General practitioner’s knowledge, attitudes, and difficulties in managing patients with dementia in primary health settings

ABSTRACT

Background:

Dementia is a global public health problem. The level of overall management of dementia by general practitioners (GPs) is unclear. This study mainly assessed the level of prevention, diagnosis, treatment, and attitudes of GPs toward dementia.

Methods:

An online questionnaire survey was sent to the wechat group from January 2021 to July 2023. A total of 120 GPs were recruited from community GPs. Data on general demographic characteristics and the preventive, diagnostic, therapeutic, and screening knowledge for dementia were collected.

Results:

The percentages of correct answers were 86.67% for overall symptoms, 30.83% for specific symptoms, 39.17% for etiology, 27.5% for diagnostic methods, 41.67% for treatment, and 55% for screening methods. Mental and behavioral symptoms were chosen by 95% respondents, cognitive impairment by 91.7%, and impaired ability of daily living by 90.8%. Regarding the specific symptoms of dementia, the highest chosen options were decreased recent memory (95%) and decreased judgment and calculation (93.3%) by all participants. Among the common causes, “degenerative diseases of the nervous system” was endorsed by the most respondents (95.8%). There was no significant difference in the knowledge level of dementia across GPs with different characteristics. The most chosen diagnostic method was medical history (95.8%), followed by dementia-related scale (91.7%) and cranial imaging examination (67.5%). 55% participants chose neuropsychological scale evaluation as the most important screening method. The percentages of participants who had the training needs of dementia knowledge were as follows: 95% for prevention of dementia, 92.5% for selection and application of dementia screening tools, 91.7% for general treatment of dementia, 90% for risk factors of dementia, 89.2% for care and social support strategies for dementia patients, and 88.3% for identification of predementia and early symptoms. Insufficient professional support (90%), lack of dementia-related knowledge (86.7%), insufficient cognition and concern of patients (85%), and lack of time for clinical consultations (75%) were the main barriers for GPs to manage dementia.

Conclusions:

GPs’ knowledges of early detection, etiology, and risk factors for dementia, and treatment still need to be further strengthened. More trainings are needed to make GPs competent to manage long-term care of dementia patients.

Introduction

Dementia is mainly manifested as a decline in intelligence, memory, thinking and social life ability, speech and behavior disorders, and even severe mental illness symptoms. The disease may impose an effect on their caregivers’ lives. In 2018, there were about 50 million people with dementia and it was speculated this number may increase to 152 million by 2050.[1] Among the elderly aged 65 years and above, the incidence of dementia was 5.60% in 2019.[2] In China, dementia is mainly diagnosed by neurologists, but they are unable to provide long-term management. As the gatekeeper of residents’ health, general practitioners (GPs) can provide full medical service to dementia patients.[3,4,5] However, very few Chinese GPs actually carry out the diagnosis and management of dementia.[6,7] The main purpose of this study is to assess GPs’ knowledge of dementia and difficulties encountered in management of dementia. Then we can carry out relevant training and policy support, so as to improve the diagnosis and treatment level of GPs, and also improve the early recognition rate of high-risk groups of dementia and ensure the long-term management of post-diagnosis dementia patients. It can further provide reference for better community-centered management of dementia patients in the future.

Methods

We carried out a wechat-based online questionnaire survey from January 2021 to July 2023. The self-designed questionnaire mainly includes items on dementia presentations, etiology for dementia, diagnostic methods, screening methods and ways of health education, difficulties encountered, attitudes toward dementia management, and so on. The online questionnaire was sent to the wechat group of GPs, and GPs participated in the questionnaire survey on a voluntary principle. In order to ensure the quality of the questionnaire, a minimum completion time was set up. This study was approved by the XXX affiliated hospital of XXX university.

Statistical analysis

Continuous data are described by means with standard deviation (SD), and categorical data are presented as count and percentage. Demographic data were analyzed using descriptive statistics. All statistical analyses were conducted with SPSS 22.0. The Kolmogorov–Smirnov test was conducted to assess normality of continuous data. Comparisons between groups were tested using the Kruskal–Wallis H or Mann–Whitney U. The statistical significance was set at 0.05.

Results

General information

A total of 120 GPs were recruited to survey. The general characteristics of the participants are shown in Table 1. Most were aged ≤30 years old. A higher proportion of respondents were women (60.8%). The years of community work were mainly <3 years and ≥8 years.

Table 1.

