Dementia Diagnosis and Management in Primary Care

Dementia diagnosis and management Dementia,2002 1(1): 11-23 Dementia diagnosis and management in primary care: developing and testing educational models ABSTRACT Dementia presents a challenge for primary care and the advent of new therapeutic options has highlighted the need to improve its detection so that early decisions about medication use can be made. Efforts at earlier diagnosis should be targeted at primary care as the gateway to specialist health and social services. There is, however, evidence that dementia remains under-detected and sub-optimally managed in general practice throughout the world. This paper reviews the obstacles to early recognition of dementia and the factors causing suboptimal management in the community, and discusses educational approaches to enhancing professional skills in the recognition of and response to dementia. Three educational interventions with different characteristics and methods of delivery are described. KEY WORDS dementia, early diagnosis, adult learning, problem based learning, reflective practice Iliffe Steve*, Wilcock Jane*, Austin Tony**, Walters Kate*, Rait Greta*, Turner Stephen***, Bryans Michelle*** & Downs Murna**** *Department of Primary Care & Population Sciences, RFUCLMS ** Centre for Health Informatics & Multiprofessional Education, UCL *** Centre for Social Research on Dementia, Dept. of Applied Social Science, University of Stirling **** Bradford Dementia Group, School of Health Studies, University of Bradford Correspondence to: Dr Steve Iliffe, Department of Primary Care & Population Sciences, Royal Free & UCL Medical School, Royal Free Campus, Rowland Hill St., London NW3 2PF Tel: 0207 830 2393 Fax: 0207 830 2339 email s.iliffe@pcps.ucl.ac.uk 1 Dementia diagnosis and management Dementia,2002 1(1): 11-23 INTRODUCTION Dementia presents a challenge for primary care, with its’ rising prevalence, often insidious onset, difficulties in early diagnosis and a generally unremitting and progressive course. The advent of new therapeutic options have highlighted the need to improve detection and management of people with dementia, so that early decisions about medication use can be made. Early diagnosis is imperative, allowing for individual patients and their carers to be informed and appropriate management instigated, allows planning for the future, and for preliminary introduction to appropriate agencies and support networks. These can relieve the significant psychological distress that carers may experience (Levin, Sinclair &Gorbach, 1989), and knowledge of the availability of medical and psycho-social support may even improve morale without support being called upon (Briggs, 1993). Efforts at earlier diagnosis should be targeted at primary care, as the first point of contact for most individuals and their carers, and as the gateway to specialist health and social services. There is, however, evidence that dementia remains under-detected and sub-optimally managed in general practice (O'Connor, Pollitt, Hyde, Reiss, Roth, 1988; Iliffe, Booroff, Gallivan, Goldenberg, Morgan, Haines, 1990). The situation may be improving because of (among other factors) the work of Alzheimer Disease Societies and similar bodies in raising public and professional awareness, but all experience suggests that significant obstacles remain. Although there is much enthusiasm for developing educational programmes for primary care there has been no review of the educational theory and practice that could underpin such programmes. This paper describes how a multi-disciplinary research team are trying to answer the question: How can we develop and implement an evidence-based educational process to change the practice of primary care practitioners of different disciplines in the recognition of and response to dementia? We will review barriers to recognising dementia, what learning theory tells us about learning about dementia, describe the problems of current approaches, and outline different educational methods that can be tested in experimental studies. 