Abstract: In both epidemiological studies and in clinical trials the patients' own health perception, self-rated health (SRH), measured by a single question, is frequently used as an overall health assessment. Researchers have been encouraged to examine ways of assessing SRH in cognitively impaired persons, but the validity and the influence on other factors on SRH among cognitively impaired persons remain unknown. This study reports how patients with mild Alzheimer's disease (AD) report SRH and which factors influence SRH. The study was based on baseline data from 321 home living patients with mild AD who participated in the Danish Alzheimer Intervention Study (DAISY). Analysis using the generalized estimating equation (GEE) models revealed that good/excellent SRH among patients with mild AD were associated with longer education, lack of other chronic conditions, higher scores of quality of life (QOL), lower scores of mini mental state examination (MMSE), and loss of insight in own cognitive deficits. The present results indicate that SRH reported by patients with mild AD may differ from SRH among cognitively intact persons. Further research is needed in order to establish the validity and implication of SRH in this group of patients.
Abstract: OBJECTIVES: To investigate the prevalence and potential clinical implications of self-reported memory impairment among elderly patients in general practice. METHODS: This was a cross-sectional study in 17 general practices serving 40,865 patients, of whom 2934 were 65 years of age or older. Outcome measures were self-reported memory impairment, health-related quality of life, and cognition. RESULTS: In total, 177 (23.4%) out of 758 elderly patients consulting their physician reported impaired memory. Only 33 (18.6%) had consulted their physician for memory problems. The only independent predictor for impaired memory was a lower quality-of-life score: scores on the EuroQoL-5D-VAS of 0 to 49 and 50-74 points both correlated with memory complaints (odds ratios=4.8 and 4.1, respectively). CONCLUSIONS: Memory impairment is a common complaint among elderly patients in general practice, but many patients will not present with these symptoms. It may be useful for general practitioners to ask about memory problems in order to identify potentially frail patients. Prospective trials are warranted.
Abstract: The aim of this study was to analyse how patients with mild Alzheimer's disease (AD) cope with the changes they face concerning everyday life and social relations. This study used a grounded theory approach in the analysis of interview data from 11 persons with mild AD, home-living with a spouse. The analysis revealed that the basic social psychological problem faced by patients with mild AD was their awareness of decline in personal dignity and value. Coping strategies used to meet these problems were adaptations to the altered situation in order to maintain a feeling of well-being. The spouse appeared to be the most important social relation. The most significant worries of the patients were about communication in relation to their spouse, and about the reaction of the spouse to the consequences of the disease.
Abstract: The purpose of this study was to investigate social participation in home-living patients with mild Alzheimer's disease (AD) and to identify predictors for low social participation. The study was based on baseline data from 330 home-living patients with mild AD who participated in The Danish Alzheimer Intervention Study (DAISY). Proxy-obtained information from primary caregiver assessed patients' social participation. The result showed that low social participation was present in mild AD. Significant independent predictors of low social participation were impairment in activities of daily living (ADL) and neuropsychiatric symptoms. The findings from this study add to the literature that social impairment is present even in the mild stage of AD. The findings underscore the importance of assessing social participation in mild AD as soon as few ADL skills are lost.
Abstract: BACKGROUND: We were unable to identify studies that have considered the diffusion of an e-learning programme among a large population of general practitioners. The aim of this study was to investigate the uptake of an e-learning programme introduced to General Practitioners as part of a nation-wide disseminated dementia guideline. METHODS: A prospective study among all 3632 Danish GPs. The GPs were followed from the launching of the e-learning programme in November 2006 and 6 months forward. Main outcome measures: Use of the e-learning programme. A logistic regression model (GEE) was used to identify predictors for use of the e-learning programme. RESULTS: In the study period, a total of 192 different GPs (5.3%) were identified as users, and 17% (32) had at least one re-logon. Among responders at first login most have learnt about the e-learning programme from written material (41%) or from the internet (44%). A total of 94% of the users described their ability of conducting a diagnostic evaluation as good or excellent. Most of the respondents used the e-learning programme due to general interest (90%). Predictors for using the e-learning programme were Males (OR = 1.4, 95% CI 1.1; 2.0) and members of Danish College of General Practice (OR = 2.2, 95% CI 1.5; 3.1), whereas age, experience and working place did not seem to be influential. CONCLUSION: Only few Danish GPs used the e-learning programme in the first 6 months after the launching. Those using it were more often males and members of Danish College of General Practice. Based on this study we conclude, that an active implementation is needed, also when considering electronic formats of CME like e-learning. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00392483.
