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Primary care practitioners (PCPs) do not routinely promote dementia risk reduction. The purpose of this study was to map the published literature on the views of PCPs about dementia risk reduction, in order to identify implementation constructs and strategies crucial to the development of an implementation intervention to support dementia risk reduction in primary care. We undertook a scoping review of the PCPs’ views about promoting brain health for reducing dementia risk. We searched MEDLINE, PsycINFO, CINAHL, and Embase for English-language articles published between 1995 and December 2017. We then applied the Consolidated Framework for Implementation Research (CFIR) and matched Expert Recommendations for Implementing Change to the scoping review findings in order to develop a preliminary implementation model. Eight articles reported views of PCPs about dementia prevention. Study findings were mapped to 5 of the 39 CFIR constructs: (i) knowledge and beliefs about dementia risk reduction, (ii) evidence strength and quality, (iii) relative priority, (iv) available resources, and (v) external policy and incentives. The findings suggest implementation strategies to consider in our preliminary model include (i) educational meetings, (ii) identifying and preparing champions, (iii) conducting local consensus discussions, (iv) altering incentive structures, and (v) capturing and sharing local knowledge. There have been few studies about the views of PCPs about dementia risk reduction. Implementation in the primary care setting is fundamental to early identification of risk and supporting preventive practices, but it needs to focus on more than just education for PCPs. We need more up-to-date and in-depth data on the views of PCPs about dementia risk reduction and context-specific analyses of implementation needs. Further research into effective primary care interventions to reduce dementia risk is expected to support implementation efforts.
Dementia in the elderly constitutes a growing challenge in healthcare worldwide, including Hungary. There is no previous report on the role of general practitioners in the management of dementia.
Aim:
The purpose of the present study was to investigate the Hungarian general practitioners’ attitude toward their patients living with dementia as well as dementia care. Our goal was also to assess their willingness and habits in assessing dementia. Additionally we wanted to explore the role of education about dementia, and its impact on their attitude in dementia management.
Methods:
As part of a large survey, a self-administered questionnaire was filled out voluntarily by 402 of general practitioners. According to our preset criteria, 277 surveys were selected for evaluation. Descriptive statistical analysis and Likert-scale analysis were performed.
Findings:
Half of the doctors (49.8%) indicated that they conducted a test to assess cognitive functions in case of suspicion. Among the respondents who did not assess, 50.0% of physicians cited lack of time as the main reason for not doing so and 14.4% of them had not proper knowledge of testing methods. The respondents most often mentioned feelings toward their patients with dementia, were regret (Likert-scale mean: 3.33), helplessness (3.28) and sadness (3.07). The majority of physicians thought the treatment of dementia was difficult (4.46). Most of the respondents (81.2%) indicated that in the past 2 years they had not participated in any training about dementia. Those practitioners who had participated in some form of education were less likely to feel helpless facing a patient with dementia, and education also determined their approach to dementia care.
This study is aimed at developing a Rural Primary Health Care (PHC) Model for delivering comprehensive PHC for dementia in rural settings and addressing the gap in knowledge about disseminating and implementing evidence-based dementia care in a rural PHC context.
Background
Limited access to specialists and services in rural areas leads to increased responsibility for dementia diagnosis and management in PHC, yet a gap exists in evidence-based best practices for rural dementia care.
Methods
Elements of the Rural PHC Model for Dementia were based on seven principles of effective PHC for dementia identified from published research and organized into three domains: team-based care, decision support, and specialist-to-provider support. Since 2013 the researchers have collaborated with a rural PHC team in a community of 1000 people in the Canadian province of Saskatchewan to operationalize these elements in ways that were feasible in the local context. The five-step approach included: building relationships; conducting a problem analysis/needs assessment; identifying core and adaptable elements of a decision support tool embedded in the model and resolving applicability issues; implementing and adapting the intervention with local stakeholders; and sustaining the model while incrementally scaling up.
Results
Developing and sustaining relationships at regional and PHC team levels was critical. A comprehensive needs assessment identified challenges related to all domains of the Rural PHC Model. An existing decision support tool for dementia diagnosis and management was adapted and embedded in the team’s electronic medical record. Strategies for operationalizing other model elements included integrating team-based care co-ordination into the decision support tool and family-centered case conferences. Research team specialists provided educational sessions on topics identified by the PHC team. This paper provides an example of a community-based process for adapting evidence-based practice principles to a real-world setting.