2 Dementia diagnosis and management Dementia,2002 1(1): 11-23 BARRIERS TO RECOGNITION OF DEMENTIA What are the difficulties with diagnosing and managing dementia in the community? A broad range of factors are likely to be important (De Lepeleire & Heyrman, 1999; Iliffe, Walters, Rait, 2000), which are summarised in table 1. Table 1: Factors contributing to under diagnosis and sub-optimal management of dementia 1. LOW INCIDENCE AND SCIENCE BIAS The low incidence of dementia offers limited opportunities to learn from experience. A focus in the scientific literature (particularly in systematic reviews) upon prescribing and preventive medicine, and only on selected chronic diseases (like asthma and diabetes) 2. PATIENT FACTORS delay in self-referral to primary care, due to stigma, fatalistic attitudes, etc. 3. PRACTITIONER FACTORS psycho-socio-biological disorder. the complexity of dementia as a ¾ the absence of certainty factors, like diagnostic tests or monitoring measures equivalent to blood pressure, glycosylated haemoglobin or peak flow rate. ¾ the limited nature of professional training in disorders of later life in the current generations of general practitioners ¾ the limited qualitative research evidence available about barriers to considering, diagnosing and treating dementia. 4. AGE BIASES The relative neglect of research on health and illness in older people, and the research bias towards physical rather than mental health issues. 5. SYSTEM ISSUES AND SERVICE FACTORS Lack of consensus of an assessment protocol. The discrepancies and lack of comprehensive services between localities Incidence, prevalence and a Science bias A general practitioner working in an area of average demography with a list of 2000 patients will see one or two new cases of dementia a year, and have 10 or 12 existing cases. This low incidence and prevalence makes learning from experience difficult, particularly given the very variable presentation of the dementias. 3 Dementia diagnosis and management Dementia,2002 1(1): 11-23 Patient and Carer Factors GPs may not recognise patients with early dementia for multiple and complex reasons. Most notably related to the variable expression of the disease process in individuals, and the variety of ways in which carers and people with dementia compensate for changes in cognitive function and ability (Bair, 1998). Individuals with cognitive impairment may view symptoms such as memory loss as normal for their age (Pollitt, 1996), and close carers may also accept some of the early characteristics of dementia, like cognitive changes, functional loss or emotional lability, as part of ageing. Carers may compensate for an affected individual’s loss of function with the result that early changes may be ignored until they impact on the household economy (or household functioning) significantly, or may not tackle the issue out of respect for their spouse or parent (Antonelli Incalzi, Marra, Gemma, Capparella, Carbonin, 1992). Those from higher socio-economic groups are more likely to seek medical attention earlier, and cultural background may influence early detection (Pollitt, 1996). The result of all these interactions is often an acute presentation of dementia with ‘confusion’ at moments of crisis, for example when a spouse or carer dies or becomes disabled. Nevertheless, carers may be the first to reach the diagnosis (O'Connor, Pollitt, Brook, Reiss, 1989), even if they do not voice it or act upon it, so informant histories are crucial to investigating any suspicion of dementia that a general practitioner may have. Practitioner factors A range of factors related to characteristics of primary care militate against the early identification of dementia by primary health care professionals. Many diagnoses of chronic illness in primary care are made on the basis of more than one consultation, using a hypothetico-deductive diagnostic process. This dynamic approach allows the GP to generate and test hypotheses and investigate over time. The practitioner requires an index of suspicion to construct a diagnosis, which is frequently ‘triggered’ by a symptom within the patient’s story. Therefore, if practice staff are unaware of the early signs of dementia they are not likely to contemplate the diagnosis. Similarly, if primary care nursing staff are unaware of the early signs, they are not likely to report a suspicion of dementia to the patient’s GP. For example, general practitioners tend to consider memory loss as the cardinal symptom of dementia, although loss of function rather than memory loss may be the earliest change (De Lepeleire, Heyman, Buntinx, 1998; De Lepeleire, Heyman, Baro, Buntinx, Lausy, 1994). The use of screening instruments cannot compensate for a lack in the specific diagnostic skills that are required to confidently diagnose dementia. Even when GPs use tests to measure cognitive function, it does not necessarily alter the management of cases identified (Iliffe, Mitchley, Gould, Haines, 1991). 