Abstract: OBJECTIVE: In order to evaluate whether elderly persons with subjective memory complaints may be regarded as a group of potentially vulnerable patients who need close follow-up, we investigated the risk of nursing home placement during a 4-year follow-up period. METHODS: Prospective cohort survey with 4-year follow-up in general practice. Cox proportional hazard models were used to examine the influence of risk factors on nursing home placement. RESULTS: A total 758 non-nursing home residents aged 65 years and older consulted the General Practitioners in October and November 2002 of whom 50 nursing home placements were observed. Subjective memory complaints were associated with an adjusted Hazard Ratio (HR) of 2.59 for nursing home placement. Other statistical significant covariates were MMSE < 24 (HR = 3.95), Age (HR = 3.92 for 75-84 years and HR = 19.90 for 85 + years) and extreme anxiety/depression (HR = 4.74). The effect of subjective memory complaints is seen to moderate when subjects are older. CONCLUSION: The data of this study indicated that in an elderly primary care population the presence of subjective memory complaints was a significant independent predictor for nursing home placement together with other known risk factors. Copyright (c) 2008 John Wiley & Sons, Ltd.
Abstract: OBJECTIVES: The aim of this qualitative study was to identify and analyse the participants' experienced outcome of an intensive structured psychosocial intervention programme with tailored counselling, education and support groups for home-living patients with mild Alzheimer's disease and their spousal caregivers. METHOD: Data were collected by semi-structured in-depth interviews conducted separately with each person in 10 couples before the intervention and 1-3 months after completed intervention. For the analysis, a template organizing style of interpretation was used. RESULTS: The analysis revealed that patients found support groups relevant: they found it stimulating to be with peers, it supported their self-esteem, and it supported them in finding new ways of managing everyday life and social relations. During and after the intervention, caregivers were better able to cope with the challenges their partner's disease involved, and they were able to face everyday life and social relations with more serenity and competence. After the intervention, both patients and caregivers sought suitable support groups they could join as a permanent activity and caregivers sought permanent counselling. CONCLUSION: Early tailored counselling and support may improve patients' and caregivers' opportunities to adapt to the challenges of Alzheimer's disease and to maintain well-being.
Abstract: INTRODUCTION: The aim of this study was to describe how Danish patients and their general practitioners (GPs) perceive physician's use of computers during consultation. MATERIALS AND METHODS: Data were collected between November 2006 and February 2007 at five primary care clinics. Nine GPs and 253 of their patients completed complementary questionnaires concerning the consultation as a whole and their perceptions of computer use during consultation. RESULTS: Patients were generally satisfied with their GP's use of computers during consultations. Compared to their practitioners, patients more often perceived computer use to be extensive. 28% of patients reported their GP's computer use as extensive. These patients more often reported discomfort with their GP's computer use (OR 1.09), or stated that they did not get help with the problem they most wanted solved (OR 0.83), compared with patients who perceived their GP's computer use as less extensive. Men (OR 2.21) and patients over 55 years of age (OR 2.45) were also overrepresented in this group. CONCLUSION: Overall, patients were satisfied with their consultations. Patients generally perceived computer use as more extensive than doctors did. Where patients perceived their GP's computer use as extensive, they tended to rate selected consultation quality indicators lower. Further study in this field of general practice is therefore needed.
