Primary dementia care based on the individual needs of the patient: study protocol of the cluster randomized controlled trial, DemStepCare

Background

Most people with dementia (PwD) are cared for at home, with general practitioners (GPs) playing a key part in the treatment. However, primary dementia care suffers from a number of shortcomings: Often, diagnoses are made too late and therapies by GPs do not follow the guidelines. In cases of acute crises, PwD are too often admitted to hospital with adverse effects on the further course of the disease.

The aim of this study is to implement and evaluate a new GP-based, complex dementia care model, DemStepCare. DemStepCare aims to ensure demand-oriented, stepped care for PwD and their caregivers.

Methods/design

In a cluster randomized controlled trial, the care of PwD receiving a complex intervention, where the GP is supported by a multi-professional team, is compared to (slightly expanded) usual care.

GPs are clustered by GP practice, with 120 GP practices participating in total. GP practices are randomized to an intervention or a control group. 800 PwD are to be included per group. Recruitment takes place in Rhineland-Palatinate, Germany. In addition, a second control group with at least 800 PwD will be formed using aggregated routine data from German health insurance companies. The intervention comprises the training of GPs, case management including repeated risk assessment of the patients’ care situation, the demand-oriented service of an outpatient clinic, an electronic case record, external medication analyses and a link to regional support services. The primary aims of the intervention are to positively influence the quality of life for PwD, to reduce the caregivers’ burden, and to reduce the days spent in hospital. Secondary endpoints address medication adequacy and GPs’ attitudes and sensitivity towards dementia, among others.

Discussion

The GP-based dementia care model DemStepCare is intended to combine a number of promising interventions to provide a complex, stepped intervention that follows the individual needs of PwD and their caregivers. Its effectiveness and feasibility will be assessed in a formative and a summative evaluation.

Trial registration

German Register of Clinical Trials (Deutsches Register Klinischer Studien, DRKS), DRKS00023560. Registered 13 November 2020 - Retrospectively registered. HTML&TRIAL_ID=DRKS00023560.

Support, needs and expectations of family caregivers regarding general practitioners - results from an online survey

Background

Family caregivers are often the first line of support for people requiring care; although they may personally stand to benefit, these activities substantially increase the risk of physical and emotional stress. General practitioners (GPs) may provide important support and stabilisation, but need to adjust to the needs and expectations of this group in order to do so. The aim of the study was to compare the needs of family caregivers from GPs to the support they actually experience. Additional aims included determining the main factors affecting satisfaction amongst family caregivers with support from GPs. The results were used to develop possible approaches towards optimisation within the purview of general medical practice.

Methods

Between January and July 2020, 612 people supporting or caring for a family member responded to an online survey posted in seventeen internet forums focused on family caregivers. In addition to the descriptive analysis, a t-test with independent samples was used to identify significant differences between two groups. We also used binary logistic regression analysis to identify indications of potentially influential factors regarding the experienced support from GPs.

Results

Around three out of every four respondents (72%) consulted GPs in care matters. The respondents gave positive responses on their GP’s knowledge of the care situation (71%), approachability in various issues connecting with care and service towards the caregiver (82%). GPs’ efforts in meeting the needs and requirements of the care recipient were also rated positively (82%). Weaknesses in support from GPs mainly involved the lack of information on advice and assistance services (55%) as well as frequently not identifying or involving caregivers as such soon enough (42%). Results from regression analysis show that the last two aspects play a major role in subjective satisfaction amongst family caregivers with support from GPs.

Conclusions

We recommend that GPs undergo further training to reinforce awareness that the care triad of needs, requirements and stresses amongst family caregivers also plays a vital role in care outcomes. With this in mind, general practice staff should adopt a pre-emptive strategy towards approaching family members about potential issues and informing them about existing assistance and support services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01381-4.

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.

