Adina Dreier

Life- and person-centred help in Mecklenburg-Western Pomerania, Germany (DelpHi): study protocol for a randomised controlled trial

BackgroundThe provision of appropriate medical and nursing care for people with dementia is a major challenge for the healthcare system in Germany. New models of healthcare provision need to be developed, tested and implemented on the population level. Trials in which collaborative care for dementia in the primary care setting were studied have demonstrated its effectiveness. These studies have been conducted in different healthcare systems, however, so it is unclear whether these results extend to the specific context of the German healthcare system.The objective of this population-based intervention trial in the primary care setting is to test the efficacy and efficiency of implementing a subsidiary support system on a population level for persons with dementia who live at home.Methods and study designThe study was designed to assemble a general physician-based epidemiological cohort of people above the age of 70 who live at home (DelpHi cohort). These people are screened for eligibility to participate in a trial of dementia care management (DelpHi trial). The trial is a cluster-randomised, controlled intervention trial with two arms (intervention and control) designed to test the efficacy and efficiency of implementing a subsidiary support system for persons with dementia who live at home. This subsidiary support system is initiated and coordinated by a dementia care manager: a nurse with dementia-specific qualifications who delivers the intervention according to a systematic, detailed protocol. The primary outcome is quality of life and healthcare for patients with dementia and their caregivers. This is a multidimensional outcome with a focus on four dimensions: (1) quality of life, (2) caregiver burden, (3) behavioural and psychological symptoms of dementia and (4) pharmacotherapy with an antidementia drug and prevention or suspension of potentially inappropriate medication. Secondary outcomes include the assessment of dementia syndromes, activities of daily living, social support health status, utilisation of health care resources and medication.DiscussionThe results will provide evidence for specific needs in ambulatory care for persons with dementia and will show effective ways to meet those needs. Qualification requirements will be evaluated, and the results will help to modify existing guidelines and treatment paths.Trial registrationNCT01401582

Rates of Formal Diagnosis in People Screened Positive for Dementia in Primary Care: Results of the DelpHi-Trial

BACKGROUND Primary data about rates of formal diagnosis of dementia in the German primary care sector are widely lacking. OBJECTIVES Main objectives are to analyze the rate of syndrome diagnosis in primary care patients who screened positive for dementia, the distribution of differential diagnoses, and factors associated with undiagnosed dementia. METHODS DelpHi-MV (Dementia: life- and person-centered help in Mecklenburg-Western Pomerania) is an ongoing general practitioner (GP)-based, randomized, controlled intervention trial. A total of 4,064 patients (≥70 years, living at home) recruited from 108 participating GP practices were screened for dementia (DemTect < 9). Of 692 eligible patients (17%), a total of 406 subjects (59%) provided informed consent. Present analyses are based on the data of 243 patients with complete baseline assessment on January 1, 2014 (preliminary data). Formal diagnoses were retrieved from the medical records of the treating GPs. A conditional fixed effect regression analysis was performed to analyze factors associated with undiagnosed dementia. RESULTS A total of 40% of patients who screened positive for dementia had been formally diagnosed with dementia. Unspecified dementia was diagnosed in 53%, vascular dementia in 24%, and Alzheimers disease in 19% of these patients. Undiagnosed dementia was significantly associated with a higher mean score in the Mini-Mental State Examination (odds ratio, 1.11; p < 0.01, 95% confidence interval 1.04-1.18). CONCLUSIONS The diagnosis rate of dementia in German primary care (40%) is well within the range of the international data (20-50%). The results emphasize the need for action to enhance recognition and differential diagnosis of dementia.

