[The practice guideline 'Diagnosis and pharmaceutical treatment of dementia'].
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Activities of Daily Living↗
Biomedical subjects
J De Lepeleire
Publications and source records attributed to J De Lepeleire.
[How do the elderly function? A study from the general practice].
UNLABELLED: Problems with instrumental activities of daily living are important in the caring for elderly people, in general practice as well. Impairment in activities and instrumental activities of daily living may be important indicators for early dementia. This study explored how people aged 65 years and over in general practice are performing on four instrumental activities of daily living. METHOD: General practitioners screened all people, aged 65 years and over, and meeting the inclusion criteria, they met during a period of one month. Personalia, instrumental activities of daily living and cognitive functioning were registered. RESULTS: Twentytwo general practitioners included 1003 persons, with a mean age of 75 year. The majority of this group (81.6%) was rather autonomous. The main cause of functional impairment were transport problems. Cognitive functioning and functional loss were correlated. CONCLUSION: Elderly people in general practice function better than is generally assumed. This phenomenon has important consequences for training and functioning of GPs as to the evaluation of activities of daily living. The fundamental role of IADL assessment therefore needs attention in the professional development of GPs.
Activities of Daily Living↗
A combination of tests for the diagnosis of dementia had a significant diagnostic value.
OBJECTIVE: To study the diagnostic parameters of a number of instruments for a diagnosis of dementia in general practice and the added diagnostic value of these tests. STUDY DESIGN AND SETTING: Cross-sectional diagnostic research in general practice. PARTICIPANTS: 152 persons aged 65 plus. The Mini-Mental State Examination (MMSE), the Clock Drawing Test, the ADMP scale, the Timed Up and Go Test, the Extrapyramidal Sign Scale, the Behavior Observation Scale, the Poon-Baro-Wens computer battery, and the Cognitive Drug Research Computerized Assessment System were evaluated against the Dutch version of the Cambridge Examination for Mental Disorders of the Elderly (CAMDEX-N). Diagnostic characteristics were calculated with their 95% CI. Using forward stepwise logistic regression analysis, a model was built with CAMDEX-N as the dependent variable and the tests under study as independent variables. Area under the curve was the main parameter for the comparisons. RESULTS: The main diagnostic gain results from age and ADMP, followed by the Clock Drawing Test. Subsequent addition of the MMSE and computer tests results in modest additional gain only. The final model including five tests has an area under the curve of 0.95. CONCLUSION: Sophisticated neuropsychological computerized tests have little added value in the diagnostic work-up of dementia in general practice. Basic clinical tests used in an appropriate sequence can be very valuable in establishing the diagnosis of dementia.
Age Distribution↗
Understanding obstacles to the recognition of and response to dementia in different European countries: a modified focus group approach using multinational, multi-disciplinary expert groups.
Experts from eight European countries (Belgium, France, The Netherlands, Ireland, Italy, Portugal, Spain and the United Kingdom) and the disciplines of clinical psychology, general practice, geriatric medicine, old age psychiatry, medical sociology, nursing and voluntary body organisation met in 2003 to explore obstacles to recognition of and response to dementia in general practice within Europe. A modified focus group methodology was used in this exploratory process. Groups were conducted over a two-day period, with five sessions lasting 1-1.5 hours each. An adapted nominal group method was used to record themes arising from the group discussion, and these themes were used in a grounded theory approach to generate explanations for delayed recognition of and response to dementia. The overarching theme that arose from the focus groups was movement, which had three different expressions. These were: population movement and its consequences for localities, services and professional experience; the journey of the person with dementia along the disease process; and the referral pathway to access services and support. Change is the core issue in dementia care, with multiple pathways of change that need to be understood at clinical and organisational levels. Practitioners and people with dementia are engaged in managing emotional, social and physical risks, making explicit risk management a potentially important component of dementia care. The boundary between generalist and specialist services is a particular problem, with great potential for dysfunctionality. Stigma and ageism are variably distributed phenomena both within and between countries.
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Disclosing the diagnosis of dementia: the performance of Flemish general practitioners.
