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Dementia management in European primary care

Petrazzuoli, Ferdinando LU orcid (2019) In Lund University, Faculty of Medicine Doctoral Dissertation Series 2019(61).
Abstract
Background: Around 50 million people worldwide have dementia and the prevalence is expected to increase to 152 million by 2050. According to the WHO, dementia is a priority health policy issue. The role of primary care physicians (PCPs) for timely dementia management can be cost-effective, yet PCP involvement in the management of patients with presumed or diagnosed dementia vary across Europe.
Aim: Exploring dementia identification and management in European primary care.
Methods: Paper I is a key informant survey across 25 countries based on self-administered questionnaires from 445 PCPs. Paper II is an adaptation into Italian of the cognitive test - A Quick Test of cognitive speed (AQT). Paper III is an explorative analysis... (More)
Background: Around 50 million people worldwide have dementia and the prevalence is expected to increase to 152 million by 2050. According to the WHO, dementia is a priority health policy issue. The role of primary care physicians (PCPs) for timely dementia management can be cost-effective, yet PCP involvement in the management of patients with presumed or diagnosed dementia vary across Europe.
Aim: Exploring dementia identification and management in European primary care.
Methods: Paper I is a key informant survey across 25 countries based on self-administered questionnaires from 445 PCPs. Paper II is an adaptation into Italian of the cognitive test - A Quick Test of cognitive speed (AQT). Paper III is an explorative analysis inspired by grounded theory examining dementia case reports from 106 key informant PCPs (same study as paper I). Paper IV examined if brief cognitive tests used in primary care could identify mild cognitive impairment (MCI) in 466 primary care patients referred to a memory clinic due to cognitive complaints. The examined tests were the Mini-Mental State Examination (MMSE), the Clock Drawing Test and AQT.
Results: In paper I we found that in some countries, PCPs were allowed to establish a diagnosis of dementia and start specific drug treatment reimbursed by health insurance. In most countries only neurologists, geriatricians, and psychiatrists were allowed to diagnose and treat dementia. A positive association found between the right to prescribe dementia drugs and pursuing dementia diagnostic work-up (OR 3.4; 95% CI 2.3–5.2) implied that dementia diagnostic activities were higher for PCPs who were entitled to prescribe dementia drugs. In paper II Italian reference norms for AQT were successfully established. In paper III we analysed 155 dementia case stories (81 women, 74 men, median age 80 years) from 106 PCPs from 23 countries. In 89 of 155 cases (57%) memantine or acetylcholinesterase inhibitors were prescribed; appropriate according to guidelines in 60% and questionable/inappropriate in 40%, showing a broadening of guideline indications. Unburdening dementia, especially by drugs, was a core pattern of dementia management by many physicians. In paper IV we showed that no single or combination of tests had sufficient accuracy to identify patients with MCI and differentiate them from those with only subjective and benign symptoms.
Conclusions: Differing regulations about who does what in dementia management affected PCP’s activities in dementia investigations and assessment. The cognitive test AQT has now been adapted to Italian speakers. Real world dementia drug treatment was characterised by a broadening of guideline indications in order to unburden dementia patients and family members. Since the currently used tests in primary care lack accuracy for identifying MCI better cognitive tests are needed.
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Abstract (Swedish)
Det beräknas att cirka 50 miljoner människor världen över har en demenssjukdom mot förväntade 152 miljoner år 2050 och enligt WHO är demenssjukdomar en prioriterad hälsopolitisk fråga.
Primärvårdsläkares roll i upptäckt och behandling av tidig demens är troligen hälsoekonomiskt fördelaktig men primärvårdens handläggning av patienter med förmodad demens varierar stort. Syftet med denna avhandling var att undersöka hur demenssjukdomar hanteras och kan identifieras i europeisk primärvård.
Artikel I baseras på en enkätundersökning till 445 strategiskt utvalda primärvårdsläkare i 25 europeiska länder.