Dementia care management: going new ways in ambulant dementia care within a GP-based randomized controlled intervention trial

Background: Increasing prevalence of dementia is a major challenge for the German healthcare system. The study DelpHi-MV (“Dementia: life- and person-centered help in Mecklenburg-Western Pomerania”) aims to implement and evaluate an innovative subsidiary support system for persons with dementia (PwDs) living at home and their caregivers. Methods: DelpHi-MV is a GP-based cluster randomized controlled intervention trial. DelpHi-Intervention aims to provide “optimum care” by integrating multi-professional and multimodal strategies to individualize and optimize treatment of dementia within the framework of the established healthcare and social service system. The intervention is conducted by Dementia Care Managers (DCMs) – nurses with dementia-specific training – at the peoples homes. Based on German guidelines for evidence-based diagnoses and treatment of dementia, a comprehensive set of 95 intervention modules – the “DelpHi-Standard” – was defined. Each module consists of predefined trigger condition(s), a subsequent intervention task, as well as at least one criterion for its completion. The intervention begins with a comprehensive assessment of the care situation, needs, and resources. The DCM develops and implements an intervention plan tailored to the individual conditions in close cooperation with the GP. Expected Results and Conclusions: We expect statistically significant differences between control and intervention group in primary outcomes (quality of life, behavioral and psychological symptoms of dementia, pharmacotherapy, caregiver burden). Results can provide evidence for the effectiveness and efficacy of dementia care management according to the “Delphi-Standard” – prerequisites for implementing this concept into routine healthcare.

A curriculum for nurses in Germany undertaking medically-delegated tasks in primary care.

AIM This paper is a report of a study conducted to develop a qualification for nurses in primary care based on the delegation of medical tasks in order to relieve general practitioners and to supply the population in rural regions today and in the future. BACKGROUND Age-demographic changes will cause medical care supply problems, especially for older people, motivating a re-evaluation of the nursing role in ambulatory medical care. METHODS An intervention study was conducted in Germany between 1 January 2006 and 31 December 2007, comprising a theoretical and practical phase evaluated by participants, general practitioners and patients through questionnaires, reflection rounds and structured interviews during and after the practice phase. FINDINGS Participants and general practitioners rated the curriculum as relevant and useful. Nurses were motivated by the ability to be self-employed and the expansion of their scope of professional work general practitioners regarded medical duty delegation as workload relief. Patients positively evaluated nurse visits, comparing medical competence and conduct to that of a general practitioners. CONCLUSION The qualification is a promising approach to compensate for the imminent under-supply of primary care and allows maintenance a high standard of healthcare quality for rural areas of Germany and countries with similar structures. It supports doctors through task delegation, and offers an option for an advanced training for nurses.

Rates of formal diagnosis of dementia in primary care: The effect of screening

Screening could improve recognition of dementia in primary care. We sought to determine the effect of screening for dementia in primary care practices on the formal diagnosis rate; the distribution of differential diagnoses; and the factors associated with receiving a formal diagnosis.

Delegation und Substitution spezifischer medizinischer Tätigkeiten als künftiger Versorgungsansatz

Changing health care needs caused by changing demographics lead to an increasing demand for medical and nursing care in Germany. A declining number of general practitioners will soon cause a lack of health care supply in a growing number of regions. Nurses constituting the largest occupational group in the health care system contribute by filling the resulting gap. Internationally, models have been developed to incorporate new responsibilities for nursing professionals. However, nursing education needs to be adapted as well. Presently nurses are not qualified to take on medical tasks. The current nursing curriculum needs to include medical skills and content to reach a qualification status comparable to other European countries. The transition towards a more team-oriented medical care will have to be supervised and evaluated by health services research in both nursing and clinical care. The aim is to also provide a basis for the further development of the relevant socio-legal framework.

Systematic, early identification of dementia and dementia care management are highly appreciated by general physicians in primary care - results within a cluster-randomized-controlled trial (DelpHi)

Background There is evidence about the benefits of early detection of dementia and subsequent provision of adequate treatment and care. However, there is a lack of knowledge about the acceptance of detection and intervention procedures. These analyses describe the attitudes of general physicians [GPs] toward 1) dementia in general, 2) systematic detection of people with dementia, and 3) an intervention approach after they have experienced both. Comparisons are made based on experience with systematic screening and dementia-specific intervention. Methods Postal, cross-sectional survey to all n=1,252 GPs in the Mecklenburg-Western Pomerania, Germany. A subsample was drawn based on participation in the randomized, controlled, prospective intervention DelpHi-MV trial (Dementia: life- and person-centered help in Mecklenburg-Western Pomerania). In this trial, systematic screening is implemented and an intervention group receives support through dementia care management (DCM). GPs were categorized into either GPs with DCM and systematic screening (DCM-GP), GPs with systematic screening only (DelpHi-GP), or GPs not participating in the trial. Data from n=257 GPs were available. Attitudes toward dementia were assessed using a validated questionnaire. Results There was strong agreement toward the helpfulness of implementing a brief cognitive screening test (89.9% agreed). Approximately two-thirds of the respondents indicated that they had identified at least some patients as being cognitively impaired for the first time. The majority of the respondents indicated agreement toward DCM. It was described as supportive and helpful. The qualified nurses were perceived as competent in dementia care and 79.3% would like to be supported with DCM. Attitudes toward dementia are positive and do not differ between groups. Conclusion The results indicate that early recognition and DCM is highly appreciated by GPs and is considered feasible or wanted to be implemented in routine care.

