The Road Ahead To Cure And Prevent Alzheimer's Disease: Implementing Prevention into Primary Care.

Most old adults receive their health care from their primary care practitioner; as a consequence, as the population ages, the manifestations and complications of cognitive impairment and dementia impose a growing burden on providers of primary care. Current guidelines do not recommend routine cognitive screening for older persons by primary care physicians, although the vast majority recommend a cognitive status assessment and neurological examination for subjects with a cognitive complaint. Also, no clinical practice guidelines recommend interventions in older adults with cognitive impairment in primary care settings. However, primary care physicians need to conduct a review of risks and protective factors associated with cognitive decline and organize interventions to improve or maintain cognitive function. Recent epidemiological studies have indicated numerous associations between lifestyle-related risk factors and incidental cognitive impairment. The development of biomarkers could also help in diagnosis, prognosis, selection for clinical trials, and objective assessment of therapeutic responses. Interventions aimed at cognitive impairment prevention should be pragmatic and easy to implement on a large scale in different health care systems, without generating high additional costs or burden on participants, medical and social care teams.

Developing a video intervention to model effective patient-physician communication and health-related decision-making skills for a multiethnic audience.

The ENDOW study is a multisite, community-based project designed to improve decision-making and patient-physician communication skills for midlife African-American, white, and Hispanic women facing decisions about hysterectomy. Based on results of initial focus groups, a patient education video was developed in English and Spanish to serve as the centerpiece of various interventions. The video uses community women to model appropriate decision-making and patient-physician communication skills. Women in the target populations rated the video as useful to very useful and would recommend it to others. The use of theory-driven approaches and pilot testing of draft products resulted in the production of a well-accepted, useful video suitable for diverse populations in intervention sites in several states.

Overview of women's decision making regarding elective hysterectomy, oophorectomy, and hormone replacement therapy.

Over 600,000 hysterectomies are performed each year in the United States, the majority of which are to improve quality of life for perimenopausal women. Hysterectomy rates for common conditions differ between African American and white women, and African American women undergo surgery at a younger age for most diagnoses. Many hysterectomies are accompanied by elective oophorectomy, and hormone replacement therapy (HRT) is commonly used, especially among women experiencing surgical menopause, despite questions about its long-term benefits and risks. Despite the high rates of hysterectomy in the United States, little is known about how women make decisions regarding this surgery and, in particular, how ethnic and cultural factors may influence these decisions. This article provides a review of what is currently known about the epidemiology of hysterectomy, oophorectomy, and HRT use and identifies gaps in knowledge about women's decision making, with a special focus on ethnic variations and cultural influences, issues addressed by the Ethnicity, Needs, and Decisions of Women (ENDOW) project.

Women's stories: ethnic variations in women's attitudes and experiences of menopause, hysterectomy, and hormone replacement therapy.

To increase understanding of women's midlife changes, 23 focus groups were held to investigate the possible ethnic variations in attitude toward and experience with menopause, hysterectomy, and hormone replacement therapy (HRT) in non-Hispanic white, Hispanic, and Navajo women in New Mexico. The medical definition of menopause, no menstrual bleeding for 12 months, did not coincide with the women's definition of menopause as the hormonal fluctuations they experienced before, during, and after any change in their menstrual cycle. More women reported having to fight to have a hysterectomy than having one unnecessarily. Women complained about the lack of information and preparation prior to having a hysterectomy and expressed dissatisfaction with doctor-patient communication, but they were satisfied with their hysterectomy because they felt better after the surgery. Although women in the study reported that menopause and hysterectomy are seldom discussed openly, they all participated freely in the storytelling focus groups. The most traditional women, primarily rural Navajo and newly immigrated Latina, related few or no menopausal symptoms with natural menopause or after hysterectomy. Many of these women had not even heard of HRT. Many women who had been prescribed HRT expressed dissatisfaction with the side effects and dosage. Unsupervised tinkering with the dosage was the rule rather than the exception. The study revealed that women are much more alike than they are different. Traditional women in all ethnic groups had more in common with each other than they did with the least traditional women in their own ethnic group.

