[Treatment of Alzheimer's disease utilising the best available evidence-based medicine -- utopia?]

Factors influencing general practitioners' perception of and attitude towards dementia diagnostics and care-results of a survey among primary care physicians in Germany

Studies have shown that primary care is not always effective when it comes to caring for people with dementia. In addition, general practitioners do not always use diagnostic instruments consistently. The aim of the study was to identify relevant factors that influence general practitioners’ attitudes and willingness with respect to consistent diagnosis and care. For this purpose, resources, viewpoints, and behavioral patterns of general practitioners with regard to dementia diagnostics as well as common challenges in everyday practice were recorded. In the course of a survey, a total of 2266 general practitioners in Hesse and Baden-Württemberg were interviewed between January and March 2020. In addition to the descriptive analysis, a t-test was used to determine significant differences between two groups. A univariate linear regression analysis was carried out to identify possible influencing factors. 81% of the respondents do provide dementia diagnostics; 51% are involved in the treatment. Most of them see the diagnostic work-up (77%), communication and compliance problems (73%), as well as the therapeutic support (71%) as common challenges. In addition, there are interface problems regarding the interdisciplinary cooperation. Some of the respondents express doubts about the value of early detection (41%). The general practitioners’ attitude with respect to dementia diagnostics and care is determined by influencing factors that relate to geriatric competencies, expectations of self-efficacy, the integration of practice staff, as well as the knowledge of and cooperation with counseling and care services. It seems advisable to strengthen the geriatric competence of general practitioners. Moreover, it appears essential to educate general practitioners more about support structures in the field of dementia care and to integrate them accordingly. In addition, practice staff should be more systematically involved in the identification and care of dementia patients.

Dementia diagnostics in general practitioner care : Do general practitioners have reservations? The findings of a qualitative study in Germany

General practitioner (GP) treatment of dementia is often criticized as being ineffective and not implemented consistently enough. The causes and specific standpoints of GPs have not previously been thoroughly investigated. This paper focuses on the reasons and the criticisms levelled at GPs with regard to diagnosing dementia, and identifies approaches to enable optimization. The analysis is based on 41 semi-structured interviews with GPs in Hesse, Germany, in 2018. During the course of a content analysis, the interviewees’ attitudes and behavioral patterns towards dementia diagnostics were to be analyzed. The results of the study show various challenges and problems of primary care in this field. The majority of the sample showed skepticism and reluctance with regard to the diagnosis of dementia. Six key problem areas were extracted from the interviews, which can be seen as root causes for the distance kept by GPs: 1) early delegation of patients due to role understanding, 2) attitude of pessimism towards dementia, 3) differential diagnosis perceived as an obstacle, 4) insufficient remuneration, 5) fear of patient stigmatization, and 6) lack of application. Some GPs demonstrated personal initiative with the aim of optimizing dementia diagnostics. Three approaches can be derived which could be used to improve the GP-based care of dementia: 1) self-efficacy, 2) differential diagnostics and treatment pathways, and 3) physician–patient communication.

[The practice staff in primary care dementia recognition-is there an untapped potential?]

BACKGROUND

It is regularly criticized that the diagnostics of dementia are not used effectively and consistently enough in general practitioner (GP) care. An important component for the optimization of early detection is the targeted training and involvement of the practice staff. To date, there is a lack of studies that capture the extent to which primary care personnel are actually integrated into dementia recognition and how they assess their own potential to contribute to a more efficient diagnosis of dementia.

MATERIAL AND METHODS

The study was based on 45 qualitative individual interviews with GP practice personnel in Rhineland-Palatinate and Hesse, which were conducted orally and personally between November 2017 and June 2018 (duration: 25-70 min).

RESULTS

The results show that GP personnel showed a great willingness to support the family doctor in dementia recognition and diagnostics; however, this potential is only partly used in primary care practices. Most of the sample showed marked uncertainties in assessing possible signs of incipient dementia. This corresponds to the fact that only a minority of the interviewees had ever completed training in which dementia was an important topic. The identification of dementia patients by the practice employees seems to function according to the random principle and less according to systematic criteria.

CONCLUSION

The analysis showed that many GPs are not yet aware of the opportunities offered by a greater involvement of practice personnel in the recognition of dementia. Accordingly, GPs should be advised of the benefits of such a solution. At the same time, more attention should be paid to low-threshold training formats, which are tailored specifically to the perspective of practice employees and convey important dementia-specific diagnostics, action and communication skills.

Use of antidementia drugs in German patients with Alzheimer's disease

The objective of this study was to evaluate the use of antidementia drugs (ADDs) in patients with Alzheimer's disease (AD) regarding German guideline recommendations and to assess correlations between the use of ADDs and the patients' characteristics. A total of 395 community-dwelling and institutionalized patients with AD across all severity stages of dementia were recruited in this cross-sectional study. Associations between the prescription of ADDs and patients' sociodemographic and clinical parameters (neuropsychiatric symptoms, cognitive capacity, daily activities, and health-related quality of life) were analyzed in multiple logistic regression analyses. ADDs were prescribed in 46.6% of all participants and less often in institutionalized patients (38.2 vs. 50.4%, P=0.025). Patients with mild-to-moderate dementia had a higher chance of receiving ADDs [odds ratio (OR)=3.752, 95% confidence interval (CI): 1.166-12.080 and OR=3.526, 95% CI: 1.431-8.688] as well as those treated by neurologists/psychiatrists (OR=2.467, 95% CI: 1.288-4.726). Overall, 39% of the patients with mild cognitive deficits (Mini-Mental Status Examination 27-30) received ADDs and 21% of the mildly demented patients (Mini-Mental Status Examination 20-26) received memantine. The treatment with ADDs was in part not in line with German guideline recommendations. Particularly, the lower use of ADDs in patients not attending neuropsychiatric specialists should be further evaluated.

