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Creavin ST, Noel-Storr AH, Langdon RJ, Richard E, Creavin AL, Cullum S, Purdy S, Ben-Shlomo Y. Clinical judgement by primary care physicians for the diagnosis of all-cause dementia or cognitive impairment in symptomatic people. Cochrane Database Syst Rev 2022; 6:CD012558. [PMID: 35709018 PMCID: PMC9202995 DOI: 10.1002/14651858.cd012558.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND In primary care, general practitioners (GPs) unavoidably reach a clinical judgement about a patient as part of their encounter with patients, and so clinical judgement can be an important part of the diagnostic evaluation. Typically clinical decision making about what to do next for a patient incorporates clinical judgement about the diagnosis with severity of symptoms and patient factors, such as their ideas and expectations for treatment. When evaluating patients for dementia, many GPs report using their own judgement to evaluate cognition, using information that is immediately available at the point of care, to decide whether someone has or does not have dementia, rather than more formal tests. OBJECTIVES To determine the diagnostic accuracy of GPs' clinical judgement for diagnosing cognitive impairment and dementia in symptomatic people presenting to primary care. To investigate the heterogeneity of test accuracy in the included studies. SEARCH METHODS We searched MEDLINE (Ovid SP), Embase (Ovid SP), PsycINFO (Ovid SP), Web of Science Core Collection (ISI Web of Science), and LILACs (BIREME) on 16 September 2021. SELECTION CRITERIA We selected cross-sectional and cohort studies from primary care where clinical judgement was determined by a GP either prospectively (after consulting with a patient who has presented to a specific encounter with the doctor) or retrospectively (based on knowledge of the patient and review of the medical notes, but not relating to a specific encounter with the patient). The target conditions were dementia and cognitive impairment (mild cognitive impairment and dementia) and we included studies with any appropriate reference standard such as the Diagnostic and Statistical Manual of Mental Disorders (DSM), International Classification of Diseases (ICD), aetiological definitions, or expert clinical diagnosis. DATA COLLECTION AND ANALYSIS Two review authors screened titles and abstracts for relevant articles and extracted data separately with differences resolved by consensus discussion. We used QUADAS-2 to evaluate the risk of bias and concerns about applicability in each study using anchoring statements. We performed meta-analysis using the bivariate method. MAIN RESULTS We identified 18,202 potentially relevant articles, of which 12,427 remained after de-duplication. We assessed 57 full-text articles and extracted data on 11 studies (17 papers), of which 10 studies had quantitative data. We included eight studies in the meta-analysis for the target condition dementia and four studies for the target condition cognitive impairment. Most studies were at low risk of bias as assessed with the QUADAS-2 tool, except for the flow and timing domain where four studies were at high risk of bias, and the reference standard domain where two studies were at high risk of bias. Most studies had low concern about applicability to the review question in all QUADAS-2 domains. Average age ranged from 73 years to 83 years (weighted average 77 years). The percentage of female participants in studies ranged from 47% to 100%. The percentage of people with a final diagnosis of dementia was between 2% and 56% across studies (a weighted average of 21%). For the target condition dementia, in individual studies sensitivity ranged from 34% to 91% and specificity ranged from 58% to 99%. In the meta-analysis for dementia as the target condition, in eight studies in which a total of 826 of 2790 participants had dementia, the summary diagnostic accuracy of clinical judgement of general practitioners was sensitivity 58% (95% confidence interval (CI) 43% to 72%), specificity 89% (95% CI 79% to 95%), positive likelihood ratio 5.3 (95% CI 2.4 to 8.2), and negative likelihood ratio 0.47 (95% CI 0.33 to 0.61). For the target condition cognitive impairment, in individual studies sensitivity ranged from 58% to 97% and specificity ranged from 40% to 88%. The summary diagnostic accuracy of clinical judgement of general practitioners in four studies in which a total of 594 of 1497 participants had cognitive impairment was sensitivity 84% (95% CI 60% to 95%), specificity 73% (95% CI 50% to 88%), positive likelihood ratio 3.1 (95% CI 1.4 to 4.7), and negative likelihood ratio 0.23 (95% CI 0.06 to 0.40). It was impossible to draw firm conclusions in the analysis of heterogeneity because there were small numbers of studies. For specificity we found the data were compatible with studies that used ICD-10, or applied retrospective judgement, had higher reported specificity compared to studies with DSM definitions or using prospective judgement. In contrast for sensitivity, we found studies that used a prospective index test may have had higher sensitivity than studies that used a retrospective index test. AUTHORS' CONCLUSIONS Clinical judgement of GPs is more specific than sensitive for the diagnosis of dementia. It would be necessary to use additional tests to confirm the diagnosis for either target condition, or to confirm the absence of the target conditions, but clinical judgement may inform the choice of further testing. Many people who a GP judges as having dementia will have the condition. People with false negative diagnoses are likely to have less severe disease and some could be identified by using more formal testing in people who GPs judge as not having dementia. Some false positives may require similar practical support to those with dementia, but some - such as some people with depression - may suffer delayed intervention for an alternative treatable pathology.
