This study examined Australian primary healthcare providers' knowledge about dementia risk fa... more This study examined Australian primary healthcare providers' knowledge about dementia risk factors and risk reduction and their perspectives on barriers and enablers to risk reduction in practice. Primary healthcare providers were recruited through Primary Health Networks across Australia (n=51). Participants completed an online survey that consisted of fixed-responses and free-text components to assess their knowledge, attitudes and current practices relating to dementia risk factors and risk reduction techniques. The results showed that Australian primary healthcare providers have good knowledge about the modifiable risk factors for dementia; however, face several barriers to working with patients to reduce dementia risk. Commonly reported barriers included low patient motivation and healthcare system level limitations. The most commonly reported recommendations to helping primary healthcare providers to work with patients to reduce dementia risk included increasing resources ...
Objective: The Zero Suicide (ZS) framework is increasingly used in Australia, but without publish... more Objective: The Zero Suicide (ZS) framework is increasingly used in Australia, but without published adaptations for older people, and limited access by older people when implemented. The aim of this paper is to inform Towards Zero Suicide (TZS) implementations to benefit older adults by considering the key differences in older adults at risk of suicide according to each clinical component of the ZS framework. Conclusion: TZS aspires to reduce deaths by suicide for people within healthcare by refocusing interventions on suicidality rather than diagnosis alone, emphasising evidence-based practices and cultural change. For TZS to be effective for older people, it is essential to ensure practices are based upon evidence relevant to older people and to ensure ageism is effectively counteracted. Older adults have distinct patterns of help seeking and service use, accompanied by differences in risk factors, presentations, and outcomes of suicidal behaviours. Ageism affects assessment, deci...
Objective: Implementing the Towards Zero Suicide (TZS) approach to suicide prevention in older ad... more Objective: Implementing the Towards Zero Suicide (TZS) approach to suicide prevention in older adults requires evidence-based adaptation. This paper aims to highlight important differences and opportunities in healthcare service use by older adults relevant to implementation. Conclusion: The TZS approach may prevent suicide in older adults, but only if implementation aligns with systemic differences in healthcare utilisation by older people. Of greatest importance in older adults are (1) most mental healthcare is delivered outside of specialist mental health services; (2) physical conditions and disability are major modifiable contributors to suicide that must be addressed within TZS; and (3) older people have very low use of Medicare-funded psychological services. Primary healthcare providers, who may be seeing older people at risk of suicide, are often neither equipped to provide expert assessment and care planning for often complex needs, nor may see this as their role. However, ...
People with dementia (PWD) and cognitive impairment are particularly vulnerable to medication pro... more People with dementia (PWD) and cognitive impairment are particularly vulnerable to medication problems, and unplanned admission to hospital presents an opportunity to address polypharmacy, potentially inappropriate medications (PIMs) and anticholinergic burden. This study aimed to compare PIMS and other medication data for PWD to determine whether these changed during hospitalization. Medications documented in patient’s records at admission and discharge were evaluated for PWD recruited to phase one of a prospective quasi-experimental pre/post-controlled trial that was conducted at two regional hospitals in NSW, Australia. The study sample included PWD or cognitive impairment having an unplanned admission to hospital. Data were collected using a purpose developed audit tool for medications and PIMs, and a Modified Anticholinergic Burden Scale. Total participants were 277, and results determined that the cognitive status of PWD is not always detected during an unplanned admission. Th...
edical deputising services are invaluable, responding to large numbers of after-hours calls, part... more edical deputising services are invaluable, responding to large numbers of after-hours calls, particularly for older people at home and in residential aged care (RAC). Without these services, emergency departments and ambulance services would be much busier than they are now. The article in this issue of the MJA by Joe and colleagues 1 reviews 357 112 bookings logged by one such service, the Melbourne Medical Deputising Service (MMDS), over a 5-year period (2008e2012).
