excluded (Becker 2018). Subsequently, the central statements were summarized into a catalog of measures and finally structured.

Results
In developing guidelines for culturally sensitive care of PwM with dementia, the following topics should be considered: 1. definition of the term "migrant", 2. raising awareness in migrant communities, 3. healthcare structures, 4. cooperation/ networking of central stakeholders regarding dementia and migration, 5. diagnostics, 6. support for family caregivers, 7. support for care providers, 8. communication between care providers and care recipients, 9. access to healthcare, 10. culturally sensitive care, and 11. research.
In the following section, the key elements are described for each topic: 1. Definition of the term "migrant" The term "migrant" needs to be clearly defined, and clear criteria must be established to determine which persons this term includes. In addition to government institutions and migration experts, migrants should play an active role in the definition process (Alzheimer Europe 2018).

Raising awareness in migrant communities
In many migrant communities, there is a high demand for information about living with dementia, symptoms of dementia, possible disease progression, diagnosis, dementia-spe cific care, and available services. Nationwide initiatives with language and culturally sensitive information events, information portals, and information materials can be useful tools to meet this need. Daily structures such as migrant facilities, places of worship, cultural centers, schools, or youth leisure facilities are particularly suitable for personal contact (Alzheimer

Healthcare structures
Structures must be created that promote the intercultural opening of healthcare, the inclusion of PwM in the healthcare system, and the participation of this group in the provision of care.  Organization of care An important step could be the establishment of national institutions for the health of PwM with a task force on dementia (Alzheimer Europe 2019). At the local level, the inception of migrant health centers with dementiaspecific trained medical staff and dementia-specific services (screening, information, counseling, primary healthcare) or migrant dementia centers can be an opportunity to include PwM in healthcare ( Government support Migrant organizations, faith/community groups, and care networks should be given more financial support and assistance in the form of dementia-specific multiplier training (Alzheimer Europe 2019; Höfler et al. 2015;Xiao et al. 2015). Investments are also needed in translation or mediation services as well as culturally sensitive education and training for health and care professionals (Alzheimer Europe 2018; Chaouni et al. 2020;Regan 2014).

Cooperation/networking of central stakeholders regarding dementia and migration
A further focus should be on the development of care networks and local, national, or international cooperation between government representatives, care providers, care recipients, organizations, initiatives, and researchers in the field of dementia and migration (European Public Health Association 2019).
Care providers and experts Cooperation and knowledge transfer between care providers and experts with expertise in the healthcare systems of the countries of origin and the host countries, dementia care, and the needs of PwM should be supported (Alzheimer Europe 2019). The establishment of networks between doctors and other care providers from the respective countries of origin and host countries (e.g., through student exchange programs) can be particularly useful (European Public Health Association 2019).
Care providers and care recipients Internet portals are an adequate networking instrument for PwM with dementia, family members, and healthcare professionals. Network maps with healthcare services and relevant organizations, videos with multilingual and culturally sensitive information on dementia, text-to-speech functions, and blogs for the interaction of relatives, migrant organizations, and care providers should be integrated into the websites (Alzheimer Europe 2019; World Health Organization 2018a).  Training of family caregivers Furthermore, linguistically and culturally sensitive training series regarding dementia and care should be developed (Höfler et al. 2015;Kaiser 2009;Piechotta-Henze and Matter 2008;Xiao et al. 2015).

Support for family caregivers
Another key element is the development of guidelines and brochures on culturally sensitive dementia care, with recommendations on specific services and activities (Alzheimer Europe 2019).
Interventions for caring relatives Measures should be taken to strengthen the exchange between family caregivers to overcome possible taboos and feelings of shame and guilt, and to allow free space from homecare (Kaiser 2009

Support for care providers
Providers of dementia care services must be supported in gaining awareness and knowledge about the importance of migration-specific, cultural, and religious elements in dementia care (Chaouni et al. 2020).
Raising awareness of care providers Intercultural training courses, handbooks on cultural sensitivity, and guidelines with recommendations for measures to convey cultural sensitivity in the education and training of professionals should be developed. Also very important is the information for care providers in workshops about the rights and needs of PwM and the available healthcare services (Alzheimer Europe 2019; World Health Organization 2018b).
Training of care/health professionals Care and health professionals should be trained regarding cultural sensitivity, the needs and treatment of PwM with dementia, dealing with barriers, and using community resources (Alzheimer

