Early recognition of dementia by nurses

The provision of dementia care in general practice: practice nurse perceptions of their role

Background

Primary care nurses can assist General Practitioner’s to identify cognition concerns and support patient health self-management for those experiencing cognitive impairment or dementia. This support may lead to more appropriate care and better health outcomes for this group. Consequently, there is a need to identify the role of the primary care nurse in dementia care provision, nurse perceptions of this role and to also understand the barriers and enablers that may influence any current or potential primary care nurse role in dementia care provision.

Methods

Eight focus groups were conducted with a total of 36 primary care nurses. Data was transcribed verbatim and thematically analysed.

Results

There was a high level of agreement between primary care nurses that they had a role in provision of dementia care. This role was largely attributed to the strong therapeutic relationship between nurses and patients. However, dementia care provision was not without its challenges, including a perceived lack of knowledge, limited resources and the hierarchical nature of general practice. Three main themes were identified: personal attributes of the primary care nurse; professional attributes of the primary care nurse role and the context of practice. Six sub-themes were identified: knowing the person; overcoming stigma; providing holistic care; knowing what to do; team culture and working in the system.

Conclusions

The findings of this study suggest primary care nurses have a role in dementia care provision and, there is a need to provide support for the nurse to deliver person-centred health care in the context of cognitive impairment. As the demand for good quality primary care for people living with dementia increases, the role of the primary care nurse should be considered in primary care policy discussions. The knowledge gained from this study could be useful in informing dementia training content, to provide better prompts in the health assessment and care planning templates used by primary care nurses to better identify the care needs of people with a cognitive impairment and to develop dementia care guidelines for primary care nurses.

Clinical practice guidelines and principles of care for people with dementia: a protocol for undertaking a Delphi technique to identify the recommendations relevant to primary care nurses in the delivery of person-centred dementia care

INTRODUCTION

Nationally and internationally it is well recognised that dementia is poorly recognised and suboptimally managed in the primary care setting. There are multiple and complex reasons for this gap in care, including a lack of knowledge, high care demands and inadequate time for the general practitioner alone to manage dementia with its multiple physical, psychological and social dimensions. The primary care nurse potentially has a role in assisting the general practitioner in the provision of evidence-based dementia care. Although dementia-care guidelines for general practitioners exist, evidence on resources to support the primary care nurse in dementia care provision is scarce. The 'Australian Clinical Practice Guidelines and Principles of Care for People with Dementia' provides 109 recommendations for the diagnosis and management of dementia. This protocol describes a Delphi study to identify which of the 109 recommendations contained in these multidisciplinary guidelines are relevant to the primary care nurse in the delivery of person-centred dementia care in the general practice setting.

METHODS AND ANALYSIS

Using a Delphi consensus online survey, an expert panel will grade each of the recommendations written in the 'Clinical Practice Guidelines and Principles of Care for People with Dementia' as high-to-low relevance with respect to the role of the primary care nurse in general practice. To optimise reliability of results, quality indicators will be used in the data collection and reporting of the study. Invited panel members will include Australian primary care nurses working in general practice, primary care nursing researchers and representatives of the Australian Primary Health Care Nurses Association, the peak professional body for nurses working in primary healthcare.

ETHICS AND DISSEMINATION

This study has been approved by The University of Newcastle Human Research Ethics Committee (HREC) (H-2019-0029).Findings will be published in a peer-reviewed journal and presented at scientific conferences.

What is the role of the practice nurse in the care of people living with dementia, or cognitive impairment, and their support person(s)?: a systematic review

Background

The potential value of expanding the Practice Nurse role to include the recognition and management of dementia has been acknowledged. Practice Nurses are well-positioned to provide comprehensive dementia information and support so that people living with dementia are better equipped to self-manage their health and live well with dementia. The purpose of this review was to systematically examine published literature to identify existing and potential roles of Practice Nurse’s in the delivery of care to people affected by dementia and to describe the characteristics and effectiveness of nurse interventions in dementia models of care.

Methods

The PRISMA statement guided the systematic review of the quantitative and qualitative evidence for roles and characteristics of the Practice Nurse in the delivery of dementia care. A comprehensive literature search of seven electronic databases and Google scholar identified relevant original research published in English between January 2000 and January 2019. Thirteen articles met the inclusion criteria and were extracted into the Covidence software for analysis.