What does pre-conception care include? Medical issues Reproductive life plan Assist your patient ... more What does pre-conception care include? Medical issues Reproductive life plan Assist your patient in developing a reproductive life plan that includes whether they want to have children. If they do, discuss the number, spacing and timing of intended children. Reproductive history Ask if there have been any problems with previous pregnancies such as infant death, foetal loss, birth defects particularly neural tube defects (NTD), low birthweight, pre-term birth, or gestational diabetes. Are there any ongoing risks that could lead to a recurrence in a future pregnancy? Medical history Ask if there are any medical conditions that may affect future pregnancies. Are chronic conditions such as diabetes, thyroid disease, hypertension, epilepsy and thrombophilia well managed? Medication use Review all current medications including over-the-counter medications, vitamins and supplements. Genetic/family history Assess risk of chromosomal or genetic disorders, (e.g. cystic fibrosis (CF), fragile X, Tay-Sachs disease, thalassaemia, sickle cell anaemia and spinal muscular atrophy), by collection of data on family history and ethnic background. Provide opportunity for carrier screening for these and other more common genetic conditions. General physical assessment Conduct Pap test and breast examinations before pregnancy if indicated or due. Also assess body mass index (BMI), and BP and ask about periodontal disease. Substance use Ask about tobacco, alcohol and illegal drug use. * It is recommended that all 50-year-olds should be given DT. dTpa is preferred instead of DT to protect from pertussis. This is funded for parents and 'carers of infants' under age 6 months in some states. It can be given regardless of timing of previous DT. * See Effect of smoking abstinence on medications, Appendix 9, New Zealand smoking cessation guidelines 2007 at www.treatobacco. net/en/uploads/documents/Treatment%20Guidelines/New%20Zealand%20treatment%20guidelines%20in%20English%202007.pdf † While enquiry about smoking should occur at every opportunity, be aware of patient sensitivity. Non-judgemental enquiry about smoking is associated with greater patient satisfaction. 283, 286, 289
Summary: In the diagnosis of dementia, information obtained from informants or proxies is importa... more Summary: In the diagnosis of dementia, information obtained from informants or proxies is important; however, little is known about the circumstances under which informants ’ reports lack accuracy. This study compares informant reports of cognitive status against psychometric tests to identify the degree of, and factors associated with, discrepant reporting. Four areas of patient cognitive ability were examined: memory of recent events, ability to remember a short list of items after a delay, language/naming abilities, and working memory. Primary care practitioners recruited 248 community-dwelling patients aged 75 years or more or aged 50–74 years with suspected memory complaints; 248 friends or relatives acted as informants. More than half of the infor-mants (60%) gave responses consistent with psychometric testing. Informants who underreported patient difficulties tended to report on patients who were diagnosed as having subclinical dementia, were less educated, and had poorer rem...
IntroductionNationally and internationally it is well recognised that dementia is poorly recognis... more IntroductionNationally and internationally it is well recognised that dementia is poorly recognised and suboptimally managed in the primary care setting. There are multiple and complex reasons for this gap in care, including a lack of knowledge, high care demands and inadequate time for the general practitioner alone to manage dementia with its multiple physical, psychological and social dimensions. The primary care nurse potentially has a role in assisting the general practitioner in the provision of evidence-based dementia care. Although dementia-care guidelines for general practitioners exist, evidence on resources to support the primary care nurse in dementia care provision is scarce. The ‘Australian Clinical Practice Guidelines and Principles of Care for People with Dementia’ provides 109 recommendations for the diagnosis and management of dementia. This protocol describes a Delphi study to identify which of the 109 recommendations contained in these multidisciplinary guideline...
Risk has become a ubiquitous presence in modern society. For individuals diagnosed with dementia ... more Risk has become a ubiquitous presence in modern society. For individuals diagnosed with dementia this preoccupation with risk can affect their day-to-day life in many ways. Maintaining autonomy while balancing risks is a continual struggle not only for those living with the disease, but also their carers, family and health professionals. To understand how these different groups of individuals conceptualise the issue of risk for those living with dementia, 83 semi-structured interviews were conducted with people living with dementia, carers, older people without significant experience of dementia, and registered nurses, and staff from a community nursing organisation. These interviews were analysed using Thematic Analysis, which suggested that the risks identified by each group were grounded in their experiences and perspective on dementia. Furthermore, context and understanding of the individual living with dementia and their preferences was central to effectively managing risk in a balanced way, ensuring that 'acceptable risks' were taken to ensure an acceptable quality of life for all involved. These findings highlight that there is no single approach to risk which can be applied to all individuals; rather, a negotiation needs to take place that takes into account the individual's preferences alongside their available resources and means.