BACKGROUND: This issue of whether or not, how and when patients should be told of the diagnosis of dementia remains a matter for discussion. Recent data confirm that the patient is told of the diagnosis in only 40 to 55% of cases. We therefore studied the performance of Flemish general practitioners (GPs) in this area. METHOD: A postal questionnaire, based on that prepared by Johnson et al., was sent to a random sample of 1000 Flemish GPs, out of a total of 7000. RESULTS: A total of 647 answers were returned, of which 521 were eligible for analysis (response rate 60%). Thirty-six percent of these 521 GPs always or usually disclose the diagnosis, while 37% provide information about the prognosis. Most doctors (75%) see benefits in disclosure, particularly as regards planning care, providing treatment and encouraging a good doctor-patient relationship. Only 61% of respondents present an appropriate differential diagnosis. DISCUSSION: The results obtained from the Flemish GPs are similar to those of other known studies. A detailed analysis of the reasons for and the benefits of disclosing the diagnosis reveal a less reluctant attitude than could be inferred from the rough data. GPs pay a great deal of attention to the patient's feelings, experiences and ability to cope and to the proper timing of their information. However, intensive educational projects have to be set up in order to stimulate a more etiologically-oriented diagnosis and to improve the quality of the process of disclosing the diagnosis of dementia.
Attitude of Health Personnel↗
The diagnostic value of IADL evaluation in the detection of dementia in general practice.
It is assumed that general practitioners can make an important contribution to the diagnosis of dementia. One of the used strategies comprises an evaluation of the Instrumental Activities of Daily Living (IADL). There are contradictory data on the value of this strategy. During one month, 21 Flemish general practitioners evaluated the IADL capacities of all subjects older than 65 years with whom they had contact. Subjects with dementia and/or living in a residential home for the elderly were excluded. Housing and living conditions, medication use and IADL were registered. The general practitioner formulated a clinical evaluation. All subjects with an IADL score > or = 1 and a random sample from the group IADL = 0 underwent a Mini Mental State Examination. Subjects with an IADL score = 4 were referred for neuropsychological and specialist examination. The average age of the 1003 registered subjects was 75.1 years (SD = 6.8). A large majority of them (85%) were totally independent. There was a large discrepancy between the family's and the patient's judgment on the presence of memory problems. There was an inverse correlation between the IADL and MMSE: when the IADL score increased, the MMSE score fell. The diagnostic value of the IADL for the diagnosis of dementia with Camdex-N as a reference standard could not be evaluated because the number of tested subjects was too small. Against the MMSE, sensitivity was 0.81 (SE = 0.03), and specificity was 0.48 (SE = 0.05). The evaluation of the IADL activities had some drawbacks as a detection method for dementia but the use of IADL data may still be clinically valuable in general practice. The correlation between the general practitioner's judgment and that of the specialist was very good. This study showed that the use of the IADL score might change the general practitioner's diagnostic judgment. Furthermore this study confirms the existence of a major threshold for the referral to a specialist of patients with suspected dementia by general practitioners.
Activities of Daily Living↗
Placements in psychiatric institutions, nursing homes, and homes for the elderly by Belgian general practitioners.
This research is an epidemiological study of long-term care facility admissions to various types of institutions (homes for the elderly, nursing homes, psychiatric institutions) during 1994 in Belgium. Data were obtained from a network of 143 general practitioners, which acts as a reliable surveillance system for health-related data. For every patient who was institutionalized, physicians were asked to record the following information: (1) type of institution in which the patient was placed; (2) medical conditions; (3) current living situation; (4) reason for institutionalization; (5) length of the waiting time for institutionalization, and (6) whether or not the patient was hospitalized prior to the institutionalization. The overall incidence for institutionalization among older patients was 1%. The most common medical conditions upon placement were functional impairments and dementia. Over half the patients lived alone just prior to the placement and family members made the majority of requests for placements. Compared to placements in other types of institutions, those to psychiatric facilities were more likely to be 'urgent' and waiting times for admission to these institutions were shorter. Over half of all placements were preceded by an admission to a medical hospital. Few placements (16%) were made with the consultation of home care services. Finally, in about two thirds of the cases, patients were cared for by their general practitioner while they were institutionalized.
Adult↗
Revealing regional differences in the institutionalization of adult patients in homes for the elderly and nursing homes: results of the Belgian network of sentinel GPs.
