A qualitative study investigating the views of stroke survivors and their family members on discussing post-stroke cognitive trajectories.

Cognitive impairment is common early after stroke but trajectories over the long term are variable. Some stroke survivors make a full recovery, while others retain a stable impairment or decline. This study explored the perceived advantages and disadvantages of discussing potential cognitive trajectories with stroke survivors and their family members. Stroke survivors at least six-months post-stroke were purposively sampled from an existing pool of research volunteers recruited originally for the OCS-Recovery study. They were invited, alongside a family member, to participate in a semi-structured interview. Interviews were audio recorded, transcribed, and analyzed using reflexive thematic analysis. Twenty-six stroke survivors and eleven family members participated. We identified one overarching theme and three related subthemes. The overarching theme was: One size does not fit all. The subthemes were: (1) Hearing about potential cognitive trajectories helps to develop realistic expectations; (2) Discussions about cognitive trajectories may be motivating; (3) Cognitive decline and post-stroke dementia discussions may be anxiety-provoking and depressing. Healthcare professionals should adopt a person-centred approach to sharing information about post-stroke cognitive trajectories. Discussions should be tailored to individual needs and preferences, with dementia-related topics in particular addressed with the utmost selectivity and sensitivity.

Barriers and facilitators to primary care research: views of GP trainees and trainers.

BACKGROUND: Primary care plays an important role in the conception and delivery of transformational research but GP engagement is lacking, prompting calls for the promotion of academic opportunities in primary care. AIM: To identify potential barriers and facilitators among GP trainees and trainers in primary care research to inform support given by Local Clinical Research Networks (LCRNs). DESIGN & SETTING: A cross-sectional online survey was developed and distributed by the CRN to GP trainees and trainers in the North East and North West. METHOD: The survey covered areas including demographics, career intentions, current and potential engagement with research, as well as their general understanding of research in primary care, which included barriers and facilitators to primary care research. RESULTS: Trainees had low intentionality to pursue research and half of trainees did not engage with any research activity. Despite one in five trainees reporting intentions to include research in their career, only 1% would undertake a solely academic career. Medical school region was the only strongly associated factor with academic career intention. Just under 30% of trainers reported engagement in research, but far fewer (8.6%) were interested in contributing to research, and only 10% felt prepared to mentor in research. CONCLUSION: Among trainees, there is limited engagement in and intentionality to pursue research, and this was crucially reflected by responses from trainers. This study identified the need for LCRNs to assist with training in research mentoring and skills, funding opportunities, and to develop resources to promote research in primary care.

Secular Trends in Dementia Prevalence and Incidence Worldwide: A Systematic Review.

BACKGROUND: Time trends for dementia prevalence and incidence rates have been reported over the past seven decades in different countries and some have reported a decline. OBJECTIVE: To undertake a systematic review to critically appraise and provide an evidence-based summary of the magnitude and direction of the global changes in dementia prevalence and incidence across time. METHODS: Medline, EMBASE, and PsychINFO were searched for studies focused on secular trends in dementia prevalence and/or incidence until 18 December 2017. In total, 10,992 articles were identified and 43 retained. RESULTS: Overall, prevalence rates are largely increasing (evidence primarily from record-based surveys and cohort studies in Japan, Canada, and France) or have remained stable (evidence primarily from cohort studies in Sweden, Spain and China). A significant decline in prevalence has however been reported in more recent studies (i.e., from 2010 onwards) from Europe (e.g., UK and Sweden) and the USA. Incidence rates have generally remained stable or decreased in China, Canada, France, Germany, Denmark, Sweden, the Netherlands, UK, and USA. An increase has only been reported in five countries: Italy, Japan, Wales, Germany, and the Netherlands. Only one study reported findings (stability in incidence) from a low and middle-income country using data from Nigeria. CONCLUSIONS: The evidence on secular trends in the prevalence and incidence of dementia is mixed including contradictory findings using different (and in some cases the same) datasets in some countries (e.g., the USA, UK, and Sweden). This making it difficult to draw concrete conclusions. However, declining trends recently observed in some high-income Western countries in the most recent two decades including the UK, USA, and Sweden are encouraging. Updated dementia prevalence and incidence estimates will inform public health and financial planning as well as development of prevention strategies.

