The debate on ethnicity and dementia: from category fallacy to person-centred care?

The concept of ethnicity remains attractive and meaningful to service developers and professionals, although research suggests that this disguises other facets of identity and difference. An epidemiological perspective on the relationship between ethnicity and dementia supports the idea that ethnicity (defined as particular shared cultural characteristics) is not likely to influence unduly the emergence of dementia in individuals. Cultural factors may protect against dementia, impeding its recognition and influencing its course and these deserve further investigation. Ethnicity is a general concept that subsumes and conceals the impact of migration, education, health beliefs and socio-economic status on health, and therefore is problematic. Empirical research on dementia and ethnicity reveals that intra-ethnic group variation is greater than inter-ethnic group variation; supporting the view that ethnicity as a category may not have great explanatory power and may foster a category fallacy. However, the experiences of people with dementia and their carers show that the important issues for service providers to consider are language, religious belief and observance, cultural practices (including food and personal care practices) and social support and coping mechanisms. In this position paper we argue that these issues are applicable to all individuals with dementia, independent of apparent ethnicity, and that promotion of cultural competence in service provision should not be relegated to an ethnic minority agenda. The task for health and social care providers is therefore to recognise the diversity of users and to increase access to appropriate quality mainstream person-centred services, rather than to develop segregated or specialized services.

Attitudes to long-term use of benzodiazepine hypnotics by older people in general practice: findings from interviews with service users and providers

The aim of this study was to explore beliefs and attitudes about continuing or stopping benzodiazepine hypnotics amongst older patients using such medicines, and amongst their general practitioners. One hundred and ninety two patients aged 65 and over who were long-term users of benzodiazepine hypnotics were recruited from 25 general practices in inner city and suburban London, as were 83 practice staff. The practices had been recruited into a randomised controlled trial of benzodiazepine withdrawal in long-term users. Semi-structured interviews were conducted with patients recruited to the trial, and non-standardized (conversational) interviews with practice staff. Sixty percent of long-term benzodiazepine users had taken their hypnotic for more than 10 years, and one-third for more than 20 years. Beliefs in the efficacy of hypnotics, and self-report of insomnia despite their use, varied according to the willingness to attempt withdrawal. The majority of patients reported no warnings from professionals about adverse effects of using benzodiazepine hypnotics. Half had tried to stop at some time but most attempts had been short-lived. Patients and doctors had distinctly different views of the advantages, disadvantages and risks of stopping benzodiazepine hypnotic use. Both increased patient awareness of the problems of long-term benzodiazepine use and an evidence-based approach to withdrawal efforts in primary care are necessary to reduce the consumption of medication that has little real benefit.

Older adults and withdrawal from benzodiazepine hypnotics in general practice: effects on cognitive function, sleep, mood and quality of life

BACKGROUND

Older adults are the main recipients of repeat prescriptions for benzodiazepine (BZD) hypnotics. BZDs can impair cognitive function and may not aid sleep when taken continuously for years. This study therefore aimed to determine if withdrawing from BZDs leads to changes in patients' cognitive function, quality of life, mood and sleep.

METHOD

One hundred and ninety-two long-term users of BZD hypnotics, aged > or = 65 years, were identified in 25 general practices. One hundred and four who wished to withdraw were randomly allocated to one of two groups under double-blind, placebo controlled conditions: group A's BZD dose was tapered from week 1 of the trial; group B were given their usual dose for 12 weeks and then it was tapered. An additional group (C) of 35 patients who did not wish to withdraw from BZDs participated as 'continuers'. All patients were assessed at 0, 12 and 24 weeks and 50% were reassessed at 52 weeks.

RESULTS

Sixty per cent of patients had taken BZDs continuously for > 10 years; 27% for > 20 years. Of all patients beginning the trial, 80% had successfully withdrawn 6 months later. There was little difference between groups A and B, but these groups differed from continuers (C) in that the performance of the withdrawers on several cognitive/psychomotor tasks showed relative improvements at 24 or 52 weeks. Withdrawers and continuers did not differ in sleep or BZD withdrawal symptoms.

CONCLUSIONS

These results have clear implications for clinical practice. Withdrawal from BZDs produces some subtle cognitive advantages for older people, yet little in the way of withdrawal symptoms or emergent sleep difficulties. These findings also suggest that, taken long-term, BZDs do not aid sleep.

