Dementia care in the context of primary care reform: an integrative review

The perspectives of people living with dementia and their carers on the role of the general practice nurse in dementia care provision: a qualitative study

Background Models that optimise the role of the general practice nurse have the potential to deliver cost-effective best-practice dementia care in the primary care setting. Patient experience is recognised as a vital contribution to the design, provision and evaluation of healthcare services. The aim of this study was to gain insights into the healthcare needs and experiences of people living with dementia and carers as relevant to the provision of dementia care by general practice nurses. Methods A qualitative design with semi-structured interviews was employed. Data were transcribed verbatim and thematically analysed. Six carers and five people living with dementia who received care from a general practice nurse in the previous 12months took part in the study. Results Five overarching themes were identified: (1) the general practice nurse and dementia care: a golden opportunity, (2) respectful communication: talk to me and hear what I am saying, (3) person-centred information: tell me what I want to know, (4) provide support: more than just information provision, and (5) include the carer: we are a team. Conclusion This study describes the experiences and healthcare needs of people living with dementia and their carer(s) with regard to the general practice nurse role. These findings can inform strategies to support the general practice nurse provision of dementia care that meet the healthcare needs of people living with dementia and carers.

Clinical Outcomes and Cost-Effectiveness of Collaborative Dementia Care: A Secondary Analysis of a Cluster Randomized Clinical Trial

Importance

Long-term evidence for the effectiveness and cost-effectiveness of collaborative dementia care management (CDCM) is lacking.

Objective

To evaluate whether 6 months of CDCM is associated with improved patient clinical outcomes and caregiver burden and is cost-effective compared with usual care over 36 months.

Design, Setting, and Participants

This was a prespecified secondary analysis of a general practitioner (GP)-based, cluster randomized, 2-arm clinical trial conducted in Germany from January 1, 2012, to December 31, 2014, with follow-up until March 31, 2018. Participants were aged 70 years or older, lived at home, and screened positive for dementia. Data were analyzed from March 2011 to March 2018.

Intervention

The intervention group received CDCM, comprising a comprehensive needs assessment and individualized interventions by nurses specifically qualified for dementia care collaborating with GPs and health care stakeholders over 6 months. The control group received usual care.

Main Outcomes and Measures

Main outcomes were neuropsychiatric symptoms (Neuropsychiatric Inventory [NPI]), caregiver burden (Berlin Inventory of Caregivers' Burden in Dementia [BIZA-D]), health-related quality of life (HRQOL, measured by the Quality of Life in Alzheimer Disease scale and 12-Item Short-Form Health Survey [SF-12]), antidementia drug treatment, potentially inappropriate medication, and cost-effectiveness (incremental cost per quality-adjusted life year [QALY]) over 36 months. Outcomes between groups were compared using multivariate regression models adjusted for baseline scores.

Results

A total of 308 patients, of whom 221 (71.8%) received CDCM (mean [SD] age, 80.1 [5.3] years; 142 [64.3%] women) and 87 (28.2%) received usual care (mean [SD] age, 79.2 [4.5] years; 50 [57.5%] women), were included in the clinical effectiveness analyses, and 428 (303 [70.8%] CDCM, 125 [29.2%] usual care) were included in the cost-effectiveness analysis (which included 120 patients who had died). Participants receiving CDCM showed significantly fewer behavioral and psychological symptoms (adjusted mean difference [AMD] in NPI score, -10.26 [95% CI, -16.95 to -3.58]; P = .003; Cohen d, -0.78 [95% CI, -1.09 to -0.46]), better mental health (AMD in SF-12 Mental Component Summary score, 2.26 [95% CI, 0.31-4.21]; P = .02; Cohen d, 0.26 [95% CI, -0.11 to 0.51]), and lower caregiver burden (AMD in BIZA-D score, -0.59 [95% CI, -0.81 to -0.37]; P < .001; Cohen d, -0.71 [95% CI, -1.03 to -0.40]). There was no difference between the CDCM group and usual care group in use of antidementia drugs (adjusted odds ratio, 1.91 [95% CI, 0.96-3.77]; P = .07; Cramér V, 0.12) after 36 months. There was no association with overall HRQOL, physical health, or use of potentially inappropriate medication. The CDCM group gained QALYs (0.137 [95% CI, 0.000 to 0.274]; P = .049; Cohen d, 0.20 [95% CI, -0.09 to 0.40]) but had no significant increase in costs (437€ [-5438€ to 6313€] [US $476 (95% CI, -$5927 to $6881)]; P = .87; Cohen d, 0.07 [95% CI, -0.14 to 0.28]), resulting in a cost-effectiveness ratio of 3186€ (US $3472) per QALY. Cost-effectiveness was significantly better for patients living alone (CDCM dominated, with lower costs and more QALYs gained) than for those living with a caregiver (47 538€ [US $51 816] per QALY).

