Tamar Koch

Dementia syndromes are under-diagnosed and under-treated in primary care. Earlier recognition of and response to dementia syndrome is likely to enhance the quality of life of people with dementia, but general practitioners consistently report limited skills and confidence in diagnosis and management of this condition. Changing clinical practice is difficult, and the challenge for those seeking change it is to find ways of working with the grain of professional knowledge and practice. Assessment of educational needs in a practice has the potential to accommodate variations in individual understanding and competence, learning preferences and skill mix. Educational prescriptions identify questions that need to be answered in order to address a clinical problem. This paper reports the development of an educational needs assessment tool to guide tailored educational interventions designed to enhance early diagnosis and management of dementia in primary care, in the Evidence Based Interventions in Dementia in the Community – Early Diagnosis trial.

With dementia ever-increasing in prevalence and cost on society, and with recent reports emphasizing the need for improved and standardized diagnosis and care for patients with dementia, the National Dementia Strategy (NDS) has been published by the English Department of Health. The NDS encourages the identification of successful innovations to implement on a wider scale. This paper uses case studies to describe some examples of innovative practice in the diagnosis and management of patients with dementia in primary care. It goes on to discuss methodological problems in the evaluation and comparison of innovations in practice, focusing on the potential to compare complex with simple interventions, and recognizing the role that commissioners play in making decisions about the choice and implementation of innovation.

Background: Early detection and management of dementia in primary care are difficult problems for practitioners. England's National Dementia Strategy 2009 seeks to improve these areas but there is limited evidence on how to achieve this most effectively. Aim: This review aims to identify and appraise empirical studies of interventions designed to improve the performance of primary care practitioners in these areas. Design: A narrative review of primary-care based studies. Method: Publications up to February 2010 were identified by searching the electronic databases MEDLINE, Embase, and PsycINFO, and bibliographies. The criterion for inclusion was that studies had to be of interventions aimed at improving detection or management of dementia in primary care. Exclusion criteria included studies in non-English publications, pharmacological interventions, and screening instrument studies. Quality was assessed using the PEDro (Physiotherapy Evidence Database) scale. Results: Fifteen studies were identified, of which 11 were randomised controlled trials. Eight reported educational interventions, and seven trialled service redesign, either by changing the service pathway or by introducing case management. Educationally, only facilitated sessions and decision-support software improved GPs' diagnosis of dementia, as did trials of service-pathway modification. Some of the case-management trials showed improved stakeholder satisfaction, decreased symptoms, and care that was more concordant with guidelines. Conclusion: The quality of the studies varied considerably. Educational interventions are effective when learners are able to set their own educational agenda. Although modifying the service pathway and using case management can assist in several aspects of dementia care, these would require the provision of extra resources, and their value is yet to be tested in different health systems.

This book aims to inform on approaches and strategies within the realm of care for the older patient in the primary-care setting. It endeavours to offer detailed but practical guidance, and each chapter is co-authored by different specialists and general practitioners. Because all contributors are British-based, its market is probably limited to a national audience.

The diagnosis of dementia in primary care is perceived as a problem across countries and systems, resulting in delayed recognition and adverse outcomes for patients and their carers. Improving its early detection is an area identified for development in the English National Dementia Strategy 2009; there are thought to be multiple benefits to the patient, family, and resources by doing this. The aim of this review was to carry out a rapid appraisal in order to inform the implementation of this policy.

The National Dementia Strategy seeks to enhance general practitioners' diagnostic and management skills in dementia. Early diagnosis in dementia within primary care is important as this allows those with dementia and their family care networks to engage with support services and plan for the future. There is, however, evidence that dementia remains under-detected and sub-optimally managed in general practice. An earlier unblinded, cluster randomised controlled study tested the effectiveness of educational interventions in improving detection rates and management of dementia in primary care. In this original trial, a computer decision support system and practice-based educational workshops were effective in improving rates of detecting dementia although not in changing clinical management. The challenge therefore is to find methods of changing clinical management. Our aim in this new trial is to test a customised educational intervention developed for general practice, promoting both earlier diagnosis and concordance with management guidelines.