Care for people with advanced dementia requires a palliative approach targeted to the illness tra... more Care for people with advanced dementia requires a palliative approach targeted to the illness trajectory and tailored to individual needs. However, care in nursing homes is often compromised by poor communication and limited staff expertise. This paper reports the protocol for the IDEAL Project, which aims to: 1) compare the efficacy of a facilitated approach to family case conferencing with usual care; 2) provide insights into nursing home- and staff-related processes influencing the implementation and sustainability of case conferencing; and 3) evaluate cost-effectiveness. A pragmatic parallel cluster randomised controlled trial design will be used. Twenty Australian nursing homes will be randomised to receive either facilitated family case conferencing or usual care. In the intervention arm, we will train registered nurses at each nursing home to work as Palliative Care Planning Coordinators (PCPCs) 16 h per week over 18 months. The PCPCs' role will be to: 1) use evidence-bas...
Background People with dementia (PWD) are at risk for medication related harm due to their impair... more Background People with dementia (PWD) are at risk for medication related harm due to their impaired cognition and frequently being prescribed many medications. Few previous studies of PWD inpatients have been focused on medication safety interventions.This study aimed to evaluate an intervention designed to improve medication safety for people with dementia (PWD) and their carers during an unplanned admission to hospital. This article reports the effect of the intervention on potentially inappropriate medications (PIMs), polypharmacy and anticholinergic burden scores for PWD in the study. Methods A quasi-experimental pre-post design using an intervention site and a control site was conducted in 2017-2019, in a regional area in New South Wales, Australia. PIMs, polypharmacy and anticholinergic burden were measured at admission, discharge and three months after discharge. In addition, medication reconciliation at admission and scoring of pharmacists recommendations using severity and ...
D ementia, or ‘major neurocognitive disorder,’ is usually characterised by the progressive deteri... more D ementia, or ‘major neurocognitive disorder,’ is usually characterised by the progressive deterioration of cognitive and functional abilities. At early stages of dementia, those affected (hereafter termed patients) may experience only slight deficits in their cognitive abilities that interfere with their capacity to function in daily life. At late stages of dementia, patients may be totally dependent on carers to survive. The course of decline varies con siderably across patients and different types of dementia. The time from diagnosis to death typically ranges from two to 10 years (see Table 1).1-3 In the previous issue of Medicine Today, we outlined 14 essentials of assessment and care planning for patients with dementia.4 Here we focus on management and describe 14 practical points that clinicians can apply to patients across different stages and types of dementia. The business case for care planning and relevant Medicare item numbers are listed in the previous article. THE FOUR...
Background Dementia is an insidious and stigmatised condition, and research indicates that GPs fi... more Background Dementia is an insidious and stigmatised condition, and research indicates that GPs find communicating this diagnosis particularly problematic. Delays in diagnosis may impede optimal patient care. Little research has been published on Australian GPs' perceptions of barriers to disclosing the diagnosis of dementia. Aim To explore GPs' perceptions of barriers to disclosing the diagnosis of dementia. Design and setting Qualitative study in the general practice consultation context. Conclusion Complex issues surround the disclosure of dementia. Communicating this diagnosis remains particularly challenging for many GPs.
This study reports carer strain and coping with medications for people with dementia with an unpl... more This study reports carer strain and coping with medications for people with dementia with an unplanned admission to hospital, and it evaluates the impact of a safe medication intervention on carer coping and carer strain. This was a quasi-experimental pre/post-controlled trial that included a survey of carers about managing medications for people with dementia after discharge. For 88 carers who completed surveys, 33% were concerned about managing medications, and 40% reported difficulties with medication management, including resistive behaviours by people with dementia. Dose administration aids were used by 72% of carers; however, only 15% reported receiving a recent home medicines review by a community pharmacist. High carer strain was reported by 74% of carers. Carer comments described many issues that contributed to high carer stress, as well as their engagement in vigilant activities to maintain medication safety. Strategies that can contribute to carers managing medications an...