A growing number of older people are accessing emergency medical services (EMS), and many calls to EMS are made by, or on behalf of, people with dementia. Their needs are frequently complex; however, EMS staff are often given minimal guidance on ensuring patient safety, accurate diagnosis, and timely transfer to the most appropriate care. This study aimed to qualitatively explore the EMS experiences of carers for people with dementia and assess the views of EMS staff on the management of dementia, using focus groups and interviews. Themes were focussed on the circumstances surrounding EMS calls to people with dementia. These can prove frustrating due to a lack of information sharing, limited alternatives to hospital attendance and the amount of time that it can take to meet the complex needs of a person with dementia.
To explore the experiences and challenges for residential care home staff when managing the healthcare needs of their residents, in particular those living with dementia.
Background
Increasing number of older people, with complex health and social care needs are living in residential care homes. Yet there is limited appreciation of why staff sometimes struggle to manage residents’ healthcare needs, or understanding of their working relationship with district nurses (DNs), whose responsibility it is to provide nursing support.
Methods
This PhD study, in a metropolitan area in the United Kingdom, was conducted by an experienced DN and involved three phases. This paper focuses on the first two phases. Phase 1 data included: semi-structured interviews (n=8), reflective field notes based on non-participant observation, documentary analysis of policies, procedures and assessment tools and other contextual data from one care home (case study site). The practitioner researcher reflected on the findings from the case study, in relation to her own knowledge and experience as a DN, focusing in particular on findings that were familiar, or which surprised. In Phase 2 she fed these findings back to other care homes (n=11) to check whether the findings from the single case study were unique or resonated with others. She gathered their feedback through semi-structured interviews with senior care staff (n=14). Data were analysed using thematic data analysis.
Findings
Findings highlight the complexity facing residential care homes: high levels of healthcare needs amongst residents, the demands of caring for residents living with dementia, variations in the knowledge and skill set of care staff, inequity in the level of healthcare support, the challenges of building a good relationship with DNs, and funding pressures facing care homes.
Implications
Any, or all of these factors can prevent care home staff from managing the healthcare needs of their residents.
Improving dementia diagnosis rates in England has been a key strategic aim of the UK Government but the variation and low diagnosis rates are poorly understood. The aim of this study was to explore the variation in actual versus expected diagnosis of dementia across England, and how these variations were associated with general practice characteristics.
Method
A cross-sectional, ecological study design using secondary data sources and median regression modelling was used. Data from the year 2011 for 7711 of the GP practices in England (92.7%). Associations of dementia diagnosis rates (%) per practice, calculated using National Health Service England’s ‘Dementia Prevalence Calculator’ and various practice characteristics were explored using a regression model.
Results
The median dementia diagnosis rate was 41.6% and the interquartile range was 31.2–53.9%. Multivariable regression analysis demonstrated positive associations between dementia diagnosis rates and deprivation of the population, overall Quality and Outcomes Framework performance, type of primary care contract and size of practice list. Negative associations were found between dementia diagnosis rates and average experience of GPs in the practice and the proportion of the practice caseload over 65 years old.
Conclusion
Dementia diagnosis rates vary greatly across GP practices in England. This study has found independent associations between dementia diagnosis rates and a number of patient and practice characteristics. Consideration of these factors locally may provide targets for case-finding interventions and so facilitate timely diagnosis.
To synthesize information about management of end of life care in people with dementia using review papers.
Background
There are increasing numbers of people being diagnosed with dementia worldwide, and the needs of people with dementia and their carers at the end of life may be different from those with other chronic diseases. By highlighting the challenges of palliative care in persons with dementia and the ways they are best managed, practitioners in primary care may be able to improve services for this group of people at the end of life.
