• Concordance with clinical practice guidelines for dementia in general practice

      Wilcock, J.; Iliffe, S.; Turner, S.; Bryans, M.; O'Carroll, R.; Keady, J.; Levin, E.; Downs, Murna G. (2009)
      BACKGROUND: Dementia is said to be under-recognized and sub-optimally managed in primary care, but there is little information about actual processes of diagnosis and clinical care. AIM: To determine general practitioners' concordance with clinical guidelines on the diagnosis and management of patients with dementia. Design: Unblinded, cluster randomized pre-test-post-test controlled trial involving 35 practices in the UK. METHODS: Patients with a diagnosis of probable or confirmed dementia were identified in practices, and permission sought from the older person and/or their carer to study the medical records of these patients. Medical records were reviewed using a data extraction tool designed for the study and based on published guidelines, and unweighted scores for diagnostic concordance and management concordance were calculated. RESULTS: We reviewed 450 records of patients aged 75 and over with a diagnosis of dementia and found that: only 4% of cases were identified first in secondary care; two-thirds of those identified in primary care were referred immediately; about one-third identified had informant history and blood tests documented at the Index consultation and one-fifth underwent cognitive function testing. DISCUSSION: The records analysed in this study came from a period before the Quality Outcomes Framework and show that the documentation in primary care of the diagnostic process in dementia syndromes is good, although there were significant gaps, particularly around depression case-finding. Information about management processes were less evident in the records.
    • General practitioners' knowledge, confidence and attitudes in the diagnosis and management of dementia.

      Downs, Murna G.; Iliffe, S.; Turner, S.; Wilcock, J.; Bryans, M.; Keady, J.; O'Carroll, R.; Levin, E. (2004)
      Objective: to measure general practitioners' knowledge of, confidence with and attitudes to the diagnosis and management of dementia in primary care. Setting: 20 general practices of varying size and prior research experience in Central Scotland, and 16 similarly varied practices in north London. Participants: 127 general practitioners who had volunteered to join a randomised controlled trial of educational interventions about dementia diagnosis and management. Methods: self-completion questionnaires covering knowledge, confidence and attitudes were retrieved from practitioners prior to the educational interventions. Results: general practitioners' knowledge of dementia diagnosis and management is good, but poor awareness of its epidemiology leads to an over-estimate of caseload. Knowledge of local diagnostic and support services is less good, and one third of general practitioners expressed limited confidence in their diagnostic skills, whilst two-thirds lacked confidence in management of behaviour and other problems in dementia. The main difficulties identified by general practitioners were talking with patients about the diagnosis, responding to behaviour problems and coordinating support services. General practitioners perceived lack of time and lack of social services support as the major obstacles to good quality care more often than they identified their own unfamiliarity with current management or with local resources. Attitudes to the disclosure of the diagnosis, and to the potential for improving the quality of life of patients and carers varied, but a third of general practitioners believed that dementia care is within a specialist's domain, not that of general practice. More experienced and male general practitioners were more pessimistic about dementia care, as were general practitioners with lower knowledge about dementia. Those reporting greater difficulty with dementia diagnosis and management and those with lower knowledge scores were also less likely to express attitudes endorsing open communication with patient and carer. Conclusion: educational support for general practitioners should concentrate on epidemiological knowledge, disclosure of the diagnosis and management of behaviour problems in dementia. The availability and profile of support services, particularly social care, need to be enhanced, if earlier diagnosis is to be pursued as a policy objective in primary care.