4 Dementia diagnosis and management Dementia,2002 1(1): 11-23 Age Bias Dementia is a complex syndrome that occurs at an age when other morbidity may be present. The absence of a definitive test can make general practitioners feel less confident in the accuracy of early diagnosis. They may also be concerned about the implications to patients and families of early diagnosis, or be especially concerned about the risk of ‘false positive’ diagnoses in a climate which increasingly encourages early disclosure, and when a wrong diagnosis may impact significantly on patient care. This is illustrated by a prevalence study of dementia in which the sensitivity of general practitioners’ diagnoses rose significantly when they used a broader label of cognitive impairment (Eefsting, Boersma, Van den Brink, Van Tilburg, 1996). Diagnostic thinking may also be inhibited by the inexorable course of the dementias, and there is some evidence that practitioners may respond to the possibility of dementia as a diagnosis with disbelief, denial, apprehension, and fear, particularly if they have known their patient for some time (De Lepeleire et al, 1994). System Issues and Service Factors There is no consensus on the optimum methods for assessing dementia in primary care (Toner, 1992) and it has been suggested that a primary care specific assessment is required (De Lepeleire et al, 1998) although there is no evidence to support whole population screening for cognitive impairment with the tools currently available. Similarly there is a lack of knowledge about the most effective ways to manage people with dementia in primary care, particularly how to integrate services across budgets and specialities, and this may have a negative inhibitory effect on the willingness of practitioners to recognise dementia. OVERCOMING BARRIERS: AN EDUCATIONAL AGENDA The lessons may be clear, but how can they best be learned? What needs to be learned about complex management issues like medication use, challenging behaviour and legal responsibilities? An educational agenda has been outlined (Downs, 1996), but its implications for training programmes have not yet been fully investigated and tested. A recent King’s Fund report on the future of GP education states “continuing education must be relevant and engaging, and it must meet their needs: there must be something in it for them, and it must take account of their maturity” (Gillam, Eversley, Snell, Wallace, 1999), which for us summarise the need to adopt an adult education approach rather than the more common 5 Dementia diagnosis and management Dementia,2002 1(1): 11-23 didactic approach that emphasises the inferiority of generalist experience and the importance of specialist expertise. There appear to be six important components to any educational process that will change professional practice in a domain as complex as dementia. 1. Practitioners must identify their own learning needs, and make the first step towards seeking knowledge (Grant, Stanton, Flood, Mack, Waring, 1998). Such awareness of learning needs and motivation to update skills and knowledge is linked to an estimation of expected benefit, both to the practitioners and their patients (Willis & Dubin, 1990), which itself depends on recognition of under-performance or lack of knowledge. This approach is the opposite of the type of education in which practitioners opt for topics with which they feel comfortable, and about which they already know much. Knowles’ principles of andragogy state that adult learners should be involved in diagnosing their own learning needs, formulating their own objectives, identifying resources and evaluating their learning (Knowles, 1980). 2. Learning should be about enhancing performance, emphasising both the resolution of clinical concerns and better outcomes for patients (Nowlem, 1988), and valuing the application of knowledge more than its acquisition. In the case of the difficult, complex and sometimes ill-defined problems encountered with dementia, such learning can be viewed as the essence of professionalism (Eraut, 2000). 3. Learning needs to be integrated with practice, in terms of convenience, relevance, individualisation, self-assessment, interest, speculation about controversial areas and systematic coverage of the issues (Harden & Laidlaw, 1992). Kolb’s (1984) experiential learning theory concludes that learning is best achieved by relating concrete practice to conceptual models. 4. Learning should focus on solving problems (Brookfield, 1986), and explicitly recognise complexities, uncertainties and conflicting values (Cervero, 1988). The more complex the problems to solve, the more realistic can practitioners’ “illness scripts” (templates for disease processes) (Feltovitch & Barrow, 1984) become, allowing the accurate allocation of cases to scripts (through pattern recognition) and the enrichment of the scripts as case memory increases with experience. Empirical evidence supports this model of learning, in that interventions that are multifaceted and that target different barriers to change have been shown to be more effective than single interventions (NHS, 1999). Approaches that emphasise simple tasks, like using a brief screening instrument for recognition of cognitive impairment, are unlikely to make much difference to practice. 