Professional Practice

A diagnosis of dementia almost inevitably moves a person into the medical and health care domain at some point and the person will certainly deal with many professionals on their journey. An increasing body of work exploring many different aspects of professional practice has emerged in recent years. There is considerable cross over between this area of the review and the sections on assessment and diagnosis, the acute environment, long term care and palliative/end of life care, so it would be advisable to also consider papers in these sections.

Development and application of medication appropriateness indicators for persons with advanced dementia; A feasibility study

Parsons, C., McCann, L., Passmore, P. and Hughes, C.
Drugs and Aging
2016
The aim of this study by Parsons et al. (2016) was to categorise the appropriateness of a comprehensive list of medications and medication classes for use in patients with advanced dementia.
It also examined the feasibility of undertaking a longitudinal prospective cohort study to collect clinical and medication use data. Using the categories developed, it aimed to determine the appropriateness of prescribing for nursing home residents with advanced dementia in NI. The study involved a Delphi Consensus study, a longitudinal prospective cohort feasibility study and the retrospective application of appropriateness ratings to medication data of residents with advanced dementia. Consensus on appropriateness was achieved for 87 of the 97 medications and medication classes included in the survey. At baseline, the average number of medications prescribed to nursing home residents was 16.2, approximately a quarter of which were considered by the expert panel to be never appropriate. All but one of the 15 residents participating had been prescribed at least one of these medications, and this did not change significantly over the course of the study. The study demonstrates that it is feasible to collect clinical and medication use data from this cohort of people.

Neuroimaging referral for dementia diagnosis: The specialist's perspective in Ireland

Ciblis, A.S., Butler, M.L., Bokde, A.L., Mullins, P.G., O'Neill, D. and McNulty, J.P.
Alzheimer's & Dementia: Diagnosis, Assessment & Disease Monitoring
2015
Dementia remains underdiagnosed and neuroimaging is acknowledged as a key step in the diagnosis process. It is used to rule out other causes, establish differential diagnosis and dementia sub type. Ciblis et al.
(2015) surveyed geriatricians, old age psychiatrists and neurologists to explore their perspectives on access to neuroimaging for dementia diagnosis in Ireland When it came to how specialists felt about the proficiency of diagnosis in their Health Service Executive region, nearly half of respondents rated this as fair or poor, while most rated neuroimaging as important or very important. Although all participants reported having access to CT and most to MRI, two thirds did not have access to other modalities they would like to use, such as PET and SPECT. Respondents reported confidence in selection of the appropriate modality and in understanding neuroimaging in dementia. However responses reflected a lack of awareness of dementia specific protocols and of the use of any guidelines so that the authors comment on the need for national guidelines, standardisation of protocols and training.

Risk communication in dementia care: Professional perspectives on consequences, likelihood, words and numbers.

Stevenson, M. and Taylor, B.J.
British Journal of Social Work
2017
This paper reports on a qualitative study exploring the perspectives of health and social care professionals on communicating risk in dementia care. Five focus groups were held in the five health and social care Trusts in Northern Ireland.
A clear understanding of the evolving nature of risk across a person's journey with dementia was evidenced as was the significance of a person's history in providing context for their current decision making. Participants framed risk within the risk culture of their own organisation, with subjective beliefs of what was an acceptable risk being key to their conceptualisation. Risk was viewed as having positive or negative consequences, with evidence of a positive risk taking culture. There was less emphasis on the likelihood of risk and where this was expressed it was in verbal rather than numericl terms, despite numberical data being available. The authors highlight the need for more research into frequency of risk occurence in dementia care to inform better estimates of likelihood, and for further analysis of how quantified risk data is understood and communicated emphasising the need for statistical literacy among health and social care professionals.

Communicating risk in dementia care: Survey of health and social care professionals.