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Affiliation(s)
| | | | - Ryan J Langdon
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
| | - Edo Richard
- Department of Neurology, Donders Institute for Brain, Behaviour and Cognition, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands
| | | | - Sarah Cullum
- Department of Psychological Medicine, University of Auckland, Auckland, New Zealand
| | - Sarah Purdy
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Yoav Ben-Shlomo
- Population Health Sciences, University of Bristol, Bristol, UK
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Creavin ST, Haworth J, Fish M, Cullum S, Bayer A, Purdy S, Ben-Shlomo Y. Clinical judgment of GPs for the diagnosis of dementia: a diagnostic test accuracy study. BJGP Open 2021; 5:BJGPO.2021.0058. [PMID: 34315715 PMCID: PMC8596317 DOI: 10.3399/bjgpo.2021.0058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 06/01/2021] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND GPs often report using clinical judgment to diagnose dementia. AIM To investigate the accuracy of GPs' clinical judgment for the diagnosis of dementia. DESIGN & SETTING Diagnostic test accuracy study, recruiting from 21 practices around Bristol, UK. METHOD The clinical judgment of the treating GP (index test) was based on the information immediately available at their initial consultation with a person aged ≥70 years who had cognitive symptoms. The reference standard was an assessment by a specialist clinician, based on a standardised clinical examination and made according to the 10th revision of the International Classification of Diseases (ICD-10) criteria for dementia. RESULTS A total of 240 people were recruited, with a median age of 80 years (interquartile range [IQR] 75-84 years), of whom 126 (53%) were men and 132 (55%) had dementia. The median duration of symptoms was 24 months (IQR 12-36 months) and the median Addenbrooke's Cognitive Examination III (ACE-III) score was 75 (IQR 65-87). GP clinical judgment had sensitivity 56% (95% confidence interval [CI] = 47% to 65%) and specificity 89% (95% CI = 81% to 94%). Positive likelihood ratio was higher in people aged 70-79 years (6.5, 95% CI = 2.9 to 15) compared with people aged ≥80 years (3.6, 95% CI = 1.7 to 7.6), and in women (10.4, 95% CI = 3.4 to 31.7) compared with men (3.2, 95% CI = 1.7 to 6.2), whereas the negative likelihood ratio was similar in all groups. CONCLUSION A GP clinical judgment of dementia is specific, but confirmatory testing is needed to exclude dementia in symptomatic people whom GPs judge as not having dementia.
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Affiliation(s)
| | - Judy Haworth
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Mark Fish
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Sarah Cullum
- Depatment of Psychological Medicine, School of Medicine, The University of Auckland, Grafton, New Zealand
| | | | - Sarah Purdy
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Yoav Ben-Shlomo
- Population Health Sciences, University of Bristol, Bristol, UK
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Lv X, Zhao M, Li T, Yuan C, Zhang H, Pu C, Li Z, Zhang N, Yu X, Wang H. Effects of an Enhanced Training on Primary Care Providers Knowledge, Attitudes, Service and Skills of Dementia Detection: A Cluster Randomized Trial. Front Neurol 2021; 12:651826. [PMID: 34367045 PMCID: PMC8342805 DOI: 10.3389/fneur.2021.651826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 06/28/2021] [Indexed: 11/24/2022] Open
Abstract
Background: Effective training programs for primary care providers (PCPs) to support dementia detection are needed, especially in developing countries. This study aimed to investigate the effect of an enhanced training on the competency and service of PCPs for dementia detection. Methods: We conducted a cluster randomized trial in Beijing, China. Community healthcare centers (CHCs) located in Fengtai or Fangshan District were eligible. The enrolled CHCs in each district were randomly assigned to the standard or the enhanced training group at a 1:1 ratio. PCPs serving older adults in enrolled CHCs were eligible to participate. The standard training group received three-hour didactic lectures, three monthly supervisions, 3 months of online support and dementia screening packages. The enhanced training group additionally received three monthly face-to-face supervisions and 3 months of online support. The participants became aware of their group membership at the end of the standard training. The knowledge, attitudes, service, and skills regarding dementia detection were assessed using questionnaires and submitted dementia detection records, respectively. Results: A total of 23 and 21 CHCs were randomly assigned to the standard and the enhanced training group, respectively, and 58 participants from 20 CHCs assigned to the standard training group and 48 from 16 CHCs assigned to the enhanced training group were included in the final analysis (mean age 37.5 years, and 67.0% women). A significant increase in the knowledge score was found in both groups, but the increase was similar in the two groups (P = 0.262). The attitude score remained stable in both groups, and no between-group difference was found. Compared with the baseline, both groups reported an increase in dementia detection service, especially the enhanced training group (24.1% to 31.0% in the standard training group and 14.6% to 45.8% in the enhanced training group). The completion rate and accuracy of submitted dementia detection records in the enhanced training group were both significantly higher than those in the standard training group (both P < 0.001). Conclusion: The enhanced training had similar effect on the knowledge of PCPs comparing with the standard training, but was better on continuous service and skills of PCPs related to dementia detection. Trial registration:www.ClinicalTrials.gov, identifier: NCT02782000. Registration date: May 2016. The trial was completed in July 2017.
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Affiliation(s)
- Xiaozhen Lv
- Beijing Dementia Key Lab, Dementia Care & Research Center, Peking University Institute of Mental Health (Sixth Hospital), Beijing, China.,NHC Key Laboratory of Mental Health, National Clinical Research Center for Mental Disorders, Beijing, China
| | - Mei Zhao
- Academic Unit for Psychiatry of Old Age, Department of Psychiatry, The University of Melbourne, Parkville, VIC, Australia
| | - Tao Li
- Beijing Dementia Key Lab, Dementia Care & Research Center, Peking University Institute of Mental Health (Sixth Hospital), Beijing, China.,NHC Key Laboratory of Mental Health, National Clinical Research Center for Mental Disorders, Beijing, China
| | - Changzheng Yuan
- Department of Big Data in Health Science, School of Public Health, School of Medicine, Zhejiang University, Hangzhou, China
| | - Haifeng Zhang
- Beijing Dementia Key Lab, Dementia Care & Research Center, Peking University Institute of Mental Health (Sixth Hospital), Beijing, China.,NHC Key Laboratory of Mental Health, National Clinical Research Center for Mental Disorders, Beijing, China
| | - Chengcheng Pu
- Beijing Dementia Key Lab, Dementia Care & Research Center, Peking University Institute of Mental Health (Sixth Hospital), Beijing, China.,NHC Key Laboratory of Mental Health, National Clinical Research Center for Mental Disorders, Beijing, China
