Understanding diagnosis and management of dementia and guideline implementation in general practice: a qualitative study using the theoretical domains framework

Background Dementia is a growing problem, causing substantial burden for patients, their families, and society. General practitioners (GPs) play an important role in diagnosing and managing dementia; however, there are gaps between recommended and current practice. The aim of this study was to explore GPs’ reported practice in diagnosing and managing dementia and to describe, in theoretical terms, the proposed explanations for practice that was and was not consistent with evidence-based guidelines. Methods Semi-structured interviews were conducted with GPs in Victoria, Australia. The Theoretical Domains Framework (TDF) guided data collection and analysis. Interviews explored the factors hindering and enabling achievement of 13 recommended behaviours. Data were analysed using content and thematic analysis. This paper presents an in-depth description of the factors influencing two behaviours, assessing co-morbid depression using a validated tool, and conducting a formal cognitive assessment using a validated scale. Results A total of 30 GPs were interviewed. Most GPs reported that they did not assess for co-morbid depression using a validated tool as per recommended guidance. Barriers included the belief that depression can be adequately assessed using general clinical indicators and that validated tools provide little additional information (theoretical domain of ‘Beliefs about consequences’); discomfort in using validated tools (‘Emotion’), possibly due to limited training and confidence (‘Skills’; ‘Beliefs about capabilities’); limited awareness of the need for, and forgetting to conduct, a depression assessment (‘Knowledge’; ‘Memory, attention and decision processes’). Most reported practising in a manner consistent with the recommendation that a formal cognitive assessment using a validated scale be undertaken. Key factors enabling this were having an awareness of the need to conduct a cognitive assessment (‘Knowledge’); possessing the necessary skills and confidence (‘Skills’; ‘Beliefs about capabilities’); and having adequate time and resources (‘Environmental context and resources’). Conclusions This is the first study to our knowledge to use a theoretical approach to investigate the barriers and enablers to guideline-recommended diagnosis and management of dementia in general practice. It has identified key factors likely to explain GPs’ uptake of the guidelines. The results have informed the design of an intervention aimed at supporting practice change in line with dementia guidelines, which is currently being evaluated in a cluster randomised trial.


Introduction
As outlined in the explanatory statement, this study aims to identify and explore the factors that influence how you care for older patients with suspected cognitive impairment or dementia.
You do not have to answer every question and can cease the interview at any time. If you need to attend to an urgent matter we can stop the interview and recommence it later.
Firstly we will talk about how you become aware of patients with suspected cognitive impairment and what you usually do in these situations. Then we will talk about what you may do next to manage these patients and communicate with their carers, if they have one.
Before I start do you have any questions you would like to ask me?

Demographic / Background Information
• How many older patients do you currently have in your care with suspected cognitive impairment (living in the community, not in a nursing home)? • How many of those with suspected cognitive impairment have come to your attention in the last 12 months? • How many patients do you currently have in your care that have had a confirmed diagnosed of dementia (living in the community, not in a nursing home)? • How many of those have been diagnosed in the last 12 months?

IDENTIFICATION OF SUSPECTED COGNITIVE IMPAIRMENT
I'm going to ask you to think of a recent patient you suspected had cognitive impairment.
• How did you become aware that the patient was experiencing cognitive changes? (GP/patient/carer/other) • What were the factors that alerted X (GP/patient/carer/other) to the possibility of cognitive impairment? • Over what period of time were these noticed?

Scenario 1: If raised by someone other than GP
• Had you noticed any of these signs/changes in the patient prior to the issue being raised by X?

Social influences •
In what way does the patient/carer/family influence your decision about conducting an assessment on a patient? • Do you ever seek the opinion of colleagues before you make a decision about conducting these assessments on a patient?

Emotion
• Is conducting these assessments a difficult situation to deal with? Is it something you would prefer to avoid?

Professional role
• Do you think it is an appropriate part of your role to undertake each of these assessments? (i.e. cognitive assessment/ depression screen/ refer for structural imaging, review medication) or do you think another healthcare provider should be responsible for this?
• Are there any situations in which you wouldn't consider conducting the assessment yourself? Explore. Is it a policy of this practice that this should be done by someone else?

Environment
• To what extent do resources (e.g. time available, access to imaging facilities, ability to refer to specialists, patient/carer co-operation) influence whether you refer elsewhere for assessment?

Social influences •
In what way does the patient/carer/family influence your decision about referring a patient elsewhere for assessment? • Do you ever seek the opinion of colleagues before you make a decision about referring a patient?

Emotion
• Is this a difficult situation to deal with? • Does referring to someone else to do the assessment make the situation easier for you?

DIAGNOSIS DISCLOSURE
Now I am going to ask you about a patient that has been diagnosed with dementia (ICD-10 definition on sheet for interviewer). (Emphasise that now talking about a diagnosed patient not a patient with suspected dementia).
What would the normal timeframe be from when a patient is first identified as possibly having dementia to actually being diagnosed? o How long does the assessment process usually take? How is a patient informed about their diagnosis? Who informs them? If GP, how do you tell them? What do you say/what words do you use? At what stage do you tell them? (eg when suspect they have dementia or when definitively diagnosed). Are patients always told of the diagnosis? Are carers/family members always told of the diagnosis? Who decides who will be told?

Recommended behaviours: (i) Referral to a specialist for dementia modifying medications (ii) Recreational activities introduced to people with dementia (iii)
Cognitive stimulation offered to people with dementia (iv) Caregiver training on effective interventions for people with dementia

Now I would like to talk to you about the management and follow-up of patients who have been diagnosed with dementia.
• Who is (primarily) responsible for the ongoing management of the patient? (e.g. GP, specialist, other).
• Who else is involved? (e.g. specialist, CDAMS, ACAS, other) What does the ongoing management of the patient involve?

Medication management
Referral to a specialist for dementia modifying medication (If not already raised) • Do you offer patients the opportunity to be referred to a specialist with a view to being prescribed dementia modifying medication? • How do patients/carers react? • Who do you refer them to? Why? • In which situations wouldn't you offer this to a patient? • Who is responsible for the ongoing management of this medication? To what extent do resources (eg time available, access to specialists, patient/carer co-operation) influence whether you refer patients for these medications?

Social influences •
In what way does the patient/carer/family influence your decision about referring patients for this medication? • Do you ever seek the opinion of colleagues before you make a decision about referring a patient for this medication?

Emotion
• Is this a difficult situation to deal with? Is it something you would prefer to avoid? • If you don't offer patients the opportunity to be referred to a specialist for dementia modifying medication, or the patient refuses, does that ever leave you feeling uncomfortable about their condition?

Non-medication Management (Psychosocial management)
• How are the non-medical/psychosocial aspects of dementia managed? (e.g. recreational activities, cognitive functioning/stimulation, caregiver training/support Recreational activities. •