Communication between care providers and care recipients
Measures must be taken to overcome communication barriers between care providers and PwM with dementia (World Health Organization 2018b). Professionals who care for PwM with dementia should have access to special publications (Adamson 2001

Access to healthcare
PwM should have the same access to the health system and be offered the same level of care as people without a migration background (Institut für Migrationsforschung und Interkulturelle Studien and Bundeszentrale für politische Bildung 2015; World Health Organization 2018a). One way to ensure this is to provide health cards for all migrant groups. Irregular migrants could anonymously receive a code for access to primary healthcare (World Health Organization 2018b). Simultaneously, it should be ensured that culturally sensitive care and support for dementia are generally accessible, and that multilingual information and mother-tongue services are comprehensively available (Alzheimer Europe 2018; Tillmann et al. 2019). The utilization of formal healthcare services can be improved through technical support for registration and appointment (World Health Organization 2018b) and early confidence-building (e.g., through visiting, mothertongue care counseling) (Tezcan-Güntekin 2018). The implementation of tools for assessing access to care can also be useful (World Health Organization 2018b).

Culturally sensitive care
PwM with dementia should receive culturally sensitive postdiagnostic support, care, and treatment, preferably from a person who speaks their mother tongue (Alzheimer Europe 2018; Alzheimer Europe 2019; Llywodraeth Cymru Welsh Government 2018). In this context, a person-centered approach has proved to be appropriate (Deutsche Alzheimer Gesellschaft 2019; Jutlla and Moreland 2009).
Culture care providers Service providers should create an inclusive environment (Jutlla 2015) and ensure that their policies, procedures, and staff are sensitized to different cultural needs (The Mental Welfare Commission for Scotland 2011). Specifically, it is useful to create internal folders with guides regarding culturally and linguistically sensitive diagnostics and care as well as available services (Deutsche Alzheimer Gesellschaft 2019). Healthcare team The healthcare team for PwM with dementia should include family members (if available), GPs and specialists (neurologist/psychiatrist), a psychologist/psychosocial caregiver, and if needed, professional caregivers and/or supportive care providers. In addition, the services of a cultural mediator and a connection specialist can be very important (Deutsche Alzheimer Gesellschaft 2019).

Identification of needs
Cultural mediator She/he should mediate culture-specific information to care providers (European Public Health Association 2019; World Health Organization 2018a) and be available on an on-call basis to GPs, hospitals, specialists, and staff in nursing services and be stationed in nursing homes (Chaouni et al. 2020; Ministry of Health Social services and Equality 2010; World Health Organization 2018a).
Connecting specialist She/he should communicate the needs of PwD to care providers, doctors, and nurses, provide PwD and their relatives with information on dementia and available healthcare services, and support them in dealing with bureaucratic challenges. The connecting specialist should be available on an on-call basis to PwM with dementia and their families (European Public Health Association 2019;Xiao et al. 2015). This service could be provided by governmentfunded social workers who have received dementia-specific training as well as culture-specific and language skills.
Cultural background of professional caregivers When recruiting their staff, service providers should ensure that caregivers have different cultural backgrounds and language skills. The recruitment of multicultural staff with intercultural experience can serve as a prevention measure with regard to language and cultural barriers in the care of PwM (Deutsche Alzheimer Gesellschaft 2019; Giebel et al. 2015;Gronemeyer et al. 2017;Höfler et al. 2015;Johl et al. 2016;Kaiser 2009;Ministry of Health and Care Services 2016).
Inclusion of people with a migration background: 1. Inclusion of professional caregivers: to meet the need for care and health professionals with a migration background, programs are required to integrate this group into the health system. Such programs should include standardized procedures for the recognition of educational qualifications acquired abroad and adaptation training for doctors and professional caregivers from different countries of origin (World Health Organization 2018a).