Taylor, B.J., Stevenson, M. and McDowell, M.
Health & social care in the community.
2017
Taylor et al. (2017) identify the tension professionals face between supporting clients choices that involve risk while demonstrating professional accountability.
This paper reports on the results of a survey distributed to all health and social care professionals working in community dementia services across Northern Ireland. The survey examined verbal and numeric expression of risk, frequency of major risks, perceptions of risk likelihood, views on the value of visual aids to communicate risk and the issues of communicating risk in practice. The authors found limited understanding or association of numerical information and risk likelihood, with variation in the words chosen to explain numeric values and the numeric interpretation of probability of harm. Professionals were also inclined to over-estimate the frequency of serious events. Value was identified in the use of visual aids to communicate risk and the authors highlight the need for research in this area. Reflecting on the fact that words are more commonly used to communicate risk than numbers, the authors suggest research should also support the development of standardised, evidence based lexicons to improve risk communication.

‘Working away in that Grey Area…’A qualitative exploration of the challenges general practitioners experience when managing behavioural and psychological symptoms of dementia.

Jennings, A.A., Foley, T., McHugh, S., Browne, J.P. and Bradley, C.P.
Age and Ageing
2017
This paper by Jennings et al. (2017) reports the findings of semi structured interviews with GPs on the challenges they experience managing behavioural and psychological symptoms of dementia (BPSD). Overall participants were pessimistic about dementia and management of BPSD.
Many described ethical struggles and difficulty maintaining their role as patient advocate in the face of competing expectations from family members and nursing home staff. A lack of clinical guidance was highlighted as was a lack of alternative resources e.g. provision of non-pharmacological therapies. GPs lacked confidence when it came to non-pharmacological approaches with some feeling it was not their role to recommend such therapies. Overall insufficent resourcing was a key issue, from clinical guidance to service provision and supports, and adequately staffed nursing homes. The findings from this study will inform the development of an intervention for managing BPSD in general practice.

The development and evaluation of peer-facilitated dementia workshops in general practice

Foley, T., Jennings, A., Boyle, S. and Smithson, W.H.
Education for Primary Care
2017
As part of a National programme to support GPs delivering dementia care (Prepared), this paper documents a number of workshops that aimed to improve knowledge and confidence among GPs. The paper describes their development, delivery and evaluation.
Content and delivery were informed by the results of an earlier triangulated educational needs analysis involving clinicians, patients and families, with the workshops being delivered by GPs to small groups, in the GP practice at lunchtime. The focus of the first workshop was diagnosis, disclosure and post diagnostic care with the second workshop focusing on assessment and management of behavioural and psychological symptoms of dementia. There was a high rate of attendance and overall participants reported a considerable improvement in both knowledge and confidence. An online resource had also been developed in response to the educational needs analysis and participants gave very positive feedback on this. Practice based workshops were viewed favourably and the content was viewed as relevant to daily general practice. The authors conclude that the study evidences the value of a triangulated educational needs analysis and of peer facilitated, practice based small group work as an educational tool

Dementia

Cunningham, E.L., Mc Guinness, B., Herron, B. and Passmore, A.P.
Ulster Medical Journal
2015
In this paper Cunningham at al. (2015) provide an overview of dementia, from clinical diagnosis to both pharmacological and non-pharmacological management of the condition. The authors discuss current prevalence and socio economic implications.
They detail clinical and pathological aspects of different types of dementia and the potential for overlapping disease processes. Referring to the current process and tools of diagnosis, they suggest a framework for assessing patients with cognitive symptoms. The recent decrease in age related dementia is highlighted and the authors suggest greater efforts are needed to continue the focus on improved public health measures that address recognised protective factors. The authors also highlight the importance of early diagnosis, particularly in the context of developing therapeutic drug treatments.

Potentially inappropriate prescribing among people with dementia in primary care: a retrospective cross-sectional study using the enhanced prescribing database.

