This article introduces findings from the first phase of a randomized controlled trial of educational interventions in primary care. The focus of the article is the knowledge, attitudes and confidence of primary care nursing staff to the diagnosis and ongoing management of dementia. A total of 78 nurses with a mean age of 46.4 years and a mean time since qualification of 23.0 years were recruited in 36 practices in central Scotland and in London. Disciplines represented by this sample were predominantly district nurses, health visitors, practice nurses and community staff nurses. Each practitioner was administered an extensive self-completion questionnaire before the educational interventions were introduced to measure baseline knowledge, confidence and perceived difficulties in dementia care management and attitudes. Results from the quiz indicate lower levels of knowledge about epidemiology and diagnosis, but slightly higher levels about management strategies. Self-reported ratings of confidence were also low and were directly related to ratings of difficulty in identifying dementia and dealing with coexisting behavioural and mental health problems. Lower scores on all domains were recorded for practice nurses than for district nurses or health visitors.

Exploratory research

10.12968/bjon.2003.12.17.11723

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Developing an educational intervention on dementia diagnosis and management in primary care for the EVIDEM-ED trial

Trials (2012)

Steve Iliffe Tamar Koch Priya Jain Frances Lefford Geoff Wong

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. A multidisciplinary team, including a lay researcher, used an iterative technology development approach to create an educational needs assessment tool, from which educational prescriptions could be written. Workplace learning was tailored to each practice using the educational prescription, and the method was field-tested in five pilot practices. The educational prescriptions appeared acceptable and useful in volunteer practices. The time commitment (no more than four hours, spread out at the practice's discretion) appeared manageable. The pilot group of practices prioritised diagnosis, assessment of carers' needs, quality markers for dementia care in general practice, and the implications of the Mental Capacity Act (2005) for their clinical practice. The content of the educational needs assessment tool seemed to be comprehensive, in that no new topics were identified by practices in the field trial. The educational needs assessment tool took into account practitioners' knowledge of the local health and social care systems, reflected the complexity of the diagnostic and care processes for people with dementia, and acknowledged the complexity of the disease process itself.

Needs assessment

10.1186/1745-6215-13-142

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Improving primary care based post-diagnostic support for people living with dementia and carers: Developing a complex intervention using the Theory of Change

PLoS ONE (2023)

Claire Bamford Jane Wilcock Greta Brunskill Alison Wheatley Karen Harrison Dening

Background The need to improve support following a diagnosis of dementia is widely recognised, but it is unclear how this can best be achieved within UK health and social care systems. A task-shared and task-shifted approach has been recommended, but there is limited guidance on how to achieve this in practice. As part of a programme of research, we developed an intervention to enhance the role of primary care in post-diagnostic care and support for people living with dementia and carers. Methods We used the Theory of Change to develop a complex intervention informed by initial literature reviews and qualitative work. The intervention was developed through an iterative series of workshops, meetings and task groups with a range of stakeholders, including the multidisciplinary project team, people living with dementia and carers, service managers, frontline practitioners, and commissioners. Results 142 participants contributed to intervention development through face-to-face or virtual meetings. The intervention comprises three complementary strands of work focusing on: developing systems, delivering tailored care and support, and building capacity and capability. Clinical dementia leads, based in primary care networks, will facilitate the intervention providing tailored expertise and support. Conclusion The Theory of Change proved useful in providing structure and engaging stakeholders. The process was challenging, took longer and was less participative than intended due to restrictions caused by the COVID-19 pandemic. We will next conduct a feasibility and implementation study to explore whether the intervention can be successfully delivered within primary care. If successful, the intervention offers practical strategies for delivering a task-shared and task-shifted approach to post-diagnostic support that could be adapted for similar health and social care contexts internationally.

Theory of change

10.1371/journal.pone.0283818

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DEVELOPMENT OF HEURISTICS TO GUIDE DECISION MAKING AT THE END OF LIFE FOR SOMEONE WITH DEMENTIA

Innovation in Aging (2017)

Nathan Davies Kethakie Lamahewa Roshan Mathew Jane Wilcock Jill Manthorpe

The end of life for someone with dementia can present a series of challenges for practitioners. Challenges may be eased with the development of heuristics (rules-of-thumb). For example, FAST is used in stroke: Facial-weakness, Arm-weakness, Slurred-speech, Time to call 911. Through a co-design process we developed a toolkit of heuristics to aid practitioners making difficult decisions when caring for someone with dementia at the end of life. The heuristic toolkit consisted of four areas which were considered difficult decisions at the end of life; eating/swallowing difficulties, agitation/restlessness, reviewing treatment/interventions, and providing routine care. Each heuristic consists of a logic tree of rules. For example, eating/swallowing difficulties have two rules; ensure eating/swallowing difficulties do not come as a surprise and reflection about ‘comfort-feeding’ only or time-trialled artificial feeding. Teams appreciated the simplicity of the heuristics, allowing their use in educating less experienced colleagues and as an aid to conversations with families.

Heuristics

Surprise

10.1093/geroni/igx004.976

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