Results

The heterogeneity of the included studies purpose, design and outcomes measures and the diversity in health systems and primary care nurses scope of practice made it difficult to synthesise the findings and draw conclusions. The heterogeneity did, however, provide important insights into the characteristics of roles undertaken by nurses working in the general practice setting, which were potentially beneficial to people living with dementia and their support person. These included patient accessibility to the Practice Nurse, early recognition and management of cognitive changes, care management and collaboration with the General Practitioner. Limitations of the provision of dementia care by Practice Nurses included a lack of definition of the role, inadequate dementia specific training, time constraints and poor communication with General Practitioners.

Conclusions

Embedding an evidence-based model that describes the role of the Practice Nurse in dementia care provision has the potential to increase early recognition of cognitive impairment and more appropriate primary care management of dementia.

Systematic review registration

PROSPERO 2018 CRD42018088191.

Implementation of a training program to increase knowledge, improve attitudes and reduce nursing care omissions towards patients with dementia in hospital settings: a mixed-method study protocol

INTRODUCTION

There is an evidence showing that when nurses have to allocate their time because of a lack of resources, older patients and especially those with dementia have a secondary care priority. The purpose of this study is to advance the level of knowledge, promote positive attitudes of nurses and reduce care deficits towards people with dementia through the implementation of a training programme. The programme will be enriched by an observational study of the care of patients with dementia to identify areas of missed care.

METHOD AND ANALYSIS

This study will follow a mixed methodology consisting of three stages: (1) evaluation of the level of nurses' knowledge and attitudes towards dementia care through the use of structured questionnaires, (2) observational study to evaluate nursing care in hospital settings, in order to detect any missed care and (3) quasi-experimental study, with a before-and-after design, through the implementation of the training programme in order to increase nurses' knowledge, improve attitudes and consequently to promote care for patients with dementia. The data will be analysed with descriptive and inferential statistics with the use of the SPSS V.24.0 and with content analysis as regard to the observational data.

ETHICS AND DISSEMINATION

The protocol was approved by the National Bioethics committee and other local committees (ΕΕΒΚ: 2018.01.02). The participants will give their informed consent and the anonymity and confidentiality. Also, the protection of data will be respected. The results of the study will be disseminated in peer-reviewed international journals and conferences. If the intervention is successful, the training package will be given to the continuous education unit of the National Professional Association in order to be used on a regular basis.

Nurses' knowledge and attitudes about dementia care: Systematic literature review

PURPOSE

To explore nurse's knowledge and attitudes toward the care of people with dementia.

DESIGN AND METHODS

A systematic review informed by the PRISMA-P (preferred reporting items for systematic reviews and meta-analyses protocols) guidelines in four databases (CINAHL, PsyINFO, Pubmed, Cohrane, EMBASE) using keywords "attitudes," "behaviors," "dementia," "knowledge," and "nurses." Predetermined inclusion criteria were selected. The review was conducted between January 1 and December 30, 2017.

FINDINGS

Sixteen quantitative studies, one qualitative, and two mixed methods studies were included. Nurses lack knowledge, communication skills, management strategies, and confidence in the provision of dementia care. Interventional studies suggested that knowledge and attitudes improved after training programs were implemented.

PRACTICE IMPLICATION

This review contributes to care advancement and practice development through the reinforcement of organizational support and educational opportunities for nurses.

Community health professionals' dementia knowledge, attitudes and care approach: a cross-sectional survey in Changsha, China

BACKGROUND

Community health professionals play a significant role in dementia care. However, little is known about community health professionals' capacity in dementia care, especially in low and middle-income countries. The aim of the present study was to assess community health professionals' dementia knowledge, attitudes and care approach in China, a country with the largest population of people with dementia in the world and where community based dementia care services are much needed.

METHODS

A cross-sectional survey was conducted. 450 health professionals were recruited into the study using random sampling from community health service centres in Changsha, China. Their knowledge, attitudes and care approach were assessed utilising the Chinese version of the Alzheimer's Disease Knowledge Scale, Dementia Care Attitude Scale and Approach to Advanced Dementia Care Questionnaire respectively.