This study examined Australian primary healthcare providers' knowledge about dementia risk fa... more This study examined Australian primary healthcare providers' knowledge about dementia risk factors and risk reduction and their perspectives on barriers and enablers to risk reduction in practice. Primary healthcare providers were recruited through Primary Health Networks across Australia (n=51). Participants completed an online survey that consisted of fixed-responses and free-text components to assess their knowledge, attitudes and current practices relating to dementia risk factors and risk reduction techniques. The results showed that Australian primary healthcare providers have good knowledge about the modifiable risk factors for dementia; however, face several barriers to working with patients to reduce dementia risk. Commonly reported barriers included low patient motivation and healthcare system level limitations. The most commonly reported recommendations to helping primary healthcare providers to work with patients to reduce dementia risk included increasing resources ...
Objective: The Zero Suicide (ZS) framework is increasingly used in Australia, but without publish... more Objective: The Zero Suicide (ZS) framework is increasingly used in Australia, but without published adaptations for older people, and limited access by older people when implemented. The aim of this paper is to inform Towards Zero Suicide (TZS) implementations to benefit older adults by considering the key differences in older adults at risk of suicide according to each clinical component of the ZS framework. Conclusion: TZS aspires to reduce deaths by suicide for people within healthcare by refocusing interventions on suicidality rather than diagnosis alone, emphasising evidence-based practices and cultural change. For TZS to be effective for older people, it is essential to ensure practices are based upon evidence relevant to older people and to ensure ageism is effectively counteracted. Older adults have distinct patterns of help seeking and service use, accompanied by differences in risk factors, presentations, and outcomes of suicidal behaviours. Ageism affects assessment, deci...
Objective: Implementing the Towards Zero Suicide (TZS) approach to suicide prevention in older ad... more Objective: Implementing the Towards Zero Suicide (TZS) approach to suicide prevention in older adults requires evidence-based adaptation. This paper aims to highlight important differences and opportunities in healthcare service use by older adults relevant to implementation. Conclusion: The TZS approach may prevent suicide in older adults, but only if implementation aligns with systemic differences in healthcare utilisation by older people. Of greatest importance in older adults are (1) most mental healthcare is delivered outside of specialist mental health services; (2) physical conditions and disability are major modifiable contributors to suicide that must be addressed within TZS; and (3) older people have very low use of Medicare-funded psychological services. Primary healthcare providers, who may be seeing older people at risk of suicide, are often neither equipped to provide expert assessment and care planning for often complex needs, nor may see this as their role. However, ...
People with dementia (PWD) and cognitive impairment are particularly vulnerable to medication pro... more People with dementia (PWD) and cognitive impairment are particularly vulnerable to medication problems, and unplanned admission to hospital presents an opportunity to address polypharmacy, potentially inappropriate medications (PIMs) and anticholinergic burden. This study aimed to compare PIMS and other medication data for PWD to determine whether these changed during hospitalization. Medications documented in patient’s records at admission and discharge were evaluated for PWD recruited to phase one of a prospective quasi-experimental pre/post-controlled trial that was conducted at two regional hospitals in NSW, Australia. The study sample included PWD or cognitive impairment having an unplanned admission to hospital. Data were collected using a purpose developed audit tool for medications and PIMs, and a Modified Anticholinergic Burden Scale. Total participants were 277, and results determined that the cognitive status of PWD is not always detected during an unplanned admission. Th...
edical deputising services are invaluable, responding to large numbers of after-hours calls, part... more edical deputising services are invaluable, responding to large numbers of after-hours calls, particularly for older people at home and in residential aged care (RAC). Without these services, emergency departments and ambulance services would be much busier than they are now. The article in this issue of the MJA by Joe and colleagues 1 reviews 357 112 bookings logged by one such service, the Melbourne Medical Deputising Service (MMDS), over a 5-year period (2008e2012).
