Dementia In Primary Care Research Articles

Antidementia drug treatment in people screened positive for dementia in primary care.

There is a lack of knowledge about antidementia drug treatment in community dwelling people with dementia in Germany. To determine the frequency of treatment with antidementia drugs in patients in primary care, and the socio-demographic and clinical variables associated with antidementia drug treatment. Present analyses are based on preliminary data from the DelpHi-trial, an ongoing GP-based, cluster-randomized, controlled intervention trial to implement and evaluate an innovative concept of collaborative dementia care management in Germany. Our sample consists of n = 243 subjects who screened positive for dementia. 29.6% (n = 72) of participants received antidementia drugs: memantine 44.5% (n = 32); donepezil 30.5% (n = 22); rivastigmine 13.9% (n = 10); galantamine 11.1% (n = 8). A total of 46.4% (n = 45) of the subgroup of participants with a formal dementia diagnosis received antidementia drug treatment. Approximately 37.5% (n = 27) of our sample received treatment with antidementia drugs without having a formal diagnosis. Treatment with antidementia drugs was significantly associated with more severe cognitive impairment and having a formal dementia diagnosis. One in three people who screened positive for dementia in primary care received antidementia drug treatment, indicating the frequent use of this class of drugs. For those with a formal dementia diagnosis, these drug treatment rates are more than triple, compared to those in nursing homes.

Improving diagnosis of dementia in primary care

Our commentaries from the Primary Care Neurology Society (P‐CNS) provide a primary care perspective on neurology articles featured in Progress. Here, Drs Susan Mary Benbow, David Jolley and Ian Greaves consider ‘Speed versus accuracy in cognitive assessment’ (see page 21).

A model of integrated care for people with dementia in Primary Care

A model of integrated care for people with dementia in Primary Care

Understanding the challenges to implementing case management for people with dementia in primary care in England: a qualitative study using Normalization Process Theory.

BackgroundCase management has been suggested as a way of improving the quality and cost-effectiveness of support for people with dementia. In this study we adapted and implemented a successful United States’ model of case management in primary care in England. The results are reported elsewhere, but a key finding was that little case management took place. This paper reports the findings of the process evaluation which used Normalization Process Theory to understand the barriers to implementation.MethodsEthnographic methods were used to explore the views and experiences of case management. Interviews with 49 stakeholders (patients, carers, case managers, health and social care professionals) were supplemented with observation of case managers during meetings and initial assessments with patients. Transcripts and field notes were analysed initially using the constant comparative approach and emerging themes were then mapped onto the framework of Normalization Process Theory.ResultsThe primary focus during implementation was on the case managers as isolated individuals, with little attention being paid to the social or organizational context within which they worked. Barriers relating to each of the four main constructs of Normalization Process Theory were identified, with a lack of clarity over the scope and boundaries of the intervention (coherence); variable investment in the intervention (cognitive participation); a lack of resources, skills and training to deliver case management (collective action); and limited reflection and feedback on the case manager role (reflexive monitoring).ConclusionsDespite the intuitive appeal of case management to all stakeholders, there were multiple barriers to implementation in primary care in England including: difficulties in embedding case managers within existing well-established community networks; the challenges of protecting time for case management; and case managers’ inability to identify, and act on, emerging patient and carer needs (an essential, but previously unrecognised, training need). In the light of these barriers it is unclear whether primary care is the most appropriate setting for case management in England. The process evaluation highlights key aspects of implementation and training to be addressed in future studies of case management for dementia.

Introducing case management for people with dementia in primary care: a mixed-methods study.