Integration of family caregivers into formal care:
The integration of relatives into professional care and increased cooperation between professional caregivers and relatives can improve the care situation of PwM with dementia (Chaouni et al. 2020;Rosendahl et al. 2016;Wittenberg et al. 2018). Nursing homes should provide opportunities for family members to live in close proximity (Sagbakken et al. 2018 Care concept The first question arising in the conception of care is whether PwM with dementia should be integrated into the established care system (integration model) or if specific offers should be developed for different migrant groups (segregation model) (Kaiser 2009). Since this question cannot be answered in general terms and only in consideration of the respective care situation, both integrative and segregative care services should be developed. Context-specific service design is the most promising concept (Alzheimer Europe 2018; Giebel et al. 2015).
Integrative care services Existing dementia-specific care services and general services for elderly people must be adapted to the individual, linguistic, cultural, religious, and migrationspecific needs of PwM (Alzheimer Europe 2019; Johl et al. 2016;Kaiser 2009;Mogar and von Kutzleben 2015;Psota 2015). Care providers have to create a framework that allows PwM with dementia to celebrate religious or cultural festivals, practice traditions, customs, and religious rituals, and eat culturally appropriate food ( Migrant health centers should offer free social and healthcare counseling and interpreting services, as well as transport and accompanying services (World Health Organization 2018a). Furthermore, in several European countries (Netherlands, UK), the concept of dementia cafés/Alzheimer's tea houses for PwM has proved successful. There, PwD, family members, caregivers, and social workers meet in an informal atmosphere and can exchange experiences or information (Alzheimer Europe 2019). Further meaningful measures are the initiation of culture-specific discussion and family groups, the implementation of biography work (Deutsche Alzheimer Gesellschaft 2019), and the use of culturally tailored activity and memory materials (Kaiser 2009).
Housing Another focus should be on the design of innovative intercultural or culture-specific housing and care concepts. The concept of outpatient assisted living communities for PwM with dementia is particularly promising. Central success factors of such projects are the close cooperation with local authorities, social welfare institutions, housing associations, care services, and migrant organizations, connection to public transport and infrastructure of daily needs, and accessibility for relatives as well as native-speaking and culturally trained caregivers (Deutsche Alzheimer Gesellschaft 2019; Kaiser 2009). State subsidies for multigeneration houses could also contribute to improving the care situation of PwD and their relatives (Gronemeyer et al. 2017).
Validation of the cultural sensitivity of care services The implementation of these strategies should be documented and reflected, and the effectiveness of the measures must be evaluated. It should be examined whether the measures are culturally sensitive and to what extent they meet the needs of PwM with dementia. The satisfaction of the service users should be systematically surveyed, and the services should be further developed in cooperation with them (Alzheimer Europe 2018; European Public Health Association 2019).

Research
In the design of studies on the care situation of PwD, more attention must be paid to ensure that PwM have an equal chance of being included (Alzheimer Europe 2018). In addition, separate studies need to be conducted on the needs and care situation of PwM with dementia (Alzheimer Europe 2018; Gronemeyer et al. 2017;Johl et al. 2016). Thereby, researchers with a migration background should be included (Kaiser 2009 Johl et al. 2016;Kaiser 2009;Xiao et al. 2015). Furthermore, studies should be carried out on the use of culturally sensitive diagnostic tools for PwM and the utilization of healthcare services by different migrant groups (Johl et al. 2016;Kaiser 2009;Socialstyrelsen 2018). The central elements in providing culturally sensitive care for PwM, which have been identified by the conducted discourse analysis and which are described in more detail in this section, are summarized in Table 2.

Discussion
The literature analysis conducted in this study has shown that topics such as raising awareness in migrant communities regarding dementia, building of structures that promote the intercultural opening of healthcare, making an early and valid diagnosis of dementia in PwM, providing support to family caregivers, ensuring culturally sensitive care of PwM with dementia, involving PwM in the development of care services, and improving access of PwM to studies on dementia care, play key roles in developing guidelines. There may be several reasons why these topics play no or only a subordinate role in most of the currently available national dementia plans or care guidelines of European countries (Canevelli et al. 2019b;Schmachtenberg et al. 2020a;Schmachtenberg et al. 2020b), despite the increasing quantitative importance of the topic of dementia and migration (Canevelli et al. 2019a; United Nations Department of Economic and Social Affairs 2017). These could include political backgrounds (e.g., low voter potential within the migrant population, rejection of migrant-friendly policies by larger voter groups, nationalistic/rightwing populist developments), discriminatory structures, lowinclusive (political/medical) discourses, underrepresentation of PwM or their representatives in the relevant working groups, and/or xenophobic attitudes among policymakers. Furthermore, political decisions and care strategies are in general mostly oriented towards the majority population. This is Research on the care situation of people with a migration background with dementia and their relatives, analysis of the use of culturally sensitive diagnostic instruments and healthcare services especially the case for a topic such as dementia, which is still highly taboo in many countries and societies and has not (if at all) been on the political agendas for a long time. To break this automatism, the targeted development of guidelines for minorities can be a solution.

