Assessing physician attitudes and perceptions of Alzheimer's disease across Europe

Abstract

Given the important role that physicians play in clinical care, disease advocacy, national health policy making and clinical research, the IMPACT survey sought to assess the attitudes and perceptions of physicians in 3 general categories: diagnosis and treatment of Alzheimer's disease (AD); caregivers and families of patients with AD; and the role of government in dealing with this disease and its consequences. Survey respondents comprised a total of 250 generalists and 250 specialists (neurologists, geriatricians, neuro-psychiatrists, psychiatrists and psychogeriatricians) from France, Germany, Italy, Spain and the United Kingdom. Physicians were aged 25 to 69 years, in practice for between 5 and 30 years and currently spending more than 50% of their time in direct patient care. Results showed that a sizable majority of physicians throughout Europe, specialists and generalists alike, agree that: 1) AD is underdiagnosed and undertreated; 2) patients and families are not prepared to recognise the early symptoms of the disease; 3) early treatment can help to slow the progression of the disease; and 4) more effective treatments are needed. Attitudes were statistically significantly different between some groups of physicians regarding disclosure of the diagnosis of AD, the benefits of lifestyle modification, and the value of AD-specific medication in patients whose symptoms are worsening. Differences in attitudes and perceptions of AD between specialists and generalists were limited; differences between countries were more common and of greater magnitude, particularly with respect to barriers to the use of prescription medications.

Introduction

One centrally important stakeholder group, upon whom the scope and quality of services available to patients with Alzheimer’s disease (AD) ultimately depends, is European physicians. From a medical perspective, physicians are generally guided in their professional actions by evidence-based guidelines. There have been recent updates of European national and international guidelines and position papers by various scientific bodies on the diagnosis, treatment and care of AD and related disorders that summarise the state of the art of the scientific knowledge and recommend specific actions derived from this knowledge (1, 2, 3). Studies that assess the extent to which these guidelines are adhered to in the community, however, have found that many people with dementia are not receiving the recommended care (4, 5).

One important reason for this discrepancy between guidelines and practice may be physicians’ attitudes and opinions regarding AD and/or ageing. In one study, attitudes amongst physicians about dementia, including stigma, denial and fear, appeared to contribute to delayed or missed diagnosis (6). Another study found that the belief that certain symptoms of dementia are a normal part of the ageing process is common, even amongst physicians (7). Thus, attitudes towards ageing, and age-related diseases and dementia in particular, appear to have a negative impact on the readiness of some physicians to practice in accordance with clinical guidelines based on state-of-the art medical knowledge.

Given the potential significance of these attitudinal issues, the Important Perspectives on Alzheimer’s Care and Treatment (IMPACT) survey explored how physicians, including specialists in the care of patients with neurodegenerative disorders and generalists, view this disease. The IMPACT survey explored a broad range of attitudes and perceptions of physicians towards AD in order to obtain a detailed and up-to-date picture of the physician mindset concerning AD. The survey sought to assess not only attitudes about clinical diagnosis and treatment, but broader issues of ageing, caregivers and families and social and governmental responsibility. Another important goal was to compare the results from physicians in each of the participant countries to ascertain whether there are any significant differences between them. An additional objective was to identify any similarities and differences between specialists and generalists in terms of their attitudes and perceptions surrounding AD.

Methods

Amongst people who responded to the IMPACT survey were 500 physicians—250 generalists and 250 specialists—from 5 European nations: France, Germany, Italy, Spain and the United Kingdom (Table 1). For the purposes of this survey, the term specialist refers to those physicians whose field of specialization includes AD; the term generalist refers to physicians whose field of specialization encompasses general adult medicine, or who do not have specialty training. Generalists included general practitioners, hospital general physicians, family physicians and internists; specialists included neurologists, geriatricians, neuro-psychiatrists, psychiatrists and psychogeriatricians. Physicians enrolled in the survey were required to be aged between 25 and 69 years, to have been in practice for between 3 and 30 years, and to currently spend more than 50% of their time in direct patient care. Enrollment was restricted to those generalists who saw at least 2 patients with AD each month. Likewise, specialists were required to see at least 8 patients with AD each month. No physician respondents were employed either full time or part time by a pharmaceutical company.