Case management may be a feasible solution to the problem of service fragmentation for people with dementia. To adapt a US model of primary care-based case management for people with dementia and test it in general practice. Mixed-methodology case studies of case management implementation in four general practices: one rural, one inner-city, and two urban practices. Practice nurses undertook the case manager role in the rural and inner-city practices, and were allocated one session per week for case management by their practices. A seconded social worker worked full time for the two urban practices. Participants were community-dwelling patients with dementia who were living at home with a family carer, and who were not receiving specialist care coordination. Case study methods included analysis of case loads and interviews with patients, carers, local NHS and other stakeholders, and case managers. Measures included numbers of patients with dementia and their carers, number of unmet needs identified, and actions taken to meet needs. Case manager records were compared with findings from interviews with patients and carers, and with other stakeholders. The number of eligible patients was smaller than expected. No practice achieved its recruitment target. Researchers identified more unmet needs than case managers. The practice nurse case managers reported lack of time and found research documentation burdensome. Patients and carers were positive about case management as a first point of contact with the practice, as a 'safety net', and for creating a one-to-one therapeutic relationship. Further investigation is required before case management for people with dementia and their carers can be implemented in primary care.

Neuropsychiatric symptoms in people screened positive for dementia in primary care.

Neuropsychiatric symptoms are major determinants for caregiver distress and institutionalization in dementia. Little is known about the prevalence of neuropsychiatric symptoms and their association with use of medication, caregiver distress, and resource utilization in primary care. We assessed frequency of neuropsychiatric symptoms in a sample retrieved from a primary care intervention study. Patients were screened for dementia by their primary care physicians. A study nurse assessed neuropsychiatric symptoms in 176 patients using the neuropsychiatric inventory (NPI) through face-to-face interviews by proxy during home visits. In addition, data on global cognition (MMSE), quality of life (QoL-AD), resource utilization in dementia (RUD), caregiver distress (BIS), and use of psychotropic medication in patients were obtained. We used linear mixed effect models taking into account the clustering of patients within general physician practices. Clinically relevant neuropsychiatric symptoms (NPI score ≥ 4) occurred in about 53% of the patients. Higher NPI scores were significantly associated with more severe cognitive impairment, higher caregiver distress, and higher utilization of caregiver resources by patients but not with a formal diagnosis of dementia from the primary care physician. Use of antipsychotics was associated with higher NPI scores, particularly in non-psychotic domains. Neuropsychiatric symptoms in a primary care cohort screened positive for dementia were associated with resource utilization and distress of caregivers. In contrast to guideline recommendations, the use of antipsychotics was associated with non-psychotic domains of behavioral symptoms. These findings underscore the relevance of neuropsychiatric symptoms for the design of future interventions in primary care.

Medication cost of persons with dementia in primary care in Germany.

Results of cost-of-illness studies in dementia have shown a considerable divergence in costs of medication for persons with dementia. However, detailed economic analyses of medication costs for community-dwelling persons with dementia are currently still missing, especially on the basis of primary data. To determine medication cost, cost per drug, and number of drugs taken of community-dwelling persons with dementia and analyze their associated factors; to estimate the current price reduction of anti-dementia drugs due to implementation of low-priced generics. The present analysis included 205 patients screened positive for dementia. Medication data were assessed within a medication review. To estimate the cost effect of implementing generics, the most favorable equivalent generic was assigned to each anti-dementia drug. Factors associated with medication cost, cost per drug, and number of drugs taken were evaluated using multiple regression models. Medication cost and cost per drug were higher and the number of taken drugs lower in advanced stages of cognitive impairment. Prescription of anti-dementia generics could decrease overall medication cost by 28%. Medication cost was associated with number of diagnoses, deficits in activities of daily living, and age. Dementia severity was related to cost per drug and number of drugs taken. Medication cost increases with the number of diagnoses and growing deficits in activities of daily living and decreases with age. Severely cognitively impaired persons are treated with a small number of high-priced drugs, which could suggest inadequate medication of multimorbid persons.

Rates of formal diagnosis in people screened positive for dementia in primary care: results of the DelpHi-Trial.

