Barbara Workman

Understanding diagnosis and management of dementia and guideline implementation in general practice: a qualitative study using the theoretical domains framework.

BackgroundDementia is a growing problem, causing substantial burden for patients, their families, and society. General practitioners (GPs) play an important role in diagnosing and managing dementia; however, there are gaps between recommended and current practice. The aim of this study was to explore GPs’ reported practice in diagnosing and managing dementia and to describe, in theoretical terms, the proposed explanations for practice that was and was not consistent with evidence-based guidelines.MethodsSemi-structured interviews were conducted with GPs in Victoria, Australia. The Theoretical Domains Framework (TDF) guided data collection and analysis. Interviews explored the factors hindering and enabling achievement of 13 recommended behaviours. Data were analysed using content and thematic analysis. This paper presents an in-depth description of the factors influencing two behaviours, assessing co-morbid depression using a validated tool, and conducting a formal cognitive assessment using a validated scale.ResultsA total of 30 GPs were interviewed. Most GPs reported that they did not assess for co-morbid depression using a validated tool as per recommended guidance. Barriers included the belief that depression can be adequately assessed using general clinical indicators and that validated tools provide little additional information (theoretical domain of ‘Beliefs about consequences’); discomfort in using validated tools (‘Emotion’), possibly due to limited training and confidence (‘Skills’; ‘Beliefs about capabilities’); limited awareness of the need for, and forgetting to conduct, a depression assessment (‘Knowledge’; ‘Memory, attention and decision processes’). Most reported practising in a manner consistent with the recommendation that a formal cognitive assessment using a validated scale be undertaken. Key factors enabling this were having an awareness of the need to conduct a cognitive assessment (‘Knowledge’); possessing the necessary skills and confidence (‘Skills’; ‘Beliefs about capabilities’); and having adequate time and resources (‘Environmental context and resources’).ConclusionsThis is the first study to our knowledge to use a theoretical approach to investigate the barriers and enablers to guideline-recommended diagnosis and management of dementia in general practice. It has identified key factors likely to explain GPs’ uptake of the guidelines. The results have informed the design of an intervention aimed at supporting practice change in line with dementia guidelines, which is currently being evaluated in a cluster randomised trial.

People aged over 75 in atrial fibrillation on warfarin: the rate of major hemorrhage and stroke in more than 500 patient-years of follow-up.

Objectives: To determine the incidence of major hemorrhage and stroke in people aged 76 and older with atrial fibrillation on adjusted‐dose warfarin who had been recently been admitted to hospital.Objectives: To determine the incidence of major hemorrhage and stroke in people aged 76 and older with atrial fibrillation on adjusted-dose warfarin who had been recently been admitted to hospital. Design: A retrospective observational cohort study. Setting: A major healthcare network involving four tertiary hospitals. Participants: Two hundred thirty-five patients aged 76 and older admitted to a major healthcare network between July 1, 2001, and June 30, 2002, with atrial fibrillation on warfarin were enrolled. Measurements: Information regarding major bleeding episodes, strokes, and warfarin use was obtained from patients, relatives, primary physicians, and medical records. Results: Two hundred twenty-eight patients (42% men) with a mean age of 81.1 (range 76–94) were included in the analysis. Total follow-up on warfarin was 530 years (mean 28 months). There were 53 major hemorrhages, for an annual rate of 10.0%, including 24 (45.3%) life-threatening and five (9.4%) fatal bleeds. The annual stroke rate after initiation of warfarin was 2.6%. Conclusion: The rate of major hemorrhage was high in this old, frail group, but excluding fatalities, resulted in no long-term sequelae, and the stroke rate on warfarin was low, demonstrating how effective warfarin treatment is.

Psychometric properties of the Pain Attitudes Questionnaire (revised) in adult patients with chronic pain

Previous evidence supports the utility of the newly developed pain attitudes questionnaire (PAQ) for assessing pain‐related stoicism and cautiousness in community‐dwelling pain‐free adults (Yong et al., 2001). A revised questionnaire (PAQ‐R) was examined in the present study to determine the generalizability of psychometric properties when used with chronic pain patients. Results from both exploratory and confirmatory factor analyses suggest that the factor‐structure of the revised questionnaire was best represented by a five‐ rather than a four‐factor solution, thus, suggesting that chronic pain patients do not conceptualize the questionnaire items, in particular, with respect to the stoicism attitudes, in the same manner as the community‐dwelling adults. A satisfactory internal consistency reliability of the PAQ‐R was replicated in chronic pain patients. There was also evidence to suggest that chronic pain patients from different age cohorts do apply a similar frame of reference and calibration scale when responding to the items on the questionnaire. However, the cohorts of patients across the age spectrum show some differences in pain attitudes and possible reasons were discussed.

Single-dose and steady-state pharmacokinetics and pharmacodynamics of perindopril in hypertensive subjects.

Summary: In a double-blind, placebo-controlled, parallel group study, 24 essential hypertensive subjects were randomised to receive either placebo or 2, 4, or 8 mg perindopril. Perindopril, its deesterified metabolite, perindoprilat, and perindoprilat glucuronide were separated with an ion-exchange resin and determined by a radioimmunoassay (RIA). Pharmacokinetic and pharmacodynamic parameters were estimated for 96 h after the first dose and after 4-week once-daily treatment. Perindopril peak levels were achieved in < 2 h after dosing with an elimination t1/2 of 1–2 h. Peak levels of perindoprilat were achieved more slowly, reaching a maximum level 5–8 h after dosing, and had an elimination t1/2 of 40 h. Levels of the perindopril glucuronide peaked ∼0.5 h later than perindopril, with an elimination t1/2 of ∼2 h. Perindopril, perindoprilat, and its glucuronide conjugate followed linear kinetics in the dose range of 2–8 mg, and there was no evidence of accumulation with chronic dosing. Perindopril 4 and 8 mg produced significant decreases in pre-dose blood pressure (BP) with chronic dosing, with maximal decreases occurring 5–7 h after dosing. Perindopril also produced a prolonged dose-dependent inhibition of plasma angiotensin-converting enzyme (ACE) activity that was maximum after 4 h and had not fully recovered by 48 h after a single dose.