Table 1.

Physician Respondents by Discipline

Respondent type	Total	France	Germany	Italy	Spain	UK
Generalists (GEN)	250	50	50	50	50	50
General practitioner/family medicine	222	37	42	49	46	48
Internist	13	3	7	1	1	1
Hospital general physician	15	10	1	0	3	1
Specialists (SP)	250	50	50	50	50	50
Neurologist	195	45	37	46	47	20
Geriatrician	19	4	1	2	1	11
Neuro-psychiatrist	14	1	10	1	1	1
Psychiatrist	11	–	2	1	1	7
Psychogeriatrician	11	–	–	–	–	11
Total	500	100	100	100	100	100

Throughout April and May 2009, physician respondents completed a 30-minute, Web-based questionnaire, during which they were presented with a series of attitudinal statements about AD. For each statement, respondents were asked to respond, on a 5-point Likert scale, whether they 1) strongly agreed; 2) agreed; 3) neither agreed nor disagreed; 4) disagreed; or 5) strongly disagreed. In addition to attitudinal statements, respondents were also asked direct questions related to their personal attitudes, behaviours and perceptions, for which they were required to select the most appropriate answer from a pre-defined list.

Statistical significance testing was performed for selected items using a standard software program for the interpretation of survey data (Quantum, http://www.spss.com/software/data-collection/quantime/quantum.htm). Only significant P-values are shown.

For a complete description of survey methodology, see the article in this issue by Jones et al (8).

Results

Views on ageing and the elderly

Overall, 63% of physicians agreed that general health inevitably deteriorates with age, but 67% of physicians agreed/strongly agreed that age does not necessarily lead to deteriorating memory, and 50% of them agreed/strongly agreed that age does not impair thinking and the ability to express oneself (Fig. 1). Similarly, 57% of physicians strongly disagreed/disagreed with the statement that little can be done about the deterioration of memory with age; this was most apparent in France (75% strongly disagreed/disagreed). Yet, 42% of physicians agreed that the health care system largely ignores the well-being of older people. Physicians’ perceptions of mental health and ageing were somewhat different across Europe, with physicians from France tending to have a more positive view, and German physicians a more negative view.

Figure 1.

Memory in normal ageing

Overall, 51% of physicians agreed that families should be primarily responsible for caring for the elderly although the government should help if needed, whilst 37% believed that the family and government should be equally responsible for care of older people (Fig. 2). The proportion of physicians who believe that the government should be primarily responsible for care was consistently low, being highest in Italy and the United Kingdom (13% each). There were no notable differences in the attitudes of specialists and generalists in this topic area. Interestingly, Italy and the United Kingdom tended to share a more governmental view on the responsibility for care of the elderly, while Germany had a more family-oriented view.

Figure 2.

Responsibility for care of older people. For items where total percentage does not equal 100%, some respondents did not offer an opinion

Recognition of early signs and symptoms

A majority of physicians (66%) reported that family members are the more likely candidates to recognise early symptoms of AD, as opposed to doctors, friends, co-workers or patients themselves (Fig. 3). Yet a comparable majority (70%) responded that lay people would not recognise the early symptoms of AD and 77% believed that they are unable to differentiate between the early stages of AD and the signs of normal ageing. Interestingly, just 26% of physicians reported that the doctor is the person most likely to recognise early symptoms of AD, and an even smaller percentage (≤5%) of physicians identified the patient as the most likely to recognise early symptoms. However, physicians’ perceptions on recognition of early symptoms of AD varied widely across the 5 countries, with physicians in France and Germany having the most favourable perception of doctors’ recognition of early symptoms and those in the United Kingdom and Spain the least favorable perception (Fig. 3).

