Dementia is a highly prevalent syndrome in industrial nations. In Germany, due to demographic developments, an increase of dementia patients can be expected. According to estimations, only 20% of all persons with dementia are adequately treated in Germany [1–4]. It seems that shortcomings in professional education and training, particularly among general practitioners (GPs) are one of the reasons for this deficiency in medical care [2–5]. Findings indicate that GPs frequently feel awkward about having to communicate with patients and their relatives about diagnosis "dementia" and therefore do not make a serious attempt at diagnosis [6–9]. In order to overcome these barriers, it is necessary to develop and evaluate appropriate instruments suited to sustainable supporting GPs' knowledge and competence in dealing with the dementia syndrome and therefore to improving medical care.
For this purpose, two training concepts have been developed in the WIDA-study which will be implemented in GP quality circles:
In study concept A, GPs participate in a structured case discussion in the context of quality circles. The structured discussion is prepared by the GPs in advance via internet-based learning material ("blended-learning" approach).
In study concept B, participants are instructed in a classical way with an oral presentation. A structured discussion of the subject matters follows the presentation of the instructor ("classical" approach).
Both training concepts communicate the essential points of an evidence-based guideline on diagnosis and treatment of dementia focusing on GPs. The effects of the two concepts are compared in a cluster randomized controlled study. In addition possible barriers of implementation will be identified.
The term dementia describes an etiologically heterogeneous clinical syndrome characterized by the loss of intellectual and mnestic abilities. Depending on etiology, dementia-related syndromes can be found in any stage of life. However, they generally show a continuously increasing prevalence in the 60+ age groups. While for those aged 65–69 incidence is below 2%, there is a rise to a 10–17% incidence for those aged 80–84; for those over 90 the incidence reaches 30% .
The most frequently occurring dementia-related forms are
the so-called degenerative forms, particularly dementias of the Alzheimer's type,
followed by vascular dementias due to ischemically caused destruction of brain tissue and
mixed degenerative-vascular forms of dementia.
Alzheimer's dementia tends to display no physical or neurological symptoms in the first years. Cognitive malfunctions generally manifest themselves in the form of a progressive reduction of short-term memory, orientation ability and word-finding difficulties. Complex daily tasks can no longer be accomplished. Typically, there is a creeping onset of the disease, which initially proceeds slowly. The intermediary stage is characterized by a disfunctioning of the long-term memory and the patients' ability to think clearly. Patients are no longer able to work in their vocation and cannot manage their household. Apart from this, non-cognitive disorders such as agitation, irritability, emotional instability or aggression, and even apathy and depression can occur. Moreover, a urinary incontinence (aconuresis) can frequently be detected. The late stage of Alzheimer's disease is characterized by profound intellectual degeneration and comprehensive need for nursing care due to symptoms such as complete urinary and anal incontinence, impaired movement, inability to control posture, cerebral convulsions, and swallowing disfunctionality. Dementia patients normally spend the late stages of the disease in a nursing home.
Further facts about the dementia syndrome:
Presently there are about one million persons suffering from dementia in Germany [5, 11, 12]; among them approximately 700,000 suffer from Alzheimer's disease [11, 12]. More than 200,000 new cases of dementia are reported each year, 125,000 of which can be attributed to Alzheimer's disease. Projections which consider demographic developments predict that the number of dementia patients will increase to more than 2 millions by 2050 in Germany [11, 12].
As a general rule, dementia displays a chronically progressive development: beginning with the first disease-related symptoms, the average survival period is eight to nine years. According to more recent studies, the median survival time following clinical diagnosis is 4.2 years for men and 5.7 years for women [13, 14]. A Canadian study even indicates a median survival time of just 3.3 years after clinical diagnosis .
Dementia has far-reaching consequences for both the patient and his or her relatives: Apart from the loss of autonomy and an increasing need for nursing care, dementia patients frequently suffer from malnutrition or undernourishment and an increased susceptibility to infection. Persons with dementia also display a greater risk of contracting pneumonia, seizure disorders, or pressure ulcers [5, 16]. Furthermore, there is a heightened risk of accident as well as an increased risk of becoming a victim of crime .
In most cases, negative consequences for the social environment surface quite rapidly; caregivers and relatives of persons with dementia often suffer from a high degree of physical and mental stress [5, 17].
Dementia is one of the most costly diseases [17, 18]. There are only a few current studies on the costs of dementia treatment in Germany. However, their results are comparable to those found in international studies [11, 18]. For the year 2002, the Federal Office of Statistics assumed that costs amounted to as much as € 5.6 ($ 7.3) billion, with 60% of the total costs incurred for in-patient or partially stationary care .
There are many reasons for the above-mentioned problems in the treatment of dementia. [2, 5, 20]:
∘ Either the acknowledgement of dementia is considered taboo or dementia is classified as a form of aging.
∘ Knowledge of diagnostic procedures and adequate treatment is deficient.
∘ Diagnosis mostly occurs in the advanced stages of the disease.
∘ Many nursing homes are not prepared to treat individuals with dementia and/or have a shortage of staff.
∘ People with dementia naturally have a hard time articulating their discomfort and wishes.
∘ A comprehensive therapeutic approach does not exist.
∘ Newly-developed drugs are too expensive (limited health care budgets); the effectiveness is controversially judged and therefore they are only reservedly prescribed.
∘ Further education and training programs in the medical profession are inadequate.