6 Dementia diagnosis and management Dementia,2002 1(1): 11-23 5. Peers and colleagues can be the most effective educators (Nowlem, 1988), especially if they use a coaching rather than a didactic approach (Schon, 1987). However, there may be limits on who is included as peer or colleague, given the lack of support for multiprofessional learning. General practitioners seem reluctant to learn with other professionals, although willing to learn from them (Grant & Stanton, 2000). 6. Learning requires a mixture of formal (didactic) and informal (experiential) styles (Durno & Gill, 1974; Reedy, 1979), corresponding to a mix of propositional (factual) and experiential knowledge (Eraut, 2000). These components of effective professional education suggest that no simple educational package will work, and that a mixture of approaches, with a significant capacity to tailor and individualise styles and methods, may be necessary. For curriculum planners the questions are how much formal and informal learning is best, how far can inter-professional learning develop given that there may be wide differences in baseline knowledge between disciplines, how much complexity is possible in a clinical domain where knowledge may be very limited, and where and by what means will practitioners learn most efficiently and effectively? For dementia there is some empirical evidence available to guide curriculum development. Improving professional awareness in primary care about dementia can be achieved through educational interventions delivering evidence-based guidelines. An example of this is the ‘Action on Alzheimer’s’ programme, which used the existing evidence base as a core curriculum for a nation-wide programme of one day workshops on dementia diagnosis and management, in 1997. The programme was organised around multidisciplinary working groups undertaking problem-solving tasks using scenarios of patients with possible or actual dementia, and was successful in recruiting large numbers of general practitioners and other primary care staff (Iliffe, Eden, Downs, Rae, 1999). In effect, the ‘Action on Alzheimer’s’ programme tested the acceptability and feasibility of multidisciplinary training in dementia care, using a mixture of formal and informal learning styles and a core method of problemsolving. However, we do not yet know if this approach actually changes clinical practice. Some relevant studies concerning diagnosis or prescribing have demonstrated improved outcomes following educational interventions (Pond, Mant, Kehoe, Hewitt, Brodaty, 1994; Yeo, Deburgh, Letton, Shaw, Donnelly, Swinburn, Phillips, Bridgeswebb, Mant, 1994), but they 7 Dementia diagnosis and management Dementia,2002 1(1): 11-23 can be criticised on methodological grounds and may not give an accurate picture of what is possible in normal care settings. Barriers to and constraints on change when implementing evidence exist at environmental and personal levels, as well as in professional education, service organisation and wider society (Haines & Donald, 1998). Many factors may affect evidence uptake and implementation, but the interplay between evidence, the context of practice and facilitation of learning around case studies appears to be a potentially powerful lever for change (Kitson, Harvey, McCormack, 1998). Case studies and case series have been overshadowed by the emergence of evidence-based medicine and its preference for rigorous experimentation, but may be the key to facilitating evidence-based practice (Van den Broucke, 1999). Self-directed learning, involving the learner as an active participant, is the educational strategy that has been suggested is most likely to promote ‘life-long learning’ and encourage doctors to respond to the changing needs of their patients (Spencer & Jordan, 1999). We know what to do, even if we are unsure how to do it. Guidelines summarise and outline the evidence for the practitioner, and several guidelines for the diagnosis and management of dementia in primary care have been published (Eccles, Clarke, Livingston, Freemantle, Mason, 1998; Alzheimer's Disease Society, 1995; Scottish Intercollegiate guidelines network, 1998). Current evidence-based guidelines have been criticised for being out