The general characteristics of the participants and GPs’ attitudes and understanding toward dementia

	n	Percentage
Age
≤30	42	35
30-40	35	29.2
40-50	30	25
≥50	13	10.8
Sex
Female	73	60.8
Male	47	39.2
Position
Resident	62	51.7
Attending doctor	48	40
Associate Chief Physician	10	8.3
Years of community work
<3	49	40.8
3-5	7	5.8
5-8	8	6.7
≥8	56	46.7
Inpatient ward
Yes	64	53.3
No	56	46.7
Dementia screening clinic
Yes	23	19.2
No	97	80.8
Identification of symptoms
Patients	10	8.3
patients’ family members	110	91.7
Admissions from dementia patients
Yes	62	51.7
No	58	48.3
Understanding the Meaning of Cognitive Function
Yes	94	78.3
No	26	21.7
GPs training
Yes	70	58.3
No	50	41.7
Importance of dementia prevention
Yes	116	96.7%
No	4	3.3%
Importance of dementia screening
Yes	117	97.5
No	3	2.5%
Discovery of dementia symptoms
Patient	10	8.3%
patients’ family members	110	91.7%
Distinguishing between forgetfulness and dementia-related cognitive impairment
Yes	116	96.7%
No	4	3.3%
Willingness to follow up with dementia patients
Yes	103	85.8
No	17	14.2

GPs’ knowledge of dementia

The total score of dementia knowledge was mainly counted from six aspects: overall symptoms, etiology, specific symptoms, diagnostic techniques, treatment, and screening methods. The percentages of correct answers were 86.67% for overall symptoms, 30.83% for specific symptoms, 39.17% for etiology, 27.5% for diagnostic methods, 41.67% for treatment, and 55% for screening methods. One point is awarded for each correct choice, and the scores from the six sections are then added together to get the total score. The average score was 22.5, ranging from 9 to 30. The full score is 30 points.

(1) Overall symptoms

Respondents were asked to select the symptom classifications of dementia from three options, which were impaired ability of daily living, mental and behavioral symptoms, and cognitive impairment. The percentage of correct answers was 86.67% (104/120), and mental and behavioral symptoms were chosen by 95% respondents, cognitive impairment by 91.7%, and impaired ability of daily living by 90.8%.

(2) Specific symptoms

Regarding the specific symptoms of dementia, the highest chosen options were decreased recent memory (95%) and decreased judgment and calculation (93.3%) by all participants. The lowest chosen options by all participants were decreased distant memory (53.3%) and anxiety and depression (45.8%). The percentage of correct answers was 30.83% (37/120). The proportions of each item identified by the participants as the dementia symptoms are presented in Figure 1.

Figure 1.

The proportions of each item identified by GPs as the dementia symptoms

(3) Etiology and risk factors

Most of the participants (76.67%, 92/120) identified at least four causes, but only 39.17% respondents identified all causes. Among the common causes, “degenerative diseases of the nervous system” was endorsed by the most respondents (95.8%), followed by cerebrovascular diseases (90%), metabolic diseases (72.5%), brain trauma (70%), central nervous system infections (66.7%), brain tumors (65.8%), alcoholics (58.3%), and vitamin B12 or folate deficiency (52.5%).

(4) Diagnostic methods

Respondents were asked to select the diagnostic method of dementia from five options, which were medical history, dementia-related scale, cranial imaging examination, biochemical examination, and comprehensive physical examination. The correct answer rate is 27.5% (33/120). The most chosen diagnostic method was medical history (95.8%), followed by dementia-related scale (91.7%), cranial imaging examination (67.5%), comprehensive physical examination (55%), and biochemical examination (34.2%).

(5) Treatment

Respondents were asked to select the therapeutic method of dementia from four options, which were drug, psychological counseling, cognitive rehabilitation, and diet therapy. The overall correct answer rate is 41.67% (50/120). The most chosen treatment was cognitive rehabilitation (94.2%), followed by drugs (93.3%), psychological counseling (87.5%), and diet therapy (46.7%).

(6) Screening method

Respondents were asked to choose the most commonly used screening method from four options including neuropsychological scale evaluation, questionnaire survey, ultrasound, and brain MRI. 55% participants chose neuropsychological scale evaluation as the most important screening method.

What kind of health education method do you think can improve residents’ attention to dementia

The proportions of each item identified by the participants as the effective education method are presented in Figure 2.

Figure 2.