Figure 3.

Who recognises early symptoms of AD?

Diagnostic concerns

Most physicians (65%) hold the opinion that AD is underdiagnosed in their country, with few differences noted between specialists and generalists but a wide range of responses from different countries (range: 77% [United Kingdom] to 45% [Spain]) (Fig. 4). Whilst the proposed reason physicians endorsed most frequently as responsible for this phenomenon of underdiagnosis was failure of families and patients to watch for symptoms (90%), it is remarkable that 86% of doctors admit lack of physician awareness and/or experience with AD as an important issue. Other notable reasons cited for the underdiagnosis of AD were: patients and families usually avoid unpleasant issues (85%), the general public has a low awareness of AD (81%), people believe memory loss is a normal part of ageing (80%) and patients/families consciously ignore symptoms (78%). Interestingly, 75% of physicians believed that underdiagnosis of AD could be a result of the medical community hesitating to make the diagnosis of AD in the earliest stages of disease because of their uncertainty. In addition, 53% of physicians felt that AD may be underdiagnosed because physicians feel uncomfortable giving bad news. With respect to this issue, almost one third (29%) of physicians indicated that being diagnosed with senile dementia is not as stressful as being diagnosed with AD. This figure was higher in Italy, where 44% of physicians agreed with the statement, as compared with the United Kingdom (17%; P≤0.001 vs Italy) or France (22%; P≤0.001 vs Italy). An additional 31% of doctors in the whole sample were skeptical (neither agree nor disagree) regarding this statement.

Figure 4.

Perception of AD diagnosis

Interestingly, physicians were also not very confident in the ability of themselves or their colleagues to detect AD in its earliest stages; approximately two thirds (59%) agreed with the statement that generalists “have difficulty” with this task and 30% perceive the same difficulty for specialists (Table 2; see also the article in this issue by Jones et al (8)). Moreover, approximately one third of the surveyed physicians (34%) believed that there are more disadvantages than advantages associated with early diagnosis. Strikingly, this figure was much higher in Italy (73%) than in any other country (range: 18% [Germany] to 34% [United Kingdom]; P≤0.001 for all comparisons]).

Table 2.

Diagnostic Statements: Respondents Who Agree/Strongly Agree

	Frequency item chosen (%)
Diagnostic statements	Total MDs		France		Germany		Italy		Spain		UK
	GEN	SP	GEN	SP	GEN	SP	GEN	SP	GEN	SP	GEN	SP
	(n=250)	(n=250)	(n=50)	(n=50)	(n=50)	(n=50)	(n=50)	(n=50)	(n=50)	(n=50)	(n=50)	(n=50)
I. I would want to know as early as possible if a family member had AD	76	80	78	90c	74	78	843	80	80	78	62	72
II. I would like to know as early as possible if I had AD	64	63	66	64	60	58	762	66	703	58	48	70‡
III. I would think there are more disadvantages than advantages to finding out if someone has AD as early as possible	36	33	26	18	16	20	741,2	72a	18	32	44‡,2	24
IV. Most people wouldn’t know the difference between the early stages of AD and normal ageing	78	77	863	78	883	78	82	86c	68	76	66	66
V. Most people would not recognise the early signs of AD	74	67	823	80b	80	78c	74	62	70	52	62	64
VI. General practitioners and hospital physicians have difficulty detecting AD in its early stages	56	61	58	62	52	62	46	62	56	52	703	68
VII. Specialists such as neurologists or geriatricians have difficulty detecting AD in its early stages	38*	23	32	16	32	24	32	16	36	34	56†,3	26
VIII. Fear about AD keeps people from speaking with their doctor about it	53	44	562	56a,c	661,3	56a,c	28	30	40†	16	761,2	60a,b
IX. Being diagnosed with dementia is not as stressful as being diagnosed with AD	30	28	16	28c	30	32c	422	46a,c	383	22	24	10