Decision support software for dementia diagnosis and management in primary care: relevance and potential

Dementia, which affects a large and growing number of older people, presents particular challenges to primary care. There is an acknowledged need to develop interventions that address practitioners' needs for information and guidance regarding the diagnosis and management of dementia. This paper examines the potential usefulness and constraints of a Computer Decision Support System (CDSS) to assist practitioners in diagnosing and managing dementia. Questionnaire information was obtained from 97 primary care practitioners regarding their current practice and views on dementia care, priority given to training and familiarity with computer use. Implications of these findings for the relevance and value of CDSS are discussed. The paper is part of a larger ongoing study, the aim of which is the evaluation of three educational interventions for primary care practitioners.

Feasibility and yield of a self-administered questionnaire for health risk appraisal in older people in three European countries

OBJECTIVE

To test the feasibility of a self-administered questionnaire for health risk appraisal in older people.

METHODS

A scientifically updated and culturally adapted English and German language version of the Health Risk Appraisal for Older Persons self-administered questionnaire identifying risk factors for functional impairment in older people was administered to three samples of older people (UK: Urban-based general practitioner list, n=348; Switzerland: Community-based lists in rural/suburban area, n=213; Germany: Occupants of residential care facilities, n=149).

RESULTS

The majority of people judged the questionnaire as easy to comprehend (UK 81.4%; Switzerland 97.2%; Germany 93.1%) and to complete (83.2%, 95.8%, 91.4%). Prevalence of risk factors was higher than 10% at each site for excessive fat intake (25-54%), lack of social activity (15-47%), low physical activity (28-46%), impaired vision (17-38%), impaired hearing (23-25%), and urinary incontinence (13-37%). Uptake of recommended preventive health measures, including screening and vaccination was below 50% in more than half of recommended items, with large variations between sites.

DISCUSSION

Acceptance of the adapted Health Risk Appraisal for Older Persons questionnaire was high and its feasibility supported. The findings identified a high prevalence of potentially modifiable risk factors for ill health and disability in older people with large variations in prevalence rates and awareness between sites. The yield supports the further development and evaluation of the approach.

Design and implementation of a computer decision support system for the diagnosis and management of dementia syndromes in primary care

BACKGROUND

Diagnosis and management of dementia is a complex process and primary care physicians are under-equipped to deal with uncertainties in the provision of optimal care for the patient.

OBJECTIVE

To develop a computer decision support system (CDSS) which could assist physicians with diagnosis and management and improve patient care.

METHODS

A design group including general practitioners derived logic pathways for diagnosis and management of dementia and validated them with a multiprofessional expert group. Logic pathways were used to construct a comprehensive CDSS rendered as a series of expert consultations. The CDSS was inserted into commercially available GP systems and bench and field-tested.

RESULTS

The complexity of dementia diagnosis and management can be captured in logic pathways which can be expressed as decision trees within existing electronic patient records. The resulting CDSS appears useable in routine practice.

CONCLUSION

The impact of this CDSS will be evaluated in a randomised controlled trial of educational interventions in primary care.

Can primary care be both patient-centred and community-led?

Examines the relationships between the macro-, meso-, and micro-levels in the NHS at the end of the fundholding period and considers their contemporary implications for primary care groups (PCGs) and local health care co-operatives (LHCCs). Fundholding achieved some success in challenging the way in which services were provided at the micro-level (the practice), but had a less marked effect in terms of changing service provision at the health authority (meso-) level or in developing collaborative working with trusts and health authorities in strategic decision making. The health authorities prioritized alternative models of devolved commissioning. Trusts regarded fundholders as a distraction who exerted influence and commanded trust management time disproportionate to their "market share". PCGs and LHCCs represent a shift back to the meso-level in service planning and purchasing. As such there is a risk that the micro-level benefits of fundholding and other forms of devolved commissioning will be lost, while uncertainties remain regarding the capacity of PCGs and LHCCs to incorporate GPs into a collaborative approach to strategic decision making.

An exploration of help-seeking behaviour in older people with unmet needs

BACKGROUND

Despite decades of research showing high rates of unmet need in older people, there currently is little understanding of why these needs remain unmet. This study was performed as part of a larger feasibility study of a multidisciplinary needs assessment tool in primary care.

OBJECTIVE

The aim of the present study was to explore patients' and carers' help-seeking behaviour and perceived barriers to meeting unmet needs.

METHOD

Four general practices were selected purposefully in inner city and suburban London A random sample of 1 in 20 people aged 75 years and over registered with each practice was selected for a multidisciplinary needs assessment using the 'Camberwell Assessment of Need for the Elderly' (CANE) schedule and unmet needs identified by patients and their informal carers. For each unmet need, a further semi-structured interview was used to explore the help-seeking behaviour and perceived barriers to meeting their needs. Responses were recorded verbatim contemporaneously and a thematic analysis performed on perceived barriers following completion of all interviews.