of date and excluding recent drug information (Matthews, Wilkinson, Holmes, 1999), for excluding qualitative research, omitting the differential diagnosis of Alzheimer’s disease and vascular dementia (Eastley, Haworth, Wilcock, Sharp, 1999), and for not explaining the difference between - ‘lack of effectiveness’ and ‘lack of evidence of effectiveness’. Nevertheless, we have a body of evidence, however incomplete. How can we implement an educational process using such knowledge, to change the practice of primary care practitioners of different disciplines in the recognition of and response to dementia? DEVELOPING AN EDUCATIONAL PROGRAMME Our method has been to take three approaches from within the body of knowledge about optimal learning styles and develop educational tools for each, all based on a common curriculum derived from the evidence base. Whilst all three approaches stem from the same need to resolve clinical problems in ways that are compatible with the demands of routine clinical practice, each emphasises different aspects of learning. The options are: 8 Dementia diagnosis and management Dementia,2002 1(1): 11-23 1. COMPUTER DECISION SUPPORT Learning driven by real cases, using a computer decision support system (CDSS) to prompt and assist clinical reasoning and care planning in real clinical time. The CDSS can be invoked by the practitioner as needed, but will also prompt thinking about dementia when relevant clinical terms (e.g. confusion, wandering) are entered onto the clinical record in EMIS. In the Scottish equivalent, the practitioner is prompted into thinking about dementia by the visual presence of a tab in the GPASS consulting screen entitled ‘Dementia DSS’ which makes the CDSS available for use for all patients aged 75 and over. In both systems it functions as a set of illness scripts within the patient record, and also as a source of propositional knowledge about, for example, medication use or causes of behaviour disturbance. 2. SMALL GROUP PROBLEM BASED LEARNING Learning from case discussion in small, multi-disciplinary groups. Learning from the discussion of problematic cases may allow rapid modification of illness scripts, especially when different disciplines offer different perspectives, and when novices can draw upon the experiences of expert practitioners and each role is emphasised as important. 3. ELECTRONIC TUTORIAL Learning from case analysis, with the emphasis on reflecting on knowledge and revisiting particularly difficult and complex clinical problems, using an electronic tutorial on a CD-ROM. The tutorial is an electronic book, with an indexing system that allows easy access to different themes, and hypertext links that allow the reader to move easily from one subject to another. The tutorial contains the same cases used in the small groups, and readers can work their way through these cases, answering questions to check that they are learning. This technology was chosen because it allows flexible, non-linear reading of information combined with both interactive testing of judgements and observation of others in consultations (using video clips) The different approaches have some characteristics in common (e.g. all are based on problemsolving as a method of learning) but also permit different combinations of educational techniques. For example, learning from peers' experience can occur directly in small group problem based learning, indirectly through observation of others, in a video clip in the electronic tutorial, and distantly with the computer decision support only in that it expresses expert opinion. In table 2 we compare and contrast some of the key educational characteristics of these three approaches, using themes derived from the analysis on pages 6 and 7, in 9 Dementia diagnosis and management Dementia,2002 1(1): 11-23 particular from the components of adult learning described by Harden and Laidlaw (Harden & Laidlaw, 1992). These themes are: convenience; relevance; tailoring; self-assessment; level of engagement; speculation about controversy; obsolescence; systematic coverage of issues; and learner motivation. The development of the curriculum from the evidence base, and its customisation for each approach is described elsewhere (Wilcock et al, 2003). Table 2 Characteristics of the educational interventions Educational characteristic Small groups workshops CD-ROM tutorial Computer decision support Convenience Practice based setting Practitioner derived setting Timing decided by practitioner Use during or after consultations controlled by practitioner Case-based Uses experiences of other practitioners, including specialists Non-linear pathways