Jane Wilcock

Effectiveness of educational interventions in improving detection and management of dementia in primary care: cluster randomised controlled study

Abstract Objective To test the effectiveness of educational interventions in improving detection rates and management of dementia in primary care. Design Unblinded, cluster randomised, before and after controlled study. Setting General practices in the United Kingdom (central Scotland and London) between 1999 and 2002. Interventions Three educational interventions: an electronic tutorial carried on a CD Rom; decision support software built into the electronic medical record; and practice based workshops. Participants 36 practices participated in the study. Eight practices were randomly assigned to the electronic tutorial; eight to decision support software; 10 to practice based workshops; and 10 to control. Electronic and manual searches yielded 450 valid and usable medical records. Main outcome measures Rates of detection of dementia and the extent to which medical records showed evidence of improved concordance with guidelines regarding diagnosis and management. Results Decision support software (P = 0.01) and practice based workshops (P = 0.01) both significantly improved rates of detection compared with control. There were no significant differences by intervention in the measures of concordance with guidelines. Conclusions Decision support systems and practice based workshops are effective educational approaches in improving detection rates in dementia.

End of life care for community dwelling older people with dementia: an integrated review

To review the evidence for end‐of‐life care for community dwelling older people with dementia (including those resident in care homes).

Dementia Diagnosis and Management in Primary Care Developing and testing educational models

Dementia presents a challenge for primary care and the advent of new therapeutic options has highlighted the need to improve its detection so that early decisions about medication use can be made. Efforts at earlier diagnosis should be targeted at primary care as the gateway to specialist health and social services. There is, however, evidence that dementia remains under-detected and sub-optimally managed in general practice throughout the world. This article reviews the obstacles to early recognition of dementia and the factors causing sub-optimal management in the community, and discusses educational approaches to enhancing professional skills in the recognition of and response to dementia. Three educational interventions with different characteristics and methods of delivery are described.

The primary care diagnosis of dementia in Europe: An analysis using multidisciplinary, multinational expert groups

Objectives: To explore the extent of variation in the detection of dementia in primary care across Europe, and the potential for the development of European guidelines. Method: A mixture of focus group and adapted nominal group methods involving 23 experts of different disciplines and from eight European countries. Results: The diagnosis of dementia should be ‘timely’ rather than ‘early’. Timeliness has an impact on the patient, on the caregiver, on healthcare professionals, and on society. Ethical and moral issues may interfere with the aim of timely diagnosis. Guidelines may be important for facilitating a timely diagnosis of dementia, but were infrequently used and not even available in three of the eight countries. Referral pathways often depended on health care system characteristics, differing throughout the eight European countries, whilst diagnostic strategies differed due to varied cultural influences. There was consensus that national variations can be reduced and timely diagnosis enhanced by combining simple tests using a systematic stepwise case-finding strategy, in conjunction with a strong infrastructure of multidisciplinary collaboration. Conclusions: This study identified three key themes that should be considered in harmonizing European approaches to the diagnosis of dementia in primary care: (1) a focus on timely diagnosis, (2) the need for the development and implementation of guidelines, and (3) the identification of appropriate referral pathways and diagnostic strategies including multi-professional collaboration. The content of guidelines may be determined by the perspectives of the guideline developers.

The identification of barriers to the recognition of, and response to, dementia in primary care using a modified focus group approach

This study reports upon the identification of barriers to the recognition of and response to dementia in primary care as perceived by general practitioners and highlights areas of information and training need. The study took a qualitative approach involving group work with 144 general practitioners in three purposively selected settings using adapted nominal group data collection methods. Six key themes were identified that explain the complexity of dementia diagnosis and management: (1) the pre-eminence of problem-solving over differential diagnosis as a working style; (2) the existence of gaps in support services; (3) problems of confidentiality; (4) the importance of ‘red flags’; (5) rules governing disclosure of diagnoses; and (6) heuristics for distinguishing dementia from normal ageing or other pathologies. In addition the practitioners identified principles governing medication use, issues around carers’ needs and implications for professional education. The National Service Framework for Older People emphasizes the need for early detection and diagnosis of dementia in primary care. This study identified barriers to be overcome by targeted educational interventions and through service provision. There is an uneven geographical distribution of support and diagnostic services and a lack of awareness of how to access these, and this needs addressing. A stepwise educational method is recommended as opposed to promotion of a formal syllabus.

