Barriers to treatment: the unique challenges for physicians providing dementia care

Caregiver Burden and the Impact of Diagnostic Disclosure of Dementia: Why Primary Care Physicians Have a Moral Responsibility to Disclose

AbstractCurrently, the number of individuals affected by Alzheimer's disease is rapidly increasing, expected to reach 14 million in the United States within 30 years. In spite of this impending crisis, less than 50 percent of primary care physicians disclose the diagnosis of dementia to their patients. This failure negatively impacts not only patients but also caregivers, whom dementia patients require to help them meet their needs and who often serve as important decision makers, either as surrogates or as designated healthcare agents for the patient. If caregivers are not informed about and prepared to deal with the challenges they face, their health, both emotional and physical, is put at risk. We will argue that both patient and caregiver have the right to be informed of the diagnosis, as their interests are intertwined, especially as the disease progresses and the caregiver becomes the primary advocate for the patient. The caregiver of an individual with dementia therefore becomes intimately connected to the patient's autonomy in a way few caregivers of other diseases do. In this article, we will show that a timely and thorough disclosure of the diagnosis is morally obligated by the core principles of medical ethics. As the population ages, primary care physicians must see themselves in a triadic relationship with both the dementia patient and caregiver, recognizing that the interests of both are deeply interdependent.

Physician Practice Patterns Associated with Diagnostic Evaluation of Patients with Suspected Mild Cognitive Impairment and Alzheimer's Disease

The diagnostic process for patients presenting with cognitive decline and suspected dementia is complex. Physicians face challenges distinguishing between normal aging, mild cognitive impairment, Alzheimer's disease, and other dementias. Although there is some evidence for improving attitudes towards the importance of prompt diagnosis, there is limited information describing how physicians approach this diagnostic challenge in practice. This was explored in the present study. Across-sectional survey of primary care and specialist physicians, in 5 European countries, Canada, and the United States, was conducted. Participants were asked about their use of cognitive screening tools and diagnostic technologies, as well as the rationales and barriers for use. In total, 1365 physicians participated in the survey, 63% of whom were specialists. Most physicians stated they use objective cognitive tools to aid the early detection of suspected mild cognitive impairment or Alzheimer's disease in patients. The Mini-Mental State Examination was the most common tool used for initial screening; respondents cited speed and ease of use but noted its lack of specificity. Cerebrospinal fluid biomarker and amyloid positron emission tomography tests, respectively, had been used by only 26% and 32% of physicians in the preceding 6 months, although patterns of use varied across countries. The most commonly cited reasons for not ordering such tests were invasiveness (for cerebrospinal fluid biomarker testing) and cost (for amyloid positron emission tomography imaging). Data reported by physicians reveal differences in the approaches to the diagnostics process in Alzheimer's. A higher proportion of primary care physicians in the United States are routinely incorporating cognitive assessment tools into annual visits, but this is due to country differences in clinical practice. The value of screening tools and regular use could be discussed further with physicians; however, lack of specificity associated with cognitive tools and the investment required from patients and the healthcare system are limiting factors.

General Practitioner's Attitudes and Confidence in Managing Patients with Dementia in Singapore

The number of people living with dementia is increasing globally as a result of an ageing population. General practitioners (GPs), as the front-line care providers in communities, are important stakeholders in the system of care for people with dementia. This commentary describes a study conducted to understand GPs' attitudes and self-perceived competencies when dealing with patients with dementia and their caregivers in Singapore. A set of study information sheet and survey questionnaires were mailed to selected GP clinics in Singapore. The survey, comprising the "GP Attitudes and Competencies Towards Dementia" questionnaire, was administered. A total of 400 GPs returned the survey, giving the study a response rate of 52.3%. About 74% of the GPs (n=296) were seeing dementia patients in their clinics. Almost all the GPs strongly agreed that early recognition of dementia served the welfare of the patients (n=385; 96%) and their relatives (n=387; 97%). About half (51.5%) of the respondents strongly agreed or agreed that they felt confident carrying out an early diagnosis of dementia. Factor analysis of questionnaire revealed 4 factors representing "benefits of early diagnosis and treatment of patients with dementia", "confidence in dealing with patients and caregiver of dementia", "negative perceptions towards dementia care" and "training needs". GPs in Singapore held a generally positive attitude towards the need for early dementia diagnosis but were not equally confident or comfortable about making the diagnosis themselves and communicating with and managing patients with dementia in the primary care setting. Dementia education and training should therefore be a critical step in equipping GPs for dementia care in Singapore. Shared care teams could further help build up GPs' knowledge, confidence and comfort in managing patients with dementia.

General practitioners' knowledge, practices, and obstacles in the diagnosis and management of dementia

OBJECTIVES

To identify general practitioners' (GPs) knowledge, practices, and obstacles with regard to the diagnosis and management of dementia.

METHODS

Standardized questionnaires covering knowledge, practices, and obstacles were distributed among a purposive sample of GPs in Kathmandu, Nepal. Three hundred and eighty GPs responded (response rate = 89%).

RESULTS

Knowledge of practitioners' with regard to the diagnosis and management of dementia was unsatisfactory (<50%). Diagnosis and management barriers are presented with regard to GP, patient, and carer factors. Specifically, the results address the following issues: communicating the diagnosis, negative views of dementia, difficulty diagnosing early-stage dementia, acceptability of specialists, responsibility for extra issues, knowledge of dementia and aging, less awareness of declining abilities, diminished resources to handle care, lack of specific guidelines, and poor awareness of epidemiology.