| | - Zhiying Li
- Beijing Dementia Key Lab, Dementia Care & Research Center, Peking University Institute of Mental Health (Sixth Hospital), Beijing, China.,NHC Key Laboratory of Mental Health, National Clinical Research Center for Mental Disorders, Beijing, China
| | - Na Zhang
- Psychological Department, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xin Yu
- Beijing Dementia Key Lab, Dementia Care & Research Center, Peking University Institute of Mental Health (Sixth Hospital), Beijing, China.,NHC Key Laboratory of Mental Health, National Clinical Research Center for Mental Disorders, Beijing, China
| | - Huali Wang
- Beijing Dementia Key Lab, Dementia Care & Research Center, Peking University Institute of Mental Health (Sixth Hospital), Beijing, China.,NHC Key Laboratory of Mental Health, National Clinical Research Center for Mental Disorders, Beijing, China
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Lee L, Hillier LM, Patel T, Weston WW. A Decade of Dementia Care Training: Learning Needs of Primary Care Clinicians. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2020; 40:131-140. [PMID: 32175933 DOI: 10.1097/ceh.0000000000000288] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
INTRODUCTION Limited knowledge of dementia among health professionals is a well-documented barrier to optimal care. This study examined the self-perceived challenges with dementia care and learning needs among primary care clinicians and assessed whether these were associated with years of practice and perceived preparedness for dementia care. METHODS Participants were multi-disciplinary clinicians attending a 5-day team-based dementia education program and physicians attending a similar condensed continuing medical education workshop. Pre-education, they completed an online survey in which they rated (5-point scales): interest in learning about various dementia-related topics, perceived challenges with various dementia-related practice activities and preparedness for dementia care, provided additional dementia-related topics of interest, number of years in clinical practice, and discipline. RESULTS Thirteen hundred surveys were completed across both education programs. Mean ratings of preparedness for dementia care across all respondents reflected that they felt somewhat prepared for dementia care. Challenge ratings varied from low to very challenging and mean ratings reflected a high level of interest in learning more about all of the dementia-related topics; significant differences between disciplines in these ratings were identified. In most cases, perceived challenges and learning needs were not correlated with number of years in clinical practice, but in some cases lower ratings of preparedness for dementia care were associated with higher ratings of the challenges of dementia care. DISCUSSION Clinicians perceived that their formal education had not prepared them well for managing dementia and desired more knowledge in all topic areas, regardless of years in practice. Implications for education are discussed.
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Affiliation(s)
- Linda Lee
- Dr. Lee: Lead Physician, MINT Memory Clinic, Centre for Family Medicine Family Health Team, Kitchener, Ontario, Canada, Associate Professor, Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada, and Schlegel Research Chair in Primary Care for Elders, Schlegel-UW Research Institute for Aging, Waterloo, Ontario, Canada. Ms. Hillier: Research Affiliate, Geriatric Education and Research in Aging Sciences (GERAS) Centre, Hamilton, Ontario, Canada. Dr. Patel: Pharmacist, MINT Memory Clinic, Centre for Family Medicine Family Health Team, Kitchener, Ontario, Canada, and Assistant Clinical Professor, School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada, and Assistant Clinical Professor, Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada. Dr. Weston: Professor Emeritus, Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
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Ranabhat CL, Kim CB, Park MB, Jakovljevic M(M. Situation, Impacts, and Future Challenges of Tobacco Control Policies for Youth: An Explorative Systematic Policy Review. Front Pharmacol 2019; 10:981. [PMID: 31551784 PMCID: PMC6745506 DOI: 10.3389/fphar.2019.00981] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 07/31/2019] [Indexed: 12/15/2022] Open
Abstract
Background: Tobacco use in youths is a major public health challenge globally, and approaches to the challenge have not been sufficiently addressed. The existing policies for tobacco control are not well specified by age. Objective: Our study aims to systematically investigate existing tobacco control policies, potential impacts, and national and international challenges to control tobacco use targeting the youth. Data sources: We used the statistics of the Global Youth Tobacco Survey (GYTS), studies, and approaches of tobacco control policies targeting youth. Considering country, continent, age, and significance, PubMed, Health Inter-Network Access to Research Initiative (HINARI), Scopus, the Cochrane Library, Google, and Google Scholar were searched. The related keywords were tobacco control, youth, smoking, smoking reduction policies, prevalence of tobacco use in youth, classification of tobacco control policies, incentives to prevent young people from using tobacco, WHO Framework Convention on Tobacco Control (FTCT), etc. The search strategy was by timeline, specific and popular policies, reliability, significance, and applicability. Results: We found 122 studies related to this topic. There were 25 studies focusing on situation, significance, and theoretical aspects of tobacco control policies associated with youth; 41 studies on national population polices and challenges; and 7 studies for global challenges to overcome the youth tobacco epidemic. All national policies have been guided by WHO-MPOWER strategies. Increases in tobacco tax, warning signs on packaging, restriction of tobacco product advertisements, national law to discourage young people, and peer-based approaches to quit tobacco are popular policies. Smuggling of tobacco products by youth and ignorance of smokeless tobacco control approach are major challenges. Limitation: Our study was flexible for the standard age of youth and we were not able to include all countries in the world and most of the studies focused on smoking control rather than all smokeless tobaccos. Conclusion: The policies of tobacco control adopted by many countries are based on the WHO Framework Convention on Tobacco Control but not necessarily focused on youth. Due to the physical and economic burden of tobacco consumption by youth, this is a high priority that needs to be addressed. Youth-focused creative policies are necessary, and more priority must be given to tobacco prevention in youth. Tobacco control should be a social, public health, and quality-of-life concern rather than a business and trade issue. Implication of key findings: There is limited research on how and in what ways tobacco control policies reach young people and their engagement with these policies from physical, physiological, and psychological aspects. Analysis of these aspects, popular polices practiced in different countries, and creative strategies support the need to review current practices and future ways to discourage youth from tobacco use.
