Background
Study setting and aims
Methods
Recruitment and participants
Data collection and analysis
GPs
Community health care workers and community representatives
Data analysis
Results
GP demographics
Community forum demographics
Qualitative data
Theme 1: GPs’ attitudes towards the diagnosis and management of cognitive impairment and dementia
Sub-themes | Example excerpts highlighting sub-theme meaning | Excerpt number relating to text |
---|---|---|
Assessment of older patients for cognitive impairment | ||
“Why do I do it? Just part of your annual check-up, part of your sort of annual assessment. Everybody over 75 gets it once a year, and you do like cognitive assessment, whether or not they might have had any falls, you know, what’s happening at home, social assessment, sort of a general health assessment, basically an assessment of their nutrition.” – 2GP | 1.1a | |
“Not as a screen, but I do see a lot, you know if there’s a trigger factor for it, like patients might have forgotten their appointment or they don’t seem to be taking their medications properly, or their spouse comes in with them and mentions trouble. Yeah, so I don’t have a system for running a cognitive screen on people.” – 12GP | 1.1b | |
‘Patients come in and there are multiple complex [problems] these days and people want me to do ten problems in 15 min, so there’s not time.’ – 3GP | 1.1c | |
Perceptions on the utility of a diagnosis of MCI or dementia | ||
‘Well I think the most important thing is to explain to the patient what’s going on with them so the patient is aware of the fact that you believe there’s a process taking place in their blame that is the reason why they’re having the symptoms they’re having, and explaining that to their family as well, so then you can treat them most effectively to manage the various aspects of the dementia.’ – 10GP | 1.2a | |
‘It gives a name to what’s happening to them if they’ve noticed symptoms and a justification for any deficits they’re noticing. It also gives them time. If it’s mild cognitive impairment they’ve got time to put in strategies and to make some plans for the future in an informed way, which they can’t if it isn’t addressed.’ – 11GP | 1.2b | |
‘And it certainly can be somewhat distressing for some people to feel that their mind’s not working as well as it should and certainly with mild cognitive impairment it does seem as though some people may show signs of that but not necessarily go on to dementia, and also that some processes are much slower or faster than others, so I find it a little bit of a vexed question when it seems at the early stages.’ – 6GP | 1.2d | |
‘It is difficult because we don’t have that many treatments that are very effective, and so that it’s hard to diagnose something and then say “sorry, we haven’t got much we can do for you.”’ – 6GP | 1.2e | |
Assistance with diagnosis and management of dementia | ||
‘I personally wouldn’t want to diagnose myself, I would want them to have like more testing and at least a CT scan in secondary care to try and make the diagnosis.’ – 9GP | 1.3a | |
‘Yes, yeah. I think I feel that, I think I can make the diagnosis myself but – because it’s usually fairly clear when you do the assessment, but just for more, again for more detail on the cognitive scale … and also takes a little bit more time and specialists will have that.’ – 3GP | 1.3c | |
‘We do require the services of specialists under the Commonwealth system requiring specialists to institute treatment which is pharmacological, pharmacotherapy for dementia, so clearly we need to refer for accessing treatments for dementia, pharmacological treatments that is.’ – 10GP | 1.3d | |
‘Well dementia definitely, yes. If they’ve got dementia I do get that diagnosis confirmed by a specialist because I think that’s very important. With mild cognitive impairment well yes, I do yeah. Well yes, I make that diagnosis, yes.’ – 21GP | 1.3e | |
‘Yeah, I think the management is the problem with – because obviously these people need a lot more support. I think the places they could go to that deal specifically with that, it would be much better, yeah.’ – 2GP | 1.3f |
“Yes, there’s no time and I think lack of public interest in it, and also probably personal fear about a diagnosis like that to be honest. I mean they’re probably the two main barriers, three main barriers.” – 3GP (excerpt 1.1d)
“I would definitely say so because early diagnosis means that they have more time to sort out their affairs, they have more time to manage the condition if it could be managed or slowed down, so all in all I think early diagnosis would definitely be beneficial.” – 9GP (excerpt 1.2c)
“I don’t personally make the final diagnosis. I’m much more comfortable kind of getting – like you know, if there’s a strong suspicion it’s dementia and usually I mean usually I’m right, I usually would just go to the geriatrician to make the final diagnosis just because it’s such a, it’s such a big diagnosis to make, it’s got a lot of ramifications, and I’d rather have like a specialist kind of give the final say about that, yeah.” – 4GP (excerpt 1.3b)
Theme 2: perceptions and attitudes towards local dementia resources and services
Sub-themes | Example excerpts highlighting sub-theme meaning | Excerpt number relating to text |