Prescribing patterns in dementia: a multicentre observational study in a German network of CAM physicians

BACKGROUND

Dementia is a major and increasing health problem worldwide. This study aims to investigate dementia treatment strategies among physicians specialised in complementary and alternative medicine (CAM) by analysing prescribing patterns and comparing them to current treatment guidelines in Germany.

METHODS

Twenty-two primary care physicians in Germany participated in this prospective, multicentre observational study. Prescriptions and diagnoses were reported for each consecutive patient. Data were included if patients had at least one diagnosis of dementia according to the 10th revision of the International Classification of Diseases during the study period. Multiple logistic regression was used to determine factors associated with a prescription of any anti-dementia drug including Ginkgo biloba.

RESULTS

During the 5-year study period (2004-2008), 577 patients with dementia were included (median age: 81 years (IQR: 74-87); 69% female). Dementia was classified as unspecified dementia (57.2%), vascular dementia (25.1%), dementia in Alzheimer's disease (10.4%), and dementia in Parkinson's disease (7.3%). The prevalence of anti-dementia drugs was 25.6%. The phytopharmaceutical Ginkgo biloba was the most frequently prescribed anti-dementia drug overall (67.6% of all) followed by cholinesterase inhibitors (17.6%). The adjusted odds ratio (AOR) for receiving any anti-dementia drug was greater than 1 for neurologists (AOR = 2.34; CI: 1.59-3.47), the diagnosis of Alzheimer's disease (AOR = 3.28; CI: 1.96-5.50), neuroleptic therapy (AOR = 1.87; CI: 1.22-2.88), co-morbidities hypertension (AOR = 2.03; CI: 1.41-2.90), and heart failure (AOR = 4.85; CI: 3.42-6.88). The chance for a prescription of any anti-dementia drug decreased with the diagnosis of vascular dementia (AOR = 0.64; CI: 0.43-0.95) and diabetes mellitus (AOR = 0.55; CI: 0.36-0.86). The prescription of Ginkgo biloba was associated with sex (female: AOR = 0.41; CI: 0.19-0.89), patient age (AOR = 1.06; CI: 1.02-1.10), treatment by a neurologist (AOR = 0.09; CI: 0.03-0.23), and the diagnosis of Alzheimer's disease (AOR = 0.07; CI: 0.04-0.16).

CONCLUSIONS

This study provides a comprehensive analysis of everyday practice for treatment of dementia in primary care in physicians with a focus on CAM. The prescribing frequency for anti-dementia drugs is equivalent to those found in other German studies, while the administration of Ginkgo biloba is significantly higher.

Primary care physicians' attitudes related to cognition enhancers in early dementia: a representative eight-year follow-up study in Lower Saxony, Germany

OBJECTIVE

By means of a representative follow-up survey, we investigated changes in family physicians' (FPs) attitudes towards cognition enhancers in early dementia during 1993 and 2001.

METHODS

One hundred and twenty-two FPs (response rate 71.8%) in Lower Saxony, Germany, were randomly assigned to one of two written case samples presenting a patient with cognitive decline suggestive of early Alzheimer's disease (DAT; case A: female patient vs case B: male patient). Using a structured face-to-face interview, they were asked to suggest their potential drug treatment. The results were compared to corresponding data from our previous survey in 1993.

RESULTS

FPs' readiness to start antidementia drug treatment decreased from 70.4% in 1993 to 43.4% at follow-up, although underlying DAT was significantly more frequently suggested (11.0% vs 26.2%, p < 0.05). Substances with questionable efficacy such as Piracetame were prescribed less frequently in 2001 whereas evidence-based medication like cholinesterase inhibitors (ChEIs) failed to compensate for this drop. Compared to 1993, when 55.2% of FPs expected no therapeutic impact, at follow-up, 75.4% expected slowdown of disease progression, stabilisation or improvement of symptoms (p < 0.05).

CONCLUSIONS

Our results demonstrate a significant decrease of therapeutic nihilism in primary care within eight years. However, in patients with suspicion of DAT, this is not reflected accordingly in potential treatment.

Fragen und Thesen zu medikamentösen Behandlungsoptionen der Alzheimer-Demenz mit Acetylcholinesterase-Hemmern

The paper reviews the evidence for the recommendation of cholinesterase inhibitors and asks critical questions concerning the reasons for the discrepancy between the weak evidence and the recommendation of these drugs in therapy guidelines. Furthermore, the argument of the severe underuse of these drugs is examined.