'The best laid schemes o' mice an' men': a workshop to teach the application of evidence based medicine in low- and middle-income countries.

Background Evidence-Based Medicine (EBM) is often an ideal, with beginnings in positivist science. More recent relativism, rights and ethics have challenged a binary view of EBM. Medical volunteering is a paradigm as GPs and trainees often run EBM projects in low- and middle-income countries (LMICs), which require significant contextual adaptation. We created a workshop to enable GPs and GP trainees to reflect on and plan for the factors important in the application of EBM in LMICs. We describe the first running at the 21st WONCA Europe Conference. Aim To enable GPs/trainees to plan for various factors when applying EBM in LMICs in order to promote mutual gains. Method A 75-min workshop with GPs/trainees was conducted using a variety of methods including didacticism, before and after brainstorming, vignettes, voting, role-play and feedback. Key-points highlighted were ethics, economics, politics, culture and relationships. Results Feedback was positive with recommendations to offer the workshop to all GPs/trainees. Lessons learnt were broad-ranging and important. Conclusion/Recommendation This is an effective workshop. More work is needed to bridge the 'EBM gap' in LMICs from both volunteers and recipients. This workshop should be extended to all high-income countries for all health professionals to undertake before medical placements abroad.

Attitudes to diagnosis and management in dementia care: views of future general practitioners.

Considerable international governmental support is focused on the timely diagnosis of dementia and post-diagnostic care of people with dementia. Identifying those at high risk of dementia is one approach to timely diagnosis. General practitioners (GPs) are well-placed clinicians in the community to provide both pre- and post-diagnostic dementia care. However, GPs have in the past consistently demonstrated low confidence in both diagnosing dementia and providing care for these complex patients particularly for patients in the post-diagnostic phase. It is currently unclear how future GPs view dementia care. We aimed to evaluate the current attitudes and experiences of future GPs in dementia care and their views on targeting high risk groups. All (n = 513) GP trainees were approached by email to participate in a cross-sectional web and paper-based survey in the North of England. A further reminder was sent out two months after the initial invitation. We received 153 responses (29.8% response rate, 66.7% female, average age 31 (range 25-55 years old). The main difficulties encountered included coordinating supporting services for carers and the person with dementia and responding to co-existing behavioral and psychiatric symptoms. Further education in dementia management was considered to be important by respondents. GP trainees were generally very positive about their future role in caring for people with dementia, particularly in the area of earlier diagnosis via identification of high-risk individuals. Future GPs in one area of England are very positive about their key role in dementia care. In order to facilitate the delivery of high quality, community-based care, work is required to establish core post-diagnostic dementia support services. Further research is needed to identify effective systems to enable accurate assessment and to ensure earlier diagnosis in high-risk groups.

Gaps in care for patients with memory deficits after stroke: views of healthcare providers.

BACKGROUND: Stroke is a common cause of physical disability but is also strongly associated with cognitive impairment and a risk for future dementia. Despite national clinical guidelines, the service provided for stroke survivors with cognitive and memory difficulties varies across localities. This study critically evaluated the views of healthcare professionals about barriers and facilitators to their care. METHODS: Seventeen semi-structured individual interviews were conducted by a single interviewer with both primary and secondary care clinicians in regular contact with stroke-survivors. This included stroke medicine specialists, specialist nurses, physiotherapists, occupational therapists, general practitioners and primary care nurses. Topics included individual experiences of the current care offered to patients with cognitive impairment, assessment processes and inter-professional communication. Interviews were audio recorded and transcribed verbatim. Transcripts were thematically analysed and themes grouped into broad categories to facilitate interpretation. RESULTS: Data analysis identified four key themes as barriers to optimal care for stroke-survivors with memory difficulties: 1) Less focus on memory and cognition in post-stroke care; 2) Difficulties bringing up memory and cognitive problems post-stroke; 3) Lack of clarity in current services; and, 4) Assumptions made by healthcare professionals introducing gaps in care. Facilitators included stronger links between primary and secondary care in addition to information provision at all stages of care. CONCLUSIONS: The care provided by stroke services is dominated by physical impairments. Clinicians are unsure who should take responsibility for follow-up of patients with cognitive problems. This is made even more difficult by the lack of experience in assessment and stigma surrounding potential diagnoses associated with these deficits. Service development should focus on increased cohesiveness between hospital and community care to create a clear care pathway for post-stroke cognitive impairment.