GEN vs SP: *P≤0.001; ^†P≤0.01; ^‡P≤0.05. GEN vs GEN between countries: ¹P≤0.001; ²P≤0.01; ³P≤0.05. SP vs SP between countries: ^aP≤0.001; ^bP≤0.01; ^cP≤0.05. I. GEN vs GEN: Italy vs UK; SP vs SP: France vs UK. II.GEN vs GEN: Italy² and Spain³ vs UK. III. GEN vs GEN: Italy vs France¹, Germany¹, Spain¹ and UK²; UK vs France, Germany and Spain; SP vs SP: Italy vs France, Germany, Spain and UK. IV. GEN vs GEN: France vs UK; Germany vs Spain and UK; SP vs SP: Italy vs UK. V. GEN vs GEN: France vs UK; SP vs SP: France vs Spain; Germany vs Spain. VI. GEN vs GEN: UK vs Italy. VII. GEN vs GEN: UK vs France, Germany and Italy. VIII. GEN vs GEN: France vs Italy; Germany vs Italy¹ and Spain³; UK vs Italy¹ and Spain²; SP vs SP: Francea, Germany^a and UK^a vs Spain; France^c, Germany^c and UK^b vs Italy. IX. GEN vs GEN: Italy and Spain vs France; SP vs SP: France and Germany vs UK; Italy vs UKa and Spain^c.

A slight majority (56%) of physicians indicated that they felt that routine screening for people aged >65 years is extremely important or very important, and 42% of physicians agreed that screening should be routinely performed on every person when they reach the age of 65 years. For further details on attitudes of physicians (and other respondent groups) to screening, see the article in this issue by Bond et al (9). Nonetheless, physicians did agree that they would want to know “as early as possible” if a family member had AD (78%; range: 67% [United Kingdom] to 84% [France]; P≤0.001), though they were somewhat more reluctant to know “as early as possible” if they personally had AD (64%; range: 59% [United Kingdom, Germany] to 71% [Italy]).

Treatment issues

Physicians across Europe reported that timing of initial treatment for AD has a critical impact on disease progression. Indeed, 75% believed that early treatment can delay the progression of AD (Table 3). However, taking all forms of treatment into account, more than half of physicians (67%) endorsed the statement that AD is undertreated in their country (Fig. 5). On the opposite end of the spectrum, <10% of physicians in all countries felt that AD is overtreated. In fact, in the United Kingdom not a single physician agreed that AD is overtreated. The majority of specialists and generalists in all countries agreed that AD patients are undertreated except for specialists in Spain, 54% of whom believed AD is adequately treated.

Table 3.

Treatment Statements: Respondents Who Agree/Strongly Agree

Frequency item chosen (%)
Treatment statements	Total MDs		France		Germany		Italy		Spain		UK
	GEN	SP	GEN	SP	GEN	SP	GEN	SP	GEN	SP	GEN	SP
	(n=250)	(n=250)	(n=50)	(n=50)	(n=50)	(n=50)	(n=50)	(n=50)	(n=50)	(n=50)	(n=50)	(n=50)
I. Early treatment can delay the progression of AD	78	71	78	70	903	82	82	70	68	70	74	64
II. Improved treatments have been made available for AD in the past 5 years	67	59	54	54	70	72c	54	46	74	56	822	68
III. Treatments for AD can still be effective even if the patient’s symptoms continue to worsen	48	63.	44	68‡	60	72	40	54	46	60	52	60
IV. All patients with AD should continue to take drug treatment for as long as they are physically able	54	56	602	68a	56	50	622	62b	56	68a	36	34
V. The government does not invest nearly enough in treating AD	56	51	40	28	56†	26	623	58b	48	52c	623	64a
VI. There are effective treatments for AD	46	47	42	54c	56	58b	36	30	44	52c	54	42
VII. Treatment is only effective in the early stages of AD	48	39	54‡	34	36	44	682,3	68a	42	32	38.	18
VIII. I expect that a break-through in the treatment of dementia of the AD type will become available within the next five years	42	36	32	24	26	16	42	44	681,2,3	68a,c	40	28
IX. The government is a barrier to those seeking medications for AD	31	26	16	6	42‡2,3	22c	30	28b	22	22c	462,3	54a,c
X. Treatments for AD generally cause a lot of side effects	29*	11	46†,3	16	22	14	24	16	28.	4	26.	6

