Identification and care of patients at risk of post-stroke dementia

PhD ThesisStroke can directly cause cognitive difficulties but also increases the risk of future dementia. There is often less focus on these consequences during standard care, which tends to concentrate on physical function. The seven publications described in this thesis focussed on four aims, which were to: a) describe the impact of cognitive difficulties post-stroke over time b) understand patient and professional views regarding current care for stroke-survivors with memory problems c) describe the acceptability and accuracy of dementia risk prediction models following stroke d) understand healthcare professional views about how to meet the cognitive needs of stroke-survivors. A mixed-methods approach was used to address these aims including: a) A systematic review of studies found there was a tendency towards cognitive decline, but this was not consistent as patients post-stroke can stabilise or even recover; b) Semi-structured interviews with i) stroke-survivors reporting memory difficulties and their family carers and ii) primary and secondary care professionals consistently reported clear gaps in care for stroke survivors with memory deficits; c) Harmonisation of international stroke cohorts to externally validate existing dementia risk prediction models which have not validated well in stroke populations. Further, in the qualitative interviews, patients, family carers and healthcare professionals identified challenges to their implementation; d) A national electronic-Delphi survey found that stroke clinicians believe assessment of post-stroke cognition needs better integration into services with clarification of when and where this should be done to streamline access. The gaps in current services mean that the support available to care for and identify those at greatest risk for dementia is lacking. Patients and carers should be offered information about the long-term cognitive consequences poststroke. If required, they should be encouraged to seek assistance in the community with the aim of being directly referred back into specialist services for assessment and intervention.NIH

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 lacks, prompting calls for the promotion of academic opportunities in primary care. Aim: To identify potential barriers and facilitators amongst 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, that 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 1 in five trainees reporting intentions to include research in their career, only 1% would undertake a solely academic career. Medical school region is 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 is crucially reflected by responses from trainers. This study identifies the need for LCRN’s to assist with training in research mentoring and skills, funding opportunities and to develop resources to promote research in primary care

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

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

Development of an audit toolkit for use in resource-poor countries

Dear Editor,We were interested to read the international series (Education for Primary Care, 2015, volume 26, No. 5) reporting on papers illustrating innovative strategies to ensure the primary care workforce is supported in both clinical and research training in Rwanda. There is a clear emphasis on two aspects from this series that particularly appeal to General Practitioners of the future: international primary care and academia.Academic primary care is an ever-expanding subspecialty within General Practice (GP) [Citation1] and all GPs naturally utilise research skills when assessing up to date available evidence during counselling or deciding on best treatments for our patients. Similarly, there is an ever-increasing demand for international primary care experiences particularly within Vocational Training Schemes as evidenced by the Global Health Fellowships, which are available this year.[Citation2] These fellowships allow GP trainees to take an Out of Programme Experience (OOPE) within training. OOPEs build on the existing two-week exchanges available through the Vasco Da Gama Movement’s Hippokrates Exchange, which is available to Associates in Training (AiTs) and First5 GPs [Citation3] through the Royal College of General Practitioner’s Junior International Committee.[Citation4] It is clear that there will also be individuals who are keen to pursue both international primary care and academia.To explore what support individuals working abroad may need we performed a survey of GPs who had previously been on an OOPE. We surveyed 25 GPs from the London Deanery and had a response rate of 20% (n = 5). OOPEs were conducted in South Africa, India, Zambia and Sierra Leone. Two respondents had conducted clinical audits and one had conducted research during their placement. Perceived barriers when conducting any form of academic activity included lack of time, support and experience as well as lack of staff engagement. However, it was clear that the majority of GPs did feel that host organisations would benefit from clinical audits and/or research. Respondents also requested further training particularly in audits with for example an audit toolkit. To ensure that future AiTs and First5s are well supported when conducting audits on OOPEs the Junior International Committee have put together an audit toolkit, which provides useful resources and highlights several issues unique to performing audits particularly in resource poor countries including: (1) why audits are necessary in resource poor settings (2) what challenges GPs may encounter when attempting to conduct an audit (3) resources that GPs could access to assist their audit experience (4) examples of successful audits, which could be used as a template for future audits.Although research will be difficult to commence, maintain and complete due to perhaps limited time and resources in developing countries, academic activities such as audits could be useful for both the individual performing the audit and the department he/she is contributing to. More support will be needed prior to commencing these exchanges or OOPEs and we hope our simple audit toolkit will be of benefit to interested GPs

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

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