RESULTS

A total of 55/84 (65.5%) of patients and 15/17 (88%) of carers completed the initial needs assessment. For 104 unmet needs identified by 31 patients and 11 carers, a further interview was completed on the barriers to meeting that need. Help had been sought for only 25/104 (24%) of unmet needs and it had been offered in only 19/104 (18%). In those not seeking help, withdrawal, resignation and low expectations were dominant themes. In those that had sought help, there were issues of perceived failure of service delivery and rationing, with themes of resignation and withdrawal again emerging in those declining help offered.

CONCLUSION

The majority of older people and their carers do not appear to seek help for their unmet needs for a range of complex reasons, often involving issues of withdrawal, resignation and low expectations. This complexity has implications for the commissioning of services for older people.

The national plan for Britain's National Health Service: toward a managed market

Britain's New Labour government has consolidated its reform of the National Health Service with an ambitious NHS Plan that links investment in staff, new buildings, and new technology to delivery of a modernization agenda combining consumerist and public health agendas. The fundamental principles of the NHS are preserved, but within a regulatory structure of a managed market. The author outlines the changes proposed and the possible responses of different stakeholders.

Assessing needs from patient, carer and professional perspectives: the Camberwell Assessment of need for Elderly people in primary care

BACKGROUND

despite evidence that needs assessment of older people can improve survival and function when linked to effective long-term management, there is no structured needs assessment tool in widespread use. The Camberwell Assessment of Need for the Elderly is a new tool not previously evaluated in primary care. It includes the views of patients, carers and health professionals, enabling a direct comparison of their perspectives.

AIM

to conduct a feasibility study of Camberwell Assessment of Need for the Elderly in primary care and to compare the needs identified by patients, carers and health professionals.

METHODS

we selected a random sample of 1:20 of all people aged 75 and over from four general practices in inner-city and suburban north-west London. We interviewed the patients, their informal carers and lead health professionals using the Camberwell Assessment of Need for the Elderly schedule.

RESULTS

55 (65.5%) of 84 patients, 15 (88.2%) of 17 carers and all of 55 health professionals completed interviews. The patients' three most frequently identified unmet needs were with 'eyesight/hearing', 'psychological distress' and 'incontinence'. The carers' three most frequently identified unmet needs were with 'mobility', 'eyesight/hearing' and 'accommodation' and the health professionals' were with 'daytime activities', 'accommodation' and 'mobility'. Kappa tests comparing patient and health professional assessments showed poor or fair agreement with 18 of the 24 variables and moderate or good agreement with six. None showed very good agreement.

CONCLUSION

the Camberwell Assessment of Need for the Elderly schedule is feasible to use in primary care and can identify perceived needs not previously known about by health professionals. A shorter version of Camberwell Assessment of Need for the Elderly focusing on areas of poor agreement and high levels of need might be useful in the assessment of needs in older people in primary care.

New labour and Britain's National Health Service: an overview of current reforms

Britain's National Health Service (NHS) has been the subject of unprecedented market reforms, which have failed to solve its problems. The New Labour government elected in 1997 has halted the drive toward the marketization of health care and replaced cost with quality as the central concern of NHS administration and policy. Major changes are occurring in the regulation of professional activity, with profound implications for the medical profession and the health service. The authors discuss these changes and possible future problems for the NHS.

Hospital-at-home versus in-patient hospital care

BACKGROUND

Hospital-at-home is defined as a service that provides active treatment by health care professionals, in the patient's home, of a condition that otherwise would require acute hospital in-patient care, always for a limited period. Hospital-at-home has become a popular response to the increasing demand for acute hospital beds.

OBJECTIVES

To assess the effects of hospital-at-home compared with in-patient hospital care for patients.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group specialised register, the Cochrane Controlled Trials Register, MEDLINE to 1996, EMBASE to 1995, Cinahl to 1996, the Social Science Citation Index (1992 to 1995), EconLit (1969 to 1996), PsycLit (1987 to 1996), Sigle (1980 to 1995), the Medical Care supplement on economic literature (1979 to 1990), and reference lists of articles.