Conclusions and Relevance

In this secondary analysis of a cluster randomized clinical trial, CDCM was associated with improved patient, caregiver, and health system-relevant outcomes over 36 months beyond the intervention period. Therefore, it should become a health policy priority to initiate translation of CDCM into routine care.

Trial Registration

ClinicalTrials.gov Identifier: NCT01401582.

Collaborative Care Models of Primary Care Clinics for People with Early-Stage Dementia: A Cross-Sectional Survey of Primary Care Physicians in Japan

Objectives

This study explored collaboration models between primary care physicians (PCPs) and care managers (CMs) and assessed each model's potential in meeting the support needs of individuals with early-stage dementia.

Methods

In 2022, a cross-sectional survey was conducted among the PCPs in Tokyo. The data regarding the participant and clinic characteristics and daily practices for individuals with early-stage dementia were collected. The clinical collaborative practice was classified using a latent class analysis; comparisons were made between the identified classes based on 14 items in seven domains of support.

Results

Two collaborative and one stand-alone models were identified. The former varied in the professionals' roles, with one led by PCPs and the other by CMs. We named them PCP-led, CM-led, and stand-alone models, accounting for 46.4%, 32.8%, and 20.6% of the clinics, respectively. The PCP-led clinics were significantly more likely to provide support than the stand-alone ones across five domains: cognitive function, care planning, carers' support, information, and social health. The CM-led model clinics generally fell between those of the other two models.

Conclusion

Different leadership styles exist in the PCP-CM collaborations in care delivery for people with early-stage dementia. This collaboration offers distinct advantages for clinics in addressing their needs.

Best-practice recommendations to inform general practice nurses in the provision of dementia care: a Delphi study

BACKGROUND

Worldwide, responsibility for dementia diagnosis and management is shifting to primary care, in particular to the general practitioner (GP). It has been acknowledged that primary care nurses, working collaboratively with GPs, have a role in dementia care by utilising their unique knowledge and skills. However, there are no best-practice guidelines or care pathways to inform nurses in general practice on what best-practice dementia care comprises and how to implement this into their practice. This study identified the recommendations in the Australian guidelines for dementia management most relevant to the role of the nurse working in general practice.

METHODS

Seventeen experts active in clinical practice and/or research in primary care nursing in general practice participated in an online three-round Delphi study.

RESULTS

All 17 participants were female with a nursing qualification and experienced in general practice clinical nursing and/or general practice nursing research. Five recommendations were identified as the most relevant to the role of the nurse in general practice. These recommendations all contained elements of person-centred care: the delivery of individualised information, ongoing support, including the carer in decision-making, and they also align with the areas where GPs want support in dementia care provision.

CONCLUSION

This novel study identified best-practice dementia care recommendations specific to nurses in general practice. These recommendations will inform a model of care for nurses in the provision of dementia care that supports GPs and better meets the needs of people living with dementia and their carer(s).

Structural capabilities in primary care practices where nurse practitioners care for persons living with dementia

BACKGROUND

Primary care structural capabilities (i.e., electronic health records, care coordination, community integration, and reminder systems) can address the multiple needs of persons living with dementia (PLWD).

OBJECTIVES

This study describes structural capabilities in primary care practices where nurse practitioners (NPs) provide care to PLWD and compares the presence of structural capabilities in practices with a high and low volume of PLWD.

METHODS

We conducted a secondary analysis of cross-sectional data from 293 NPs in 259 practices in California. Logistic regression models were used to determine the association between the volume of PLWD and the presence of structural capabilities.

RESULTS

NPs reported that 96% of practices had electronic health records, 61% had community integration, 55% had reminder systems and 35% had care coordination capabilities. Practices with a high volume of PLWD were less likely to have community integration compared to practices with a low volume of PLWD.

CONCLUSION

Many PLWD-serving practices do not have the essential infrastructure for providing optimal dementia care. Practice managers should focus on implementing the essential structural capabilities to address the complex needs of PLWD.