Development of the Knowledge of Dementia Competencies Self-Assessment Tool

Competent dementia care requires caregivers with specialized knowledge and skills. The Knowledge of Dementia Competencies Self-Assessment Tool was developed to help direct care workers (DCWs) assess their knowledge of 7 dementia competencies identified by the Michigan Dementia Coalition. Item selection was guided by literature review and expert panel consultation. It was given to 159 DCWs and readministered to 57 DCWs in a range of long-term care settings and revised based on qualitative feedback and statistical item analyses, resulting in 82 items demonstrating good internal consistency and test-retest reliability. Performance on items assessing competencies rated as most important was significantly related to training in these competencies. The DCWs in day care obtained higher scores than those in home care settings, and their sites reported a greater number of hours of dementia training. Validation in a more diverse group of DCWs and assessing its relationship to other measures of knowledge and skill is needed.

Improving dementia diagnosis and management in primary care: a cohort study of the impact of a training and support program on physician competency, practice patterns, and community linkages

BACKGROUND

Primary care physicians routinely provide dementia care, but may lack the clinical skills and awareness of available resources to provide optimal care. We conducted a community-based pilot dementia training intervention designed to both improve clinical competency and increase utilization of local dementia care services.

METHODS

Physicians (N = 29) and affiliated staff (N = 24) participated in a one-day training program on dementia screening, diagnosis and management that included direct engagement with local support service providers. Questionnaires about their dementia care competency and referral patterns were completed before and 6 months after the training intervention.

RESULTS

Physicians reported significantly higher overall confidence in their dementia care competency 6 months post-training compared to pre-training. The largest reported improvements were in their ability to educate patients and caregivers about dementia and making appropriate referrals to community care services. Participants also reported markedly increased use of cognitive screening tools in providing care. Community service providers recorded approximately 160 physician-initiated referrals over a 2 year-period post-training, compared to few beforehand.

CONCLUSIONS

Combining a targeted physician practice-based educational intervention with community service engagement improves dementia care competency in clinicians and promotes linkages between clinical and community dementia care providers.

Variations in self-reported practice of physicians providing clinical care to individuals with dementia: a systematic review

OBJECTIVES

To determine to what extent actual practice as reported in the literature is consistent with clinical guidelines for dementia care.

DESIGN

A systematic review of empirical studies of clinical services provided by physicians to older adults with a diagnosis of dementia.

SETTING

All settings involving primary care physicians in which a diagnosis of dementia is provided.

PARTICIPANTS

Physicians providing care to individuals aged 60 and older with a primary or secondary diagnosis of dementia.

INTERVENTION

Seven dementia care processes recommended by guidelines: formal memory testing, imaging, laboratory testing, interventions, counseling, community service, and specialist referrals.

MEASUREMENTS

Web of Knowledge, PubMed, Science Direct, MedLine, PsychINFO, EMBASE, and Google Scholar databases were searched for articles in English published before March 1, 2012.

RESULTS

Twelve studies met the final inclusion criteria, all of which were self-reported cross-sectional surveys. There was broad variation in the proportion of physicians who reported conducting each dementia care process, with the widest variation in formal memory testing (4-96%). Recently published studies reflected a shift in scope of care, reporting that high proportions of physicians provided interventions, counseling, and referrals to specialist.

CONCLUSION

Despite the availability and dissemination of established best practice guidelines, there is still wide variation in physician practice patterns in dementia care. The quality of currently available studies limits the ability to draw strong conclusions. Better information on practice patterns and their relationship to outcomes for individuals with dementia and their caregivers using more-robust study designs is needed to address the needs of the increasing number of individuals who will require dementia care.

Improving physician awareness of Alzheimer disease and enhancing recruitment: the Clinician Partners Program

BACKGROUND

Primary care providers routinely evaluate older adults and are thus in a position to first detect symptoms and signs of Alzheimer disease. In urban areas, diagnostic or management difficulties may be referred to specialists; however, in rural areas, specialists may not be available. The Clinician Partners Program (CPP) was initiated to enhance rural health providers' ability in the diagnosis of dementia and care, and to increase research recruitment into dementia research studies of participants from rural communities.

METHODS

The CPP is a 3-day "miniresidency" of didactic, observational, and skill-based teaching techniques. Participants completed pretests and posttests evaluating dementia knowledge, confidence in providing care, and practice behaviors.

