J. De Lepeleire

Understanding obstacles to the recognition of and response to dementia in different European countries: a modified focus group approach using multinational, multi-disciplinary expert groups.

Experts from eight European countries (Belgium, France, The Netherlands, Ireland, Italy, Portugal, Spain and the United Kingdom) and the disciplines of clinical psychology, general practice, geriatric medicine, old age psychiatry, medical sociology, nursing and voluntary body organisation met in 2003 to explore obstacles to recognition of and response to dementia in general practice within Europe. A modified focus group methodology was used in this exploratory process. Groups were conducted over a two-day period, with five sessions lasting 1–1.5 hours each. An adapted nominal group method was used to record themes arising from the group discussion, and these themes were used in a grounded theory approach to generate explanations for delayed recognition of and response to dementia. The overarching theme that arose from the focus groups was movement, which had three different expressions. These were: population movement and its consequences for localities, services and professional experience; the journey of the person with dementia along the disease process; and the referral pathway to access services and support. Change is the core issue in dementia care, with multiple pathways of change that need to be understood at clinical and organisational levels. Practitioners and people with dementia are engaged in managing emotional, social and physical risks, making explicit risk management a potentially important component of dementia care. The boundary between generalist and specialist services is a particular problem, with great potential for dysfunctionality. Stigma and ageism are variably distributed phenomena both within and between countries.

The diagnostic value of IADL evaluation in the detection of dementia in general practice

It is assumed that general practitioners can make an important contribution to the diagnosis of dementia. One of the used strategies comprises an evaluation of the Instrumental Activities of Daily Living (IADL). There are contradictory data on the value of this strategy. During one month, 21 Flemish general practitioners evaluated the IADL capacities of all subjects older than 65 years with whom they had contact. Subjects with dementia and/or living in a residential home for the elderly were excluded. Housing and living conditions, medication use and IADL were registered. The general practitioner formulated a clinical evaluation. All subjects with an IADL score ≥ 1 and a random sample from the group IADL = 0 underwent a Mini Mental State Examination. Subjects with an IADL score = 4 were referred for neuropsychological and specialist examination. The average age of the 1003 registered subjects was 75.1 years (SD = 6.8). A large majority of them (85%) were totally independent. There was a large discrepancy between the familys and the patients judgment on the presence of memory problems. There was an inverse correlation between the IADL and MMSE: when the IADL score increased, the MMSE score fell. The diagnostic value of the IADL for the diagnosis of dementia with Camdex-N as a reference standard could not be evaluated because the number of tested subjects was too small. Against the MMSE, sensitivity was 0.81 (SE = 0.03), and specificity was 0.48 (SE = 0.05). The evaluation of the IADL activities had some drawbacks as a detection method for dementia but the use of IADL data may still be clinically valuable in general practice. The correlation between the general practitioners judgment and that of the specialist was very good. This study showed that the use of the IADL score might change the general practitioners diagnostic judgment. Furthermore this study confirms the existence of a major threshold for the referral to a specialist of patients with suspected dementia by general practitioners.

Disclosing the diagnosis of dementia: the performance of Flemish general practitioners

BACKGROUND This issue of whether or not, how and when patients should be told of the diagnosis of dementia remains a matter for discussion. Recent data confirm that the patient is told of the diagnosis in only 40 to 55% of cases. We therefore studied the performance of Flemish general practitioners (GPs) in this area. METHOD A postal questionnaire, based on that prepared by Johnson et al., was sent to a random sample of 1000 Flemish GPs, out of a total of 7000. RESULTS A total of 647 answers were returned, of which 521 were eligible for analysis (response rate 60%). Thirty-six percent of these 521 GPs always or usually disclose the diagnosis, while 37% provide information about the prognosis. Most doctors (75%) see benefits in disclosure, particularly as regards planning care, providing treatment and encouraging a good doctor-patient relationship. Only 61% of respondents present an appropriate differential diagnosis. DISCUSSION The results obtained from the Flemish GPs are similar to those of other known studies. A detailed analysis of the reasons for and the benefits of disclosing the diagnosis reveal a less reluctant attitude than could be inferred from the rough data. GPs pay a great deal of attention to the patients feelings, experiences and ability to cope and to the proper timing of their information. However, intensive educational projects have to be set up in order to stimulate a more etiologically-oriented diagnosis and to improve the quality of the process of disclosing the diagnosis of dementia.