SELECTION CRITERIA

Randomised trials of hospital-at-home care compared with acute hospital in-patient care. The participants were patients aged 18 years and over. The outcomes were mortality, clinical complications, re-admissions, cost (to the patient and family, to general practice, to the hospital and to the community), hospital days saved from the provision of hospital-at-home, discharge destination from hospital-at-home, general and disease specific health status, functional status, psychological well-being, patient satisfaction, carer satisfaction, carer burden, and staff views (including the satisfaction of doctors working in primary care).

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality.

MAIN RESULTS

Five studies were included involving 866 patients. All studies were small and lacked power. No statistically significant differences were detected for patient health outcomes. Patients discharged early from hospital to hospital-at-home following elective surgery expressed greater satisfaction with care than those who remained in hospital. Carers however expressed less satisfaction with hospital-at-home compared with hospital care. Only one trial formally tested for a difference in cost, with no statistically significant difference detected for overall health care costs.

REVIEWER'S CONCLUSIONS

There is insufficient evidence to assess the effects of hospital-at-home on patient outcomes or the cost to the health service. Given the heterogeneity of what hospital-at-home encompasses and the uncertainty over its effects, future research should clearly specify the type of service being provided, both at home and at hospital, and the specific patient groups. Patient health outcomes, patient and carer satisfaction, and costs should be measured, and studies should include a formal, planned economic analysis. Studies should be large enough to detect important differences and to ensure generalisability of the results.

Community screening for visual impairment in the elderly

BACKGROUND

While the aims of multicomponent screening of older people are broad, any benefit arising from the inclusion of a vision component in the assessment will necessarily be dependent on improved vision.

OBJECTIVES

The objective of this review is to assess the effects on vision of mass screening of older people for visual impairment.

SEARCH STRATEGY

We searched the Cochrane Eye and Vision Group specialised register, the Cochrane Controlled Trials Register - Central, MEDLINE, EMBASE, SciSearch and reference lists of relevant trial reports and review articles. We contacted investigators to identify additional published and unpublished trials. The most recent searches were conducted in April 1998.

SELECTION CRITERIA

We included randomised trials of visual or multicomponent screening for vision impairment in people aged 65 or over in a community setting.

DATA COLLECTION AND ANALYSIS

Both reviewers independently extracted data and assessed trial quality.

MAIN RESULTS

Visual outcome data were available for 3494 people in five trials of multicomponent assessment. Length of follow up ranged from two to four years. All the trials used self-reported measures for visual impairment, both as screening tools and as outcome measures. In four of the trials people reporting visual problems were referred to either the eye services or to a physician. In one trial people reporting visual problems received information about resources in the community designed to assist those with poor vision. The proportions of participants in the intervention and control groups who reported visual problems at the time of outcome assessment were 0.26 and 0.23 respectively (relative risk for visual impairment 1.03, 95% confidence interval 0.92 to 1.15).

REVIEWER'S CONCLUSIONS

There is no evidence that community-based screening of asymptomatic older people results in improvements in vision.

Promoting physical activity in general practice: should prescribed exercise be free?

In the UK there are numerous schemes whereby general practitioners can prescribe exercise programmes, usually based in leisure centres. Of the factors that discourage adherence to such programmes in the USA, cost has proved important. We collected demographic and questionnaire data from 152 inner-London patients (108 women, 44 men) before they started an exercise programme on a National Health Service prescription, and analysed the results according to whether they dropped out of the programme (78%) or not. Use of logistic regression revealed only one previous barrier to exercise, 'not knowing about local exercise facilities', as a significant positive determinant of adherence (adjusted odds ratio 3.51, 95% confidence interval, 1.04 to 11.86). For 'lack of money' patients were more likely to drop out of the programme (adjusted odds ratio 0.25, 95% CI 0.07-0.85). The very low cost of participation in this scheme, did not encourage adherence, particularly by those who had cited 'lack of money' as a previous barrier. The case of making prescribed exercise free or even low-cost remains unproven.

The effectiveness of hospital at home compared with in-patient hospital care: a systematic review

BACKGROUND

Despite the widespread adoption of hospital at home services it is not known if these services represent an effective way to manage patients, compared with in-patient hospital care.

METHOD

A systematic review was carried out of randomized controlled trials comparing hospital at home care with acute hospital in-patient care for patients age 18 years and over, excluding those with long-term care needs, obstetric patients, and those requiring mental health services. The following databases were searched: Medline, Embase, Social Science Citation Index, CINAHL, EconLit, PsychLit, SIGLE, Medical Care supplement on economic literature, and the EPOC (Cochrane Effective Practice and Organization of Care Review Group) register. Data were extracted for the following outcomes: mortality, clinical complications, re-admissions, costs, hospital days saved from the provision of hospital at home, discharge destination from hospital at home, functional status, psychological well-being, patient satisfaction and carer satisfaction. Data analysis and quality assessment were undertaken independently by two reviewers using a data checklist, following standard methods described by the EPOC group.