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Affiliation(s)
- Chhabi Lal Ranabhat
- Policy Research Institute, Kathmandu, Nepal
- Institute for Poverty Alleviation and International Development, Yonsei University, Wonju, South Korea
- Manmohan Memorial Institute of Health Science, Kathmandu, Nepal
- Department of Gerontology, Pai Chai University, Daejeon, South Korea
| | - Chun-Bae Kim
- Institute for Poverty Alleviation and International Development, Yonsei University, Wonju, South Korea
- Department of Preventive Medicine, Yonsei University Wonju College of Medicine, Wonju, South Korea
| | - Myung Bae Park
- Department of Gerontology, Pai Chai University, Daejeon, South Korea
| | - Mihajlo (Michael) Jakovljevic
- Department of Global Health Economics and Policy, University of Kragujevac, Kragujevac, Serbia
- Division of Health Economics, Lund University, Lund, Sweden
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Pond D, Mate K, Stocks N, Gunn J, Disler P, Magin P, Marley J, Paterson N, Horton G, Goode S, Weaver N, Brodaty H. Effectiveness of a peer-mediated educational intervention in improving general practitioner diagnostic assessment and management of dementia: a cluster randomised controlled trial. BMJ Open 2018; 8:e021125. [PMID: 30121596 PMCID: PMC6104761 DOI: 10.1136/bmjopen-2017-021125] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE Test effectiveness of an educational intervention for general practitioners (GPs) on quality of life and depression outcomes for patients. DESIGN Double-blind, cluster randomised controlled trial. SETTING General practices in Australia between 2007 and 2010. PARTICIPANTS General practices were randomly allocated to the waitlist (n=37) or intervention (n=66) group, in a ratio of 1:2. A total of 2030 (1478 intervention; 552 waitlist) community-dwelling participants aged 75 years or older were recruited via 168 GPs (113 intervention; 55 waitlist). INTERVENTIONS A practice-based academic detailing intervention led by a peer educator that included: (1) training in use of the GP assessment of cognition dementia screening instrument; (2) training in diagnosis and management based on Royal Australian College of General Practitioners Dementia Guidelines; (3) addressing GPs' barriers to dementia diagnosis; and (4) a business case outlining a cost-effective dementia assessment approach. OUTCOME MEASURES Primary outcome measures were patient quality of life and depression; secondary outcome measures were: (1) sensitivity and specificity of GP identification of dementia; (2) referral to medical specialists and/or support services; (3) patient satisfaction with care; and (4) carer quality of life, depression and satisfaction with care. RESULTS The educational intervention had no significant effect on patient quality of life or depression scores after 12 months. There were however improvements in secondary outcome measures including sensitivity of GP judgement of dementia (p=0.002; OR 6.0, 95% CI 1.92 to 18.73), satisfaction with GP communication for all patients (p=0.024; mean difference 2.1, 95% CI 0.27 to 3.93) and for patients with dementia (p=0.007; mean difference 7.44, 95% CI 2.02 to 12.86) and enablement of carers (p=0.0185; mean difference 24.77, 95% CI 4.15 to 45.40). CONCLUSION Practice-based academic detailing did not improve patient quality of life or depression scores but did improve detection of dementia in primary care and patient satisfaction with GP communication. TRIAL REGISTRATION NUMBER ACTRN12607000117415; Pre-results.
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Affiliation(s)
- Dimity Pond
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Karen Mate
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, New South Wales, Australia
| | - Nigel Stocks
- Discipline of General Practice, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Jane Gunn
- Department of General Practice, University of Melbourne, Melbourne, Victoria, Australia
| | - Peter Disler
- School of Rural Health, Monash University, Bendigo, Victoria, Australia
| | - Parker Magin
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - John Marley
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Nerida Paterson
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Graeme Horton
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Susan Goode
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Natasha Weaver
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Henry Brodaty
- Dementia Centre for Research Collaboration and the Centre for Healthy Brain Ageing, School of Psychiatry, University of New South Wales, Sydney, New South Wales, Australia
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Foley T, Jennings A, Boyle S, Smithson WH. The development and evaluation of peer-facilitated dementia workshops in general practice. EDUCATION FOR PRIMARY CARE 2017; 29:27-34. [PMID: 29050541 DOI: 10.1080/14739879.2017.1390693] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Rising dementia prevalence rates, combined with the policy objectives of integrated care in the community, means that general practitioners (GPs) are playing an increasing and pivotal role in dementia care. However, GPs are challenged by dementia care and have identified it as an area of learning need. We describe the development, roll-out and evaluation of peer-facilitated workshops for GPs, as part of a national programme to support GPs in their delivery of dementia care. METHOD Informed by a triangulated educational needs analysis, small-group case-based workshops were designed. Five GPs were trained as facilitators and delivered workshops in GP practices within their own locality. A mixed-methods evaluation was undertaken, incorporating participant completion of post-workshop questionnaires along with the collection and analysis of qualitative data obtained from a focus group with workshop facilitators. RESULTS 104 GPs attended 39 workshops (median attendance number 3, range 2-9). The majority of participants reported an improvement in their knowledge and confidence in dementia care. In particular, participants felt that workshop content was relevant and they liked peer-facilitation within their own practices. Facilitators emphasised the importance of skilful facilitation of sensitive topics and described the tension between being regarded as a facilitator and a subject expert. CONCLUSIONS The findings of this study indicate that practice-based, peer-facilitated, small-group workshops improve self-reported knowledge and confidence in dementia care and are well-received by GPs. Findings further suggest that similar educational approaches may be effective in supporting GPs in other areas of complex chronic care in general practice.