Subjective memory impairment: No suitable criteria for case-finding of dementia in primary care

Subjective memory impairment (SMI) might be used for the case‐finding of dementia. Present analyses aim to determine the diagnostic value and the predictive ability of SMI and related worries for the discrimination of patients screened positive or negative for dementia.

The benefits of implementing a computerized Intervention-Management-System (IMS) on delivering integrated dementia care in the primary care setting

BACKGROUND A computerized Intervention-Management-System (IMS) has been developed and implemented to facilitate dementia care management. IMS is a rule-based expert decision support system that matches individual patient characteristics to a computerized knowledge base. One of the most important functionalities of IMS is to support the compilation of the individual intervention plan by systematically identifying unmet needs and suggesting the corresponding specific interventions for recommendation to the general practitioner (GP). The present analysis aimed to determine if the implementation of IMS improves the identification of unmet needs and the recommendation of adequate specific interventions. In addition, the feasibility and acceptability of the IMS were evaluated. METHODS Delphi-MV is an on-going GP-based, cluster-randomized, controlled intervention trial to implement and evaluate a collaborative dementia care management program for community-dwelling PWDs and their caregivers. IMS was developed and implemented over the course of the DelpHi-trial. The identified unmet needs and the interventions that were recommended to the GP before and after the implementation of IMS were compared. To evaluate the feasibility and acceptability of the IMS, a survey was conducted among the current users of IMS. RESULTS AND CONCLUSIONS After the implementation of IMS, the number of specific interventions recommended to the GP increased by 85%. Our findings provide evidence that IMS improves the systematic identification of unmet needs and the subsequent recommendation of interventions to address these needs. The users evaluated IMS as very helpful and would like to use it for their future work. However, the usability could be further improved.

Community-Dwelling People Screened Positive for Dementia in Primary Care: A Comprehensive, Multivariate Descriptive Analysis Using Data from the DelpHi-Study

BACKGROUND Efficient help and care for people with dementia (PWD) is dependent on knowledge about PWD in primary care. OBJECTIVE This analysis comprehensively describes community-dwelling PWD in primary care with respect to various dementia care specific variables. METHODS The analyses are based on baseline data of the ongoing general practitioner-based, randomized, controlled intervention trial DelpHi-MV (Dementia: life- and person-centered help). 6,838 patients were screened for dementia in 136 GP practices; 17.1% were screened positive, 54.4% of those agreed to participate and data could be assessed in n = 516 subjects. We assessed age, sex, living situation, cognitive status, functional status, level of impairment, comorbidities, formal diagnosis of dementia, depression, neuropsychiatric symptoms, quality of life, utilization of medical support, and pharmacological therapy. RESULTS Concerning clinical-, dementia-, and health-related variables, the sample under examination was on average mildly cognitively and functionally impaired (MMSE, m = 22.2; BADL, m = 3.7). A level of care was assigned in 38.0%. Depression was identified in 15.4% and other frequent comorbidities were high blood pressure (83.3%), coronary heart diseases (37.1%), cerebrovascular diseases (22.3%), among others. In 48.6%, neuropsychiatric symptoms were present in a clinically relevant severity. Pharmacological treatment with antidementia medication was received by 25.8% and antidepressant medication by 14.0%. Utilization of services was generally low. CONCLUSION The comprehensive description of people screened positive for dementia in primary care reveals a complex and unique population of patients. They are considerably underdiagnosed and in their majority mildly to moderately affected. More in-depth analyses are needed to study relations, associations and interactions between different variables.