The proportions of each item identified by GPs as the effective education method

Screening methods used

Respondents were asked to select the dementia screening tool they used from four options, namely, clock drawing test, MMSE, MoCA, and the General Practitioner Assessment of Cognition (GPCOG). 88.3% GPs used GPCOG for the diagnosis of dementia, 24.2% for MMSE, 13.3% for clock drawing test, and 10% for MoCA. Only 10 GPs selected all four screening methods.

Is there any training on the identification, diagnosis, and treatment of dementia in the community? Respondents were asked to choose one of two options: “Yes” and “no”

26.7% GPs chose “yes.”

Is there any relevant content on the identification, diagnosis, and treatment of dementia in the forums or lectures that we have attended?

66.7% GPs said that there were no relevant contents on the identification, diagnosis, and treatment of dementia.

Training needs of community medical staff on dementia-related knowledge

The knowledge about dementia they expected to know was prevention of dementia, followed by selection and application of dementia screening tools, general treatment of dementia, risk factors of dementia, care and social support strategies for dementia patients, and identification of predementia and early symptoms in sequence. The proportions of each item identified by the participants as a training need for dementia are presented in Figure 3. A total of 95% respondents thought that they were not well informed of dementia prevention, and most respondents (92.5%) preferred receiving training on selection and application of dementia screening tools.

Figure 3.

The proportions of each item identified by GPs as the training need for dementia

Difficulty in dementia prevention and treatment for community medical staff

The section of the questionnaire asks the respondents whether they had some difficulties in dementia prevention and treatment. Participants were asked to tick their difficulty in the questionnaire. The main difficulties were insufficient professional support for dementia prevention and treatment (90%), their own lack of professionalism and qualifications (86.7%), insufficient concern of residents (85%), and lack of time (75%). The proportions of each item identified by the participants as the difficulties are presented in Figure 4.

Figure 4.

The proportions of each item identified by the participants as the difficulties

Do you think it is necessary to improve your professional knowledge and treatment skills for cognitive impairment? Respondents were asked to choose one of three options: “very important,” “important,” and “not important”

73.3% GPs chose “very important,” and 26.7% chose “important.”

The scores of dementia knowledge between GPs with different characteristics

There were no significant differences in dementia knowledge score between GPs with different characteristics, including training, sex, professional title, age, and working years in the community [Table 2].

Table 2.

The scores of dementia knowledge between GPs with different characteristics

	X̄±S	χ²/Z	P
Training
Yes	22.54±4.74	-0.072	0.943
No	22.44±5.28
Sex
Male	21.43±5.32	-1.648	0.099
Female	23.19±4.65
Professional title
Resident	21.70±5.38	2.579	0.275
Attending	23.09±4.45
Associate chief physician	23.36±4.07
Age
≤30	22.05±5.90	1.51	0.68
30-40	22.14±4.41
40-50	23.10±4.20
≥50	23.54±4.81
Working years in community
<3	21.92±5.53	2.149	0.542
3-5	21.43±4.31
5-8	22.13±4.49
>8	23.20±4.56

Discussion

China has a high incidence of dementia, and with the rapid aging of China, the situation will become more serious among older adults.[8] By 2030, the annual cost for dementia is estimated to reach 2 trillion dollars.[9] Dementia is now being paid more attention, and the country is implementing policies and strategies for prevention, early diagnosis, and long-term care.

However, dementia seems to have been lowly detected and not optimally managed in primary care.[10] The diagnostic rate in primary care still needs to be improved. In China, less than 10% of patients with dementia were diagnosed through GPs’ dementia screening services.[11] In Germany, the identification rate of dementia in primary health care institutions was lower than 40%.[12] In developing countries, caregivers of people with dementia rarely seek help from GPs.[13] In this study, most GPs reported that they encountered very few dementia cases, which was consistent with previous research.[11,13] The low consultation rate of dementia patients in the community may be based on three reasons: First, although the caregivers noticed some symptoms of dementia, they thought it might be a normal aging phenomenon; second, they sought help from a neurologist at a tertiary hospital; third, there is insufficient understanding of the symptoms of dementia among GPs. Therefore, it is necessary to popularize the knowledge of dementia and improve the diagnostic capacity of GPs.