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Affiliation(s)
- Tony Foley
- a Department of General Practice , University College Cork, National University of Ireland , Cork , Ireland
| | - Aisling Jennings
- a Department of General Practice , University College Cork, National University of Ireland , Cork , Ireland
| | - Siobhan Boyle
- a Department of General Practice , University College Cork, National University of Ireland , Cork , Ireland
| | - W Henry Smithson
- a Department of General Practice , University College Cork, National University of Ireland , Cork , Ireland
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Foley T, Boyle S, Jennings A, Smithson WH. "We're certainly not in our comfort zone": a qualitative study of GPs' dementia-care educational needs. BMC FAMILY PRACTICE 2017; 18:66. [PMID: 28532475 PMCID: PMC5441069 DOI: 10.1186/s12875-017-0639-8] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 05/14/2017] [Indexed: 11/13/2022]
Abstract
Background Rising dementia prevalence rates rise combined with the policy objective of enabling people with dementia to remain living at home, means that there will be a growing demand for dementia care in the community setting. However, GPs are challenged by dementia care and have identified it as an area in which further training is needed. Previous studies of GPs dementia care educational needs have explored the views of GPs alone, without taking the perspectives of people with dementia and family carers into account. The aim of the study was to explore GPs’ dementia care educational needs, as viewed from multiple perspectives, in order to inform the design and delivery of an educational programme for GPs. Methods A qualitative study of GPs, people with dementia and family carers in a community setting was undertaken. Face-to-face interviews were performed with GPs, people with dementia and with family carers. Interviews were audio-recorded, transcribed verbatim and thematically analysed. Results Thirty-one people were interviewed, consisting of fourteen GPs, twelve family carers and five people with dementia. GPs expressed a wish for further education, preferentially through small group workshops. Five distinct educational needs emerged from the interviews, namely, diagnosis, disclosure, signposting of local services, counselling and the management of behavioural and psychological symptoms (BPSD). While GPs focused on diagnosis, disclosure and BPSD in particular, people with dementia and family carers emphasised the need for GPs to engage in counselling and signposting of local services. Conclusions The triangulation of data from multiple relevant sources revealed a broader range of GPs’ educational needs, incorporating both medical and social aspects of dementia care. The findings of this study will inform the content and delivery of a dementia educational programme for GPs that is practice-relevant, by ensuring that the curriculum meets the needs of GPs, patients and their families.
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Affiliation(s)
- Tony Foley
- Department of General Practice, Western Gateway Building, University College Cork, Cork, Ireland.
| | - Siobhán Boyle
- Department of General Practice, Western Gateway Building, University College Cork, Cork, Ireland
| | - Aisling Jennings
- Department of General Practice, Western Gateway Building, University College Cork, Cork, Ireland
| | - W Henry Smithson
- Department of General Practice, Western Gateway Building, University College Cork, Cork, Ireland
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van den Dungen P, Moll van Charante EP, van de Ven PM, van Marwijk HWJ, van der Horst HE, van Hout HPJ. Case Finding of Mild Cognitive Impairment and Dementia and Subsequent Care; Results of a Cluster RCT in Primary Care. PLoS One 2016; 11:e0156958. [PMID: 27310616 PMCID: PMC4910994 DOI: 10.1371/journal.pone.0156958] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Accepted: 05/22/2016] [Indexed: 11/19/2022] Open
Abstract
PURPOSE Despite a call for earlier diagnosis of dementia, the diagnostic yield of case finding and its impact on the mental health of patients and relatives are unclear. This study assessed the effect of a two-component intervention of case finding and subsequent care on these outcomes. METHODS In a cluster RCT we assessed whether education of family physicians (FPs; trial stage 1) resulted in more mild cognitive impairment (MCI) and dementia diagnoses among older persons in whom FPs suspected cognitive decline and whether case finding by a practice nurse and the FP (trial stage 2) added to this number of diagnoses. In addition, we assessed mental health effects of case finding and subsequent care (trial stage 2). FPs of 15 primary care practices (PCPs = clusters) judged the cognitive status of all persons ≥ 65 years. The primary outcome, new MCI and dementia diagnoses by FPs after 12 months as indicated on a list, was assessed among all persons in whom FPs suspected cognitive impairment but without a formal diagnosis of dementia. The secondary outcome, mental health of patients and their relatives, was assessed among persons consenting to participate in trial stage 2. Trial stage 1 consisted of either intervention component 1: training FPs to diagnose MCI and dementia, or control: no training. Trial stage 2 consisted of either intervention component 2: case finding of MCI and dementia and care by a trained nurse and the FP, or control: care as usual. RESULTS Seven PCPs were randomized to the intervention; eight to the control condition. MCI or dementia was diagnosed in 42.3% (138/326) of persons in the intervention, and in 30.5% (98/321) in the control group (estimated difference GEE: 10.8%, OR: 1.51, 95%-CI 0.60-3.76). Among patients and relatives who consented to stage 2 of the trial (n = 145; 25%), there were no differences in mental health between the intervention and control group. CONCLUSIONS We found a non-significant increase in the number of new MCI diagnoses. As we cannot exclude a clinically relevant effect, a larger study is warranted to replicate ours. TRIAL REGISTRATION Nederlands Trial Register NTR3389.
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Affiliation(s)
- Pim van den Dungen
- Department of General Practice and Elderly Care Medicine, EMGO Institute for Health and Care Research, VU University Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Eric P. Moll van Charante
- Department of General Practice, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Peter M. van de Ven
- Department of Epidemiology and Biostatistics, VU University Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Harm W. J. van Marwijk
- Department of General Practice and Elderly Care Medicine, EMGO Institute for Health and Care Research, VU University Medical Center Amsterdam, Amsterdam, The Netherlands
- Primary Care Research Centre, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Henriëtte E. van der Horst
- Department of General Practice and Elderly Care Medicine, EMGO Institute for Health and Care Research, VU University Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Hein P. J. van Hout
- Department of General Practice and Elderly Care Medicine, EMGO Institute for Health and Care Research, VU University Medical Center Amsterdam, Amsterdam, The Netherlands
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10
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Iliffe S, Wilcock J, Drennan V, Goodman C, Griffin M, Knapp M, Lowery D, Manthorpe J, Rait G, Warner J. Changing practice in dementia care in the community: developing and testing evidence-based interventions, from timely diagnosis to end of life (EVIDEM). PROGRAMME GRANTS FOR APPLIED RESEARCH 2015. [DOI: 10.3310/pgfar03030] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BackgroundThe needs of people with dementia and their carers are inadequately addressed at all key points in the illness trajectory, from diagnosis through to end-of-life care. The EVIDEM (Evidence-based Interventions in Dementia) research and development programme (2007–12) was designed to help change this situation within real-life settings.ObjectivesThe EVIDEM projects were (1) evaluation of an educational package designed to enhance general practitioners’ (GPs’) diagnostic and management skills; (2) evaluation of exercise as therapy for behavioural and psychological symptoms of dementia (BPSD); (3) development of a toolkit for managing incontinence in people with dementia living at home; (4) development of a toolkit for palliative care for people with dementia; and (5) development of practice guidance on the use of the Mental Capacity Act (MCA) 2005.DesignMixed quantitative and qualitative methods from case studies to large database