Methods
A search of electronic databases of English language papers published in peer-reviewed journals, 2000–2011 inclusive was undertaken using broad terms related to palliative care and dementia. 6167 papers were identified. Titles and abstracts were read. Papers were included if they were literature reviews of palliative or end of life care for people with dementia/Parkinson's disease/Lewy body dementia/cognitive impairment/Alzheimer's disease or any other cognitive impairment, in any setting (hospital, care home, community) and covering people of all ages. Papers were excluded if they covered palliative care focusing on other conditions, or were about an aspect of dementia care and treatment not related to palliative care.
Findings
Our critical synthesis generated five main themes from this review of the reviews: (1) carers’ (family caregivers’) experiences; (2) person-centred care; (3) practice (including advance care planning, pain and comfort, nutrition, medical complications and minimizing the distress of behavioural symptoms); (4) system factors, including ethical dilemmas, decision making, information, and training; and (5) research priorities. There appears to be good evidence on the care and management of patients with dementia at the end of life which can be used to influence policy development and emerging specificity about research priorities in palliative care practice for people with dementia.
Little is known about the views of rural family physicians (FPs) regarding collaborative care models for patients with dementia. The study aims were to explore FPs’ views regarding this issue, their role in providing dementia care, and the implications of providing dementia care in a rural setting. This study employed an exploratory qualitative design with a sample of 15 FPs. All rural FPs indicated acceptance of collaborative models. The main disadvantages of practicing rural were accessing urban-based health care and related services and a shortage of local health care resources. The primary benefit of practicing rural was FPs’ social proximity to patients, families, and some health care workers. Rural FPs provided care for patients with dementia that took into account the emotional and practical needs of caregivers and families. FPs described positive and negative implications of rural dementia care, and all were receptive to models of care that included other health care professionals.
The need to improve the response of primary care in terms of identification of people with undiagnosed dementia has long been recognised. The role of Primary Care Liaison was identified as a possible solution. An in-depth consultation was undertaken to identify professional competencies required in executing such a role.
Methods
Comprehensive literature and policy reviews were conducted to establish draft competencies or different options/combinations of competencies and competency levels. Consultations with a wide range of professional stakeholders (n = 23) and over 70 users and carers were conducted through focus groups, electronic document circulation and telephone interviews. An Equality Impact Assessment was conducted concurrent to the consultation.
Results
The literature demonstrated a clear need both to improve the rate of diagnosis for people with dementia and to improve the way in which the diagnosis is made. The stakeholder consultation repeatedly affirmed that without a diagnosis the person with dementia and their caregivers did not get access to the appropriate services, and validated the need for a role that would be able to improve a system that would deliver an early and ‘timely’ diagnosis. Competencies, based on the literature and policy documents, were developed and debated through the consultation processes.
Conclusions
Three main areas of competency were identified: counselling; screening; and health education and promotion. The competencies identified require a skilled experienced professional approach. A useful team model would be that the role is placed within a ‘GP cluster’ as accessibility to GP records and collaborative working with GPs is essential within the role. Personal continuing professional development has a high profile in maintaining these competencies.
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.
This article reports on the implementation of community-based prevention of dementia among older adults in Japan. It is expected that the incidence of dementia will continue to increase as the population ages and thus care of those at risk of and with dementia is an important issue for nursing practice in the community. Community-based prevention of dementia comprises a comprehensive range of activities such as obtaining an understanding of community residents, early detection of dementia, fostering of volunteers, implementation of dementia prevention activities, provision of nursing care for older adults with dementia, as well as collaboration with local administrative institutions. We are working with a Japanese community (population of 65 years or more: about 2480 out of a total population of 10800) and in this article our activities are described. Among our activities we focus on itemizing the signs of dementia for early detection of the disease and on fostering volunteers. For early detection of dementia it is important to itemize the signs of dementia that close family members would notice in daily life. For fostering of volunteers it is necessary to enable them to develop skills to provide activities/clubs to interest the older adults and which are effective for prevention of dementia. We have started with clubs including a personal computer club, children's songs club and a picture mail club. Such activities are important strategies for a community-based intervention. The article concludes with reference to the need for verification studies to evaluate the impact of the community-based approach to the prevention of dementia outlined here which includes anticipatory education of the population concerning dementia, development of a method of early detection of dementia using a check-list and a means of secondary prevention via the activities of a group of volunteers (Ichigo Kai).