Artikel II är en transkulturell anpassning till italienska av ett i Sverige utvecklat screeninginstrument för kognitiv snabbhet – A... (More)
Det beräknas att cirka 50 miljoner människor världen över har en demenssjukdom mot förväntade 152 miljoner år 2050 och enligt WHO är demenssjukdomar en prioriterad hälsopolitisk fråga.
Primärvårdsläkares roll i upptäckt och behandling av tidig demens är troligen hälsoekonomiskt fördelaktig men primärvårdens handläggning av patienter med förmodad demens varierar stort. Syftet med denna avhandling var att undersöka hur demenssjukdomar hanteras och kan identifieras i europeisk primärvård.
Artikel I baseras på en enkätundersökning till 445 strategiskt utvalda primärvårdsläkare i 25 europeiska länder.
Artikel II är en transkulturell anpassning till italienska av ett i Sverige utvecklat screeninginstrument för kognitiv snabbhet – A Quick Test of cognitive speed (AQT) - där 128 italienska primärvårdspatienter i olika åldrar genomförde AQT och Mini Mental Test (MMT).
Artikel III är en induktiv explorativ analys inspirerad av grundad teori baserad på samma enkätundersökning som i artikel I men med tillägg av minst en fallhistoria om demens från 106 primärvårdsläkare i 23 länder.
Artikel IV är en analys av 466 patienter remitterade till minneskliniken vid Skånes universitetssjukhus och Ängelholms sjukhus med milda kognitiva symptom. Syftet var att undersöka om dagens primärvårdstester kan identifiera lindrig kognitiv svikt (mild cognitive impairment på engelska) [MCI]).

I artikel I visades att i vissa länder fick primärvårdsläkare diagnosticera demens och starta specifik läkemedelsbehandling ersatt av sjukförsäkringen. I flertalet länder hade endast neurologer, geriatriker och psykiatriker officiell rätt att diagnostisera och behandla demens. Regler, riktlinjer och attityder till demensdiagnostik, handläggning och behandling varierade stort bland de 25 länderna. Det fanns en stark koppling mellan primärvårdsläkares tillåtelse att förskriva specifik läkemedelsbehandling och aktivitetsgraden av demensdiagnostik i primärvård (Oddskvot 3,4; 95 % konfidensintervall 2,3-5,2) så att demensdiagnostik bedrevs i större omfattning då primärvårdsläkare hade rätt att skriva ut demensläkemedel.
I artikel II fastställdes italienska referenstider för AQT på samma sätt som gjorts för andra språk så att AQT- kan användas för personer med italienska som modersmål.
I artikel III analyserades 155 fallberättelser om demens (81 kvinnor, 74 män, medianålder 80 år) från 106 primärvårdsläkare i 23 länder och fyra regioner: Nordeuropa, Centraleuropa, Östeuropa och Medelhavsområdet. Acetylkolinesterashämmare och memantin förskrevs i 89 av 155 fall (57 %), varav 60 % av fallen i överensstämmelse med riktlinjer vilket innebar en indikationsglidning då läkemedel användes utanför riktlinjerna i 40% av fallen . Att försöka avlasta kognitiva symptom, särskilt med läkemedel, var ett kärnmönster för hur demenssjukdomar hanterades av många läkare både i primärvård och sekundärvård.
Resultat från artikel IV visade att inget enskilt test eller kombination av testerna Mini-Mental Test (MMT), klocktest och AQT hade tillräcklig känslighet och träffsäkerhet för diagnos av MCI hos patienter som sökte sjukvård för lindriga kognitiva symtom.