In this study, 73.3% of the respondents reported the community did not hold dementia-related training. One study found only 15.2% GPs had participated in relevant training of dementia in the past year.[14] In the usual trainings, only 33.3% respondents said the knowledge of dementia was involved. In this study, more than 88% GPs have a great demand for dementia knowledge training, such as risk factors prevention, screening methods, diagnosis, and treatment, which is similar to previous studies.[15,16] Mythily Subramaniam found dementia education and training was an important first step in equipping GPs as qualified dementia managers in Singapore.[16]

Evidence proved that GPs could benefit from the professional dementia training.[17] In the future, it is urgent to provide opportunities for GPs to receive professional training. In this study, GPs’ knowledge of dementia symptoms, diagnosis, treatment, screening methods, and etiology needs to be improved, which was consistent with previous studies.[18] The level of dementia knowledge was not influenced by gender, age, or working years in the community. Some studies found significant associations of the knowledge test score with the GPs’ age.[19,20] Different research results may result from the complexity and diversity of knowledge.

Early detection of symptom is one of the most important determinants for the early treatment. So, it is significant to grasp the common and rare symptoms of dementia. In this study, these symptoms were recognized by less than 85% of responders, including decreased distant memory, the same question asked repeatedly, decreased memory recalled by reminder, difficulty in performing some familiar household affairs, anxiety, and depression. One study found some GPs failed to identify some syndrome of dementia patients.[14] For the overall symptoms of dementia, the percentage of correct answers was 86.67%. The selection rate of mental and behavioral symptoms was the lowest (91.7%). Hence, we should focus on strengthening GPs’ recognition of the specific symptoms of dementia.

The diagnosis of dementia is based on a combination of different examinations including neuropsychological tests, brain imaging techniques, CSF, and blood testing.[21] In this study, GPs are not well aware that the diagnosis of dementia requires a comprehensive assessment of multiple methods. In addition to the scales, imaging, medical history, and blood tests are also important.

Dementia is a disease that progresses slowly, which means that the diagnosis is possible in the years before symptoms appear. So, the usage of screening tools plays an important role in the early diagnosis of dementia.[22,23] In this study, more than half of GPs can recognize the importance of neuropsychological screening scales. 88.3% of respondents reported that the General Practitioner Assessment of Cognition (GPCOG) was commonly used in primary care, and the result can be supported by one study which considered GPCOG was more appropriate for routine use in primary care.[19] The result was inconsistent with one study which found that the low identification rate of dementia was due to a lack of knowledge about screening tools; the reason may be the fact that different screening tools were selected.[14]

The selection rate for every cause and risk factor is above 50%, but awareness of vitamin B12 or folic acid deficiency and alcoholics as risk factors still needs to be improved. At present, low concentrations of serum folate or vitamin B12[24] and alcohol[25] were recognized as the risk factors of dementia. There have been few studies investigating GPs’ knowledge of the causes of dementia, particularly with regard to vitamin deficiencies.

Medications have a modest beneficial impact on neuropsychiatric and functional outcomes for patients with dementia.[26] However, the treatment of dementia also requires symptom modification, such as nonpharmacological interventions to ameliorate cognitive and neuropsychiatric symptoms.[27] In this study, 93.3% participants considered medications can be a treatment method for dementia. Psychological counseling and cognitive rehabilitation were also recognized as the treatment methods by most GPs.

The main difficulties identified by GPs were insufficient professional support for dementia prevention and treatment,[28,29] their own lack of professionalism and qualifications for dementia,[30] insufficient cognition and concern of patients,[31,32] and lack of time,[28,29] which were consistent with previous reports. Hence, in addition to strengthening professionalism of GPs, it was also necessary to improve the concern of residents to dementia and related knowledge. In this study, GPs considered the dementia knowledge should be well publicized through some health education delivery format, such as health talks, promotional videos, and so on. In all, the government, media, and medical institutions, and the communities should make joint efforts to better popularize knowledge of dementia, including opening more specialized dementia clinics. In this study, only 19.2% respondents reported there was a dementia screening clinic in their communities.

This study has some shortcomings, such as the small number of participants, and the single-center study results cannot represent the knowledge level and attitudes of GPs in the entire Chinese community. In future, we will conduct multicenter, multiarea assessments on GPs’ knowledge of all aspects of dementia.

In all, the knowledge level of dementia among the GPs is poor. Some difficult factors exist for GPs during the overall management of dementia. However, the attitude of GPs to the prevention and treatment of dementia is positive. The study can provide reference for the strategy development of prevention and treatment of dementia.

Conflict of interest

There is no conflict of interest

Fundings

There is no funding