GEN vs SP: *P≤0.001. †P≤0.01; ‡P≤0.05; GEN vs GEN between countries: ¹P≤0.001; ²P≤0.01; ³P≤0.05. SP vs SP between countries: ^aP≤0.001; ^bP≤0.01; ^cP≤0.05. I. GEN vs GEN: Germany vs Spain. II. GEN vs GEN: UK vs France and Italy; SP vs SP: Germany vs Italy. IV. GEN vs GEN: Italy and France vs UK; SP vs SP: France and Spain vs UK^a Italy vs UK^b. V. GEN vs GEN: UK and Italy vs France; SP vs SP: Italy vs France and Germany; Spain vs France and Germany; UK vs France and Germany. VI. SP vs SP: France and Spain vs Italy^c; Germany vs Italy^b. VII. GEN vs GEN: Italy vs Germany and UK²; Italy vs Spain³; SP vs SP: Italy vs France, Spain and UK^a; Italy vs Germany^c. VIII. GEN vs GEN: Spain vs UK¹; Spain vs Italy²; Spain vs France and Germany³; SP vs SP: Spain vs France, Germany and UK^a; Spain vs Italy^c. IX. GEN vs GEN: Germany and UK vs France²; Germany and UK vs Spain³; SP vs SP: Germany and Spain vs Francec; Italy vs France^b. X. GEN vs GEN: France vs Germany and Italy.

Figure 5.

Perception of AD treatment

With respect to underprescribing of AD-specific drugs, the reason chosen by most physicians (38%) was that undertreatment was related to underdiagnosis or excessively delayed diagnosis (Table 3). In addition, the main barriers to wider prescribing were identified as the limited impact of treatment (30%), the cost of drugs to government or health care system (29%) and government restrictions (22%). Somewhat paradoxically, although 63% of physicians indicated that they believed that improved treatments for AD have become available over the previous 5 years, less than half (47%) agreed that there are currently effective treatments for the disease (Table 3). German physicians were the most likely and Italian physicians the least likely to agree that current treatments are effective (57% vs 33%; P≤0.001).

Physicians were more divided on the benefits of continuing pharmacotherapy throughout the course of the disease. Overall, 55% of physicians agreed that all patients with AD should continue to take drug treatment for as long as they are physically able, and 56% believed that drug treatment could be effective even if patients’ symptoms continue to worsen. Specialists were more likely than generalists to endorse persistent drug therapy despite worsening symptoms (63% vs 48%; P≤0.01), and were less likely to agree that AD-specific medications “generally cause a lot of side effects” (11% vs 29%; P≤0.001) (Table 3). One of the few country-specific findings in this area was that German physicians―90% of generalists and 82% of specialists―were especially convinced that early treatment may delay progression of AD.

Three quarters of respondents believed that participation in social activities can slow the progression of AD (Table 4). The comparable percentages for other lifestyle modifications were brain exercises, 66%; physical exercise, 53%; and diet, 27%. There were some notable differences between countries and between specialists and generalists in this regard. In France, 41% of physicians felt that proper diet could slow progression of AD, compared with 18% in Germany and Spain (P≤0.001), whereas 68% of physicians in Italy and 61% in Germany, vs 31% in Spain (P≤0.001 for both comparisons), thought that physical exercise was helpful. Just 44% of physicians in the United Kingdom agreed that brain exercises could be beneficial, compared with 77% of physicians in Italy and 76% in Germany (P≤0.001 for both comparisons). With few exceptions, specialists and generalists had similar responses to questions regarding the potential benefits of non-pharmacological interventions.