Primary data about rates of formal diagnosis of dementia in the German primary care sector are widely lacking. Main objectives are to analyze the rate of syndrome diagnosis in primary care patients who screened positive for dementia, the distribution of differential diagnoses, and factors associated with undiagnosed dementia. DelpHi-MV (Dementia: life- and person-centered help in Mecklenburg-Western Pomerania) is an ongoing general practitioner (GP)-based, randomized, controlled intervention trial. A total of 4,064 patients (≥70 years, living at home) recruited from 108 participating GP practices were screened for dementia (DemTect < 9). Of 692 eligible patients (17%), a total of 406 subjects (59%) provided informed consent. Present analyses are based on the data of 243 patients with complete baseline assessment on January 1, 2014 (preliminary data). Formal diagnoses were retrieved from the medical records of the treating GPs. A conditional fixed effect regression analysis was performed to analyze factors associated with undiagnosed dementia. A total of 40% of patients who screened positive for dementia had been formally diagnosed with dementia. Unspecified dementia was diagnosed in 53%, vascular dementia in 24%, and Alzheimer's disease in 19% of these patients. Undiagnosed dementia was significantly associated with a higher mean score in the Mini-Mental State Examination (odds ratio, 1.11; p < 0.01, 95% confidence interval 1.04-1.18). The diagnosis rate of dementia in German primary care (40%) is well within the range of the international data (20-50%). The results emphasize the need for action to enhance recognition and differential diagnosis of dementia.

Cognitive screening for dementia in primary care: a systematic review

Identifying dementia in primary care could minimize the impact of a late intervention; however, it shows high rates of misdiagnosis. One of the reasons seems to be the lack of knowledge of adequate cognitive screening instruments. This is a systematic review of the available instruments for the primary care context. For this systematic review, articles were collected according to the following combined key terms: "cognitive screening" and "dementia" and "primary care" and "review". Studies should be reviews focusing on cognitive screening instruments best used in primary care setting. Thirteen reviews were selected. In total, it was considered 34 cognitive screening instruments. Half of the instruments can be applied in an adequate time-limit for primary care context. Memory is the most commonly assessed cognitive function (91%). Almost half of the tests are mentioned to have influence of education or cultural factors (44%). Tests such as 6CIT, AMT, GPCOG, Mini-Cog, MIS, MoCA, and STMS seem to be good alternatives to the use of the Mini-Mental State Examination when considering factors such as application time, sensitivity, specificity, and number of studies. However, there is a wide range of tests with different characteristics, therefore it is recommended that the professional gets some expertise in a few number of instruments in order to be able to choose which to use, or use in combination, depending on the setting and the profile of the patient.

Long-term cycles in admissions for neurological conditions

British Journal of Healthcare ManagementVol. 20, No. 4 Money MattersLong-term cycles in admissions for neurological conditionsRod JonesRod JonesSearch for more papers by this authorRod JonesPublished Online:14 May 2014https://doi.org/10.12968/bjhc.2014.20.4.192AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View articleReferencesFerrari C, Tarelli R (2011) Parkinson's disease and systemic inflammation. Parkinson's Disease doi: https://doi.org/10.4061/2011/436813 Google ScholarRussell P, Banerjee S, Watt Jet al. (2013) Improving the identification of people with dementia in primary care: evaluation of the impact of primary care dementia coding guidance on identified prevalence. BMJ Open 3(12): e004023 Crossref, Google ScholarJones R (2013a) Could cytomegalovirus be causing widespread outbreaks of chronic poor health. In: Shoja M, ed. Hypotheses in Clinical Medicine. Nova Science Publishers Inc, New York, NY: 37–79. Available at: www.hcaf.biz/2013/CMV_Read.pdf (accessed 26 March 2014) Google ScholarJones R (2013b) Recurring outbreaks of a subtle condition leading to hospitalization and death. Epidemiology: Open Access 4(3): 137 Google ScholarJones R (2013c) Do recurring outbreaks of a type of infectious immune impairment trigger cyclic changes in the gender ratio at birth? Biomedicine International 4(1): 26–39 Google ScholarJones R (2013d) A recurring series of infectious-like events leading to excess deaths, emergency department attendances and medical admissions in Scotland. Biomedicine International 4(2): 72–86 Google ScholarJones R (2013e) What every GP needs to know about financial risk in commissioning. General Practice Online. Available at: www.priory.com/family_medicine/GP_commissioning_risk.htm (accessed 26 March 2014) Google ScholarJones R (2014a) Infectious-like spread of an agent leading to increased medical hospital admission in the North East Essex area of the East of England. Biomedicine International 5(1): in press Google ScholarJones R (2014b) What is happening in unscheduled care? Journal of Paramedic Practice 5(2): 60–62 Link, Google ScholarJones R (2014c) Unexpected and semipermanent increase in emergency medical admissions: admission threshold or infectious-like spread? Public Health (submitted) Google ScholarJones R (2014d) Unexpected single-year-of-age changes in the elderly mortality rate in 2012 in England and Wales. British Journal of Medicine and Medical Research 4(16): 3196–207 Crossref, Google ScholarJones R, Beauchant S (2014e) Spread of a new type of infectious condition across Berkshire in England between June 2011 and March 2013: Effect on medical emergency admissions. Public Health (submitted) Google ScholarJones R, Goldeck D (2014f) Unexpected and unexplained increase in death due to neurological disorders in 2012 in England and Wales: Is cytomegalovirus implicated? Med Hypotheses (in press) Google Scholar FiguresReferencesRelatedDetails 1 April 2014Volume 20Issue 4ISSN (print): 1358-0574ISSN (online): 1759-7382 Metrics History Published online 14 May 2014 Published in print 1 April 2014 Information© MA Healthcare LimitedPDF download