Barry, H.E., Cooper, J.A., Ryan, C., Passmore, A.P., Robinson, A.L., Molloy, G.J., Darcy, C.M., Buchanan, H. and Hughes, C.M.
Journal of Alzheimer's Disease
2015
Barry et al. (2015) applied a subset of the Screening Tool of Older Persons Prescriptions (STOPP) criteria to data from the Enhanced Prescribing Database, Northern Ireland.
The aim was to estimate the extent of potentially inappropriate prescribing (PIP) among people with dementia and to consider any association with polypharmacy, age and gender. Data on 6826 patients indicated that polypharmacy (81.5%) and PIP (64.4%) were prevalent with PIP being associated with female gender but not age. Both of these findings are much greater than those reported in previous studies. The authors suggest the finding indicate the need for medication reviews and the potential for using systems that alert physicians to high risk patients and potentially inappropriate medication combinations. While they acknowledge the difficulties of its use among this population and the limited evidence base, they suggest consideration should be given to the use of deprescribing, for example “drug holidays”.

Uniforms in dementia care: A barrier or a necessity?

MITCHELL, G.
Nursing ethics
2016
In this case study Mitchell (2016) discusses a real ethical dilemma in a dementia care home in Northern Ireland. Two groups of care staff were divided on the issue of whether or not to continue wearing a uniform.
It had been proposed that staff wear their own clothes, including nightwear for night shifts or wear clothes appropriate for the 50s and 60s, an era familiar to most residents. Those supporting the change felt that clothes related to this era would stimulate discussion and reminiscence while staff wearing nightwear would help to orient residents to the fact that it was night time. Staff in favour of retaining uniforms felt that the change in practice might be disruptive and confusing to residents and that it could also contribute to stigma as agency staff and visitors might perceive that people with dementia are living in a fantasy world. There was also some concern that staff wearing nightwear could trigger inappropriate sexual responses from some residents. Both sets of views were framed within a person centred approach and management decided that the continued use of uniforms was the best approach for residents at this time.

“We’re certainly not in our comfort zone”: A qualitative study of G.P.’s dementia – Care educational needs.

Foley, T., Boyle, S., Jennings, A. and Smithson, W.H.
BMC Family Practice
2017
In this qualitative study Foley et al. (2017) explored the dementia educational needs of GPs from multiple perspectives; GPs, family carers and people with dementia.
The triangulation of data revealed a broader range of educational needs that included diagnosis, disclosure, management of behavioural and psychological symptoms, counselling, signposting to local services and supports. The latter two were highlighted by people with dementia and family carers. GPs were found to experience uncertainty in providing dementia care and decision making was found to be both complex and challenging. The results of this analysis have been used by the Primary Care, Education, Pathways and Research of Dementia (PREPARED) team to inform a series of GP workshops and to launch an educational website: www.dementiapathways.ie.

Ageing, cognitive disorders and professional practice

FITZGERALD, D., KEANE, R., REID, A., O’NEILL, D.
Age and Ageing
2013

Fitzgerald et al. (2013) point to the increasing number of people over 65 years remaining in the workplace and the potential impact of cognitive decline, particularly among those in the liberal professions.

 They distributed a questionnaire to 22 regulatory and professional bodies to assess whether their policies and practices were ‘age attuned’.  None of the respondents had supports in place for older workers with chronic conditions such as dementia to continue to work safely and effectively, with over half stating that professionals were responsible for their own health and safety.  The authors suggest that a joint initiative between occupational health, geriatric medicine and old age could assist professional and regulatory bodies, and protect the public, pointing to a current independent model of support in the UK; The National Clinical Assessment Service.

Education in geriatric medicine for community hospital staff

O’HANLON. S., LISTON, R.
British Journal of Community Nursing
2010

O’Hanlon and Liston (2010) used a questionnaire to assess the provision of education in geriatric medicine among community hospital staff.

 While not specific to dementia, the results indicated that staff found dementia and challenging behaviour to be one of the most difficult areas of their practice.  The authors conclude that geriatricians have little input to education in community hospitals and that staff would value regular, structured input.