Abstract: INTRODUCTION: The aim was to describe and analyse signs that make caregivers suspect memory problems among elderly patients in general practice. METHODS: This prospective study was conducted in October and November 2002 among all patients aged 65 or older who consulted a GP in a total of 17 practices in Copenhagen inner city. The patients who agreed to participate were asked to complete a questionnaire regarding memory, quality of life, etc. Their GP completed a questionnaire independently, and a MMSE was subsequently given to the patient. Where consent was obtained from a patient, a postal questionnaire regarding the patient's memory was mailed to a caregiver chosen by the patient. RESULTS: Out of 775 patients 62% (483) gave consent to contact a caregiver. Among the caregivers who received the questionnaire a total of 74% returned the questionnaire. A total of 88 (26%) of the caregivers suspected that the patient had memory problems. Predictors for caregiver suspicion of memory problems were: patient had complained about memory problems to caregiver (OR 21.7), caregiver had received information for other sources that the patient suffered from memory problems (OR 5.0), a MMSE in the interval between 0-24 (OR 4.5) and a low quality of life (OR 3.1). Furthermore, if the patient was male, caregivers were more likely to report memory problems. CONCLUSION: Memory impairment is commonly observed by caregivers, but is rarely discussed with a GP. The results indicate that more focus on the possibility of memory impairment among elderly patients is important in general practice.
Abstract: OBJECTIVE: To investigate the rate of diagnostic evaluation of dementia for patients in whom a suspicion of dementia was raised, and to investigate reasons why a diagnostic evaluation was not always being performed. DESIGN: A prospective study among elderly patients aged 65+, and a follow-up study. SETTING: In all, 17 general practices in Copenhagen with 40 865 patients on their lists of whom 2934 were aged 65+. SUBJECTS: A total of 793 patients consulting their GP regardless of reason of encounter, in October and November 2002. MAIN OUTCOME MEASURES: MMSE score < or = 23, GP clinical impression of dementia, laboratory-screening tests prescribed by the GPs and referral status after 6 months, and follow-up questionnaire. RESULTS: Of 793 patients a total of 138 patients were identified with possible dementia. Among the identified patients 26 (20%) were referred for further evaluation within 6 months, and 4 (3%) were treated for depression or referred for another condition. A total of 6 patients were lost to follow-up. In the remaining 102 undiagnosed patients the main reasons for not performing a diagnostic evaluation of dementia were patient/relative hesitation (34%), the GP thought that it would not have any consequences for the patient, or the GP estimated that the patient was too fragile (21%). CONCLUSION: In 17% of elderly patients in general practice a suspicion of dementia could be raised based on the clinical impression of the GP or MMSE score. However, only 23% of this group were evaluated by their GP or referred to a memory clinic within a subsequent period of 6 months.
Abstract: With our limited resources, the national colleges of general practice in the Nordic countries should select only a few important topics and only get involved in guideline preparations if they have a primary care perspective. We need not develop our own guidelines from scratch, but should take existing international GP clinical guidelines and literature reviews as a starting point and conduct the first steps in the guideline preparation jointly in the Nordic countries. More effort could then be directed towards the subsequent stages of guideline preparations and the implementation process. Key stakeholders should be involved at all stages in guideline development and at all levels of the health services to ensure commitment and improve the likelihood of implementation.
Abstract: OBJECTIVE: To assess the impact of a multifaceted implementation strategy aiming to improve GP adherence to a clinical guideline on dementia. DESIGN: Controlled before and after study using data records from regional laboratories. The guideline was mailed to all GPs. The multifaceted implementation strategy was planned with local GPs, and consisted of seminars, outreach visits, reminders and continuing medical education (CME) small group training. SETTING: Primary health care. SUBJECTS: 535 GP practices with 727 physicians in Denmark. MAIN OUTCOME MEASURES: The diffusion and use of the guideline was measured by a mailed survey. Adherence to guideline recommendations was monitored by data on laboratory tests from general practice in patient's > or = 65 years: thyroid stimulating hormone requested with vitamin B12 or methylmalonate. The use of these tests as part of a diagnostic evaluation of dementia was subsequently verified by a questionnaire to the practices. RESULTS: Of the GPs who read the guideline, 88% found it applicable in primary care. No increase in the adherence to guideline recommendations was observed regarding the use of laboratory tests or cognitive tests in the diagnostic evaluation of dementia in general practice. CONCLUSION: Although GPs regarded the guideline applicable in primary care, no change in practice adherence to guideline recommendations was detected after a multifaceted implementation.