Neuropsychiatric symptoms in patients with dementia in primary care: a study protocol

BackgroundNeuropsychiatric symptoms (NPS) frequently occur in patients with dementia. To date, prospective studies on the course of NPS have been conducted in patients with dementia in clinical centers or psychiatric services. The primary goal of this study is to investigate the course of NPS in patients with dementia and caregiver distress in primary care. We also aim to detect determinants of both the course of NPS in patients with dementia and informal caregiver distress in primary care.Methods/designThis is a prospective observational study on the course of NPS in patients with dementia in primary care. Thirty-seven general practitioners (GPs) in 18 general practices were selected based on their interest in participating in this study. We will retrieve electronic medical files of patients with dementia from these general practices. Patients and caregivers will be followed for 18 months during the period January 2012 to December 2013. Patient characteristics will be collected at baseline. Time to death or institutionalization will be measured. Co-morbidity will be assessed using the Charlson index. Psychotropic drug use and primary and secondary outcome measures will be measured at 3 assessments, baseline, 9 and 18 months. The primary outcome measures are the Neuropsychiatric Inventory score for patients with dementia and the Sense of Competence score for informal caregivers. In addition to descriptive analyses frequency parameters will be computed. Univariate analysis will be performed to identify determinants of the course of NPS and informal caregiver distress. All determinants will then be tested in a multivariate regression analysis to determine their unique contribution to the course of NPS and caregiver distress.DiscussionThe results of this study will provide data on the course of NPS, which is clinically important for prognosis. The data will help GPs and other professionals in planning follow-up visits and in the timing for offering psycho-education, psychosocial interventions and the provision of care. In addition, these data will enlarge health professionals’ awareness of NPS in their patients with dementia.

Differentiating Alzheimer Disease, Lewy Body, and Parkinson Dementia Using DSM-5

Dementia is a growing problem with global, social, and financial repercussions. Early screening, diagnosis, education, planning, and treatment of dementia in primary care may reduce this burden. Presently, dementia is often diagnosed relatively late in the disease process, resulting in greater financial and caregiver burden. Primary care providers are often most likely to encounter patients with cognitive impairment early. The new guidelines outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition are presented to promote annual screening and early diagnosis of mild cognitive deficits by primary care providers.

Improving the identification of people with dementia in primary care: evaluation of the impact of primary care dementia coding guidance on identified prevalence

ObjectiveImproving dementia care is a policy priority nationally and internationally; there is a ‘diagnosis gap’ with less than half of the cases of dementia ever diagnosed. The English Health Department's...