analyses, including longitudinal surveys, randomised controlled trials and research register development, with patient and public involvement built into all projects.SettingGeneral practices, community services, third-sector organisations and care homes in the area of the North Thames Dementia and Neurodegenerative Diseases Research Network local research network.ParticipantsPeople with dementia, their family and professional carers, GPs and community mental health team members, staff in local authority social services and third-sector bodies, and care home staff.Main outcome measuresDementia management reviews and case identification in general practice; changes in behavioural and psychological symptoms measured with the Neuropsychiatric Inventory (NPI); extent and impact of incontinence in community-dwelling people with dementia; mapping of pathways to death of people with dementia in care homes, and testing of a model of collaborative working between primary care and care homes; and understandings of the MCA 2005 among practitioners working with people with dementia.ResultsAn educational intervention in general practice did not alter management or case identification. Exercise as a therapy for BPSD did not reduce NPI scores significantly, but had a significant positive effect on carer burden. Incontinence is twice as common in community-dwelling people with dementia than their peers, and is a hidden taboo within a stigma. Distinct trajectories of dying were identified (anticipated, unexpected and uncertain), and collaboration between NHS primary care and care homes was improved, with cost savings. The MCA 2005 legislation provided a useful working framework for practitioners working with people with dementia.ConclusionsA tailored educational intervention for general practice does not change practice, even when incentives, policy pressure and consumer demand create a favourable environment for change; exercise has potential as a therapy for BPSD and deserves further investigation; incontinence is a common but unrecognised problem for people with dementia in the community; changes in relationships between care homes and general practice can be achieved, with benefits for people with dementia at the end of life and for the UK NHS; application of the MCA 2005 will continue to improve but educational reinforcements will help this. Increased research capacity in dementia in the community was achieved. This study suggests that further work is required to enhance clinical practice around dementia in general practice; investigate the apparent beneficial effect of physical activity on BPSD and carer well-being; develop case-finding methods for incontinence in people with dementia; optimise working relationships between NHS staff and care homes; and reinforce practitioner understanding of the MCA 2005.Trial registrationEVIDEM: ED-NCT00866099; EVIDEM: E-ISRCTN01423159.FundingThis project was funded by the Programme Grants for Applied Research programme of the National Institute for Health Research.
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Affiliation(s)
- Steve Iliffe
- Research Department of Primary Care & Population Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Jane Wilcock
- Research Department of Primary Care & Population Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Vari Drennan
- Centre for Health and Social Care Research, The Faculty of Health, Social Care and Education at Kingston University London & St George’s University of London (previously at University College London), London, UK
| | - Claire Goodman
- Centre for Research in Primary and Community Care, School of Health and Social Work, University of Hertfordshire, Hertfordshire, UK
| | - Mark Griffin
- Research Department of Primary Care & Population Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Martin Knapp
- Personal Social Services Research Unit (PSSRU), Department of Social Policy, London School of Economics and Political Science, London, UK
| | - David Lowery
- Older Peoples Mental Health Services, Central and North West London NHS Foundation Trust (previously known as Central & NW London Mental Health NHS Trust), London, UK
| | - Jill Manthorpe
- Social Care Workforce Research Unit, Policy Institute at King’s, King’s College London, London, UK
| | - Greta Rait
- Research Department of Primary Care & Population Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - James Warner
- Older Peoples Mental Health Services, Central and North West London NHS Foundation Trust (previously known as Central & NW London Mental Health NHS Trust), London, UK, Department of Psychiatry, Faculty of Medicine, Imperial College London, London, UK
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11
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Mukadam N, Cooper C, Kherani N, Livingston G. A systematic review of interventions to detect dementia or cognitive impairment. Int J Geriatr Psychiatry 2015; 30:32-45. [PMID: 25132209 DOI: 10.1002/gps.4184] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Accepted: 07/09/2014] [Indexed: 01/28/2023]
Abstract
BACKGROUND Memory services have been implemented nationally to increase early dementia diagnosis, and further evaluation of their impact and other strategies to increase timely dementia diagnosis are needed. AIMS To systematically review the literature for interventions intended to increase the detection of dementia or suspected dementia or people presenting with memory complaints. METHOD We searched electronic databases, hand searched references and contacted authors of included papers, contacted field experts and UK charities and councils for data about their dementia awareness programmes. RESULTS We included 13 studies, of which four were randomised controlled trials (RCT). Two RCTs found that general practitioner (GP) education increased suspected dementia cases. One RCT found up to six home visits from a specialist geriatric nurse over 30 months increased the rate of accurately diagnosed dementia. There was preliminary evidence from non-randomised studies that memory clinics increase timely diagnosis, but no evidence they increase the overall diagnosis rate. CONCLUSIONS There is good quality evidence that GP education increases the number of suspected dementia cases but not accurate or earlier dementia diagnoses. One RCT reported that multiple visits from a trained nurse increase the diagnosis rate. There is no cost effectiveness evidence. Our findings suggest good quality RCTs are needed to test the effectiveness and cost-effectiveness of interventions to increase dementia detection.
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Affiliation(s)
- Naaheed Mukadam
- Division of Psychiatry, University College London, Charles Bell House, 2nd Floor, 67-73 Riding House Street, London, W1W 7EJ, UK
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12
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Caruana-Pulpan O, Scerri C. Practices in diagnosis, disclosure and pharmacotherapeutic management of dementia by general practitioners--a national survey. Aging Ment Health 2014; 18:179-86. [PMID: 23869797 DOI: 10.1080/13607863.2013.819833] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To explore the practice patterns of general practitioners (GPs) for the diagnosis, disclosure and pharmacological management of individuals with dementia. We also investigated whether the number of years working in general practice is a determinant factor associated with the responses obtained. METHOD A national survey was sent to all registered GPs in the Maltese islands. The return rate was 54.2% with the majority of respondents having 15 years or more working experience in general practice. Chi-square analysis of variance was used to determine any relationship effects. RESULTS Although the majority of GPs indicated lack of competence in diagnosing dementia, only a small percentage showed a preference towards specialist referral. Lack of training was mostly envisaged by physicians with the least number of years in general practice. Significant differences in pharmacotherapeutic prescribing were noted depending on the stage of disease progression and the number of years working as a GP. Disease disclosure was not routinely carried out even though GPs were aware of the fact that disclosure may help individuals with dementia and their caregivers or relatives with future planning. CONCLUSION The findings show notable shortcomings in various aspects of dementia management by GPs. This highlights the need of providing continued educational support and training opportunities to enhance not only GPs' clinical competence, but also their role as key players in providing quality support to individuals with dementia in the primary care setting.