RESULTS

A total of 390 participants returned the questionnaire (response rate 87%). Age, education, professional group and care experience were associated with knowledge scores, and overall dementia knowledge was poor. Attitudes were generally positive and influenced by age, professional group, gender and care experience. The experience of caring for people with dementia was positively associated with a person-centred care approach, although the participants tended not to use a person-centred care approach. A statistically significant association was found between knowledge and attitudes (r = 0.379, P < 0.001), and between attitudes and care approach (r = 0.143, P < 0.001). However, dementia knowledge has no relationship with a person-centred approach.

CONCLUSIONS

Community health professionals showed generally positive attitudes towards people with dementia. However, they demonstrated poor dementia knowledge and tended not to use a person-centred care approach. The results suggest that a multifaceted approach consisting of educational interventions for community health professionals, and policy and resource development to meet the demand for community dementia care services, is urgently needed in China.

Dementia skills and competencies for primary care liaison: a model for improving identification and timely diagnosis

OBJECTIVES

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.

Factors associated with dementia care practices among community health nurses: results of a postal survey

BACKGROUND

The incremental prevalence of dementia is making dementia management a worldwide issue. The role of community health nurses must grow along with the increasing aging population and the resulting increase in dementia cases.

OBJECTIVES

Explore the factors related to dementia care practices among the different types of community health nurses in Taiwan.

DESIGN

Cross-sectional study.

SETTING

Primary care centers or institutions in New Taipei City.

PARTICIPANTS

Community health nurses who work in health care centers (district nurses), long-term care centers (care managers), or home care institutions (home health care nurses).

METHODS

Self-completion questionnaires sent by mail.

RESULTS

A total of 195 participants returned the questionnaires (response rate 81.9%). Although 65.8% of participants had experience in case finding, just 34.6% of them reported using validated cognitive testing tools. Only 15% of participants provided case management following dementia case findings. The regression models showed that the different types of community health nurses, number of years working as a nurse, and their level of confidence was significantly related to their dementia care practice. District nurses identified significantly less suspected dementia cases and provided less nursing care to caregivers of dementia patients than care managers and home health care nurses. Among community health nurses, the care managers most often used formal cognitive instruments. District nurses provided the least amount of supportive resources information, had the most negative attitude and the lowest level of confidence toward dementia care than care managers and home health care nurses.

CONCLUSIONS

This study presented the profiles of dementia care practice in Taiwan. It showed the considerable variation in knowledge, attitude, confidence and dementia care practices among the different community health nurses. The professional roles regarding dementia care in Taiwan remain blurred. Future training must focus on promoting the level of confidence of community health nurses to identify and manage people with dementia and raise awareness about demented person's and their caregiver's need. The priority of the policy on dementia care in the community must be raised to high, and the professional responsibilities and roles of the different types of community health nurses for the ever increasing dementia population in Taiwan must be redefined and optimized.

Sharing stories: a meta-ethnographic analysis of 12 autobiographies written by people with dementia between 1989 and 2007

People with dementia are finding increasingly creative and diverse ways of making their voice heard in society and one such method is through the publication of autobiographical accounts. Following set inclusion criteria, this meta-ethnographic analysis compares and contrasts the contents of 12 books written by people with dementia and published between 1989 (the year of publication of the first text) and the end of 2007 (the selected cut-off point for inclusion). Of the 12 books, three authors were published twice, five were male, eight were from the United States of America, one was Australian and all nine had a professional background. Eight of the authors had Alzheimer's disease and one had fronto-temporal dementia. The average age of the narrator was 51.5 years (age range 38–61 years). Meta-ethnographic analysis of the 12 books inductively generated five themes that linked each story and these were: (a) awareness of change; (b) experiencing loss; (c) standing up and bearing witness; (d) sustaining continuity; and (e) liberation and death. The importance of reconstructing identity appeared a pivotal process in living with the onset and progression of dementia together with maintaining key social relationships and networks.

Primary care and dementia: 1. diagnosis, screening and disclosure

OBJECTIVES

To write a narrative review of the roles of primary care practitioners in caring for people with dementia in the community.

METHODS

The systematic review carried out for the NICE/SCIE Guidelines was updated from January 2006, Cochrane Reviews were identified, and other publications found by consultation with experts.