Suitability of the 6CIT as a screening test for dementia in primary care patients

Objectives: To map the suitability of the Six Item Cognitive Impairment Test's (6CIT) as a screening instrument for dementia in primary care and to assess its feasibility, reliability, and validity in a real-world setting.Method: The present study was part of a population-based prospective trial aimed at reducing the incidence of stroke and dementia. The 6CIT was administered by general practitioners (GPs) at routine examinations every two years. Incidence of dementia was obtained from health insurance records. Psychometric qualities of the 6CIT were evaluated for two different cut-offs.Results: At baseline, 72 GPs examined 3908 patients. In total, 528 patients were diagnosed with new dementia. Less than 1% of the tests were not completed. Internal consistency (Cronbach's alpha), stability over time (Pearson's r), and the agreement between successive tests (Cohen's kappa) reached values of 0.58, 0.62, and 0.45, respectively. Sensitivity and specificity reached values of 0.49 and 0.92 at the 7/8 cut-off and of 0.32 and 0.98 at the 10/11 cut-off, respectively. Patients with dementia had significantly higher mean error scores than patients without dementia. High scores at baseline posed a more than fourfold risk of being diagnosed with dementia.Conclusion: The 6CIT's psychometric properties in a real-world setting suggest that the test is not suited as a routine screening instrument. Factors inherent to screening in primary care likely contributed to its low reliability and validity. This highlights the need for training GPs in the conduct of cognitive screening before such procedures can be implemented on a routine basis.

Medication management for people with dementia in primary care: description of implementation in the DelpHi study.

BackgroundAs the population ages, the relative and absolute number of age-associated diseases such as dementia will increase. Evaluation of the suitability and intake of medication and pharmacological treatment is an important aspect of care for people with dementia, especially if they live at home. Regular medication reviews and systematic cooperation between physicians and pharmacists are not common in routine care. Medication management (MM), based on such a comprehensive home medication review could help to reduce drug-related problems and costs. The present article presents a medication management specifically for the application in the ambulatory setting and describes its implementation as part of a larger trial.Methods/designA home medication review (HMR) and MM is implemented as part of the DelpHi study, a population based prospective, cluster-randomized controlled intervention study to test the efficacy and efficiency of the implementation of a collaborative care model in primary care.Participants: people with dementia (PWD) and their caregivers are recruited by the patient’s general practitioner. Inclusion criteria are a positive screening result for dementia, living at home and regular intake of drugs. PWD are asked to specify their regular pharmacy which is asked to participate in the study, too.Intervention: a comprehensive HMR is conducted as computer-assisted personal interview by specifically qualified Dementia Care Manager (DCM) at the people’s home. It includes detailed information about drugs taken, their storage, administration, adherence and adverse events. The MM is conducted in cooperation between DCM, pharmacist and general practitioner and consists of a pharmaceutical evaluation, pharmaceutical recommendations and their application. Pharmacists are trained and provided with regularly updated information. The MM is designed to give information and recommendations concerning antidementia drugs, occurrence of drug related problems, intake of anticholinergic drugs, potentially clinically relevant drug-drug-interactions, adverse drug events and medication adherence.DiscussionThe DelpHi-approach for medication management employs comprehensive instruments and procedures in the primary care setting under routine care conditions, and this approach should be useful in improving pharmacotherapy as part of the comprehensive treatment and care for people with dementia.Trial registrationThe trial is registered at ClinicalTrials.gov, number NCT01401582.

Improving diagnosis and management of dementia in primary care

AbstractOur series of Commentaries from the Primary Care Neurology Society (P‐CNS) provide a primary care perspective on neurology articles featured in Progress in Neurology and Psychiatry. Here, Dr Jill Rasmussen discusses ‘Closing the diagnosis gap and improving care: the primary care memory clinic’ (see page 27).

