BMJ  2006;332:681-682 (25 March), doi:10.1136/bmj.332.7543.681

Editorial

Improving the management of dementia

Simple educational initiatives for primary care teams are not enough

The prevalence of dementia in the United Kingdom will have risen from the current 600 000 to 1.2 million by 2050, increasing the already considerable financial and social burdens of this disorder.¹ In many countries, including in the United Kingdom, primary care is the first point of contact for many people with dementia, providing longitudinal support to families and coordinating ongoing multiagency management of dementia.² Patients with early dementia and their families may not always get the early help they need, however.

Early recognition and detection of dementia enables people with dementia and their families to better understand and come to terms with the diagnosis and to discuss future care. It also enables more timely access to treatments and drugs.³ With this in mind, a randomised controlled trial in this week's BMJ by Downs and colleagues (p 692) assesses the effectiveness of educational interventions in improving detection and management of dementia in primary care.⁴

Several studies in primary care have reported high levels of unmet need, with widespread underdetection of dementia, poor long term management of patients' problems, and low rates of referrals to specialist care and to other statutory agencies. This situation is not confined only to primary care in the United Kingdom.⁵

There are several reasons for these less than optimal standards of care. Dementia rarely presents with clear, well demarcated symptoms. Its diagnosis can be confusing, with symptoms sometimes mimicking other conditions. Members of primary care teams may feel that they have too little appropriate training in diagnosing dementia and providing treatment. Tools to aid diagnosis are often not culturally sensitive and can be biased by characteristics of both patients and informants such as age, sex, and education.⁶ Inadequate resources and poor cooperation between community services, specialist clinics, and primary care teams may also be barriers to good care.⁷

A thorough search of the literature yields few papers that examine the impact of educational interventions on detecting and managing dementia in primary care. Approaches such as introducing clinical practice guidelines and educational tools were ineffective and too expensive to implement and sustain or have failed to show changes in doctors' behaviour, in terms of detection rates or outcomes.⁸ This week, Downs and colleagues report that they, too, have found little evidence in their study to support any improvement in the diagnosis of dementia using guidelines alone.⁴

A Canadian study did find a positive effect of an educational and diagnostic toolkit on doctors' knowledge and confidence in dealing with dementia and driving.⁹ Downs and colleagues' study found a significant increase in the number of reported cases of dementia in practices where two educational initiatives—decision support software and practice based workshops—were introduced. These improvements did not extend, however, to increasing doctors' concordance with clinical guidelines on managing dementia. The authors argued that this might have reflected the low number of cases of dementia detected after the intervention and in the control arm, which affected the power of their study, and also incomplete recording in the medical records of any changes in doctors' behaviour.⁴

The wider evidence base on educational initiatives in primary care suggest that multifaceted interventions are the most effective ways to improve doctors' behaviour.¹⁰ More comprehensive initiatives might also improve doctors' knowledge of or attitudes to dementia care, as Downs and colleagues say, but such initiatives have not yet been formally evaluated.¹¹

A more clinically oriented policy that might make a difference to the quality of care in dementia in the United Kingdom is the revised quality and outcomes framework of the NHS contract for general practitioners, which includes a new focus on dementia.¹² Practices in England and Wales will be expected to show improved record keeping and ongoing management of patients with dementia, through the introduction of a dementia register and evidence that patients' care and needs have been reviewed in the preceeding 15 months. However, practitioners may find it difficult to reconcile the increased focus on dementia of the new NHS contract, which encourages earlier diagnosis of Alzheimer's disease, with the recently published controversial guidelines from the National Institute for Health and Clinical Excellence (NICE), recommending drugs only in patients with later moderate Alzheimer's disease.

Department of Primary Care and General Practice, University of Birmingham, Edgbaston B15 2TT
(e.j.england{at}bham.ac.uk)

---

Competing interests: None declared.

Research p 692

References

1. Bosanquet N, May J, Johnson N. Alzheimer's disease in the United Kingdom: burden of disease and future care. In: Health policy review. London: Imperial College School of Medicine, 1998. (Paper 12.)
2. Department of Health. National service framework for older people. London: Stationery Office, 2001.
3. Audit Commission. Forget me not: developing mental health services for older people in England. London: Audit Commission, 2000.
4. Downs M, Turner S, Bryans M, Wilcock J, Keady J, Levin E, et al. Effectiveness of educational interventions in improving detection and management of dementia in primary care: cluster randomised controlled study. BMJ 2006;332: 692-5.[Abstract/Free Full Text]
5. Van Hout H, Vernooij-Dassen M, Bakker K, Blom M, Grol R. General practitioners on dementia: tasks, practices and obstacles. Patient Educ Couns 2000;39: 219-25.[CrossRef][ISI][Medline]
6. Brodaty H, Kemp NM, Low LF. Characteristics of the GPCOG, a screening tool for cognitive impairment. Int J Geriatr Psychiatry 2004;19: 870-4.[CrossRef][Medline]
7. Turner S, Iliffe S, Downs M, Wilcock J, Bryans M, Levin E, et al. General practitioners' knowledge, confidence, and attitudes in the diagnosis and management of dementia. Age Aging 2004;33: 461-7.[Abstract/Free Full Text]
8. Reuben DB, Roth C, Kamberg C, Wenger NS. Restructuring primary care practices to manage geriatric syndromes: the ACOVE-2 intervention. J Am Geriatr Soc 2003;51: 1787-93.[Medline]
9. Byszewski AM, Graham ID, Amos S, Man-Son-Hing M, Dalziel WB, Marshall S, et al. A continuing medical education initiative for Canadian primary care physicians: the driving and dementia toolkit: a pre- and post evaluation of knowledge, confidence gained, and satisfaction. Am Geriatr Soc 2003;51: 1484-9.[CrossRef]
10. NHS Centre for Reviews and Dissemination. Effective healthcare: getting evidence into practice. Vol 5. York: CRD, 1999.
11. Croudace T, Evans J, Harrison G, Sharp DJ, Wilkinson E, McCann G, et al. Impact of the ICD-10 primary health care (PHC) diagnostic and management guidelines for mental disorders on detection and outcome in primary care: cluster randomised controlled trial. Br J Psychiatry 2003;182: 20-30.[Abstract/Free Full Text]
12. Department of Health. New GMS contract 2006/07. London: Stationery Office, 2006.

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