IMPLICATIONS FOR PRACTICE

Clinicians and practice administrations can use the findings of this study to improve the delivery of care in practices that provide care to PLWD.

The Association between Primary Care Practices' Structural Capabilities and Hospitalizations among Persons Living with Dementia

Background: Persons living with dementia (PLWD) are more likely to be hospitalized than individuals without dementia. Little is known about key features (i.e., structural capabilities) in primary care practices where PLWD receive care. This study assessed the relationship between structural capabilities (i.e., care coordination, community integration, and reminder systems) and hospitalizations among PLWD. Methods: We conducted a secondary analysis of cross-sectional data from 5001 PLWD in 192 practices and used three datasets: nurse practitioner surveys, Medicare claims, and Minimum Data Set. Using generalized estimating equations, we evaluated the association between structural capabilities and hospitalizations. Results: PLWD who received care from practices with care coordination were less likely to have hospitalizations (OR = 0.62, p < .05). No statistically significant associations were observed between community integration and reminder systems and hospitalizations. Conclusion: Primary care practices need to tailor structural capabilities to address the needs of PLWD to reduce hospitalizations.

Promoting Physical Activity in a Primary Care Practice in People Living with Dementia and Their Family Caregivers

People living with dementia (PLWD) and their family caregivers report higher rates of having a sedentary lifestyle than their non-disabled peers do. This study analyzed the effectiveness of an intervention designed to increase physical activity among PLWD and their family caregivers in primary health care settings. A cluster-randomized multicenter clinical trial was conducted. Participants from four health centers were randomly assigned to the intervention group (IG) or the control group (CG) in a 1:1 ratio using Epidat software. After a seven-day period with a digital pedometer (Omron Hj-321 lay-UPS), participants were asked to complete the International Physical Activity Questionnaire Short Form (IPAQ-SF). PLWD and caregivers allocated to the IG were given brief advice, educational materials and an additional 15 min appointment to prescribe an individualized physical activity plan. Seventy PLWD and 80 caregivers were assigned to the CG and 70 PLWD and 96 caregivers were assigned to the IG. Results of the pedometer assessment show that in PLWD, the IG's activity increased by 52.89 aerobic steps at 6 months and the CG's activity decreased by 615.93 aerobic steps, showing a net increase in the IG of 668.82 (95% CI: -444.27 to 1781.91; p = 0.227). For caregivers in the IG, activity increased by 356.91 aerobic steps and in the CG it decreased by 12.95 aerobic steps, showing a net increase in favor of the IG of 369.86 (95%CI: -659.33 to 1399.05; p = 0.476). The effectiveness of interventions to increase physical activity in this group of people with dementia and their caregivers did not achieved positive results overall but may have provided suggestions for family physicians and physical therapists to improve physical activity among people with dementia and their families.

Improving Patient-Centered Dementia Screening for General, Multicultural Population and Persons with Disabilities from Primary Care Professionals with a Web-Based App

BACKGROUND

Primary care serves as the first point of contact for people with dementia and is therefore a promising setting for screening, assessment, and initiation of specific treatment and care. According to literature, online applications can be effective by addressing different needs, such as screening, health counseling, and improving overall health status.

AIM

Our goal was to propose a brief, inexpensive, noninvasive strategy for screening dementia to general, multicultural population and persons with disabilities, through a web-based app with a tailored multicomponent design.

METHODS

We designed and developed a web-based application, which combines cognitive tests and biomarkers to assist primary care professionals screen dementia. We then conducted an implementation study to measure the usability of the app. Two groups of experts participated for the selection of the screening instruments, following the Delhi method. Then, 16 primary care professionals assessed the app to their patients (n = 132), and after they measured its usability with System Usability Scale.

OUTCOMES

Two cognitive tools were integrated in the app, GPCOG and RUDAS, which are adequate for primary care settings and for screening multicultural and special needs population, without educational or language bias. Also, for assessing biomarkers, the CAIDE model was preferred, which resulted in individualized proposals, concerning the modifiable risk factors. Usability scored high for the majority of users.

CONCLUSION

Utilization of the Dementia app could be incorporated into the routine practices of existing healthcare services and screening of multiple population for dementia.