Variation in recommendations for cancer screening among primary care physicians in New Mexico.

The acceptance of age-appropriate cancer screening as an integral part of primary care has grown among physicians over the past decade. We conducted a mailed survey of all primary care physicians in New Mexico in order to better understand their current cancer screening practices. We found a high rate of self-reported screening, particularly for prostate and colorectal cancer. The screening rates were influenced only slightly by the introduction of evidence-based guidelines, with younger physicians and those with university affiliations more likely to follow recommendations. Female physicians and obstetrician-gynecologists endorsed breast and cervical cancer screening among all age groups and were less likely to follow recommendations for less frequent screening in women as they age. Since a physician's practice beliefs influence his/her attitude toward testing, tailoring education by physician specialty may be more effective than using generic messages in encouraging compliance with the most recent evidence-based guidelines.

An evaluation of professional education efforts for breast and cervical cancer in public health nurses.

This article describes training programs instituted in 1992 by the North Carolina Breast and Cervical Cancer Control Program (BCCCP) to improve skills of public health nurses in breast and cervical cancer education and clinical services. Public health nurses traditionally serve as primary health care providers in medically underserved communities and are the main providers of BCCCP services. The training programs were evaluated by a statewide survey of public health nurses in 1996. The authors discuss the findings of this survey, its limitations, and the goals it has led the authors to set for improving the education program in the future.

Predictors of the performance of breast and cervical cancer early detection by public health nurses.

INTRODUCTION: Public health nurses (PHNs) often serve as primary care providers, yet few studies have examined their practice patterns in the early detection of breast and cervical cancer. METHODS: We conducted a cross-sectional survey of all PHNs (N = 1,894) employed by the county health departments of North Carolina in July 1993 to describe the predictors of their performance of breast and cervical cancer early detection. The main outcome measures were self-report of cancer prevention and screening services provided for their adult clients, nursing self-confidence for counseling clients about cancer prevention, and training experience. Self-confidence for counseling clients about cancer prevention was measured by asking whether a nurse had sufficient knowledge to educate clients about cancer prevention as well as by obtaining nursing perception of the quality of their clinical skills. RESULTS: The response rate was 78%. Final sample consisted of 1,369 PHNs, after exclusion of 101 nurse practitioners. Nurses reported high performance rates of cancer screening, although self-rating of the quality of their clinical skills was often low. However, nurses who reported having higher quality clinical skills or who reported having sufficient knowledge to educate clients were significantly more likely to report a greater frequency of performing cancer screening and counseling. This self-confidence and performance association was independent of nursing certification to perform screening, job classification, education, knowledge, or continuing education coursework. CONCLUSIONS: Self-confidence is a significant predictor of PHNs' reported performance of cancer screening and counseling. Further studies to verify whether self-report predicts actual performance of cancer early detection are needed.

Cancer prevention knowledge, attitudes, and clinical practice of nurse practitioners in local public health departments in North Carolina.

This study discusses the findings from a survey of the knowledge, attitudes, and clinical practice regarding cancer prevention and early detection of 101 nurse practitioners (NPs) working in the 87 county public health departments in North Carolina. Results show that nurse practitioners provide breast and cervical cancer screening services for most women over age 40 but are less likely to provide other types of cancer prevention, such as smoking cessation counseling or education about diet and cancer. NPs tended to rate their clinical skills in providing cancer screening as excellent but rate their skills in educating clients about cancer risk lower. Most NPs were interested in practice related to cancer control, especially learning more about the latest recommendations on cancer. However, in this study they indicated the least interest in learning more about smoking cessation methods or cancer prevention issues for men. These findings suggest that NPs in public health need further education and skills training related to cancer control, in addition to breast and cervical cancer screening.

Variation in recommendations for breast and cervical cancer screening among primary care physicians in North Carolina, 1991.