allow individual to exert selective and variable use of material Self-testing available which allows revision of topics Case-driven Can be used during consultations Designed for visual impact, with video clips and positive reinforcements for tests of knowledge In-depth exploration in tutorial content, but can be avoided by the practitioner Web pages readily updateable Tutorial pages reflect work book content, but practitioner does not need to work through all pages High: user controlled technology Case driven, customisable to patient Timing decided by practice Relevance Individualisation to practitioners' needs Self-assessment Level of engagement Case-based Uses group members' own experience Learning experience can be experiential for the group and individual Group discussion can focus on gaps in knowledge Pace of learning variable New material arises in group discussion Speculation permitted (recognition of grey areas and controversies) Actively encouraged in group work Level of obsolescence Curriculum can be readily updated Groups work through a standard curriculum, in a work book Systematic Motivational level Low: attendance at group is minimum requirement Individualised to patient's circumstances rather than to practitioners' needs System prompts for required information not yet documented Limited expression in text advice on-screen Protocol script updateable All themes in work book represented in a group of consultation templates, these can be bypassed High: user must incorporate CDSS into consultations 10 Dementia diagnosis and management Dementia,2002 1(1): 11-23 These three approaches to learning are now being tested in a randomised controlled trial funded by the Alzheimer's Society in 40 practices in the rural area around Stirling and in London, with a control group of practices providing usual care and receiving no educational intervention. Recognition of dementia, and concordance with guidelines in its management, are being measured before and after the educational interventions by document analysis of medical records. Carer satisfaction is also being measured before and after the educational interventions. CONCLUSION Primary care is the focal point for early detection and co-ordination of care for people with dementia. A range of barriers has been identified to delivering the highest quality dementia care. An educational agenda that is practical, evidence-based and relevant to both medical and nursing primary care practitioners is needed to address these barriers. Case-based learning led by the practitioners themselves appears to be the best way to deliver this agenda, but it is not yet clear which approaches to knowledge acquisition about dementia are most effective in primary care settings. Does effective education about dementia depend on the exchange of experiences and a collective approach to problem-solving that can occur in a well facilitated small group, or are more individual learning styles equally effective, whether in the form of a tutorial or decision support for use in the consultation? The randomised trial of different educational approaches currently underway will help to answer these questions. ACKNOWLDEGMENTS The project management group comprising the following members in addition to the authors: Dr J Keady, School of Nursing and Midwifery Studies, Faculty of health Studies, University of Wales, Bangor; Ms E Levin, National Institute for Social Work, London; Professor R O’Carroll, School of Psychology, University of St Andrews; Dr R Simpson, MSP We thank Martin Campbell of Campbell Software (www.campbellsoftware.co.uk) for writing the API module and translating the CDSS into GPASS. Funding: The study has been funded by the Dykes Award from the Alzheimer’s Society. 11 Dementia diagnosis and management Dementia,2002 1(1): 11-23 References Alzheimer’s Disease Society (1995). Managing dementia in the community. London. Antonelli Incalzi R, Marra C, Gemma A, Capparella O, Carbonin PU (1992). Unrecognised dementia; sociodemographic correlates. Aging (Milano), 4(4): 327-32 Bair, B. (1998). Frequently missed diagnosis in geriatric psychiatry. In Tomb D (ed.) The Psychiatric Clinics of North America, 21: 941-972 Briggs, R (1993). Comment: Alzheimer's disease- your views. Geriatric Medicine, 23(1): 40-1 Brookfield SD (1986). Understanding and facilitating adult learning. Open University Press, Buckingham. Cervero RM (1988). Effective continuing education for professionals. Jossey Bass, San Francisco. De Lepeleire J & Heyman J (1999). Diagnosis and management of dementia in primary care at an early stage: the need for a new concept and an adapted structure. Theoretical