Abstract: INTRODUCTION: The aim was to explore the context and experiences of collaboration between the general practitioner (GP) and the district nurse (DN) on diagnosing dementia, in order to identify possible procedures to improve care. MATERIAL AND METHODS: Two group interviews respectively with four DNs and five GPs working in the municipality of Copenhagen. RESULTS: The group interviews revealed that the suboptimised collaboration could be caused by different inter-professional diagnostic strategies and a lack of understanding of the importance of early, shared, decision-making. This could create conflicts between the groups. DISCUSSION: This study indicates a possibility of improving the collaboration between the two professional groups on diagnosing dementia. Possible approaches to improved care should focus on an inter-professional understanding of the importance of early, shared, decision-making, emphasising early identification and care of diagnosed demented patients.
Abstract: OBJECTIVE: To examine GPs' self-reported basic diagnostic evaluation of dementia according to the recommendations in multidisciplinary consensus guidelines and to analyse explanatory factors for GP performance. DESIGN: Postal questionnaire study, spring 1998. SETTING: General practice in Denmark. SUBJECTS: All 3379 GPs in Denmark. RESULTS: The questionnaire was completed by 75.1%. According to our Diagnostic Evaluation Index, 47.2% of the GPs were classified as conducting a good basic diagnostic evaluation of dementia, and tended to have the following characteristics: they conducted regular follow-up consultations with demented patients (odds ratio (OR) 2.4), they were inclined to state that all patients with possible dementia should undergo diagnostic evaluation (OR 2.0), they considered that the GP should play the major role in diagnostic evaluation (OR 1.7) and they believed their methods were adequate identify dementia (OR 1.7). Gender, attitude to development of clinical guidelines and being able to refer patients to specialists were not influential. CONCLUSION: We conclude that the previously reported reluctant attitude of GPs is now more positive.
Abstract: OBJECTIVE: The objective of this study was to explore the context and experiences of collaboration between the GP and the district nurse (DN) in diagnosing dementia, in order to identify possible procedures to improve care. METHODS: Two group interviews were conducted with four DNs and five GPs, respectively, working in the municipality of Copenhagen. RESULTS: The group interviews revealed that the suboptimized collaboration could be due to different inter-professional diagnostic strategies and a lack of understanding of the importance of early, shared, decision making. This could create conflicts between the groups. CONCLUSIONS: This study indicates a possibility for improved collaboration between the two professional groups in diagnosing dementia. Possible approaches for improved care should focus on an inter-professional understanding of the importance of early, shared, decision making, emphasizing early identification and care of diagnosed demented patients. Establishing a shared collaboration model including out-patient memory clinics, GPs and DNs could be a first step. This model should also take into account an evaluation of possible consequences for the diagnosed demented patients in terms of treatment and care and consider the indication for referrals to a comprehensive diagnostic evaluation. We are at present planning a study to address these aspects.
Abstract: The study objective was to describe the GP's referrals of patients to diagnostic evaluation of dementia and the GP's perception of the organization of this process++. The study is based on postal questionnaire mailed to all GPs in Denmark, spring 1998. Seventy-five percent of 3379 GPs answered the questionnaire. Seventy-one percent (1799) of the GPs had referred a patient to diagnostic evaluation of dementia within the last 12 months. Thirty-nine percent had referred to a geriatric psychiatric service, 36% to a neurologic service, 18% to a psychiatric service, 11% to a geriatric service, and 16% had referred to other services. Fifteen percent of the GPs had referred to two or more of the services. The study concludes that there is considerable regional variation as to where the GPs refer patients for diagnostic evaluation of dementia as well as to the GPs perception of the possibilities of referrals in Denmark. The implications are discussed.