Subjective achievement from psychiatry rotation in the Japanese postgraduate residency system: a longitudinal questionnaire study

BACKGROUND

Psychiatry rotation has been mandatory in the Japanese postgraduate residency system since 2020. Some psychiatry-related competency items are stipulated as mandatory for residents. The current study aimed to clarify whether psychiatry rotation affected residents' subjective achievement of these competency items.

METHODS

This longitudinal study was conducted among postgraduate residents who completed a rotation in the psychiatry department at Nagasaki University Hospital across two academic years (2020-2021). The survey was administered at the start and at the end of the psychiatry rotation. Residents evaluated their subjective understanding and confidence regarding initiating treatment for these competency items using a six-point Likert scale. The average scores for each item were compared between pre-rotation and post-rotation.

RESULTS

In total, 99 residents (91.7%) responded to this survey. Residents had significantly higher scores at post-rotation compared with pre-rotation in all psychiatry-related competency items in both subjective understanding and confidence in initiating treatment. Additionally, strong effect sizes were found for many items.

CONCLUSION

Residents improved learning about psychiatry-related competency items through psychiatry rotation. This finding suggests that it is reasonable for psychiatry rotation to be mandatory in the current Japanese postgraduate residency system. The importance of psychiatry is likely to increase in both undergraduate and postgraduate medical education in the future. It is necessary to continuously update educational strategies to meet changing social needs over time. As this study was conducted at a single institution, a multi-center study is needed to expand the current findings.

Factors influencing sustainability and scale-up of rural primary healthcare memory clinics: perspectives of clinic team members

Background

The aging of rural populations contributes to growing numbers of people with dementia in rural areas. Despite the key role of primary healthcare in rural settings there is limited research on effective models for dementia care, or evidence on sustaining and scaling them. The purpose of this study was to identify factors influencing sustainability and scale-up of rural primary care based memory clinics from the perspective of healthcare providers involved in their design and delivery.

Methods

Participants were members of four interdisciplinary rural memory clinic teams in the Canadian province of Saskatchewan. A qualitative cross-sectional and retrospective study design was conducted. Data were collected via 6 focus groups (n = 40) and 16 workgroup meetings held with teams over 1 year post-implementation (n = 100). An inductive thematic analysis was used to identify themes.

Results

Eleven themes were identified (five that influenced both sustainability and scale-up, three related to sustainability, and three related to scale-up), encompassing team, organizational, and intervention-based factors. Factors that influenced both sustainability and scale-up were positive outcomes for patients and families, access to well-developed clinic processes and tools, a confident clinic leader-champion, facilitation by local facilitators and the researchers, and organizational and leadership support. Study findings revealed the importance of particular factors in the rural context, including facilitation to support team activities, a proven ready-to-use model, continuity of team members, and mentoring.

Conclusions

Interdisciplinary models of dementia care are feasible in rural settings if the right conditions and supports are maintained. Team-based factors were key to sustaining and scaling the innovation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07550-0.

Revisiting the four core functions (4Cs) of primary care: operational definitions and complexities

BACKGROUND

The four primary care (PC) core functions (the '4Cs', ie, first contact, comprehensiveness, coordination and continuity) are essential for good quality primary healthcare and their achievement leads to lower costs, less inequality and better population health. However, their broad definitions have led to variations in their assessment, in the innovations implemented to improve these functions and ultimately in their performance.

OBJECTIVES

To update and operationalise the 4Cs' definitions by using a literature review and analysis of enhancement strategies, and to identify innovations that may lead to their enhancement.

METHODS

Narrative, descriptive analysis of the 4Cs definitions, coming from PC international reports and organisations, to identify measurable features for each of these functions. Additionally, we performed an electronic search and analysis of enhancement strategies to improve these four Cs, to explore how the 4Cs inter-relate.

RESULTS

Specific operational elements for first contact include modality of contact, and conditions for which PC should be approached; for comprehensiveness, scope of services and spectrum of population needs; for coordination, links between PC and higher levels of care and social/community-based services, and workforce managing transitions and for continuity, type, level and context of continuity. Several innovations like enrolment, digital health technologies and new or enhanced PC provider's roles, simultaneously influenced two or more of the 4Cs.

CONCLUSION

Providing clear, well-defined operational elements for these 4Cs to measure their achievement and improve the way they function, and identifying the complex network of interactions among them, should contribute to the field in a way that supports efforts at practice innovation to optimise the processes and outcomes in PC.

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.