RESULTS

Between 2000 and 2009, 146 health care professionals with a mean age of 45.7±10.8 years attended the CPP; 79.2% were white, 58.2% were women, and 58% of participants had been in practice for more than 10 years. Posttests showed an improvement in knowledge and confidence for diagnosis and treatment and increased the use of dementia screening tools. Rural research participation in an urban Alzheimer Disease Research Center increased 52% over the pre-CPP period.

CONCLUSIONS

The following primary goals were accomplished: increased knowledge and confidence, changed practice habits, and enhanced research recruitment. Educational programs such as the CPP may be beneficial for increasing access to accurate diagnoses and appropriate treatment for Alzheimer disease while also enhancing research participation.

A systematic review of 'knowledge of dementia' outcome measures

Knowledge of dementia measures are key to identifying areas of misinformation and establishing knowledge levels, thus guiding educational programmes and interventions. A three-step literature search was undertaken to identify measures of knowledge in dementia. An evaluation framework was employed articulating quality indicators for the psychometric properties of measures, based on their development and use within research studies. Five measures were identified: the Alzheimer's Disease Knowledge Test (ADKT, Dieckmann et al., 1988); the University of Alabama Alzheimer's Disease Knowledge Test for Health Professionals (UAB-ADKT, Barrett et al., 1997); the Dementia Quiz (DQ, Gilleard and Groom, 1994); the Knowledge of Aging and Memory Loss and Care (KAML-C, Kuhn et al., 2005) and the Alzheimer's Disease Knowledge Scale (ADKS, Carpenter et al., 2009). All measures followed a standard scale development process, generally with acceptable reliability and validity. Many studies used measures on populations beyond the target sample, without re-establishing the psychometric properties of the scales. There are limitations with all the measures, including weaknesses in psychometric properties, being outdated and having limited scope. Although the ADKT was once suited to international use and has established psychometric properties, some items are now outdated. The ADKS positions itself as an updated version of the ADKT, yet has not been used beyond the original development study. The DQ is most the suitable for family carers. All measures require periodic updates, to keep pace with the expanding field of dementia. More robust, contemporary measures of knowledge are required.

Practice patterns in the evaluation and management of dementia by primary care residents, primary care physicians, and geriatricians

With the aim of determining if specialty type or the amount of geriatric training during primary care residencies correlated with the rate of and comfort with dementia identification and management in patients 65 years and older, physician practice patterns were compared through a web-based survey. The survey was sent to family medicine, internal medicine, and geriatric physicians in Dallas County and the HealthTexas Provider Network as well as third-year family medicine and internal medicine residents in Texas. Chi-square analyses revealed no relationship between the quantity of geriatric training and either dementia screening rates or comfort with dementia diagnosis. However, there was a significant difference in these areas based on specialty: more geriatricians reported asking senior patients about memory problems and being very comfortable in making a diagnosis of dementia, while fewer family medicine and internal medicine physicians reported being very comfortable in making the dementia diagnosis. Most physicians surveyed supported instituting routine screening and evaluation of senior patients during residency training. Further research is needed to determine if brief screening modalities, enhanced training, and institution of national guidelines would result in earlier identification and management of dementia in primary care.

Dementia knowledge among general practitioners: first results and psychometric properties of a new instrument

BACKGROUND

General practitioners (GPs) play an important role in dementia care. Sufficient knowledge is one of the prerequisites for adequate dementia management, and educational activities do include knowledge transfer. There is no up-to-date measure of GPs' knowledge of dementia, resulting in the use of unreliable ad hoc questionnaires in recent studies, thus increasing the risk of biased results.

METHODS

In a cross-sectional, observational questionnaire study, 292 German GPs answered 37 questions regarding factual dementia knowledge. For the purpose of cross-validation, the psychometric properties of the test and its associations with GP characteristics were analyzed in independent samples with item and regression analyses.

RESULTS

Twenty questions constituted a reliable questionnaire (Cohen's alpha = 0.733) with a normal distribution of test scores. Linear regression analysis revealed significant associations of the knowledge test score with the GPs' age and their attitudes towards dementia.

CONCLUSIONS

The newly developed dementia-knowledge test for GPs can be used in observational studies, in which a rough and easy to use instrument is required.