Psychological trauma and fear for personal safety as a result of behaviours that challenge in dementia: The experiences of healthcare workers

SCOTT, A., RYAN, A., JAMES, I.A., MITCHELL, E.A.
Dementia: The International Journal of Dementia Research and Practice
2011

Scott et al. (2011) use a questionnaire to explore the psychological effects of exposure to aggression among healthcare workers in care homes in NI.  The evidence suggests that staff often fear for their safety and that experience did not impact on risk of assault.

 Workers were injured in just over half of the incidents and most assaults took place during care interventions.  Almost a quarter of the respondents met the criteria for ‘avoidance’, a characteristic of depersonalisation and the authors suggest care home staff may avoid ‘aggressive’ residents, thus risking compromised care.  They recommend education that focuses on the skills of communication, empathy, compassion and understanding, and the introduction of infrastructures and guidelines to support staff.

A multicentre survey of acute hospital nursing staff training in dementia care

COFFEY, A., TYRRELL, M., BUCKLEY, M., MANNING, E., BROWNE, V., BARRETT, A., TIMMONS, S.
Clinical Nursing Studies
2014

This paper by Coffey et al.

(2014) reports the findings of a survey of 150 nurses in six acute hospitals in the southern region of ROI, and was conducted as part of a multicentre study of prevalence of dementia, course of dementia and long-term outcomes for people with dementia in acute hospitals. The survey found that 83% of nursing staff in the acute hospitals perceived that they had insufficient training in dementia care. This was despite the availability of a national dementia education programme across all care services and reflects poor uptake of dementia education offered in acute hospitals. However, the survey clearly indicated that nurses at ward level are aware of their poor dementia knowledge and are open to dementia training and the authors recommend strengthened awareness and management support for enhanced and specialist skills in dementia care for nurses practicing in acute care settings

Behavioural and psychological symptoms of dementia in primary care: a survey of general practitioners in Ireland

BUHAGIAR, K., AFZAL, N., COSGRAVE, M.
Mental Health in Family Medicine
2011

Using an anonymous questionnaire issued to GPs in North Dublin, Buhagiar et al. (2011) explored how GPs self-evaluate their confidence and knowledge on the detection and management of behavioural and psychological symptoms of dementia (BPSD).

GP confidence in diagnosing and managing BPSD was found to be low; all GPs reported having diagnosed and managed patients presenting with new-onset BPSD during the previous year but they were somewhat critical of their perceived skills in these areas, despite showing a high level of knowledge about management of BPSD. The authors conclude that GP confidence is likely to be compromised by a lack of guidance and support, limited resources and a health service framework that does not necessarily promote support from specialist services. The study argues that GPs need to be better supported by educational programmes on dementia care, and by a structured shared care approach between primary and specialist services, which would potentially lead to better patient and caregiver outcomes.  

Occupational therapy and dementia care: A survey of practice in the Republic of Ireland

CGRATH, M., O’CALLAGHAN, C.
Australian Occupational Therapy Journal
2014

McGrath and O’Callaghan (2014) used an online survey to consider practice among Occupational Therapists (OTs) in ROI working with people who have dementia, or carers of someone with dementia.

 They examine the reported practices in the context of a growing body of research in this area.  The authors report a gap between practice in Ireland and the research, for example, most therapists assess performance components rather than occupational participation; non standardised functional assessments were used; interventions to address behavioural and psychological symptoms were generally not used.  They recommend a global occupational therapy strategy for knowledge translation in dementia care and that future research should focus on developing and evaluating interventions to support translation of research to practice for people with dementia. 

Occupational therapists' experiences and interventions when working with people with early stage dementia

CUMMINS, C., WARREN, A.
The Irish Journal of Occupational Therapy
2010

Cummins and Warren (2010) report on a qualitative study of six occupational therapists working in Ireland with people with early stage dementia.  They investigated their experiences and the type of interventions they used with this client group.

 Five themes emerged: reaffirming peoples’ right to be independent; looking beyond the diagnosis; facilitating occupational performance; enabling occupational identity; inaccessible and inadequate resources.  The authors suggest that the scope of work for occupational therapists in this area is vast and is taking place in a service landscape that is fragmented, inadequate and slow to respond.