Perspective of General Practice
Dementia is a syndrome that typically occurs in general medicine even though the setting of general practice is only rarely considered in the literature [6–9, 21–33]. Wagner and Abholz stated:" The medical and psychosocial care of people with dementia lies largely in the hands of GPs. The GP knows the patient, his or her relatives, and the social setting. Therefore, s/he is in the best position to notice even slight changes of intellectual performance". The same publication points out that GPs – due to the lack of therapeutic consequences – do not seriously wish to diagnose the illness. Moreover, there is evidence that GPs feel awkward about having to talk with patients about such an emotionally charged diagnosis [6–8, 33]. A study carried out in Wales and England with more than 1,000 GPs found that only 52% of all respondents considered early diagnosis to be useful . A 1992 Australian study observed only marginal knowledge of dementia on the part of primary care practitioners . In Germany, GPs frequently diagnose dementia only when the need of nursing care already exists .
A summary of various studies shows that GPs either lack knowledge and professional skills in the treatment of dementia or do not make use of their existing knowledge when treating their patients.
Field and Lohr define clinical practice guidelines (CPGs) as "systematically developed decision support regarding the adequate medical modus operandi for special health-related problems". Moreover, the following aspects are relevant :
Guidelines present the consensus reached by several experts from diverse faculties and working groups on certain medical approaches (if possible by considering the patients' view).
Guidelines are scientifically founded recommendations for action.
Methodological instruments for creating guidelines are (among others): consensus conferences, Delphi analyses, therapeutic studies, and meta-analyses.
Guidelines are orientation aids in the sense of "guidelines for action and decision making". In some cases divergence from the guideline is possible or even essential.
Guidelines are regularly checked and updated if necessary.
Evidence-based medical guidelines are considered to be the central implementation tool for evidence-based medicine (EbM). In this capacity they can also serve as a basis for further professional education and training [39–43]. Various strategies for implementing guidelines, including electronic guidelines, have been evaluated [44, 45, 80]. However, no strategies have been identified which, in all circumstances, will result in a successful implementation of new knowledge or in the desired behavioral changes [46, 47]. A Health Technology Report (HTA) published in 2004 states that " [...] despite 30 years of research in this area, we still lack a robust generalisable evidence base to inform decisions about strategies to promote the introduction of guidelines or other evidence-based messages into practice" .
Continuing medical education and knowledge translation
The German Society for General and Family Medicine (DEGAM) has identified general deficits in the professional training of GPs. A statement stresses: "From the point of view of general practitioners, the current situation in the field of further education is a discontenting one, characterized by outdated didactical methods, insufficient consideration of individual learning requirements, and an overemphasized focus on specialized disciplines as well as on the interests of the pharmaceutical industry" . Worldwide there are efforts to improve the further education of GPs. Studies indicate that roughly one third of all changes in clinical practice are related to further education and training . In this regard, a shift from "continuing medical education (CME)" to "continuing professional development (CPD)" can be detected [51–55]. Professional development is characterized by methodological variety and a diverse curriculum which attempts to consider the various preferences and types of learning. The methods also include the formative or summative assessment of acquired competences. "Stand-alone" CME programs seem to be less successful than programs with multi-modal interventions [47, 56–58].
The "new media" are clearly gaining relevance within standard curricula. Electronic programs are being used for knowledge translation as well as knowledge assessment [59–63]. Data suggest that online-training may even result in a change of the GPs' behavior [62, 64]. Problem-oriented learning via internet may also provide another promising option . If students are accustomed to this form of learning, positive experiences made during the university education may be transferred to continuing education [66–68].
"Blended learning", which blends the features of classical or ex-cathedra teaching with those of e-learning, marks the threshold to a new concept of further education in the field of medicine [60, 66, 69, 70]. "Blended learning is based on the recognition that a learning system based purely on electronic learning can only offer limited efficiency. Therefore blended learning combines e-learning with standard teaching methods or, rather, various teaching/learning media. Course content is conveyed face-to-face as well as via WBT (web based training), CD-Rom or print media. Learners are not bound to a specific medium. Instead they have the option of choosing a medium with suits their individual learning preferences. Thus blended learning involves the merging of e-learning/teaching with classical forms of learning/teaching, with the goal of providing an optimal overall concept" .
Strategies for applying the relatively new tools of e-learning to medicine have yet to be developed . In order to do so, the needs of the users should first be analyzed. In addition, it should also be clarified what they want to learn and how they want to learn [8, 38]. Suitable instruments need to be developed for this purpose. Only then we will be able to develop efficient (online) CME and CPD programs that implement sustainable, evidence-based guidelines respectively new knowledge and lead to an improvement of medical care. In this respect, a large need for research has been identified.
As a first step, it is important to clarify how doctors learn and make sure that their knowledge and skills are up-to-date. The following questions serve to determine this [40
"Which educational interventions work in which situations?"
"What factors promote the adoption of guidelines?"
"Which factors inhibit their adoption?" (Authors note: barrier analysis)
"What type of physician learning happens at what stages?"
The goal of the WIDA study is to compare the blended-learning concept with conventional training methods in order to assess whether the new concept can lead to an improved knowledge translation of dementia-related methods of diagnosis and treatment.
WIDA seeks to achieve the following goals:
Creation of two different training concepts for transferring evidence-based knowledge on dementia to participants of GP quality circles (randomization on the level of the quality circles)
Testing of contents and didactic materials with a large number of GPs in terms of knowledge gain and (to some extent) behavior-related changes
Identification and description of
∘ content-related barriers, for example GPs' reluctance to deal with the dementia syndrome
∘ technical barriers, for example the chosen media or e-learning tools
The study results provide insights into how GPs can best be trained in an evidence-based and decentralized way.