User-centered and theory-based design of a professional training program on shared decision-making with older adults living with neurocognitive disorders: a mixed-methods study

BACKGROUND

We know little about the best approaches to design training for healthcare professionals. We thus studied how user-centered and theory-based design contribute to the development of a distance learning program for professionals, to increase their shared decision-making (SDM) with older adults living with neurocognitive disorders and their caregivers.

METHODS

In this mixed-methods study, healthcare professionals who worked in family medicine clinics and homecare services evaluated a training program in a user-centered approach with several iterative phases of quantitative and qualitative evaluation, each followed by modifications. The program comprised an e-learning activity and five evidence summaries. A subsample assessed the e-learning activity during semi-structured think-aloud sessions. A second subsample assessed the evidence summaries they received by email. All participants completed a theory-based questionnaire to assess their intention to adopt SDM. Descriptive statistical analyses and qualitative thematic analyses were integrated at each round to prioritize training improvements with regard to the determinants most likely to influence participants' intention.

RESULTS

Of 106 participants, 98 completed their evaluations of either the e-learning activity or evidence summary (93%). The professions most represented were physicians (60%) and nurses (15%). Professionals valued the e-learning component to gain knowledge on the theory and practice of SDM, and the evidence summaries to apply the knowledge gained through the e-learning activity to diverse clinical contexts. The iterative design process allowed addressing most weaknesses reported. Participants' intentions to adopt SDM and to use the summaries were high at baseline and remained positive as the rounds progressed. Attitude and social influence significantly influenced participants' intention to use the evidence summaries (P < 0.0001). Despite strong intention and the tailoring of tools to users, certain factors external to the training program can still influence the effective use of these tools and the adoption of SDM in practice.

CONCLUSIONS

A theory-based and user-centered design approach for continuing professional development interventions on SDM with older adults living with neurocognitive disorders and their caregivers appeared useful to identify the most important determinants of learners' intentions to use SDM in their practice, and validate our initial interpretations of learners' assessments during the subsequent evaluation round.

Effectiveness of different post-diagnostic dementia care models delivered by primary care: a systematic review

BACKGROUND

Global policy recommendations suggest a task-shifted model of post-diagnostic dementia care, moving towards primary and community-based care. It is unclear how this may best be delivered.

AIM

To assess the effectiveness and cost-effectiveness of primary care-based models of post-diagnostic dementia care.

DESIGN AND SETTING

A systematic review of trials and economic evaluations of post-diagnostic dementia care interventions where primary care was substantially involved in care plan decision making.

METHOD

Searches were undertaken of MEDLINE, PsychINFO, EMBASE, Web of Science, and CINAHL (from inception to March 2019). Two authors independently critically appraised studies and inductively classified interventions into types of care models. Random effects meta-analysis or narrative synthesis was conducted for each model where appropriate.

RESULTS

From 4506 unique references and 357 full texts, 23 papers were included from 10 trials of nine interventions, delivered in four countries. Four types of care models were identified. Primary care provider (PCP)-led care (n = 1) led to better caregiver mental health and reduced hospital and memory clinic costs compared with memory clinics. PCP-led care with specialist consulting support (n = 2) did not have additional effects on clinical outcomes or costs over usual primary care. PCP-case management partnership models (n = 6) offered the most promise, with impact on neuropsychiatric symptoms, caregiver burden, distress and mastery, and healthcare costs. Integrated primary care memory clinics (n = 1) had limited evidence for improved quality of life and cost-effectiveness compared with memory clinics.

CONCLUSION

Partnership models may impact on some clinical outcomes and healthcare costs. More rigorous evaluation of promising primary care-led care models is needed.

Challenges and strategies in communication with people with dementia and their informal caregivers in community pharmacies - a narrative approach

BACKGROUND

People with dementia and their informal caregivers get in touch with the healthcare system predominantly via contacts with primary care providers. Among these, community pharmacists have been denominated as the health professionals most accessible to the public. Communication with and counselling people with dementia and their informal caregivers present particular challenges to pharmacists.

AIM

This study aims to research the challenges faced and strategies used by community pharmacists who deal with people living with dementia and their informal caregivers.

METHODS

Within the context of two workshops with 74 participants, 15 small groups were formed, each of which generated and discussed a small story. Fourteen of those narratives were reported, tape recorded and transcribed. In these 14 narratives, community pharmacists reflected on their experiences with people with dementia or their informal caregivers. The narratives were systematically analysed and interpreted.