CONCLUSIONS

Demographic changes mean that dementia will represent a significant problem in the future. The following paper outlines the problems and solutions that the Nepalese medical community needs to adopt to deal effectively with diagnosis, care, and management of dementia.

Strengthening the dementia care triad: identifying knowledge gaps and linking to resources

This article describes a project to identify the needs of family caregivers and health care providers caring for persons with dementia. Participants included 128 caregivers, who completed a survey, and 27 health care providers, who participated in a focus group and completed a survey. Caregivers reported their primary source of information about the disease was the doctor; however, the majority also reported they were primarily informed of medications and not about needed resources. Health care providers identified limited time with patients and families, and lack of awareness of community services, as their main challenges. Recommendations include strengthening the partnership between physicians, patients, and caregivers (the dementia care triad) through additional support and training for physicians and caregivers, increasing awareness of the Alzheimer's Association, and utilization of technology for families and professionals to track the needs of persons with dementia.

Diagnosis and treatment of dementia: 4. Approach to management of mild to moderate dementia

BACKGROUND

The management of mild to moderate dementia presents complex and evolving challenges. Practising physicians are often uncertain about the appropriate approaches to issues such as the disclosure of the diagnosis, driving and caregiver support. In this article, we provide practical guidance on management based on recommendations from the Third Canadian Consensus Conference on the Diagnosis and Treatment of Dementia.

METHODS

We developed evidence-based guidelines using systematic literature searches, with specific criteria for the selection and quality assessment of articles, and a clear and transparent decision-making process. We selected articles published from January 1996 to December 2005 that dealt with the management of mild to moderate stages of Alzheimer disease and other forms of dementia. Recommendations based on the literature review were drafted and voted on. Consensus required 80% or more agreement by participants. Subsequent to the conference, we searched for additional articles published from January 2006 to April 2008 using the same major keywords and secondary search terms. We graded the strength of evidence using the criteria of the Canadian Task Force on Preventive Health Care.

RESULTS

We identified 1615 articles, of which 954 were selected for further study. From a synthesis of the evidence in these studies, we made 48 recommendations for the management of mild to moderate dementia (28) and dementia with a cerebrovascular component (8) as well as recommendations for addressing ethical issues (e.g., disclosure of the diagnosis) (12). The updated literature review did not change these recommendations. In brief, patients and their families should be informed of the diagnosis. Although the specifics of managing comorbid conditions might require modification, standards of care and treatment targets would not change because of a mild dementia. The use of medications with anticholinergic effects should be minimized. There should be proactive planning for driving cessation, since this will be required at some point in the course of progressive dementia. The patient's ability to drive should be determined primarily on the basis of his or her functional abilities. An important aspect of care is supporting the patient's primary caregiver.

INTERPRETATION

Much has been learned about the care of patients with mild to moderate dementia and the support of their primary caregivers. There is a pressing need for the development, and dissemination, of collaborative systems of care.

Bereavement in cognitively impaired older adults: case series and clinical considerations

The intersection of bereavement and cognitive impairment presents unique clinical challenges that have been overlooked in the literature. Cognitive impairment can interfere with normal ways of coping in the aftermath of loss. Elderly persons with cognitive impairment may have difficulty processing their loss and may even forget that their loved one has died, repeatedly asking other family members when the deceased is coming to visit. This can prove devastating for such individuals and their families, who are forced to keep reexperiencing their grief. This article examines the phenomenology of bereavement-related distress in older adults with cognitive impairment and dementia through a case series gathered from a large geriatric facility. The dilemmas in caring for bereaved elderly with cognitive difficulties and their families are highlighted, drawing attention to a vulnerable population. The purpose of this undertaking is to present a novel classification of a clinically relevant but overlooked issue as well as provide strategies for management and suggestions for future research.

Attitudes Toward the Diagnosis and Disclosure of Dementia Among Family Caregivers and Primary Care Physicians

PURPOSE

This study examined attitudes of caregivers and physicians toward assessing and diagnosing dementia, with an emphasis on how a diagnosis is disclosed.

DESIGN AND METHODS

Seventeen focus group interviews were conducted with caregivers or physicians from three sites; 52 caregivers participated in nine interviews (three each at the three sites), and 39 physicians participated in eight interviews (three each at two sites; two at one site). Structured interview protocols were used to assess diagnostic disclosure, first reactions, and suggestions for improving the diagnostic process.

RESULTS

Caregivers recounted a highly negative emotional response to the disclosure, whereas many physicians reported that families handled the information well. Caregivers expressed a range of preferences for how the diagnosis should have been disclosed, from a direct approach to having the physician ease them into the results.

IMPLICATIONS

Whenever possible, physicians should consult with the patient and family at the outset of the diagnostic process to better understand their preferences for diagnostic disclosure. Addressing diagnostic disclosure as part of physician education programs on dementia is recommended.

Cognitive dementia and memory service clinics: opinions of general practitioners

This study examined general practitioners' (GPs) satisfaction with services provided by memory clinics and the extent to which the clinics were seen as assisting with the management of their patients with dementia. Thirty-five GPs, who had recently referred patients to the Cognitive Dementia and Memory Service (CDAMS) in Victoria, Australia, were interviewed about their experiences. Overall, most were satisfied with the service the clinic provided. They were most positive about the completeness and utility of the assessment and diagnostic information provided, but relatively less satisfied with advice regarding the family's coping and community support services for the patient. It was concluded that the CDAMS is enhancing the capacity of GPs to provide ongoing care to people with dementia. However, the establishment of firmer communication and collaborative protocols between the clinics and GPs would improve their usefulness.