Concordance with clinical practice guidelines for dementia in general practice

Background: Dementia is said to be under-recognized and sub-optimally managed in primary care, but there is little information about actual processes of diagnosis and clinical care. Aim: To determine general practitioners’ concordance with clinical guidelines on the diagnosis and management of patients with dementia. Design: Unblinded, cluster randomized pre-test–post-test controlled trial involving 35 practices in the UK. Methods: Patients with a diagnosis of probable or confirmed dementia were identified in practices, and permission sought from the older person and/or their carer to study the medical records of these patients. Medical records were reviewed using a data extraction tool designed for the study and based on published guidelines, and unweighted scores for diagnostic concordance and management concordance were calculated. Results: We reviewed 450 records of patients aged 75 and over with a diagnosis of dementia and found that: only 4% of cases were identified first in secondary care; two-thirds of those identified in primary care were referred immediately; about one-third identified had informant history and blood tests documented at the Index consultation and one-fifth underwent cognitive function testing. Discussion: The records analysed in this study came from a period before the Quality Outcomes Framework and show that the documentation in primary care of the diagnostic process in dementia syndromes is good, although there were significant gaps, particularly around depression case-finding. Information about management processes were less evident in the records.

Tailored educational intervention for primary care to improve the management of dementia: the EVIDEM-ED cluster randomized controlled trial

BackgroundEarly diagnosis of dementia is important because this allows those with dementia and their families to engage support and plan ahead. However, dementia remains underdetected and suboptimally managed in general practice. Our objective was to test the effect of a workplace-based tailored educational intervention developed for general practice on the clinical management of people with dementia.MethodsThe tailored educational intervention was tested in an unblinded cluster randomized controlled trial with a pre/post-intervention design, with two arms: usual/normal care control versus educational intervention. The primary outcome measure was an increase in the proportion of patients with dementia who received at least two documented dementia-specific management reviews per year. Case identification was a secondary outcome measure.Results23 practices in South-East England participated. A total of 1,072 patients with dementia (intervention: 512, control: 560) had information in their medical records showing the number of reviews within 12 months (or a proportion of) before intervention or randomization and within 12 months (or a proportion of) after. The mean total number of dementia management reviews after the educational intervention for people with dementia was 0.89 (SD 1.09; minimum 0; median 1; maximum 8) compared with 0.89 (SD 0.92; minimum 0; median 1; maximum 4) before intervention. In the control group prior to randomization the mean total number of dementia management reviews was 1.66 (SD 1.87; minimum 0; median 1; maximum 12) and in the period after randomization it was 1.56 (SD 1.79; minimum 0; median 1; maximum 11). Case detection rates were unaffected. The estimated incidence rate ratio for intervention versus control group was 1.03 (P = 0.927, 95% CI 0.57 to 1.86).ConclusionsThe trial was timely, coinciding with financial incentives for dementia management in general practice (through the Quality Outcomes Framework); legal imperatives (in the form of the Mental Capacity Act 2005); policy pressure (The National Dementia Strategy 2009); and new resources (such as dementia advisors) that increased the salience of dementia for general practitioners. Despite this the intervention did not alter the documentation of clinical management of patients with dementia in volunteer practices, nor did it increase case identification.Trial registrationNCT00866099/Clinical Trials

Delivering psychosocial interventions for people with dementia in primary care Jobs or skills