FINDINGS

Among the main challenges reported by the workshop participants are the difficulty of identifying a person with dementia; the question of what appropriate communication is; the only partially successful networking with doctors, nursing personnel and support institutions; unsuccessful counselling; and the tension between the economic situation and the care for people with dementia and their informal caregivers. In general, strategies for dealing with people with dementia are characterised by uncertainty whereas communication with informal caregivers is well rehearsed and effective.

CONCLUSIONS

Community pharmacies require possibilities to retreat for counselling as well as the possibility for pharmacists to take time for people with dementia and their informal caregivers in everyday pharmacy life. Reflective spaces for narrations about difficult situations provide relief for staff in community pharmacies.

Barriers and facilitators to development and implementation of a rural primary health care intervention for dementia: a process evaluation

BACKGROUND

With rural population aging there are growing numbers of people with dementia in rural and remote settings. The role of primary health care (PHC) is critical in rural locations, yet there is a lack of rural-specific PHC models for dementia, and little is known about factors influencing the development, implementation, and sustainability of rural PHC interventions. Using a community-based participatory research approach, researchers collaborated with a rural PHC team to co-design and implement an evidence-based interdisciplinary rural PHC memory clinic in the Canadian province of Saskatchewan. This paper reports barriers and facilitators to developing, implementing, and sustaining the intervention.

METHODS

A qualitative longitudinal process evaluation was conducted over two and half years, from pre- to post-implementation. Data collection and analyses were guided by the Consolidated Framework for Implementation Research (CFIR) which consists of 38 constructs within five domains: innovation characteristics, outer setting, inner setting, individual characteristics, and process. Data were collected via focus groups with the PHC team and stakeholders, smaller team workgroup meetings, and team member interviews. Analysis was conducted using a deductive approach to apply CFIR codes to the data and an inductive analysis to identify barriers and facilitators.

RESULTS

Across all domains, 14 constructs influenced development and implementation. Three domains (innovation characteristics, inner setting, process) were most important. Facilitators were the relative advantage of the intervention, ability to trial on a small scale, tension for change, leadership engagement, availability of resources, education and support from researchers, increased self-efficacy, and engagement of champions. Barriers included the complexity of multiple intervention components, required practice changes, lack of formal incentive programs, time intensiveness of modifying the EMR during iterative development, lack of EMR access by all team members, lack of co-location of team members, workload and busy clinical schedules, inability to justify a designated dementia care manager role, and turnover of PHC team members.

CONCLUSIONS

The study identified key factors that supported and hindered the development and implementation of a rural-specific strategy for dementia assessment and management in PHC. Despite challenges related to the rural context, the researcher-academic partnership was successful in developing and implementing the intervention.

The needs of informal caregivers and barriers of primary care workers toward dementia management in primary care: a qualitative study in Beijing

BACKGROUND

Informal caregivers of people with dementia in Beijing are increasingly called upon to provide home-based care for their patients due to the increasing number of dementia patients and the shortage of standardized institutional solutions of care for patients in China. This study aimed to clarify the needs of informal caregivers and barriers of primary care workers toward dementia management in primary care in Beijing to provide references that may help to improve the care and services provided to individuals with dementia and their family caregivers residing in urban China.

METHODS

A mixed-methods approach was used in this study. We performed individual in-depth interviews with 10 informal caregivers. Moreover, we carried out focus group interviews with 29 primary care workers. Content analysis was used to separately identify themes and codes. Discrepancies were discussed until final agreement was achieved.

RESULTS

Three themes representing the core attitudes of informal caregivers and primary care workers were identified: care knowledge and skills, psychological counseling, and collaborative management. Most primary care workers believed that the management of dementia patients in primary care was necessary. However, due to the heavy work load and different medical specialties involved, these workers were unable to manage it.

CONCLUSIONS

Professional training focused on dementia for primary care workers should be strengthened. At the same time, the establishment of a community-based dementia team management model that includes specialists, community health service centers (CHSCs), and community committees should be explored.