What does pre-conception care include? Medical issues Reproductive life plan Assist your patient ... more What does pre-conception care include? Medical issues Reproductive life plan Assist your patient in developing a reproductive life plan that includes whether they want to have children. If they do, discuss the number, spacing and timing of intended children. Reproductive history Ask if there have been any problems with previous pregnancies such as infant death, foetal loss, birth defects particularly neural tube defects (NTD), low birthweight, pre-term birth, or gestational diabetes. Are there any ongoing risks that could lead to a recurrence in a future pregnancy? Medical history Ask if there are any medical conditions that may affect future pregnancies. Are chronic conditions such as diabetes, thyroid disease, hypertension, epilepsy and thrombophilia well managed? Medication use Review all current medications including over-the-counter medications, vitamins and supplements. Genetic/family history Assess risk of chromosomal or genetic disorders, (e.g. cystic fibrosis (CF), fragile X, Tay-Sachs disease, thalassaemia, sickle cell anaemia and spinal muscular atrophy), by collection of data on family history and ethnic background. Provide opportunity for carrier screening for these and other more common genetic conditions. General physical assessment Conduct Pap test and breast examinations before pregnancy if indicated or due. Also assess body mass index (BMI), and BP and ask about periodontal disease. Substance use Ask about tobacco, alcohol and illegal drug use. * It is recommended that all 50-year-olds should be given DT. dTpa is preferred instead of DT to protect from pertussis. This is funded for parents and 'carers of infants' under age 6 months in some states. It can be given regardless of timing of previous DT. * See Effect of smoking abstinence on medications, Appendix 9, New Zealand smoking cessation guidelines 2007 at www.treatobacco. net/en/uploads/documents/Treatment%20Guidelines/New%20Zealand%20treatment%20guidelines%20in%20English%202007.pdf † While enquiry about smoking should occur at every opportunity, be aware of patient sensitivity. Non-judgemental enquiry about smoking is associated with greater patient satisfaction. 283, 286, 289
Summary: In the diagnosis of dementia, information obtained from informants or proxies is importa... more Summary: In the diagnosis of dementia, information obtained from informants or proxies is important; however, little is known about the circumstances under which informants ’ reports lack accuracy. This study compares informant reports of cognitive status against psychometric tests to identify the degree of, and factors associated with, discrepant reporting. Four areas of patient cognitive ability were examined: memory of recent events, ability to remember a short list of items after a delay, language/naming abilities, and working memory. Primary care practitioners recruited 248 community-dwelling patients aged 75 years or more or aged 50–74 years with suspected memory complaints; 248 friends or relatives acted as informants. More than half of the infor-mants (60%) gave responses consistent with psychometric testing. Informants who underreported patient difficulties tended to report on patients who were diagnosed as having subclinical dementia, were less educated, and had poorer rem...
IntroductionNationally and internationally it is well recognised that dementia is poorly recognis... more IntroductionNationally and internationally it is well recognised that dementia is poorly recognised and suboptimally managed in the primary care setting. There are multiple and complex reasons for this gap in care, including a lack of knowledge, high care demands and inadequate time for the general practitioner alone to manage dementia with its multiple physical, psychological and social dimensions. The primary care nurse potentially has a role in assisting the general practitioner in the provision of evidence-based dementia care. Although dementia-care guidelines for general practitioners exist, evidence on resources to support the primary care nurse in dementia care provision is scarce. The ‘Australian Clinical Practice Guidelines and Principles of Care for People with Dementia’ provides 109 recommendations for the diagnosis and management of dementia. This protocol describes a Delphi study to identify which of the 109 recommendations contained in these multidisciplinary guideline...
Risk has become a ubiquitous presence in modern society. For individuals diagnosed with dementia ... more Risk has become a ubiquitous presence in modern society. For individuals diagnosed with dementia this preoccupation with risk can affect their day-to-day life in many ways. Maintaining autonomy while balancing risks is a continual struggle not only for those living with the disease, but also their carers, family and health professionals. To understand how these different groups of individuals conceptualise the issue of risk for those living with dementia, 83 semi-structured interviews were conducted with people living with dementia, carers, older people without significant experience of dementia, and registered nurses, and staff from a community nursing organisation. These interviews were analysed using Thematic Analysis, which suggested that the risks identified by each group were grounded in their experiences and perspective on dementia. Furthermore, context and understanding of the individual living with dementia and their preferences was central to effectively managing risk in a balanced way, ensuring that 'acceptable risks' were taken to ensure an acceptable quality of life for all involved. These findings highlight that there is no single approach to risk which can be applied to all individuals; rather, a negotiation needs to take place that takes into account the individual's preferences alongside their available resources and means.