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Affiliation(s)
- Oana Caruana-Pulpan
- a Department of Clinical Pharmacology and Therapeutics, Faculty of Medicine and Surgery , University of Malta , Msida , Malta
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13
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McKenzie JE, French SD, O'Connor DA, Mortimer DS, Browning CJ, Russell GM, Grimshaw JM, Eccles MP, Francis JJ, Michie S, Murphy K, Kossenas F, Green SE. Evidence-based care of older people with suspected cognitive impairment in general practice: protocol for the IRIS cluster randomised trial. Implement Sci 2013; 8:91. [PMID: 23958469 PMCID: PMC3765181 DOI: 10.1186/1748-5908-8-91] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Accepted: 07/26/2013] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Dementia is a common and complex condition. Evidence-based guidelines for the management of people with dementia in general practice exist; however, detection, diagnosis and disclosure of dementia have been identified as potential evidence-practice gaps. Interventions to implement guidelines into practice have had varying success. The use of theory in designing implementation interventions has been limited, but is advocated because of its potential to yield more effective interventions and aid understanding of factors modifying the magnitude of intervention effects across trials. This protocol describes methods of a randomised trial that tests a theory-informed implementation intervention that, if effective, may provide benefits for patients with dementia and their carers. AIMS This trial aims to estimate the effectiveness of a theory-informed intervention to increase GPs' (in Victoria, Australia) adherence to a clinical guideline for the detection, diagnosis, and management of dementia in general practice, compared with providing GPs with a printed copy of the guideline. Primary objectives include testing if the intervention is effective in increasing the percentage of patients with suspected cognitive impairment who receive care consistent with two key guideline recommendations: receipt of a i) formal cognitive assessment, and ii) depression assessment using a validated scale (primary outcomes for the trial). METHODS The design is a parallel cluster randomised trial, with clusters being general practices. We aim to recruit 60 practices per group. Practices will be randomised to the intervention and control groups using restricted randomisation. Patients meeting the inclusion criteria, and GPs' detection and diagnosis behaviours directed toward these patients, will be identified and measured via an electronic search of the medical records nine months after the start of the intervention. Practitioners in the control group will receive a printed copy of the guideline. In addition to receipt of the printed guideline, practitioners in the intervention group will be invited to participate in an interactive, opinion leader-led, educational face-to-face workshop. The theory-informed intervention aims to address identified barriers to and enablers of implementation of recommendations. Researchers responsible for identifying the cohort of patients with suspected cognitive impairment, and their detection and diagnosis outcomes, will be blind to group allocation. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry: ACTRN12611001032943 (date registered 28 September, 2011).
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Affiliation(s)
- Joanne E McKenzie
- School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, 99 Commercial Road, Melbourne, Australia.
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14
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Delva F, Pimouguet C, Helmer C, Péres K, Bréchat B, Le Goff M, Jacqmin-Gadda H, Amieva H, Orgogozo JM, Auriacombe S, Berr C, Tzourio C, Barberger-Gateau P, Dartigues JF. A simple score to predict survival with dementia in the general population. Neuroepidemiology 2013; 41:20-8. [PMID: 23548733 DOI: 10.1159/000346497] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Accepted: 12/03/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS This study was designed to develop a practical risk score for predicting 5-year survival after the diagnosis of dementia. METHODS Using the Paquid Study (prospective, population-based, long-term cohort study), we created a prognosis score with incident cases of dementia and validated it in another prospective, population-based, long-term cohort study, the Three City Study. - RESULTS Among the 3,777 subjects enrolled in the Paquid Study, 454 incident cases of dementia were included in this study. After a 5-year follow-up period, 319 (70.3%) were deceased. The score was constructed from three independent prognostic variables (gender, age at diagnosis and number of ADL restricted). The discriminant ability of the score was good with a c index of 0.754. Sensitivity was 64.7% and specificity 76.3%. In the validation cohort, the discriminant ability of the prognostic score with c statistics was 0.700. Sensitivity was 26.3% and specificity 95.4%. CONCLUSIONS The prognostic factors selected in the predictive model are easily assessable, so this simple score could provide helpful information for the management of dementia, particularly to identify patients with duration of the disease greater than 5 years.
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Affiliation(s)
- F Delva
- Centre INSERM U897, ISPED, CHU de Bordeaux, Bordeaux, France.
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15
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Clarkson P, Abendstern M, Sutcliffe C, Hughes J, Challis D. The identification and detection of dementia and its correlates in a social services setting: Impact of a national policy in England. DEMENTIA 2011. [DOI: 10.1177/1471301211421089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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16
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Mitchell AJ, Meader N, Pentzek M. Clinical recognition of dementia and cognitive impairment in primary care: a meta-analysis of physician accuracy. Acta Psychiatr Scand 2011; 124:165-83. [PMID: 21668424 DOI: 10.1111/j.1600-0447.2011.01730.x] [Citation(s) in RCA: 131] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We aimed to examine the ability of the general practitioners (GPs) to recognize a spectrum of cognitive impairment from mild cognitive impairment (MCI) to severe dementia in routine practice using their own clinical judgment. METHOD Using PRISMA criteria, a meta-analysis of studies testing clinical judgment and clinical documentation was conducted against semi-structured interviews (for dementia) and cognitive tests (for cognitive impairment). We located 15 studies reporting on dementia, seven studies that examined recognition of broadly defined cognitive impairment, and eight regarding MCI. RESULTS By clinical judgment, clinicians were able to identify 73.4% of people with dementia and 75.5% of those without dementia but they made correct annotations in medical records in only 37.9% of cases (and 90.5% of non-cases). For cognitive impairment, detection sensitivity was 62.8% by clinician judgment but 33.1% according to medical records. Specificity was 92.6% for those without cognitive impairment by clinical judgment. Regarding MCI, GPs recognized 44.7% of people with MCI, although this was recorded in medical notes only 10.9% of the time. Their ability to identify healthy individuals without MCI was between 87.3% and 95.5% (detection specificity). CONCLUSION GPs have considerable difficulty identifying those with MCI and those with mild dementia and are generally poor at recording such diagnoses in medical records.