Psychosocial interventions are emerging as potentially important therapies for primary care, partly to fill a therapy ‘vacuum’ and partly because the evidence base for their effectiveness is growing. They can be labour-intensive and their effectiveness depends on the skills of those working with people with dementia. This creates an immediate problem, since the workforce necessary to extend psychosocial interventions beyond innovative schemes does not exist. The existing workforce in health and social care in the UK is already too small to implement all of the changes required by the National Service Framework for Older People and National Service Framework for Mental Health. This has clear implications for the labour-intensive work of dementia care. If the job categories cannot expand as fast as is needed, the tasks of dementia care will have to be redistributed, suggesting that skills will have to be shared and transferred between different disciplines. The question for service commissioners and providers is: how can smarter working be achieved? This article attempts to answer this question with a qualitative study in general practice settings and with specialist informants. A triangulation approach to data collection was used, involving nominal groups, individual interviews and participant observation. We identified five skills that appear key in primary care: pattern recognition; deductive synthesis to reduce uncertainty; dialogue and disclosure; disability perspectives; and case management with shared care. The paucity of understanding of psychosocial interventions across disciplines who offer dementia care in the community is, we suggest, a major problem for those attempting to deploy such interventions in primary care settings. The pervasive tendency to frame the tasks of dementia care in terms of a medical management model brings responses that can undermine the view that people with dementia may in fact have a tractable disability. We use our findings to suggest solutions to this problem.

Methodological problems in dementia research in primary care: a case study of a randomized controlled trial

The emerging UK national research network in neurodegenerative diseases and dementias aims to promote large-scale community-based studies of therapeutic interventions, based in primary care. However, trials in primary care settings can be problematic, a common difficulty being the recruitment of a large enough sample. The article discusses recruitment issues in a multi-centre randomized controlled trial of differing educational approaches to improving dementia care in general practice. Sample size calculations based on community studies of prevalence may be misleading in intervention trials which may recruit practices with atypical demography. Recruitment rates for practitioners in this study were lower than expected. Professionals excluded themselves from the study mainly due to pressures of time and staff shortages, and we detected both ambivalent attitudes to primary care research and a perception that research into dementia care was not a high priority. Evaluation of the quality of care may be perceived as criticism of clinical practice, at a time when general practice is undergoing major administrative and contractual changes. Variations in Research Ethics Committee conditions for approval led to different methods of recruitment of patients and carers into the study, a factor which may have contributed to disparate levels of recruitment across study sites. Patient and carer levels of recruitment were lower than expected and were affected partly by carers’ time pressures and other family commitments, but largely by problems in identifying patients and carers in the practices. The development of research potential in primary care is at an early stage and studies reliant on patient recruitment in general practice must allow for multiple obstacles to enrollment. This is particularly relevant for studies of dementia care, where the prevalence of dementia in a demographically average population is low and the incidence very low, compared with other disabilities. Professionals may give dementia low priority in allocating practice time for research projects, and strategies to address this problem are needed.

Developing an educational intervention on dementia diagnosis and management in primary care for the EVIDEM-ED trial

BackgroundDementia syndromes are under-diagnosed and under-treated in primary care. Earlier recognition of and response to dementia syndrome is likely to enhance the quality of life of people with dementia, but general practitioners consistently report limited skills and confidence in diagnosis and management of this condition. Changing clinical practice is difficult, and the challenge for those seeking change it is to find ways of working with the grain of professional knowledge and practice. Assessment of educational needs in a practice has the potential to accommodate variations in individual understanding and competence, learning preferences and skill mix. Educational prescriptions identify questions that need to be answered in order to address a clinical problem. This paper reports the development of an educational needs assessment tool to guide tailored educational interventions designed to enhance early diagnosis and management of dementia in primary care, in the Evidence Based Interventions in Dementia in the Community – Early Diagnosis trial.MethodsA multidisciplinary team, including a lay researcher, used an iterative technology development approach to create an educational needs assessment tool, from which educational prescriptions could be written. Workplace learning was tailored to each practice using the educational prescription, and the method was field-tested in five pilot practices.ResultsThe educational prescriptions appeared acceptable and useful in volunteer practices. The time commitment (no more than four hours, spread out at the practice’s discretion) appeared manageable. The pilot group of practices prioritised diagnosis, assessment of carers’ needs, quality markers for dementia care in general practice, and the implications of the Mental Capacity Act (2005) for their clinical practice. The content of the educational needs assessment tool seemed to be comprehensive, in that no new topics were identified by practices in the field trial.ConclusionsThe educational needs assessment tool took into account practitioners’ knowledge of the local health and social care systems, reflected the complexity of the diagnostic and care processes for people with dementia, and acknowledged the complexity of the disease process itself.