Care for people with advanced dementia requires a palliative approach targeted to the illness tra... more Care for people with advanced dementia requires a palliative approach targeted to the illness trajectory and tailored to individual needs. However, care in nursing homes is often compromised by poor communication and limited staff expertise. This paper reports the protocol for the IDEAL Project, which aims to: 1) compare the efficacy of a facilitated approach to family case conferencing with usual care; 2) provide insights into nursing home- and staff-related processes influencing the implementation and sustainability of case conferencing; and 3) evaluate cost-effectiveness. A pragmatic parallel cluster randomised controlled trial design will be used. Twenty Australian nursing homes will be randomised to receive either facilitated family case conferencing or usual care. In the intervention arm, we will train registered nurses at each nursing home to work as Palliative Care Planning Coordinators (PCPCs) 16 h per week over 18 months. The PCPCs' role will be to: 1) use evidence-bas...
Background People with dementia (PWD) are at risk for medication related harm due to their impair... more Background People with dementia (PWD) are at risk for medication related harm due to their impaired cognition and frequently being prescribed many medications. Few previous studies of PWD inpatients have been focused on medication safety interventions.This study aimed to evaluate an intervention designed to improve medication safety for people with dementia (PWD) and their carers during an unplanned admission to hospital. This article reports the effect of the intervention on potentially inappropriate medications (PIMs), polypharmacy and anticholinergic burden scores for PWD in the study. Methods A quasi-experimental pre-post design using an intervention site and a control site was conducted in 2017-2019, in a regional area in New South Wales, Australia. PIMs, polypharmacy and anticholinergic burden were measured at admission, discharge and three months after discharge. In addition, medication reconciliation at admission and scoring of pharmacists recommendations using severity and ...
D ementia, or ‘major neurocognitive disorder,’ is usually characterised by the progressive deteri... more D ementia, or ‘major neurocognitive disorder,’ is usually characterised by the progressive deterioration of cognitive and functional abilities. At early stages of dementia, those affected (hereafter termed patients) may experience only slight deficits in their cognitive abilities that interfere with their capacity to function in daily life. At late stages of dementia, patients may be totally dependent on carers to survive. The course of decline varies con siderably across patients and different types of dementia. The time from diagnosis to death typically ranges from two to 10 years (see Table 1).1-3 In the previous issue of Medicine Today, we outlined 14 essentials of assessment and care planning for patients with dementia.4 Here we focus on management and describe 14 practical points that clinicians can apply to patients across different stages and types of dementia. The business case for care planning and relevant Medicare item numbers are listed in the previous article. THE FOUR...
Background Dementia is an insidious and stigmatised condition, and research indicates that GPs fi... more Background Dementia is an insidious and stigmatised condition, and research indicates that GPs find communicating this diagnosis particularly problematic. Delays in diagnosis may impede optimal patient care. Little research has been published on Australian GPs' perceptions of barriers to disclosing the diagnosis of dementia. Aim To explore GPs' perceptions of barriers to disclosing the diagnosis of dementia. Design and setting Qualitative study in the general practice consultation context. Conclusion Complex issues surround the disclosure of dementia. Communicating this diagnosis remains particularly challenging for many GPs.
This study reports carer strain and coping with medications for people with dementia with an unpl... more This study reports carer strain and coping with medications for people with dementia with an unplanned admission to hospital, and it evaluates the impact of a safe medication intervention on carer coping and carer strain. This was a quasi-experimental pre/post-controlled trial that included a survey of carers about managing medications for people with dementia after discharge. For 88 carers who completed surveys, 33% were concerned about managing medications, and 40% reported difficulties with medication management, including resistive behaviours by people with dementia. Dose administration aids were used by 72% of carers; however, only 15% reported receiving a recent home medicines review by a community pharmacist. High carer strain was reported by 74% of carers. Carer comments described many issues that contributed to high carer stress, as well as their engagement in vigilant activities to maintain medication safety. Strategies that can contribute to carers managing medications an...
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