Table 4.

Progression of AD Statements: Respondents Who Agree/Strongly Agree

Frequency item chosen (%)
Progression statements	Total MDs		France		Germany		Italy		Spain		UK
	GEN	SP	GEN	SP	GEN	SP	GEN	SP	GEN	SP	GEN	SP
	(n=250)	(n=250)	(n=50)	(n=50)	(n=50)	(n=50)	(n=50)	(n=50)	(n=50)	(n=50)	(n=50)	(n=50)
I. AD can lead to other health conditions such as depression	86	91	90	98b	92	96b	78	74	88	96b	84	90
II. The time in which a person with AD gets sicker can be slowed by participating in social activities	74	75	76		78	78	901,2	70	66	74	60	66
III. AD can put patients at greater risk for developing other conditions	62	72‡	58	60	703	86b	46	76	66	56	683	80c
IV. The time in which a person with AD gets sicker can be slowed by participating in brain exercises (e.g. crossword puzzles, games…)	71‡	60	66	60b	822	70a	842	70a	68	68a	54	34
V. The time in which a person with AD gets sicker can be slowed by participating in physical exercise	50	56	48	54	48	74†,a	78‡1,2	58	32	38	46	54
VI. The time in which a person with AD gets sicker can be slowed by a good diet	26	27	383	44a,b,c	18	18	28	38b,c	22	14	24	20

GEN vs SP: *P≤0.001; †P≤0.01; ‡P≤0.05; GEN vs GEN between countries: ¹P≤0.001; ²P≤0.01; ³P≤0.05. SP vs SP between countries: ^aP≤0.001; ^bP≤0.01; ^cP≤0.05. I. SP vs SP: France, Germany and Spain vs Italy. II. GEN vs GEN: Italy vs Spain² and UK¹; SP vs SP: France vs Italy and UK. III. GEN vs GEN: Germany and UK vs Italy; SP vs SP: Germany vs France and Spain; UK vs France and Spain. IV. GEN vs GEN: Germany and Italy vs UK; SP vs SP: France vs UK^b; Germany, Italy and Spain vs UK^a; V. GEN vs GEN: Italy vs Spain¹, France², Germany² and UK²; SP vs SP: Germany vs Spain. VI. GEN vs GEN: France vs Germany; SP vs SP: France vs Spaina, Germany^b and UK^c; Italy vs Spain^b and Germany^c.

Most of the physicians (89%) also believed that AD can lead to other health conditions, such as depression, and can put patients at risk for developing certain additional medical conditions (67%). In general, specialists endorsed these statements to a greater degree (72% vs 62% in the case of additional medical conditions).

Social impact of AD

Almost all physicians (98%) agreed with the proposition that AD represents a major societal problem, with virtually no variation between groups. Similarly, 94% of physicians agreed that AD can have devastating effects on the family of the person with AD.

Perceptions of the role of government

Overall, 53% of physicians across Europe agreed that the government does not invest nearly enough in treatment; percentages ranged from 41% in France to 68% in the United Kingdom (Table 3). A total of 36% of physicians responded that health care policy-makers are not concerned about AD (range: 26% in France to 46% in Italy). Moreover, 29% of physicians felt that their government is a barrier to those seeking AD medications, again exhibiting a wide variation between the countries (range: 11% in France to 50% in the United Kingdom) (Table 3).

Discussion

The main finding of this survey of physician attitudes and perceptions concerning a broad array of issues related to AD is that physicians, as a group, demonstrated concern about the timeliness of diagnosis and treatment of AD in Europe today. With respect to non-medical matters such as attitudes about ageing in general, the personal/familial/societal impact of AD and the role of government, physicians’ attitudes were much like those of other stakeholder groups surveyed (see the article in this issue by Jones et al (8)). Whereas there were some moderate differences between responses of AD specialists and generalists, more frequent and sizable differences were found between countries.