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Affiliation(s)
- Alex J Mitchell
- Leicester General Hospital, Leicestershire Partnership Trust, UK.
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17
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Koch T, Iliffe S. Dementia diagnosis and management: a narrative review of changing practice. Br J Gen Pract 2011; 61:e513-25. [PMID: 21801564 PMCID: PMC3145536 DOI: 10.3399/bjgp11x588493] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2010] [Revised: 05/04/2010] [Accepted: 05/20/2010] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Early detection and management of dementia in primary care are difficult problems for practitioners. England's National Dementia Strategy 2009 seeks to improve these areas but there is limited evidence on how to achieve this most effectively. AIM This review aims to identify and appraise empirical studies of interventions designed to improve the performance of primary care practitioners in these areas. DESIGN A narrative review of primary-care based studies. METHOD Publications up to February 2010 were identified by searching the electronic databases MEDLINE, Embase, and PsycINFO, and bibliographies. The criterion for inclusion was that studies had to be of interventions aimed at improving detection or management of dementia in primary care. Exclusion criteria included studies in non-English publications, pharmacological interventions, and screening instrument studies. Quality was assessed using the PEDro (Physiotherapy Evidence Database) scale. RESULTS Fifteen studies were identified, of which 11 were randomised controlled trials. Eight reported educational interventions, and seven trialled service redesign, either by changing the service pathway or by introducing case management. Educationally, only facilitated sessions and decision-support software improved GPs' diagnosis of dementia, as did trials of service-pathway modification. Some of the case-management trials showed improved stakeholder satisfaction, decreased symptoms, and care that was more concordant with guidelines. CONCLUSION The quality of the studies varied considerably. Educational interventions are effective when learners are able to set their own educational agenda. Although modifying the service pathway and using case management can assist in several aspects of dementia care, these would require the provision of extra resources, and their value is yet to be tested in different health systems.
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Affiliation(s)
- Tamar Koch
- Department of Primary Care and Population Health, University College, London, UK.
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18
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Perry M, Drašković I, Lucassen P, Vernooij-Dassen M, van Achterberg T, Rikkert MO. Effects of educational interventions on primary dementia care: A systematic review. Int J Geriatr Psychiatry 2011; 26:1-11. [PMID: 21157845 DOI: 10.1002/gps.2479] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine the effects of educational interventions about dementia, directed at primary care providers (PCPs). DESIGN We searched Medline, Embase, PsycInfo, Cinahl and the Cochrane library for relevant articles. Two researchers independently assessed the citations identified against the following inclusion criteria: educational intervention on dementia directed at PCPs and study designs being randomized controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) or interrupted time series (ITS) analyses. Outcomes of interest were PCPs' knowledge and attitude on dementia, and quality of dementia care at PCP and patient level. RESULTS Of 3953 citations identified, six articles representing five studies (four cluster RCTs and one CBA) were eligible, describing educational interventions directed at 1904 PCPs. Compliance to the interventions varied from 18 to 100%. Systematic review of the studies showed moderate positive results. Five articles reported at least some effects of the interventions. A small group workshop and a decision support system (DSS) increased dementia detection rates. An interactive 2-h seminar raised GPs' suspicion of dementia. Adherence to dementia guidelines only improved when an educational intervention was combined with the appointment of dementia care managers. This combined intervention also improved patients' and caregivers' quality of life. Effects on knowledge and attitudes were minor. CONCLUSION Educational interventions for PCPs that require active participation improve detection of dementia. Educational interventions alone do not seem to increase adherence to dementia guidelines. To effectively change professionals' performance in primary dementia care, education probably needs to be combined with adequate reimbursement or other organizational incentives.
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Affiliation(s)
- M Perry
- Department of Geriatric Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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19
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Roedl JB, Bleich S, Schlötzer-Schrehardt U, von Ahsen N, Kornhuber J, Naumann GOH, Kruse FE, Jünemann AGM. Increased homocysteine levels in tear fluid of patients with primary open-angle glaucoma. Ophthalmic Res 2008; 40:249-56. [PMID: 18437035 DOI: 10.1159/000127832] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2006] [Indexed: 11/19/2022]
Abstract
AIMS We assessed homocysteine (Hcy) levels in tear fluid and plasma of patients with primary open-angle glaucoma (POAG). We determined the association between Hcy levels, dry eye syndrome and B vitamin status. METHODS This prospective case-control study included 36 patients with POAG and 36 controls. Hcy concentrations were measured by high-performance liquid chromatography. RESULTS Patients with POAG had significantly higher mean Hcy levels both in tear fluid (205 +/- 84 nmol/l; p < 0.001, t test) and in plasma (13.43 +/- 3.53 micromol/l; p = 0.001, t test) than control subjects (130 +/- 53 nmol/l and 10.50 +/- 3.33 micromol/l, respectively). Hcy in tear fluid was significantly correlated with plasma Hcy in POAG patients (r = 0.459; p = 0.005, Pearson's correlation), but not in controls (r = 0.068; p = 0.695). POAG patients with dry eye disease had significantly higher Hcy levels both in tear fluid and plasma than POAG patients without dry eye disease. There was no association between Hcy levels and B vitamin status in subjects with POAG. CONCLUSIONS The study suggests increased Hcy levels in tear fluid and plasma of patients with POAG. Elevated Hcy levels might be a risk factor for POAG and dry eye syndrome in subjects with glaucoma.
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Affiliation(s)
- J B Roedl
- Department of Ophthalmology, University Eye Hospital, Erlangen-Nuremberg, Germany.
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