RESULTS

The insidious and very variable development of dementia syndromes makes recognition of the syndrome problematic in primary care. Dementia is probably under-diagnosed and under treated with an estimated 50% of primary care patients over 65 not diagnosed by their primary care physicians. This problem of under-diagnosis is probably not due to lack of diagnostic skills, but rather to the interaction of case-complexity, pressure on time and the negative effects of reimbursement systems. Primary care physicians often over-estimate the prevalence of dementia syndromes, but in some countries may also overestimate the prevalence of vascular dementia compared with Alzheimer's disease. Diagnosis is a step-wise process which can be aided by use of a cognitive function test, of which there are a number suitable for primary care use. Evidence based practice protocols can enhance detection rates in primary care, and there is growing evidence that communication skills in talking to people with dementia about dementia can be improved. Nevertheless there are multiple obstacles to bringing recognition forward in time, both in public awareness and professional understanding of the early changes in dementia.

CONCLUSIONS

There is insufficient evidence of benefit to justify population screening in primary care but earlier recognition of people with dementia syndrome is possible within primary care. The diagnosis of dementia is a shared responsibility between generalist and specialist disciplines. Primary care physicians should explore patients' ideas and concerns around their symptoms prior to referral and tentatively discuss possible diagnoses. Once the diagnosis has been confirmed, the primary care physician should provide both practical and emotional support to allow the patient and their family to come to terms with living with dementia, and refer them for additional psychosocial support if required.

Feasibility of a new community-based geriatric intervention programme: an exploration of experiences of GPs, nurses, geriatricians, patients and caregivers

PURPOSE

To determine the feasibility of the Dutch Geriatric Intervention Programme (DGIP) in primary care. Within the DGIP, a nurse cooperates with a General Practitioner (GP) and a clinical geriatrician to assess and manage care for community-living older patients. The aim of this study was to describe both views of care receivers and those of professionals in order to identify facilitating factors and barriers for implementation of the DGIP.

METHOD

Combined quantitative and qualitative data collection methods were used. Pre- and post-questionnaires were taken from GPs (n= 15), nurses (n = 6) and geriatricians (n = 2). These professionals were also interviewed. In addition patients (n = 11 out of total n = 54) and their carers (n = 37) were interviewed.

RESULTS

GPs appreciated the support by the DGIP for problems in cognition, mood and mobility. Lack of knowledge and time restriction was the cause of their incapability at that point. In the cooperation between professionals, nurses felt that they had to initiate the contact. Personal contact helped the mutual communication. Involving the carer of the patient proved very important. All disciplines found this of crucial importance in order to deliver a tailored intervention and create conditions for optimal care. Barriers, for which the programme was tailored during the implementation, were: resistance in referrals of patients to the programme, nurses' and GPs' knowledge of diagnostic tests, communication problems and insufficient involvement of caregivers.

CONCLUSIONS

The implementation of the DGIP was feasible, but several barriers need ongoing attention by implementation, like communication between disciplines.

Can an EASYcare based dementia training programme improve diagnostic assessment and management of dementia by general practitioners and primary care nurses? The design of a randomised controlled trial

Background

Early diagnosis of dementia benefits both patient and caregiver. Nevertheless, dementia in primary care is currently under-diagnosed. Some educational interventions developed to improve dementia diagnosis and management were successful in increasing the number of dementia diagnoses and in changing attitudes and knowledge of health care staff. However, none of these interventions focussed on collaboration between GPs and nurses in dementia care. We developed an EASYcare-based Dementia Training Program (DTP) aimed at stimulating collaboration in dementia primary care. We expect this program to increase the number of cognitive assessments and dementia diagnoses and to improve attitudes and knowledge of GPs and nurses.

Methods

The DTP is a complex educational intervention that consists of two workshops, a coaching program, access to an internet forum, and a Computerized Clinical Decision Support System on dementia diagnostics. One hundred duos of GPs and nurses will be recruited, from which 2/3 will be allocated to the intervention group and 1/3 to the control group. The effects of implementation of the DTP will be studied in a cluster-randomised controlled trial. Primary outcomes will be the number of cognitive assessments and dementia diagnoses in a period of 9 months following workshop participation. Secondary outcomes are measured on GP and nurse level: adherence to national guidelines for dementia, attitude, confidence and knowledge regarding dementia diagnosis and management; on patient level: number of emergency calls, visits and consultations and patient satisfaction; and on caregiver level: informal caregiver burden and satisfaction. Data will be collected from GPs' electronic medical records, self-registration forms and questionnaires. Statistical analysis will be performed using the MANOVA-method. Also, exploratory analyses will be performed, in order to gain insight into barriers and facilitators for implementation and the possible causal relations between the rate of success of the intervention components and the outcomes.