Improving access to dementia care: development and evaluation of a rural and remote memory clinic

The availability, accessibility and acceptability of services are critical factors in rural health service delivery. In Canada, the aging population and the consequent increase in prevalence of dementia challenge the ability of many rural communities to provide specialized dementia care. This paper describes the development, operation and evaluation of an interdisciplinary memory clinic designed to improve access to diagnosis and management of early stage dementia for older persons living in rural and remote areas in the Canadian province of Saskatchewan. We describe the clinic structure, processes and clinical assessment, as well as the evaluation research design and instruments. Finally, we report the demographic characteristics and geographic distribution of individuals referred during the first three years.

Self-reported competence, attitude and approach of physicians towards patients with dementia in ambulatory care: results of a postal survey

Background

Caring for patients with dementia is a demanding task. Little is known as to whether physicians feel competent enough to perform this task or whether a lack of self-perceived competence influences attitudes and professional approach. Even less is known with respect to potential differences between general practitioners (GPs) and specialists. The purpose of this study was to investigate the interrelationship between the self-perceived competence, attitude and professional approach of physicians in ambulatory care in Germany. A further aim was to compare GPs and specialists with regard to differences in these areas.

Methods

A standardised postal survey was sent to 389 GPs and 239 neurologists and psychiatrists in six metropolitan areas in Germany. The 49-item questionnaire consisted of attitudinal statements to be rated on a Likert-type scale. Return rates were 54 percent for GPs and 40 percent for specialists. Statistical methods used to analyze data included correlation analysis, cluster analysis and ordinal regression analysis.

Results

No differences were found between GPs and specialists with regard to their general attitude towards caring for patients with dementia. Approximately 15 percent of both disciplines showed a clearly negative attitude. Self-reported competence was strongly associated with general attitude. In particular among GPs, and less so among specialists, a strong positive association was found between self-reported competence, general attitude and professional approach (e.g. early detection, active case finding and cooperation with caregivers). Differences between GPs and specialists were smaller than expected and appear to predominantly reflect task differences within the German health care system.

Conclusion

Training opportunities which enable in particular GPs to enhance not only their competence but also their general attitude towards dementia care would appear to be beneficial and might carry positive consequences for patients and their caregivers.

Rural families caring for a relative with dementia: barriers to use of formal services

Planning for the care of increasing numbers of elderly persons with dementia has become an urgent health services concern in Canada and elsewhere, yet little is known about the challenges of providing appropriate dementia care in rural areas. A community-based approach was used to obtain input from decision-makers and others to develop the objectives and design for a study of rural dementia care in the province of Saskatchewan, Canada. The resulting study design, which used both qualitative and quantitative methods, was then pilot tested in one rural health district (16,000 km2, population 20,000). This paper describes the study development process and reports selected findings from focus groups conducted with home care staff and family members, focussing on the theme of low use of formal supportive services such as home care and support groups by family caregivers. Participants identified eight barriers to the use of formal services, described consequences of low service use, and suggested strategies for addressing this concern.

Reported practices of primary care physicians in the diagnosis and management of dementia

The shortage of geriatric specialists in the US may require that primary care physicians (PCPs) receive more education on diagnosing and managing dementia since the number of older Americans with dementia will increase from about five million in 2010 to up to 14 million in 2050. Thus, we administered a brief, anonymous questionnaire to determine PCPs' diagnostic, referral, and management practices to a convenience sample of 142 PCPs in Arkansas. We reworded a Scottish survey to conform to terminology used in the US and added items on referral practices. The PCPs who reported difficulty establishing the diagnosis of dementia had more difficulty telling the diagnosis (O.R = 3.59, p < 0.004). The PCPs were less likely (p < 0.001) to tell the patient if they suspected dementia (73%) than if they were sure the patient had dementia (88%). In both cases, they were more likely to tell the family (92% & 100%, respectively), although this difference was not statistically significant. The PCPs discussed disease progression and driving risks with patients and families, but few referred them to social workers or community agencies. Findings support training PCPs in the diagnosis and management of persons with dementia and providing tools to improve care.