Integrated care for adults with dementia and other cognitive disorders

The importance of better care integration is emphasized in many national dementia plans. The inherent complexity of organizing care for people with dementia provides both the justification for improving care integration and the challenges to achieving it. The prevention, detection, and early diagnosis of cognitive disorders mainly resides in primary care, but how this is best integrated within the range of disorders that primary care clinicians are expected to screen is unclear. Models of integrated community dementia assessment and management have varying degrees of involvement of primary and specialist care, but share an emphasis on improving care coordination, interdisciplinary teamwork, and personalized care. Integrated care strategies in acute care are still in early development, but have been a focus of investigation in the past decade. Integrated care outreach strategies to reduce transfers from long-term residential care to acute care have been consistently effective. Integrated long-term residential care includes considerations of end-of-life care. Future directions should include strategies for training and education, early detection in anticipation of disease modifying treatments, integration of technological developments into dementia care, integration of dementia care into general health and social care, and the encouragement of a dementia-friendly society.

Specialist services in early diagnosis and support for older people with dementia in England: Staff roles and service mix

OBJECTIVES

This study investigated staff roles and tasks in Community Mental Health Teams (CMHT) and memory clinics, which are provided within a framework determined by local Clinical Commissioning Groups.

METHODS

A cross-sectional survey design was used to collect data in England in 2015. Teams were identified by mental health providers (n = 68) and invited to complete a questionnaire.

RESULTS

Fifty-one NHS Trusts responded to the request. The response rate varied. Data were obtained for all Clinical Commissioning Groups areas in 3 of the 9 regions in England, but only half in one of them. CMHTs were significantly more likely to have larger staff groups. Compared with memory clinics they were also more likely to have staff that were not professionally qualified. The occupational therapist role showed a strong association with the provision of all services in CMHTs. Both CMHTs and memory clinics provided information and advice about dementia. CMHTs provided more services associated with the support of a person with dementia at home.

CONCLUSION

Variations in the staff mix in CMHTs and memory clinics reflected their different functions. There was limited evidence in both of profession specific interventions relating to the provision of support, information, therapy and education, associated with either diagnosis or long-term support. The potential for a single service to undertake both diagnostic and long-term support and the associated costs and benefits are areas for future research.

Effectiveness and Safety of Dementia Care Management in Primary Care: A Randomized Clinical Trial

IMPORTANCE

Dementia care management (DCM) can increase the quality of care for people with dementia. Methodologically rigorous clinical trials on DCM are lacking.

OBJECTIVE

To test the effectiveness and safety of DCM in the treatment and care of people with dementia living at home and caregiver burden (when available).

DESIGN, SETTING, AND PARTICIPANTS

This pragmatic, general practitioner-based, cluster-randomized intervention trial compared the intervention with care as usual at baseline and at 12-month follow-up. Simple 1:1 randomization of general practices in Germany was used. Analyses were intent to treat and per protocol. In total, 6838 patients were screened for dementia (eligibility: 70 years and older and living at home) from January 1, 2012, to March 31, 2016. Overall, 1167 (17.1%) were diagnosed as having dementia, and 634 (9.3%) provided written informed consent to participate.

INTERVENTIONS

Dementia care management was provided for 6 months at the homes of patients with dementia. Dementia care management is a model of collaborative care, defined as a complex intervention aiming to provide optimal treatment and care for patients with dementia and support caregivers using a computer-assisted assessment determining a personalized array of intervention modules and subsequent success monitoring. Dementia care management was targeted at the individual patient level and was conducted by 6 study nurses with dementia care-specific qualifications.

MAIN OUTCOMES AND MEASURES

Quality of life, caregiver burden, behavioral and psychological symptoms of dementia, pharmacotherapy with antidementia drugs, and use of potentially inappropriate medication.

RESULTS

The mean age of 634 patients was 80 years. A total of 407 patients received the intended treatment and were available for primary outcome measurement. Of these patients, 248 (60.9%) were women, and 204 (50.1%) lived alone. Dementia care management significantly decreased behavioral and psychological symptoms of dementia (b = -7.45; 95% CI, -11.08 to -3.81; P < .001) and caregiver burden (b = -0.50; 95% CI, -1.09 to 0.08; P = .045) compared with care as usual. Patients with dementia receiving DCM had an increased chance of receiving antidementia drug treatment (DCM, 114 of 291 [39.2%] vs care as usual, 31 of 116 [26.7%]) after 12 months (odds ratio, 1.97; 95% CI, 0.99 to 3.94; P = .03). Dementia care management significantly increased quality of life (b = 0.08; 95% CI, 0 to 0.17; P = .03) for patients not living alone but did not increase quality of life overall. There was no effect on potentially inappropriate medication (odds ratio, 1.86; 95% CI, 0.62 to 3.62; P = .97).