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Understanding of available resources and services | ||
Resources | ‘I think like diagnosis there are things like screening tools, MMSEs and GPcogs and those kind of things. In terms of like general management resources, I mean there are of course like the referral pathways that we have like geriatricians, for driving assessments there’s actually the RMS can do it, which is good. There’s the home – like there’s like the ACAT assessment and then the home care, like the HACC packages, like each, whatever each thing.’ – 4GP | 2.1a |
‘Yeah, so I think the thing with resources, I think it’s sort of more general and more generic resources. I think there are some good stuff that’s available already and I don’t really think we should sort of reinvent the wheel both internationally and in Australia. There’s some good sort of general resources.’ – 22GP | 2.1b | |
Services | ‘There’s lots of programs, lots of each programs and different programs which really cover a lot of things. There’s a centre of excellence at Hammondville. There’s Carrington and the other providers in the Whiddon Group. There’s Broughton House has got a really good dementia day care as well as Myrtle Cottage. The aged care assessments, there’s Alzheimer’s Australia, there’s speech therapists, podiatrists, physios, doctors and specialists. The people on the transport are really wonderful, on the train and the bus and the taxi. They’re excellent with wheelchairs and so kind. And there’s Meals on Wheels.’ – 14CF | 2.1d |
‘Look, I’m actually really happy with what we’ve got, which is a secondary service that we can refer to’ – 19GP | 2.1e | |
‘Q. Are you familiar with any dementia specialised services in the local area? A. Not in the local area here, no.’ – 9GP | 2.1f | |
‘In my case I don’t have the – I don’t have any qualms in referring someone if I think that they need to be referred [to a dementia-specialised service].’ – 10GP | 2.1 g | |
‘Yes, there are a number, and often it’s the person themselves that doesn’t want referral. A lot of people are very independent or they don’t really want to know. If there’s anything happening they just want to soldier on, and so that often does stop us referring, or if we do refer they are not very keen to have any services involved.’ – 6GP | 2.1 h | |
Barriers to current resources and services | ||
Resources | ‘We would like accessible information in a format that all of us can use.’ – 14CF | 2.2a |
‘I think some resources to help people navigate their way into receiving services or through that, sort of follow that pathway and receiving services and getting some direction with that I think is useful. So some more resources along those lines to help people understand the website, how to use it and you know, how to access services.’ – 10GP | 2.2b | |
‘I think if once a diagnosis is made, I think it would be useful for them to be given a list of various common things that they might face and who they might be able to contact to get more help with regards to that.’ – 9GP | 2.2d | |
‘We don’t have enough resources now.’ – 15CF | 2.2e | |
Services | ‘Cost effective specialists, because specialists cost a lot of money and there’s a long waiting list within the actual health system.’ – 14CF | 2.2f |
‘A great need for all of those things, trying to navigate – yes, everything. So as you said, education, allied health, you mentioned psychology but yeah, allied health, legal. All of those things are really, really needed, and at the moment you can access them a bit but they’re fragmented all around the place and not easy for people who are trying to – you know, may not be able to drive either, not being able to get to. So in a single site would be wonderful.’ – 11GP | 2.2 g | |
‘We find that with all of the hospital or area health service-based services, they may be there but we’re often not informed as GPs on how to actually access them, and then they often change the access process or the requirements. Nobody actually tells us.’ – 11GP | 2.2 h | |
‘I think the issue with dementia-specific services is that when My Aged Care came in they decided not to make services dementia-specific, so whereas you had dementia monitoring services and those sorts of things, they’ve become just social support services.’ – 16CF | 2.2i | |
‘I might include some of the past comments, but we’d like to see more skilled workers who have specific training in dementia.’ – 14CF | 2.2j | |
What resources and services should focus on | ||
Resources | ‘I think education is very helpful for – to educate the carers as well as for patients about what’s going on.’ – 10GP | 2.3a |
‘There needs – I mean we’re going back to the putting things in newspapers, but we’ve got to do whatever we can to remove the stigma of the word ‘dementia.’ If it’s out there in the community and generally talked about then I don’t think there’s quite such an issue to get somebody diagnosed. I mean if it’s as well-known out there as cancer is or any of those other sorts of things then there might be a little bit more – or little bit less resistance from people.’ – 16CF | 2.3c | |