Physicians play an important role in recommending and doing cancer screening for their patients. In 1991, the North Carolina Department of Environment, Health and Natural Resources and the Centers for Disease Control and Prevention conducted a survey to determine the counseling and referral practices of primary care physicians practicing in North Carolina. Physicians were asked to report the percentage of patients in various age groups that they recommended receive a clinical breast examination, referral for mammography screening, or a Pap test and at what intervals they recommended each study. They were also asked their perceived barriers to cervical cancer screening. Obstetrician-gynecologists recommended annual Pap smear screening more frequently than did physicians in other specialties for patients of all ages. For mammography, variation existed for recommended screening intervals for all specialties by patient age (35 to 39 years, 40 to 49 years, 50 to 64 years, and over age 65). Recommendations for mammography also differed significantly according to physicians' age and sex. The medical community and the public need a consistent and clear message to promote effective screening maneuvers.

Improving compliance with breast cancer screening in older women. Results of a randomized controlled trial.

BACKGROUND: To compare three approaches for improving compliance with breast cancer screening in older women. METHODS: Randomized controlled trial using three parallel group practices at a public hospital. Subjects included women aged 65 years and older (n = 803) who were seen by residents (n = 66) attending the ambulatory clinic from October 1, 1989, through March 31, 1990. All provider groups received intensive education in breast cancer screening. The control group received no further intervention. Staff in the second group offered education to patients at their visit. In addition, flowsheets were used in the "Prevention Team" group and staff had their tasks redefined to facilitate compliance. RESULTS: Medical records were reviewed to determine documented offering/receipt of clinical breast examination and mammography. A subgroup of women without previous clinical breast examination (n = 540) and without previous mammography (n = 471) were analyzed to determine the effect of the intervention. During the intervention period, women without a previous clinical breast examination were offered an examination significantly more often in the Prevention Team group than in the control group, adjusting for age, race, and comorbidity and for physicians' gender and training level. The patients in the Prevention Team group were offered clinical breast examination (31.5%) more frequently than those in the patient education or control groups, but this was not significant after adjusting for the above covariates. Likewise, mammography was offered more frequently to patients in the Prevention Team and in the patient education group than to patients in the control group, after adjusting for the factors above using logistic regression. CONCLUSIONS: The results provide support for patient education and organizational changes that involve nonphysician personnel to enhance breast cancer screening among older women, particularly those without previous screening.

Improving compliance with immunization in the older adult: results of a randomized cohort study.

OBJECTIVE: To compare three approaches for improving compliance with influenza and pneumococcal vaccination of elderly patients. DESIGN: Randomized controlled trial using three parallel group practices at a public urban teaching hospital. SETTING: Public teaching hospital. SUBJECTS: All patients 65 years of age and older (n = 1202) seen by resident physicians (n = 66) attending three ambulatory medical practices from October 1, 1989 to March 31, 1990. INTERVENTIONS: All three provider groups received intensive education in immunization standards. The control group received no further intervention. Staff in the second group offered education to patients at their visits. In the third group, the prevention team, a flowsheet was used, patient education offered, and staff had their tasks redefined to facilitate compliance; for vaccinations, eg, nurses could vaccinate independent of MD initiative. MEASUREMENTS AND MAIN RESULTS: Medical records were reviewed for the 1202 patients seen, including 756 patients seen during both the 1988-89 and 1989-90 influenza seasons, to determine documented offering and receipt of vaccinations. During the intervention period (1989-90), influenza vaccinations were offered significantly more frequently to prevention team patients (68.3%) than to patients in either the patient education (50.4%) or control (47.6%) groups (P = 0.006), even after adjusting for the patients' prior vaccination status, age, gender, race, and high-risk co-morbidity and for physicians' level of training. Likewise, pneumococcal vaccinations were offered more frequently to previously unvaccinated prevention team patients (28.3%) than to patient education (6.5%) or control (5.4%) group patients (P = 0.001), even after adjusting for the factors using multivariate analysis. Compliance rates did not differ between patient education and control subjects for either vaccine. Pre-intervention physician surveys documented higher perceived than actual compliance for both vaccines, with 89.0% and 52.8% of physicians believing that they complied with influenza and pneumococcal vaccination guidelines, respectively. CONCLUSIONS: The results of this trial provide strong support for organizational changes that involve non-physician personnel to enhance vaccination rates among older adults.