A number of important themes emerge from these data. The first is the robust perception that AD is underdiagnosed throughout Europe. Although the concept of underdiagnosis was not clearly defined in the survey question, it may be understood as a summation of perceptions of mistaken, absent and delayed diagnosis. These perceptions are in line with recently published position papers, e.g. the DeNDRoN Primary Care Clinical Studies Group (1) or the IAGG task force (2), and are supported by data from primary care setting and population-based epidemiological studies showing that up to one half of dementia cases remain undiagnosed in the community (5, 6, 10). The rates of underdiagnosis appear to be even higher for mild dementia cases (11).

In contrast, the IMPACT survey showed that the prevailing attitude of physicians is that early treatment is the most beneficial. Clinical research (12), most published clinical trial data (13) and expert opinion (3, 14) are clearly supportive of this perspective. Thus, the most important consequence of underdiagnosis was perceived as missing the window of opportunity to provide the patient with the most effective treatment. This issue will become even more important as we learn more about the optimal use of existing treatments and as more effective treatments become available.

Physicians attributed delayed diagnosis in part to delayed recognition of early symptoms of AD as well as delay from the time of symptom recognition to presentation at a physician’s office. Interestingly, most physicians felt that family members are the most likely candidates for recognising the signs and symptoms of AD, but a similarly high percentage of physicians believe that most people struggle to recognise the early signs of AD and find it difficult to differentiate these symptoms from signs of normal ageing. These apparently contradictory perceptions do fit, however, with the general understanding that most lay people do not believe that AD is present until the onset of evident deficits in instrumental basic activities of daily living, which occur at later stages of disease. To the extent that this is the case, an intensive and widespread educational and public health effort to inform the population at large about the typical sequence of emergence of symptoms of dementia might improve their ability and willingness to recognise early symptoms and bring them to the attention of a physician. Although screening programmes have been proposed to address this issue, the IMPACT survey documents that there is substantial opposition to the implementation of routine screening programmes for AD (see the article in this issue by Bond et al (9).

Physicians also indicated that a lack of knowledge/experience amongst their peers may be one of the top reasons why AD is underdiagnosed in their country. Moreover, many physicians acknowledged that they and their peers find it difficult to recognise the early signs of AD. This concurs with the findings of empirical studies of clinical practice that showed that between one half and two thirds of cases of AD were undiagnosed and undocumented in primary care clinic and private practice settings (11, 15, 16, 17, 18). Given this perception of missed or delayed diagnosis demonstrated by the IMPACT survey, and the literature which has documented it, efforts to improve the diagnostic process are needed in Europe so that care may be provided sooner than it is now. Pilot programmes aimed at increasing the rate of early diagnosis have been conducted in both the European Union (7) and the United States (8), but more than this clearly needs to be done.

A second major theme involves issues pertaining to the disclosure of the diagnosis of AD. When physicians were asked for reasons for underdiagnosis of AD, many chose reasons associated with fear and denial on the part of the patient/family, suggesting that they believe people would rather not know. It seems that physicians may be underestimating the patient’s and family’s desire to know about a diagnosis of AD, and may therefore avoid disclosure. Data from the IMPACT survey actually strongly suggest that a solid majority of caregivers and the general public DO want to know as soon as possible if they or a family member has AD (See article in this issue by Wortmann et al (19)). On the other hand, more physicians than caregivers indicated that they believe the disease is devastating to the family (95% vs 75%), suggesting that physicians may overestimate the negative consequence of receiving the diagnosis of AD.