Effect of age on pharmacokinetics of and blood pressure responses to prazosin and terazosin.

Prazosin and terazosin are two (α1-adrenoceptor blocking agents, their principal difference being the longer half-life of terazosin. The present study was carried out to determine if elderly subjects are different from the young in their pharmacokinetic handling of these two drugs and if age influences the blood pressure response to each drug. Ten young healthy subjects (aged 19–30 years) and five older healthy subjects (aged 54–62 years) received 1 or 2 mg terazosin. 1 or 2 mg prazosin. or placebo 1 week apart according to a 5 × 5 Latin square design. Concentrations of prazosin and terazosin were measured using a high-performance liquid chromatographic procedure with a detection limit of −0.25 ng/ml. Pharmacokinetic parameters of prazosin were virtually the same in both groups, whereas mean terazosin plasma concentrations were higher in the older group and pharmacokinetic analysis revealed higher peak plasma concentrations and a longer terminal elimination half-life. There was no evidence of increased sensitivity to the hypotensive action of the drug, as peak upright blood pressure falls were similar in the two groups. Symptoms of dizziness in the upright position were also less common. In view of their lack of sedative effects and minimal metabolic disturbances, further studies should be conducted to assess the suitability of these drugs as monotherapy for hypertension in elderly patients.

Responding to the death of a resident in aged care facilities: Perspectives of staff and residents

A qualitative study using individual semistructured interviews was undertaken to explore the perceptions and experiences of 23 aged care residents with mild dementia concerning the deaths of coresidents. The views of 25 facility staff members were also explored. The study was based in 3 aged residential facilities in Victoria, Australia. Interview data indicated that residents and staff had differing views. Residents reported that the impact of the death of a coresident was much less than staff members thought. Residents generally wanted to be told about the death of someone they knew and considered attempts to hide the death and the removal of the body both unnecessary and disrespectful. Both groups agreed that the celebration of the life of a resident was important, although they differed in their preferences for the way this is done. These findings have implications for staff education and practice.

MAXCOG—Maximizing Cognition: A Randomized Controlled Trial of the Efficacy of Goal-Oriented Cognitive Rehabilitation for People with Mild Cognitive Impairment and Early Alzheimer Disease

OBJECTIVES To review the efficacy of a home-based four-session individualized face-to-face cognitive rehabilitation (MAXCOG) intervention for clients with mild cognitive impairment (MCI) or early dementia and their close supporters. DESIGN Randomized controlled trial comparing the intervention group (MAXCOG) with treatment as usual (control). PARTICIPANTS A total of 55 client-supporter dyads were enrolled in the study and 40 completed; 25 client-supporter dyads completed MAXCOG and 15 completed treatment as usual. Both MAXCOG and control groups included more MCI cases than dementia (22 versus 3 and 12 versus 3, respectively). INTERVENTION Four weekly individual sessions of MAXCOG consisting of personalized interventions to address individually relevant goals, supported by the provision of the MAXCOG information resource. MEASURES The primary outcomes were goal performance and satisfaction, assessed using the Canadian Occupational Performance Measure (COPM). Questionnaires assessing mood, illness adjustment, quality of life, and carer burden were also administered. RESULTS The intervention group displayed significantly higher performance and satisfaction with primary goals on the COPM post-intervention than the control group, using a per-protocol analysis. CONCLUSIONS The MAXCOG intervention is effective in improving goal performance and satisfaction in clients with MCI and early dementia.

Comparison of pharmacokinetics and pharmacodynamics of adrenoceptor agonists and antagonists as antihypertensive agents.

&NA; Central and peripheral &agr;‐adrenoceptors play an important role in cardiovascular regulation, and selective &agr;1‐adrenoceptor antagonists and &agr;2‐adrenoceptor agonists have an established place in the therapy of hypertension. Prazosin is a selective &agr;1‐antagonist that is both effective in lowering blood pressure and well tolerated. However, the more recently developed &agr;1‐antagonists doxazosin and terazosin offer the advantage of having longer half‐lives, allowing once daily administration. Clonidine is a centrally acting &agr;2‐agonist whose clinical use has often been limited by the dose dependent side effects of dry mouth and sedation, and the belief that it should be given three times per day. However, recent studies have shown that it has substantial antihypertensive efficacy with minimal side effects at low doses, and that half‐life is long enough to allow twice daily administration. An improved understanding of the pharmacodynamics and pharmacokinetics of drugs acting on &agr;‐adrenoceptors allows a more rational approach to their clinical application.

Cardiovascular Risk Reduction in the Extreme Elderly

An American Heart Association statement on secondary prevention of coronary heart disease in the elderly reported that 50% of women and 70% to 80%) of men over 75 years have obstructive coronary artery disease. The total direct and indirect costs of cardiovascular disease and stroke in the US for 2007 was around

A reality check on virtual communications in aged care: Pragmatics or power?

286 billion and annual costs are projected to rise to over