An evaluation of a computer based education program for the diagnosis and management of dementia in primary care. An international study of the transcultural adaptations necessary for European dissemination.

Objectives: The aim of this study is to make an inventory of the changes that are needed to make an interactive computer based training program (ICBT) with a specific educational content, acceptable to professional communities with different linguistic, cultural and health care backgrounds in different European countries. Methods: Existing educational software, written in two languages was reviewed by GPs and primary care professionals in three different countries. Reviewers worked through the program using a structured critical reading grid. Results: A ‘simple’ translation of the program is not sufficient. Minor changes are needed to take account of linguistic differences and medical semantics. Major changes are needed in respect of the existing clinical guidelines in every country related to differences in the existing health care systems. Conclusions: ICTB programs cannot easily be used in different countries and cultures. The development of a structured educational program needs collaboration between educationalists, domain experts, information technology advisers and software engineers. Simple validation of the content by local expert groups will not guarantee the programs exportability. It is essential to involve different national expert groups at every phase of the development process in order to disseminate it in other countries.

Progression and improvement after mild cognitive impairment

ObjectiveWe studied progression to dementia and improvement rates of mild cognitive impairment (MCI) to help clinicians decide whether or not to screen older people for MCI.MethodProspective cohort study in which 156 vulnerable patients with (n = 24) and without (n = 132) MCI are followed and reassessed after two years with MMSE and Camdex.ResultsNine (38%) out of 24 patients initially diagnosed with MCI and 20 (15%) out of 132 considered normal or depressed progressed to dementia within two years. This results in a relative risk of progression of 2.48 (95% confidence interval = 1.29-4.77), a sensitivity of 31%(95%CI = 16-51) and a predictive value of 38% (95%CI = 20-59). Out of 24 people with MCI at baseline, 8 (33%; 95%CI = 16-55) had improved at follow-up.ConclusionThe low sensitivity of MCI for subsequent occurrence of dementia and the high improvement rate found in our study as well as by others, and the absence of a proven therapy, provide cumulative evidence against screening for MCI.

Studying the impact of a medication use evaluation for polymedicated older patients by the community pharmacist (SIMENON): study protocol

BackgroundAged polymedicated patients are particularly vulnerable for drug-related problems. A medication review aims to optimize the medication use of patients and improve health outcomes. In this study, the effect of a pharmacist-led medication use review is investigated for polymedicated ambulatory older patients with the aim of implementing this pharmaceutical care intervention across Belgium.MethodsThis article describes the study protocol of the SIMENON study and reports the results of the feasibility study, which aimed to test and optimize this study protocol. In the SIMENON intervention study, 75 Belgian community pharmacies each recruit 12 patients for a medication use review. For each patient, the identified drug-related problems and subsequent interventions are registered using the PharmDISC classification. In a subset of Dutch speaking patients, a pretest-posttest single group design is used to measure the impact of this review on patient related outcomes using questionnaires. The main outcome of the study is the type and number of drug-related problems and related interventions. A second outcome is the impact of the medication use review on adherence, objectively measured with dispensing data. Evolution in medication related quality of life is another outcome, measured with the Living with Medicines Questionnaire version 3. Other patient reported outcomes include adherence, self-management, patient satisfaction, fall incidents and use of emergency healthcare services.DiscussionThe findings of this study can provide data on the effectiveness of a medication use review in the Belgian primary care setting. Furthermore, it will provide insights in which patients benefit most of this intervention and therefore facilitate the implementation of medication review in Belgium.Trial registrationClinicalTrials.gov NCT03179722. Retrospectively registered 7 June 2017.

