Role Expectations in Dementia Care Among Family Physicians and Specialists

Abstract

BackgroundThe assessment and ongoing management of dementia falls largely on family physicians. This pilot study explored perceived roles and attitudes towards the provision of dementia care from the perspectives of family physicians and specialists.MethodsSemi-structured, one-to-one interviews were conducted with six family physicians and six specialists (three geriatric psychiatrists, two geriatricians, and one neurologist) from University of Toronto-affiliated hospitals. Transcripts were subjected to thematic content analysis.ResultsPhysicians’ clinical experience averaged 16 years. Both physician groups acknowledged that family physicians are more confident in diagnosing/treating uncomplicated dementia than a decade ago. They agreed on care management issues that warranted specialist involvement. Driving competency was contentious, and specialists willingly played the “bad cop” to resolve disputes and preserve long-standing therapeutic relationships. While patient/caregiver education and support were deemed essential, most physicians commented that community resources were fragmented and difficult to access. Improving collaboration and communication between physician groups, and clarifying the roles of other multi-disciplinary team members in dementia care were also discussed.ConclusionsFuture research could further explore physicians’ and other multi-disciplinary members’ perceived roles and responsibilities in dementia care, given that different health-care system-wide dementia care strategies and initiatives are being developed and implemented across Ontario.

Who Is Providing the Predominant Care for Older Adults With Dementia?

“…Among the specialties we have categorized as primary care, geriatrics is the only one that has substantial training in the diagnosis and treatment of dementia [3]. Studies of primary care providers in the US have shown that a substantial number of primary care providers prefer to refer dementia patients to specialists because of uncertainty in making diagnosis of dementia[5] and managing behavioral and psychological symptoms[6], and to recommend driving evaluation [6]. The potential groups to refer dementia beneficiaries to: geriatric psychiatry, neurology or geriatrics, are all small specialties and may not be easily accessible for the volume of patients [3].…”

Negotiating access to a diagnosis of dementia: Implications for policies in health and social care

“…Interactions between primary care physicians and patients are challenged by time constraints (Hum et al, 2014;Koch & Iliffe, 2010). Another factor may be a culturally influenced reluctance on the part of the physician to share a diagnosis of dementia (Hinton, Franz, & Friend, 2004;Zhan, 2004).…”

“…That's what I find is that there is no support.' Previous research suggests that although PsWD and their families rely on their primary care physician for access to care, physicians may not think they have the training or time to implement these resources with patients (Hum et al, 2014;Koch & Iliffe, 2010;Schoenmakers et al, 2009).…”

Are we Providing the Best Possible Care for Dementia Patients?

“…Another study cited low sensitivity to dementia among PCPs (62.8%) and lack of documentation in medical records (33.1%) [15]. Yet family physicians are growing more confident in diagnosing and treating dementia, with help of recent educational efforts and guidelines [13]. A workgroup convened by the Alzheimer's Foundation of America and the Alzheimer's Drug Discovery Foundation reviewed evidence for implementation of screening for cognitive impairment and made a strong recommendation to promote in-depth education of the public, healthcare providers, organizations and insurers about screening for cognitive impairment and dementia with the goal of initiating dementia care [16].…”

“…Most practice guidelines advocate for a central role of primary care providers (PCPs) in the detection, diagnosis and management of cognitive impairment and dementia [12,13]. Yet physicians are often unaware of cognitive impairment in their patients, one study citing numbers as high as 40% of undiagnosed cases [14].…”