Discussion

We developed multifaceted dementia training programme. Novelties in this programme are the training in fixed collaborative duos and the inclusion of an individual coaching program. The intervention is designed according to international guidelines and educational standards. Exploratory analysis will reveal its successful elements. Selection bias and contamination may be threats to the reliability of future results of this trial. Nevertheless, the results of this trial may provide useful information for policy makers and developers of continuing medical education.

Trial registration

ClinicalTrials.gov ID NCT00459784

Access to diagnostic evaluation and treatment for dementia in Europe

This paper reviews and discusses existing barriers to diagnosis and treatment for patients with dementia in Europe as well as approaches to overcome these barriers. The barriers to care are manifold, being present at all levels in each society and between countries in Europe. Multilevel and multifaceted strategies are needed to improve diagnosis and treatments for all patients with cognitive complaints. A multidisciplinary approach based on close collaboration between GPs and specialised memory clinics may be the ideal model for early accurate diagnosis and subsequently early pharmacological and psychosocial interventions. For all healthcare professionals, there should be specialised training in dementia and frequently updated practice guidelines to provide the framework for standards of care. Culture-sensitive strategies to promote public knowledge and destigmatize dementia are essential. Policy makers and authorities should be made aware of the benefits of early access to diagnosis and treatment.

Higher education provision for professionals working with people with dementia: a scoping exercise

This paper reports on the first national UK survey of higher education provision related to dementia care. A questionnaire was distributed to lecturers in Higher Education Institutions (HEIs) in England and Wales seeking information about the amount of coverage of dementia within their pre-registration and pre-qualifying courses for health and social care professionals, and continuing professional development (CPD) courses on dementia care. Information was sought regarding the content of courses, and their relation to a published "dementia curriculum" [Pulsford et al., The contribution of higher education to dementia care, Journal of Dementia Care 11(4) (2003) 27-29]. Results show that coverage of dementia within the mental health branch of pre-registration nursing programmes is very variable, and may be related to the presence of an experienced and committed lecturer within the HEI. Coverage of dementia on adult branch programmes is limited, and sometimes non-existent, despite reported deficits in the ability of general nurses to work effectively with people with dementia. Occupational Therapists and Social Workers receive similar input to adult branch nurses. CPD courses are provided by around 70% of HEIs overall, but there is a shortage of specialised diploma and degree level courses on dementia care. Most areas of the dementia curriculum are covered in both pre-registration and CPD courses, but culture and diversity, young onset dementia, and physical health care may be less well addressed. Recommendations are made for developing higher education provision for professionals working with this group of people.

Community mental health nursing and early intervention in dementia: developing practice through a single case history

People Nursing in association with Journal of Clinical Nursing 13, 6b, 57-67 Community mental health nursing and early intervention in dementia: developing practice through a single case history This paper reports on a single case history taken from the 'Dementia Action Research and Education' project, a 15-month primary care intervention study that was undertaken in North Wales in the early part of 2000. The study sought to address the meaning, context and diversity of early intervention in dementia care and employed a community mental health nurse and a psychiatric social worker to undertake early and psychosocial interventions with older people with dementia (aged 75 years and over) and their families. The workers tape-recorded, documented and analysed their interventions with 27 older people with dementia and their families over the 15-month duration of the study. Clinical supervision was also undertaken during the intervention phase. One case history is presented in this paper to illustrate the work of the community mental health nurse and to identify areas of practice development. Greater role transparency, collaborative working and improvement in educational preparation for practice are called for.

Working with organizations to implement dementia awareness training for public contact staff

People with dementia living in the community interact with a range of people who provide services to the public. Within these interactions, there may be communication problems associated with symptoms of the person's dementia. Problems include memory loss, difficulty communicating clearly, inability to grasp complex ideas, and problems handling money. This article describes a project that set out to promote training in dementia awareness for public contact staff with the expectation that it would help them better cater to people living with dementia. We worked with a police service, members of a city council, and staff of community pharmacies. This report provides suggestions about appropriate learning outcomes and program content and recommends steps to help others set up similar education programs.