A randomized clinical trial using an educational intervention demonstrated no effect on interobserver agreement on assessments of functional status

AimTo evaluate the effect of an educational intervention on interobserver agreement of assess-ments of functional status performed by registered nurses and care assistants in a nursing home and to compare interobserver agreement in persons with and without cognitive impairment.BackgroundHigh accuracy of assessments of functional status in care settings for older persons is needed for the efficacy of the planning and the evaluation of the nursing care.MethodRandomized clinical trial. Six registered nurses and six care assistants were randomized to participate in an educational session about assessment instruments for functional status (intervention) or in a session about falls in the elderly (control). Each of the registered nurses and care assistants performed assessments on the same thirty-four residents using the Belgian Evaluation Scale (BES) and the AGGIR instrument. The kappa statistic (κ) for multiple observers (and its 95% confidence interval) was the main outcome measure.FindingsAt baseline, interobserver agreement for BES total score was: κ = 0.43 (0.35-0.51) in the intervention group and κ = 0.48 (0.39-0.57) in the control group. At the second assessment, agreement measures were: κ = 0.48 (0.41-0.57) in the intervention group and κ = 0.58 (0.50-0.66) in the control group. Results for AGGIR total scores were similar.ConclusionInterobserver agreement of assessments on nursing home residents was moderate and did not improve significantly after an educational session.

Hoe functioneren ouderen? Een studie vanuit de huisartspraktijk

SummaryProblems with instrumental activities of daily living are important in the caring for elderly people, in general practice as well. Impairment in activities and instrumental activities of daily living may be important indicators for early dementia. This study explored how people aged 65 years and over in general practice are performing on four instrumental activities of daily living. Method General practitioners screened all people, aged 65 years and over, and meeting the inclusion criteria, they met during a period of one month. Personalia, instrumental activities of daily living and cognitive functioning were registered. Results Twentytwo general practitioners included 1003 persons, with a mean age of 75 year. The majority of this group (81.6%) was rather autonomous. The main cause of functional impairment were transport problems. Cognitive functioning and functional loss were correlated. Conclusion Elderly people in general practice function better than is generally assumed. This phenomenon has important consequences for training and functioning of GPs as to the evaluation of activities of daily living. The fundamental role of IADL assessment therefore needs attention in the professional development of GPs.SamenvattingProblemen van Instrumentele activiteiten van het Dagelijks Leven (IADL) zijn erg belangrijk bij de zorg voor ouderen, ook in de huisartspraktijk. Afwijkingen van de activiteiten in het dagelijkse leven (ADL) en de instrumentele activiteiten van het dagelijkse leven (IADL) kunnen belangrijke indicatoren zijn voor vroege dementie. In deze studie werd nagegaan hoe personen ouder dan 65 jaar in de huisartspraktijk scoren op vier instrumentele activiteiten van het dagelijkse leven. Methode Huisartsen screenden alle personen ouder dan 65 jaar met wie zij contact hadden en die voldeden aan de inclusiecriteria. Personalia, Instrumentele activiteiten dagelijks leven en cognitief functioneren door middel van de Mini Mental State Examination werden bepaald. Resultaten Tweëentwintig huisartsen includeerden 1003 patiënten. De gemiddelde leeftijd was 75,1 jaar. De grote meerderheid (81,6%) was erg autonoom in het functioneren. De belangrijkste reden voor functieverlies waren verplaatsingsproblemen. Cognitief en functioneel verlies waren gecorreleerd. Besluit Oudere patiënten in een huisartspraktijk functioneren doorgaans beter dan wordt aangenomen. Dit gegeven heeft belangrijke implicaties voor de opleiding en het functioneren van huisartsen met betrekking tot het evalueren van activiteiten dagelijks leven. Omdat de beoordeling van IADL van essentieel belang is in de zorg voor ouderen, moet dit element meer aandacht krijgen in de opleiding en de praktijkvoering van huisartsen.

De Ziekte van Alzheimer

De ziekte van Alzheimer en andere vormen van dementie vormen een grote bedreiging voor het welzijn van ouderen en voor iedereen die er mee te maken krijgt. Dementie komt relatief vaak voor: 1 op de 3 Nederlanders krijgt ermee te maken, hetzij zelf, hetzij in de directe omgeving. Getalsmatig vormt dementie (nog) geen groot probleem voor de huisarts: hooguit enkele patienten per jaar zullen aan zijn zorg toevertrouwd zijn. De aard van de problemen vereist echter een intensieve en actieve bemoeienis. De huisarts heeft vooral een belangrijke functie in het tijdig signaleren en nader diagnosticeren van dementie vanwege het langdurige en vaak nauwe contact dat hij onderhoudt met de patient en zijn naasten.