Emotional barriers may also make it difficult or may even prevent physicians from disclosing a diagnosis of AD because they don’t want to give bad news. Moreover, around a third of physicians believe there is little to gain from diagnosis, which may make them even less enthusiastic about addressing the issue with patients and their families. It is somewhat concerning that one third of physicians in the IMPACT survey agreed with the statement that a diagnosis of dementia is not as stressful as a diagnosis of AD. The problem with this attitude, if translated into action, is that patients “diagnosed” with senile dementia instead of AD—and their caregivers—would potentially not pursue treatment and support services. Although it cannot be concluded from this survey that some doctors in fact follow this approach, the finding suggests that this may represent an important topic to be discussed in medical educational programmes.

Indeed, these results suggest that physicians could be better educated on patient and caregiver communication issues, including how to talk about dementia with patients and caregivers, how best to share the diagnosis of AD with them and how to provide appropriate guidance on treatment options and available governmental and non-governmental resources. Strategies need to be developed to educate physicians in ways that will alter current attitudes towards disclosing the diagnosis of AD and to provide accessible training to improve communication skills and practices (20).

A third theme is the relatively restricted perception of the value of currently available options with which to treat AD. Physicians did predominantly agree that early treatment can delay AD progression and therefore should be initiated at, or within 1 month of, diagnosis. This attitude is in accord with clinical trial evidence, which does indicate that earlier initiation of treatment provides additional benefits compared with even a short delay in initiating therapy (13, 21). Physicians also endorsed certain lifestyle interventions, particularly social interaction and brain exercises, as being potentially valuable in slowing progression of AD. Preliminary evidence also suggests that these approaches are effective (22, 23, 24, 25, 26, 27, 28), and a major study is now under way to further investigate these lifestyle interventions (3).

Nonetheless, most physicians were of the opinion that AD is undertreated in their country and cited a lack of impact of current therapies as the top reason for this undertreatment. One example of this is the perception of almost half of surveyed physicians that continuing AD-specific medication in patients whose symptoms are worsening is not worthwhile. However, in a progressive disorder such as AD, symptomatic progression is inevitable in the long term, even with treatment. As such, treatments that can delay or reduce the rate of decline can still be of benefit to the patient and caregiver (4, 5). Indeed, end points based on reduced decline have been recommended for AD clinical trials (6, 7). In addition, only around a half of physicians agreed that treatment should be continued as long as the patient is physically able. This is concerning as evidence indicates 1) that interruption or withdrawal of treatment may result in a reversal of benefits achieved during therapy (8, 9), and 2) that treatment for AD can be effective even at the advanced stages of the disease (29, 30, 31, 32).

There seems to be a paradox involving the high percentage of physicians who believe that AD treatments have improved over the last 5 years and that early treatment delays progression vs the relatively low percentage who believe that current treatments for AD are effective. This paradox may stem from differing interpretations of the word “effective”; for example, when asked if drugs were effective, some physicians may have defined “effective” as “curing” the disease, whereas others may have defined “effective” as delaying progression of the disease, hence the disparate responses. In any case, patients and caregivers may be better served if physicians’ attitudes concerning the benefits of existing therapies were more positively guided by existing data regarding early and continuous treatment. This may be accomplished, in part, through education about the long-term benefits of continuous treatment (21), including effects on quality of life, caregiver burden and health care resource utilization.

In summary, a sizable majority of physicians throughout Europe, specialists and generalists alike, agree that AD is underdiagnosed and undertreated, that patients and families are not good at recognising the early symptoms of the disease, that early treatment can help to slow the progression of the disease and that more effective treatments are needed. Attitudes were mixed regarding disclosure of the diagnosis of AD, the benefits of lifestyle modification and the value of AD-specific medication in patients whose symptoms are worsening. Differences between specialists and generalists were limited; differences between countries were more common and of greater magnitude.

Disclosure: The IMPACT study was sponsored by Pfizer Inc and Eisai Inc. This article was funded by Pfizer Inc and Eisai Inc. Editorial support was provided by Bill Kadish, MD, of PAREXEL and was funded by Pfizer Inc and Eisai Inc.