RESULTS

Five trials were included in the review. No statistically significant differences were detected for patient health outcomes. Patients discharged early from hospital to hospital at home following elective surgery expressed greater satisfaction with care than those who remained in hospital. Carers, however, expressed less satisfaction with hospital at home compared with hospital care. Only one trial, which recruited patients requiring terminal care, formally tested for a difference in cost. No statistically significant difference was detected for overall net health costs.

CONCLUSIONS

This review does not support the widespread adoption of hospital at home, nor the discontinuation of existing schemes for elderly medical patients, patients who have had elective surgery, or those with a terminal illness. There is insufficient evidence to determine the effect of hospital at home on patient outcomes, or cost to the health service.

The 'research magnificent' in late life: psychiatric epidemiology and the primary health care of older adults

OBJECTIVE

Primary care occupies a strategic positive in the evaluation, treatment, and prevention of the mental disturbances of later life. This article highlights four themes that are crucial to understanding mental disturbances among older adults: 1) subsyndromal depression, 2) coexisting depression and anxiety, 3) comorbidity of depression and chronic medical conditions, and 4) risk factors for cognitive impairment.

METHOD

The literature was selectively reviewed for each theme to ask the central question, "What can primary care physicians learn about mental disturbances of their older patients from epidemiologic and community studies?"

RESULTS

The primary care setting itself is an important venue for an examination of aging issues and mental health. Workers in the "middle ground of psychiatric epidemiology"--primary health care--have not yet reached a full appreciation for the value of research in the primary care setting for enhancing our understanding of the mental disturbances of late life, and how these intersect with other salient factors.

CONCLUSIONS

Primary care physicians and others who work in primary care should advocate for further mental health integration and research in primary care. Research is needed that will lead to new ways of maximizing the health and quality of life of older adults and their families.

The London Academic Training Scheme: learning research methods through teaching

BACKGROUND

The London Academic Training Scheme (LATS) provides a 1-year training programme in research methods and teaching for GPs who have recently finished vocational training. This paper describes an adult educational approach to learning about research methods through teaching as part of the LATS trainees' weekly academic programme.

OBJECTIVE

We aimed to provide and evaluate a course exploring research methodologies used in primary care by a three-step approach to learning, with trainees taking the main role as teachers.

METHOD

Trainees on the LATS programme met for one afternoon each week for one term. During alternate sessions a pair of trainees would deliver a whole afternoon's seminar on one aspect of primary care research methodology. The teaching of each session was evaluated by the whole group, by academic supervisors and by experts.

RESULTS

Sessions were scored by participants for content, style of presentation, educational value and enjoyment on a seven-point rating scale where 1 = no value, 4 = neutral and 7 = very valuable. All sessions scored above 4 and usually above 5 for each aspect. Open comments collected showed that trainees greatly appreciated this self-directed approach to learning and teaching.

CONCLUSION

The active involvement of learners as teachers is a practical and rewarding means of using adult educational principles in providing an academic programme.

Effectiveness of screening older people for impaired vision in community setting: systematic review of evidence from randomised controlled trials

OBJECTIVE

To assess whether population screening for impaired vision among older people in the community leads to improvements in vision.

DESIGN

Systematic review of randomised controlled trials of population screening in the community that included any assessment of vision or visual function with at least 6 months' follow up.

SUBJECTS

Adults aged 65 or over.

MAIN OUTCOME MEASURE

Proportions with visual impairment in intervention and control groups with any method of assessing visual impairment.

RESULTS

There were no trials that primarily assessed visual screening. Outcome data on vision were available for 3494 people in five trials of multiphasic assessment. All the trials used self reported measures for vision impairment, both as screening tools and as outcome measures. The inclusion of a visual screening component in the assessment did not result in improvements in self reported visual problems (pooled odds ratio 1.04:95% confidence interval 0.89 to 1.22). A small reduction (11%) in the number of older people with self reported visual problems cannot be excluded.

CONCLUSIONS

Screening of asymptomatic older people in the community is not justified on present evidence. Visual impairment in this age group can usually be reduced with treatment. It is unclear why no benefit was seen. Further work is needed to clarify what interventions are appropriate for older people with unreported impairment of vision.