‘Someone else comes in, either is not aware or doesn’t realise polypharmacy is bad and get yet another drug and another drug, and I’ve seen as many as five different antipsychotics, mood stabilisers and antidepressants for really the same behaviours.’ – 15CF | 2.3d | |
Services | ‘There’s not enough respite full stop in the area. And carers and also working carers support, there’s no support there for us because we work while support groups are on.’ – 14CF | 2.3e |
‘I suppose sort of at the more pointy end, so for people who are having fairly severe dementia, particularly with sort of behavioural challenges as well for the family, practical advice and support for family in managing those behaviours.’ – 22GP | 2.3f |
“There just seems to be so much information out there and we deal with so many different types of illnesses in general practices, and we have guidelines and pathways for every different one. It’s often hard to keep them in your head certainly, and so I don’t know whether something could be put on maybe Health Pathways1 or something that we can access easily and know where to look.” – 6GP (excerpt 2.1c)
“One number. That’s one, just one phone number. It’s too difficult for elderly people to navigate their way through the maze of aged care.” – 15CF (excerpt 2.2c)
“In the beginning stages, we feel that it’s family members who have to refer to the GPs before they get any sort of diagnosis at all, and it would help if we knew a bit earlier what to look for. People who are on their own feel that they have to work really hard to get any support because they don’t really know where to go. It’s often hidden from GPs unless relatives or very close friends speak of what the problems are. Some of these people in the beginning stages can hide it very well, and we do need an assessment criteria in our homes when we’re talking to our friends, so oh yes, perhaps I’d better have a look at that or be referred for that.” – 14CF (excerpt 2.3b)
“We’d like to bring back case management with guided referrals, and case managers to do complex care plans so that it’s not the onus of the carer to try and navigate their way around services that should be. A case manager that takes that concern off the carer and helps them with guided referrals.” – 14CF (excerpt 2.3 g)
Theme 3: expectations for a new memory clinic
Sub-themes | Example excerpts highlighting sub-theme meaning | Excerpt number relating to text |
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A new memory clinic could optimise patient care | ||
‘I’m not sure what there is in terms of provision of services. I know that there’s – there are some day centres around and suchlike things, and there are some things available via packages, but just having – either having the resource from the local area health to tell us what is available and where it is would be really helpful because we just don’t – haven’t had any communication for a very long time about what there is and how to get to it.’ – 11GP | 3.1a | |
‘They can go in there and we never hear anything again and there’s no – there’s a lack of communication. The community is very one-sided you know, like you’re involved initially as a patient and then we hear nothing back about what has been done or whatever … I think that anything that’s going to be successful I think will require you know engaging with GPs and communication with GPs. I think that’s really important so that, you know.’ – 2GP | 3.1b | |
‘I think if it has precise and as much information that they can give about the process and everything would be useful, and just to keep us informed about how things are progressing and when to expect these things to start, so information transfer would be useful at this stage, yes.’ – 9GP | 3.1c | |
Expected services provided | ||
Specialised diagnostic services | ‘To a memory clinic, I support what I would use a memory clinic for … is for there to be a quite clear and definitive diagnosis. So if it is dementia, clearly dementia, and hopefully some information about – and prognosis as well.’ – 10GP | 3.2a |
Rapid access to care and case management | ‘I suppose if you want to prioritise them, rapid access would probably be top of the list, and then certainly case management’ – 23GP | 3.2b |
Allied health | ‘The allied health as well, I think that would be helpful in terms of like getting the most out of it.’ – 13GP | 3.2c |
Support groups | ‘I’m thinking that rather than counselling, probably more support type groups might be more useful for carers and patients and gender assessing for groups for patients. That sort of support group type counselling rather than individual counselling I think.’ – 2GP | 3.2d |
Expected features of the clinic | ||
Easily accessible | ‘We also feel that the main building for the memory clinic needs to be extremely accessible, it needs to have parking, it needs to be accessible by public transport.’ – 14CF | 3.3c |
Culturally sensitive | ‘I think that if there were a local service, I’d feel more confident to send them to a local service that I know has also a multicultural sort of staffing or approach because yeah, the people that are most like hmmm are people who – English is their second language, they have a tendency to minimise their symptoms and sort of get on with things, so I would be less likely to send them to a clinic that I felt was just going to see them like a regular patient as opposed to a clinic that was like yeah, also we have people who can like you know connect on that like cultural and language level.’ – 13GP | 3.3d |