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Please use this url to cite or link to this publication:
author
supervisor
opponent
  • professor Iliffe, Steven, University College London
organization
alternative title
Demenshantering i europeisk primärvård
publishing date
type
Thesis
publication status
published
subject
keywords
dementia, mild cognitive impairment, Grounded Theory, Demens, lindrig kognitiv svikt, grundad teori
in
Lund University, Faculty of Medicine Doctoral Dissertation Series
volume
2019
issue
61
pages
107 pages
publisher
Lund University: Faculty of Medicine
defense location
Agardhsalen, Medicinskt forskningscentrum, Jan Waldenströms gata 5, Skånes Universitetssjukhus i Malmö
defense date
2019-06-13 13:00:00
ISSN
1652-8220
ISBN
978-91-7619-790-5
language
English
LU publication?
yes
id
1a496290-ec9c-4742-886f-00548f9c79fb
date added to LUP
2019-05-04 19:19:29
date last changed
2021-04-16 12:45:56
@phdthesis{1a496290-ec9c-4742-886f-00548f9c79fb,
  abstract     = {{Background: Around 50 million people worldwide have dementia and the prevalence is expected to increase to 152 million by 2050. According to the WHO, dementia is a priority health policy issue. The role of primary care physicians (PCPs) for timely dementia management can be cost-effective, yet PCP involvement in the management of patients with presumed or diagnosed dementia vary across Europe.<br/>Aim: Exploring dementia identification and management in European primary care. <br/>Methods: Paper I is a key informant survey across 25 countries based on self-administered questionnaires from 445 PCPs. Paper II is an adaptation into Italian of the cognitive test - A Quick Test of cognitive speed (AQT). Paper III is an explorative analysis inspired by grounded theory examining dementia case reports from 106 key informant PCPs (same study as paper I). Paper IV examined if brief cognitive tests used in primary care could identify mild cognitive impairment (MCI) in 466 primary care patients referred to a memory clinic due to cognitive complaints. The examined tests were the Mini-Mental State Examination (MMSE), the Clock Drawing Test and AQT.<br/>Results: In paper I we found that in some countries, PCPs were allowed to establish a diagnosis of dementia and start specific drug treatment reimbursed by health insurance. In most countries only neurologists, geriatricians, and psychiatrists were allowed to diagnose and treat dementia. A positive association found between the right to prescribe dementia drugs and pursuing dementia diagnostic work-up (OR 3.4; 95% CI 2.3–5.2) implied that dementia diagnostic activities were higher for PCPs who were entitled to prescribe dementia drugs. In paper II Italian reference norms for AQT were successfully established. In paper III we analysed 155 dementia case stories (81 women, 74 men, median age 80 years) from 106 PCPs from 23 countries. In 89 of 155 cases (57%) memantine or acetylcholinesterase inhibitors were prescribed; appropriate according to guidelines in 60% and questionable/inappropriate in 40%, showing a broadening of guideline indications. Unburdening dementia, especially by drugs, was a core pattern of dementia management by many physicians. In paper IV we showed that no single or combination of tests had sufficient accuracy to identify patients with MCI and differentiate them from those with only subjective and benign symptoms. <br/>Conclusions: Differing regulations about who does what in dementia management affected PCP’s activities in dementia investigations and assessment. The cognitive test AQT has now been adapted to Italian speakers. Real world dementia drug treatment was characterised by a broadening of guideline indications in order to unburden dementia patients and family members. Since the currently used tests in primary care lack accuracy for identifying MCI better cognitive tests are needed.<br/>}},
  author       = {{Petrazzuoli, Ferdinando}},
  isbn         = {{978-91-7619-790-5}},
  issn         = {{1652-8220}},
  keywords     = {{dementia; mild cognitive impairment; Grounded Theory; Demens; lindrig kognitiv svikt; grundad teori}},
  language     = {{eng}},
  number       = {{61}},
  publisher    = {{Lund University: Faculty of Medicine}},
  school       = {{Lund University}},
  series       = {{Lund University, Faculty of Medicine Doctoral Dissertation Series}},
  title        = {{Dementia management in European primary care}},
  url          = {{https://lup.lub.lu.se/search/files/64009821/Ferdinando_Petrazzuoli_WEBB_1_.pdf}},
  volume       = {{2019}},
  year         = {{2019}},
}