First Diagnosis and Management of Incontinence in Older People with and without Dementia in Primary Care: A Cohort Study Using The Health Improvement Network Primary Care Database

Dementia is one of the most disabling and burdensome diseases. Incontinence in people with dementia is distressing, adds to carer burden, and influences decisions to relocate people to care homes. Successful and safe management of incontinence in people with dementia presents additional challenges. The aim of this study was to investigate the rates of first diagnosis in primary care of urinary and faecal incontinence among people aged 60-89 with dementia, and the use of medication or indwelling catheters for urinary incontinence. We extracted data on 54,816 people aged 60-89 with dementia and an age-gender stratified sample of 205,795 people without dementia from 2001 to 2010 from The Health Improvement Network (THIN), a United Kingdom primary care database. THIN includes data on patients and primary care consultations but does not identify care home residents. Rate ratios were adjusted for age, sex, and co-morbidity using multilevel Poisson regression. The rates of first diagnosis per 1,000 person-years at risk (95% confidence interval) for urinary incontinence in the dementia cohort, among men and women, respectively, were 42.3 (40.9-43.8) and 33.5 (32.6-34.5). In the non-dementia cohort, the rates were 19.8 (19.4-20.3) and 18.6 (18.2-18.9). The rates of first diagnosis for faecal incontinence in the dementia cohort were 11.1 (10.4-11.9) and 10.1 (9.6-10.6). In the non-dementia cohort, the rates were 3.1 (2.9-3.3) and 3.6 (3.5-3.8). The adjusted rate ratio for first diagnosis of urinary incontinence was 3.2 (2.7-3.7) in men and 2.7 (2.3-3.2) in women, and for faecal incontinence was 6.0 (5.1-7.0) in men and 4.5 (3.8-5.2) in women. The adjusted rate ratio for pharmacological treatment of urinary incontinence was 2.2 (1.4-3.7) for both genders, and for indwelling urinary catheters was 1.6 (1.3-1.9) in men and 2.3 (1.9-2.8) in women. Compared with those without a dementia diagnosis, those with a dementia diagnosis have approximately three times the rate of diagnosis of urinary incontinence, and more than four times the rate of faecal incontinence, in UK primary care. The clinical management of urinary incontinence in people with dementia with medication and particularly the increased use of catheters is concerning and requires further investigation. Please see later in the article for the Editors' Summary.

A Program to Improve Detection of Undiagnosed Dementia in Primary Care and Its Association with Healthcare Utilization

Alzheimer's disease and related dementias are common and costly, with increased healthcare utilization for patients with these disorders. The current study describes a novel dementia detection program for veterans and examines whether program-eligible patients have higher healthcare utilization than age-matched comparison patients. Using a telephone-based case-finding approach, the detection program used risk factors available in the electronic medical record (EMR) and telephone-based brief cognitive screening. Holding illness severity constant, dementia detection and healthcare utilization were compared across age-matched groups with and without program risk factors. Five Veterans Affairs Healthcare Network Upstate New York primary care clinics. Veterans aged 70 years and older. EMR data and the Charlson comorbidity index. Program-eligible patients (n= 5,333) demonstrated significantly greater levels of medical comorbidity relative to comparison patients and were on average more than twice as likely to be admitted to the hospital. They also had nearly double the number of outpatient visits to several services. Similar patterns were seen in those who screened positive on a brief cognitive measure, compared with those who screened negative. A novel program using EMR data to assist in the detection of newly diagnosed dementia in a clinical setting was found to be useful in identifying older veterans with multiple comorbid medical conditions and increased utilization of hospital and clinic services. Results suggest undetected cognitive impairment and dementia may significantly contribute to healthcare utilization and costs of care in older veterans.

More than just a listening ear

‘Always supported, never alone’ is the motto of a new breed of worker who links up with patients who have dementia and their families via GP surgeries. Their job title is primary care dementia practitioners (PCDPs), but Julie Anderson, clinical community manager with Cornwall Partnership NHS Foundation Trust, describes them as ‘conduits’. It is an apt description. Communication in dementia care is a complex business. As well as understanding and articulating the needs of patient and carer, a host of other agencies that have the potential to improve lives must be marshalled and directed. Everything hinges on that effective conduit: someone who can channel information in all directions to benefit the person who matters most.

Case management for patients with dementia in primary care: Why it doesn't work—A mixed studies systematic review

Case management for patients with dementia in primary care: Why it doesn't work—A mixed studies systematic review