Barriers to the clinic | ||
Accessibility | ‘Because that’s why I’m thinking that you know, if there was like a pick- up community bus thing that picked all these people up to go to these services, it would be easier I think.’ – 2GP | 3.4b |
Awareness of the clinic | ‘So they wouldn’t be able to – I suppose another barrier is that GPs have no idea about this clinic. They have no idea, they don’t know anything about it so they’re not going to refer.’ – 15CF | 3.4c |
Referrals and costs | ||
Referral process | ‘You know, something that’s fairly quick so that I know it’s being organised and the patients will be seen’ – 1GP | 3.5b |
‘A pro forma, yeah, so that you kind of – sort of you kind of can narrow down what information you need from us, right, so it’s easier, and then we know what you want so we can write it down.’ – 5GP | 3.5c | |
‘In this day and age a lot of people probably like to email or fax, or occasionally some people like faxing, sending the referral to the specialist.’ – 10GP | 3.5d | |
Referral criteria | ‘By the time you get to severe they’re often no longer you know, in general practice area because they’re more in a nursing home. So mild to moderate for diagnosis and management, particularly when they’re out in the community. There’s such a great need.’ – 11GP | 3.5f |
‘I think anybody with memory problems. It’s a memory clinic isn’t it?’ – 21GP | 3.5 g | |
Cost | ‘Most people at that stage are not financially well off, so if it was bulk billable or covered by some sort of fund it would be very helpful.’ – 11GP | 3.5 h |
“Okay, so it’s the ability to have good access to diagnostic services and treatment, early treatment for those patients that require it started, and there would also be – obviously education is extremely important always for the carers as well as for patients, and I think the ability to link into community services is part of that, but it’s sort of broader than just education, it’s more specifically giving the patients and the families a good idea of what is available online as resources as well as locally the various resources that are available.” – 10GP (excerpt 3.2e)
“And then in terms of what should be on offer, obviously having a clinician if we’re thinking about diagnosis side of things, but even having some sort of plan in terms of prevention to make it seem – I mean in a true multidisciplinary service, things like having a speech path review or having an OT or physio, having those kinds of – a one stop shop type arrangement would be highly beneficial.” – 7GP (excerpt 3.3a)
“I think at the very beginning people don’t want to hear any of the information that we have, but if we can connect that key person at that point and say this is your go to person and these are the things that you should be doing and outline them, I think that that will be – when they take it all in and it overwhelms them, at least they have that key person that they say this is my contact, this is my link at the clinic to support them” – 16CF (excerpt 3.3b)
“Access to public transport, so if you’ve got people who are in those outlying areas, being able to access this service is a real issue.” – 14CF (excerpt 3.4a)
“It’s basically to try and get everything done under one roof and sort of be given what the thought process is, what’s the outcome of it, all in one place and given a sense of direction, and it will mean that the patient is not running around and getting a bit confused with where things are that go and with what. So I think overall in terms of patient care I think that will definitely be useful.” – 9GP (excerpt 3.5a)
“I think we’d be looking at patients with mild to moderate because we want to pick people up and we want to have them appropriately investigated and with access to treatment that’s there when they need it. So you know, we don’t want to wait until they’re moderate to severe, we want them to be still managing in the community at you know whatever we can optimise their level of functioning is.” – 10GP (excerpt 3.5e)
Discussion
Conclusions
(1) Services and resources: (a) Specialised diagnostic services promoting early and definitive diagnoses (b) Rapid access to care via brief referral processes and short waiting lists (c) Case management via a key worker (d) Access to allied health providers (e) Support groups for patients and carers (f) Links to community services (g) Medico-legal assistance (h) Advance care planning (i) Psychological support including counselling (j) Educational resources (k) Provide or refer to an outreach team (e.g., Community Geriatrics Service) (2) Features: (a) One-stop-shop (b) Multidisciplinary team (c) Easy referral process (particularly via fax or email) (d) Focus on improving integrated care through clear communication with GPs and stakeholders (e) Easily accessible (public transport, sufficient parking, free shuttle bus) (f) Culturally sensitive via multicultural and/or bilingual workers (g) Research participation opportunities including clinical trials (h) Affordable (i) Continuity of funding |