OBJECTIVES: The aim of this study was, firstly, to determine the number of institutionalizations in homes for the elderly and nursing homes and, secondly, to learn about regional differences in the placement procedure and the pre-existing problems and diseases. METHODS: Data were recorded during 1994 by the 143 GPs of the network of sentinel practices, which is representative of Belgian GPs. All placements of adult patients in homes for the elderly and nursing homes were registered. RESULTS: During 1994, Belgian sentinel GPs placed 297 patients in a nursing home or a home for the elderly. Most of them were women and patients who lived alone. At the time of institutionalization, motor function impairment and dementia were the most common diseases. The institutionalizations were motivated mostly by a need for assistance with daily living activities and nursing assistance. An interim hospitalization was necessary in 60% of all institutionalizations. Two-thirds of all patients were on a waiting list. The average length of these waiting lists was shorter in the southern (Walloon) region than in the northern (Flemish) region. Home care services were consulted in 16% of all institutionalizations. In the southern region, home care services were consulted more often than in the northern region. CONCLUSIONS: Motor function impairment and dementia were the most common pre-existing impairments. Placements were often hampered by long waiting lists and interim hospitalization. In the southern region, waiting lists were shorter and home care services consulted more often. Some placements could be avoided or delayed by a better organization and promotion of the possibilities of professional home care services.
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Diagnosis and management of dementia in primary care at an early stage: the need for a new concept and an adapted procedure.
Diagnosis of dementia in primary care is both difficult and important. The recommendations by several authors to improve the diagnosis of dementia by general practitioners are important, but insufficient. It is argued that perhaps the disease concept in itself is a cause of confusion for clinicians. Primary care physicians need an adapted procedure, gradually leading to the final diagnosis of dementia. It has to be a stepwise labelling strategy, using global descriptions and non-disease specific labels in the beginning, ending up with well-defined disease criteria. In this process, there is circularity: previous diagnoses have to be kept in mind because symptoms and signs may gradually change during the progression of the disease, leading to reconsideration of previous deleted options. To frame this properly, the primary care physician needs to adopt a broad "frail elderly" geriatric concept. Implementation of this concept not only helps the diagnostic process, but also stimulates the care for dementing patients and their caregivers. Relevant arguments for early diagnostic involvement of primary care physicians can be put forward on condition that a new concept, adapted procedures and adapted instruments are used.
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The early diagnosis of dementia: triggers, early signs and luxating events.
BACKGROUND: In order to make it possible and feasible that GPs diagnose dementia at an earlier phase than usual, it is important to know what elements in the available information on the patient and the family may trigger the diagnostic hypothesis of dementia. METHOD: By qualitative research, the stories of family members of dementia patients, according to DSM-III-R criteria, were analysed. RESULTS AND CONCLUSIONS: This work produced the following hypotheses: disturbances in functioning at work and ADL-IADL disturbances, the seeking of the carer's support and emotional problems-in addition to the more classical memory problems-are early signs and may be essential triggers for the GP to consider the possibility of an emerging dementia. Change of medication, narcosis, loss of the carer and hospital admission are luxating moments for the sudden appearance of symptoms and disturbances caused by dementia. Further research should be carried out to develop instruments for the early detection of dementia that step across neuropsychological tests and are feasible for daily use in a primary care setting.
Dementia↗
Cardiovascular risk factor distribution above the age of 75 years in a Belgian community.
An elderly Belgian population group anno 1986 consisting of 53 men and 110 women above the age of 75 years with a mean age of 80 and 81 years, respectively, is characterized by relative obesity and low diastolic blood pressure, both in men and women. The SBP/DBP ratio is 1.91 in men and 1.88 in women. HDL-cholesterol levels are relatively high in men. Women still have slightly higher HDL-cholesterol levels than men, the difference between women and men being 3.4 mg/dl. In both sexes HDL-cholesterol correlates negatively with body weight. The 24-hour urinary sodium/potassium ratio is 2.9 in men and 2.5 in women. Factors significantly related to diastolic blood pressure in a multiple regression analysis included being on a low-salt diet, the level of 24-hour urinary potassium excretion and of 24-hour urinary creatinine excretion in men, and body weight, heart rate and the level of 24-hour urinary calcium excretion in women. It may be concluded that significant differences exist between the distribution of cardiovascular risk factors in older compared to middle-aged subjects.
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