Murna Downs

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.

The Emergence of the Person in Dementia Research

The purpose of this review is to identify and explore the emerging attention being paid to the individual in dementia research. Following a brief introduction, the review will examine literature which recognises three aspects of the person with dementia: the individuals sense of self; the persons rights; and the value to be gained from a concern with the perspectives of people with dementia. To date the medical model has dominated dementia research. This model tends to reduce the person with dementia to his/her neurobiology or neuropsychology (Cotrell and Schulz 1993). The experience and manifestation of dementia has been attributed solely to the disease process, with a consequent neglect of the psychosocial context surrounding the individual (Lyman 1989). Research on the psychosocial aspects of dementia has concentrated on family carers. Keady (1996) provides a useful categorisation of this research into the following topics: gender and coping style; marital relationships and the impact of dementia; access to information and services; participation in and effectiveness of support groups; adjustment and circumstances surrounding admission into care; and perception of own health needs. No literature focuses on people with dementia.

Meaningful social interactions between older people in institutional care settings

This paper is a contribution to the developing understanding of social relationships in institutional care settings. It focuses on two areas that have been neglected in research: the reasons for and types of social interaction in institutional settings, and the ways in which the context of peoples lives shapes social interaction. The paper draws on ethnographic observations conducted in four care settings in Scotland using a symbolic interactionist perspective. It finds that residents communicate and interact, and that the personal, cultural and structural contexts frame social interaction and influence the ways that residents use humour, express sexuality, and show hostility. The paper concludes that residents create social interactions in which action is embedded, but do so within specific structural and cultural contexts. These contexts ‘control’ resident action by establishing frameworks for the interpretation of meaning. At the same time, each facet of context is ‘controlled’ by the ways in which residents actively take on the ‘role’ of others, and project ‘self’ and a ‘label’.

Assessing the pain of people with cognitive impairment

This review presents evidence of the undertreatment of pain for people with cognitive impairment and explores reasons for this, emphasizing inadequate detection due to lack of suitable pain assessment protocols. Implications for practice and suggestions for further research are made. Copyright

The role of general practice and the primary care team in dementia diagnosis and management

General practitioners (GPs) and the primary care team are uniquely situated to play a central role both in the diagnosis and ongoing care of dementia. Anecdotal reports and empirical work suggest that GPs face several challenges in fulfilling this role. This paper describes the various roles GPs and the primary care team could play in diagnosis and ongoing management. It then discusses the legitimate anxieties and difficulties faced in fulfilling these roles. The paper concludes with suggestions for how GPs and the primary care team might be supported to maximize their role in dementia diagnosis and management.

Dementia in a socio-cultural context: an idea whose time has come

Dementia studies are currently dominated by biomedical and psychological models that focus on the individual without regard to their socio-cultural context (Bond 1992, 1999; Lyman 1989; Harding and Palfry 1997; Whitehouse et al. 2000). There is now a growing interest in how socio-cultural factors may mediate the experience of, and response to, dementia (Holstein 1998). The purpose of this review is to examine this growing interest in the socio-cultural context of dementia with reference to earlier developments in disability studies (Oliver 1990; Thomas 1999) and ageing research in general (Estes et al. 1984). The implications of placing dementia in a socio-cultural context for research, policy and practice will be discussed. Most of the theoretical work on dementia has been devoted to pointing out the inadequacies of biomedical and psychological models in which problems are attributed solely to an individuals neuropathology with a simultaneous neglect of socio-cultural factors (Binney and Swan 1991; Lyman 1989; Harding and Palfry 1998; Kitwood 1998). The study of dementia, it is argued, has been limited by the broader ‘biomedicalisation of ageing’ whereby problems of ageing have been attributed to the ‘tragedy’ of the individuals pathology rather than as a function of an inadequate societal response. Robertson (1991) describes how people so labelled are referred to as ‘victims’ or ‘sufferers’. All difficulties in the persons life are attributed to their underlying disease with a consequent neglect of social and environmental factors that may ameliorate or prevent such ‘symptoms’.

What Do General Practitioners Tell People with Dementia and their Families about the Condition?: A survey of experiences in Scotland

There has been growing discussion in the literature about the merits and demerits of disclosing a diagnosis to a person with dementia. There is growing empirical evidence that general practitioners (GPs) are reluctant to share the diagnosis with people with dementia. To date little research has examined what GPs tell their patients and their families. The purpose of the reported study was to examine what GPs tell people with dementia and their families about the condition. The study relied on data gathered from an opportunistic sample of 114 GPs who were attending a training course in care of people with dementia. Findings reveal a disparity between what GPs tell the family and the person. People with dementia tend to be given information about the symptoms and the cause is described predominantly as part of ageing. Family members are given information about symptoms, cause, prognosis and available supports. Best practice regarding diagnosis disclosure to people with dementia needs to be established. This includes what people with dementia are told, how they are told and what supports are made available to those who have been told.

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 diagnosis and management of dementia in primary care: Development, implementation and evaluation of a national training programme

General practitioners (GPs) and their teams are uniquely situated to achieve early diagnosis and optimal management in the community of dementia, yet there is evidence of under-diagnosis, under-response to established dementia, and inadequate management. An educational agenda has been proposed on the basis of a review of existing studies and a national training programme has been designed to test the feasibility, acceptability and relevance of this agenda for primary care workers in the UK. A nationwide programme of workshops was successfully implemented, using educational methods based on adult learning principles, and received a very positive response from a multidisciplinary audience. This educational agenda has been shown to be congruent with the reported experiences of primary care workers, particularly GPs. Community psychiatric nurses (CPN) emerge from the findings of this study as a professional group who might have an important educational role for other professionals in primary care.

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.