Limitations
The results of this study are based exclusively on an analysis of scientific publications and are therefore derived theoretically. In addition, the measures described have a general, crossnational, and cross-group character. Consequently, they need to be adapted to the country-specific context, economic opportunities, structural conditions, and healthcare systems of each country and tailored to the individual migrant groups. It is also necessary to evaluate these measures in practice. Furthermore, the online search for written statements in articles and other documents was limited to the PsycARTICLES, Psychology and Behavioral Sciences Collection, PsycINFO, and PubMed databases, the search engine Google, and the Alzheimer Europe website, and the search for oral statements was limited to events attended by the authors. The screening of the databases was conducted exclusively based on the keywords 'care', 'Versorgung', 'dementia', 'Demenz', 'migration', and 'Migration', and was limited to the abstracts and titles. When compiling the data corpus, only articles in German and English were selected, and the investigation was limited to the period from 1 November 2009 to 1 November 2019. In addition, a filtering procedure with the application of material quality criteria was carried out for the selection of articles for the systematic literature analysis. Due to these limitations, this study represents a selection of the scientific, political, and medical discourses on care for PwM with dementia. Statements about elements or measures related to this topic that were not accessible online, on the determined platforms, or via the attended events, that were included in articles that were not published during the defined investigation period, and that could not be identified by the selected keywords, were not considered. However, due to the systematic approach, this study gives an overview of central elements of culturally sensitive dementia care. In doing this, we did not limit our search on publications with a pure scientific focus, but also integrated publications that aim at improvement of medical practice or comprise a political framework for action.

Conclusions
This study provides a systematic overview of measures recommended in scientific, political, and medical special discourses, to ensure culturally sensitive care of PwM with dementia. These recommendations should be considered in the discussion of national guidelines on dementia care. Due to the specific needs and the particular challenges with regard to the care of PwM with dementia, which require a specific healthcare strategy with a comprehensive set of measures, the development of separate guidelines for the care of PwM with dementia at the national level is also recommended. Furthermore, the development of European guidelines for culturally sensitive care of PwM with dementia can be an instrument for reducing dementia-specific inequalities in care between the various migrant groups in the individual European countries, between the individual migrant groups in the various European countries, and between the European migrant population and the population without a migration background, as well as for establishing European minimum care standards for these people. As a first step, a consensus on the definition of the term "migrant" should be sought at the European level (Alzheimer Europe 2018).
Abbreviations EFTA, European Free Trade Association; GPs, General practitioners; PwD, People with dementia; PwM, People with a migration background; RUDAS, Rowland Universal Dementia Assessment Scale Authors' contributions TS prepared the first draft. JRT participated in the study design and analysis. JM and JRT revised the manuscript and provided further contributions and suggestions. TS, JM, and JRT read and approved the final manuscript. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Funding Open Access funding enabled and organized by Projekt DEAL.
The study was carried out within the project "Atlas zu Prävalenz von dementiell erkrankten Menschen mit Zuwanderungsgeschichte in Europa" funded by the Robert Bosch Stiftung. The Robert Bosch Stiftung did not influence the design of the study, the analysis of the data, or the process of writing the manuscript.
Data and materials availability Most of the data (written statements) analyzed in this study are available on the databases PsycARTICLES, Psychology and Behavioral Sciences Collection, PsycINFO, and PubMed, the search engine Google or the website of Alzheimer Europe (https://www.alzheimer-europe.org/Policy/National-Dementia-Strategies).

Ethics approval Not applicable
Consent Not applicable Competing interests The authors have no conflicts of interest to declare that are relevant to the content of this article.
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