Exploring dementia management attitudes in primary care: a key informant survey to primary care physicians in 25 European countries.

BACKGROUND: Strategies for the involvement of primary care in the management of patients with presumed or diagnosed dementia are heterogeneous across Europe. We wanted to explore attitudes of primary care physicians (PCPs) when managing dementia: (i) the most popular cognitive tests, (ii) who had the right to initiate or continue cholinesterase inhibitor or memantine treatment, and (iii) the relationship between the permissiveness of these rules/guidelines and PCP's approach in the dementia investigations and assessment. METHODS: Key informant survey. SETTING: Primary care practices across 25 European countries. SUBJECTS: Four hundred forty-five PCPs responded to a self-administered questionnaire. Two-step cluster analysis was performed using characteristics of the informants and the responses to the survey. MAIN OUTCOME MEASURES: Two by two contingency tables with odds ratios and 95% confidence intervals were used to assess the association between categorical variables. A multinomial logistic regression model was used to assess the association of multiple variables (age class, gender, and perceived prescription rules) with the PCPs' attitude of "trying to establish a diagnosis of dementia on their own." RESULTS: Discrepancies between rules/guidelines and attitudes to dementia management was found in many countries. There was a strong association between the authorization to prescribe dementia drugs and pursuing dementia diagnostic work-up (odds ratio, 3.45; 95% CI 2.28-5.23). CONCLUSIONS: Differing regulations about who does what in dementia management seemed to affect PCP's engagement in dementia investigations and assessment. PCPs who were allowed to prescribe dementia drugs also claimed higher engagement in dementia work-up than PCPs who were not allowed to prescribe.

Risk Prediction Models for Post-Stroke Dementia.

A strong association exists between stroke and dementia with both diseases linked to ageing. Survival rates from stroke are improving which would equate to an ever-expanding population of patients at risk of future dementia. Early or timelier identification of dementia has become a priority in many countries, including the UK. Although screening for dementia is not advocated, targeting at risk populations could be used to reduce an individual's risk via intervention (i.e., personalised medicine), where available. One approach to improving identification of high-risk dementia individuals is using risk prediction models. Such models could be applied to stroke survivors. Dementia risk prediction models specific to stroke survivors have recently been developed and will be discussed here.

Dementia with Lewy bodies: The emerging role of primary care.

INTRODUCTION: Dementia with Lewy bodies (DLB) is an under recognized but frequent subtype of dementia. Misdiagnosis and delays in referral from primary care are common when compared to other forms of dementia. CASE: We present a case of a 63-year-old man who was eventually diagnosed with DLB three and a half years after his initial presentation. DISCUSSION: Core features of DLB such as hallucinations, Parkinsonism and fluctuating levels of cognition need to be recognized in primary care as being part of the DLB phenotype. DLB is a complex and debilitating neurodegenerative disorder often requiring multidisciplinary support to enable affected individuals to live well in the community. Carers of DLB patients often develop higher levels of subjective burden compared to carers of patients with other forms of dementia; this needs to be recognized and managed appropriately. There is limited research into the role of primary care physicians in DLB. Efforts should be made to reduce delays in identification. CONCLUSION: Primary care has an important role in identifying those who are at risk for DLB and in referring these patients timely to the appropriate specialist. Adequate management of these patients in the community might reduce the burden associated with the DLB phenotype.