CONCLUSIONS AND RELEVANCE

Dementia care management provided by specifically trained nurses is an effective collaborative care model that improves relevant patient- and caregiver-related outcomes in dementia. Implementing DCM in different health care systems should become an active area of research.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01401582.

Diagnosis and Disruption: Population-Level Analysis Identifying Points of Care at Which Transitions Are Highest for People with Dementia and Factors That Contribute to Them

OBJECTIVES

To examine transitions that individuals with dementia experience longitudinally and to identify points of care when transitions are highest and the factors that contribute to those transitions.

DESIGN

Population-based 10-year retrospective cohort study from 2000 to 2011.

SETTING

General community.

PARTICIPANTS

All individuals aged 65 and older newly diagnosed with dementia in British Columbia, Canada.

MEASUREMENTS

The frequency and timing of transitions over 10 years, participant characteristics associated with greater number of transitions, and the influence of recommended dementia care and high-quality primary care on number of transitions.

RESULTS

Individuals experience a spike in transitions during the year of diagnosis, driven primarily by hospitalizations, despite accounting for end of life or newly moving to a long-term care facility (LTCF). This occurs regardless of survival time or care location. Regardless of survival time, individuals not in LTCFs experience a marked increase in hospitalizations in the year before and the year of death, often exceeding hospitalizations in the year of diagnosis. Receipt of recommended dementia care and receipt of high-quality primary care were independently associated with fewer transitions across care settings.

CONCLUSION

The spike in transitions in the year of diagnosis highlights a distressing period for individuals with dementia during which unwanted or unnecessary transitions might occur and suggests a useful target for interventions. There is an association between recommended dementia care and outcomes and evidence of the continued value of high-quality primary care in a complex population at a critical point when gaps in continuity are especially likely.

Comorbidity and dementia: a mixed-method study on improving health care for people with dementia (CoDem)

Background

Among people living with dementia (PLWD) there is a high prevalence of comorbid medical conditions but little is known about the effects of comorbidity on processes and quality of care and patient needs or how services are adapting to address the particular needs of this population.

Objectives

To explore the impact of dementia on access to non-dementia services and identify ways of improving the integration of services for this population.

Design

We undertook a scoping review, cross-sectional analysis of a population cohort database, interviews with PLWD and comorbidity and their family carers and focus groups or interviews with health-care professionals (HCPs). We focused specifically on three conditions: diabetes, stroke and vision impairment (VI). The analysis was informed by theories of continuity of care and access to care.

Participants

The study included 28 community-dwelling PLWD with one of our target comorbidities, 33 family carers and 56 HCPs specialising in diabetes, stroke, VI or primary care.

Results

The scoping review (n = 76 studies or reports) found a lack of continuity in health-care systems for PLWD and comorbidity, with little integration or communication between different teams and specialities. PLWD had poorer access to services than those without dementia. Analysis of a population cohort database found that 17% of PLWD had diabetes, 18% had had a stroke and 17% had some form of VI. There has been an increase in the use of unpaid care for PLWD and comorbidity over the last decade. Our qualitative data supported the findings of the scoping review: communication was often poor, with an absence of a standardised approach to sharing information about a person’s dementia and how it might affect the management of other conditions. Although HCPs acknowledged the vital role that family carers play in managing health-care conditions of PLWD and facilitating continuity and access to care, this recognition did not translate into their routine involvement in appointments or decision-making about their family member. Although we found examples of good practice, these tended to be about the behaviour of individual practitioners rather than system-based approaches; current systems may unintentionally block access to care for PLWD. Pathways and guidelines for our three target conditions do not address the possibility of a dementia diagnosis or provide decision-making support for practitioners trying to weigh up the risks and benefits of treatment for PLWD.

Conclusions

Significant numbers of PLWD have comorbid conditions such as stroke, diabetes and VI. The presence of dementia complicates the delivery of health and social care and magnifies the difficulties that people with long-term conditions experience. Key elements of good care for PLWD and comorbidity include having the PLWD and family carer at the centre, flexibility around processes and good communication which ensures that all services are aware when someone has a diagnosis of dementia. The impact of a diagnosis of dementia on pre-existing conditions should be incorporated into guidelines and care planning. Future work needs to focus on the development and evaluation of interventions to improve continuity of care and access to services for PLWD with comorbidity.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.