Medicine & Bioethics, 20:215-228 De Lepeleire, J., Heyman, J and Buntinx, F. (1998). The early diagnosis of dementia: triggers, early signs and luxating events. Family Practice, 15: 431-436. De Lepeleire, J., Heyman, J., Baro, B, Buntinx, F and Lausy, C. (1994). How do general practitioners diagnose dementia? Family Practice, 11: 148-152. Downs, M. (1996). The role of general practice and the primary care team in dementia diagnosis and management. International Journal of Geriatric Psychiatry, 11, 937-942. Durno D & Gill M (1974). Survey of general practitioners’ views on postgraduate education in north east Scotland. J Royal Coll Gen Practitioners, 24, 648-54 Eastley R, Haworth J, Wilcock G & Sharp D (1999). Guideline should cover differential diagnosis. British Medical Journal, 318:731 Eccles, M., Clarke, J., Livingston, M., Freemantle, N and Mason, J. (1998). North of England evidence based guidelines development project; guideline for the primary care management of dementia. British Medical Journal, 317: 802-808. Eefsting JA, Boersma F, Van den Brink W, Van Tilburg W (1996). Differences in the prevalence of dementia based on community survey and general practitioner recognition. Psych Medicine, 26:1223-30 Eraut M (2000). Developing professional knowledge and competence. Falmer, London, p152. 12 Dementia diagnosis and management Dementia,2002 1(1): 11-23 Feltovitch PJ & Barrow HS (1984). Issues of generality in medical problem solving. in Schmidt HG & De Volder ML (eds) Tutorials in problem-based learning. Van Gorcum, Assen, p128-42. Gillam S, Eversley J, Snell J, Wallace P. (1999). Building Bridges: the future of GP education – developing partnerships with the service. Kings Fund, London. Grant J & Stanton F (2000). The effectiveness of continuing professional development. The Association for the Study of Medical Education, Edinburgh. Grant J, Stanton F, Flood S, Mack J, Waring C (1998). An evaluation of educational needs and provision for doctors within three years of completion of training. Joint Centre for Education in Medicine, London. Haines A & Donald A (1998). Making better use of research findings. British Medical Journal, 317:72-5 Harden RM & Laidlaw JM (1992). Effective continuing education: the CRISIS criteria. Medical Education, 26:408-22 Iliffe S, Booroff A, Gallivan S, Goldenberg E, Morgan P, Haines A (1990). Screening for cognitive impairment in the elderly using the mini-mental state examination. British Journal of General Practice, 40 (336): 277-279. Iliffe S, Eden A, Downs M & Rae C (1999). The diagnosis and management of dementia in primary care: development, implementation and evaluation of a national training programme. Aging & Mental Health, 3(2): 129-135 Iliffe S, Walters, K & Rait G (2000). Shortcomings in the diagnosis and management of dementia in primary care: towards an educational strategy. Aging and Mental Health, 4(4): 286-291 Iliffe, S., Mitchley, S., Gould, M and Haines A. (1991). Evaluation of the use of brief screening instruments for dementia, depression and problem drinking among elderly people in general practice. British Journal of General Practice, 44: 503-507 Kitson A, Harvey G & McCormack B (1998). Enabling the implementation of evidence based practice: a conceptual framework. Quality in Health Care, 7:149-158 Knowles MS. (1980). The modern practice of adult education: from pedagogy to andragogy. 2nd Ed New York, Cambridge Books. Kolb DA. (1984). Experiential learning: experience as the source of learning and development. Englewood Cliffs, Prentice Hall. Matthews H, Wilkinson D & Holmes C (1999). Some recommendations given are not directly based on evidence cited. British Medical Journal, 318:802-8 NHS Centre for Reviews & Dissemination (1999). Effective Health Care: Getting evidence into practice. Volume 5 (1) 13 Dementia diagnosis and management Dementia,2002 1(1): 11-23 Nowlem PM (1988). A new approach to continuing education for business and the professions. MacMillan, New York. O’Connor, D., Pollitt, P., Hyde, J., Reiss, B and Roth, M. (1988). Do general practitioners miss dementia in elderly patients? British Medical Journal, 297: 11071110 O'Connor D W, Pollitt C P, Brook C P B & Reiss B B (1989). The validity of informant studies histories in a community study of dementia. Int J Geriatr Psychiatry, 4:203-8 Pollitt, P. (1996). Dementia in old age: an anthropological perspective. Psychological Medicine, 26: 1061-1074 Pond, C., Mant, W., Kehoe, L., Hewitt and Brodaty, H. (1994). General practitioner diagnosis of depression and dementia in the elderly: can academic detailing make a difference. Family Practice, 11:141-147 Reedy BLEC (1979). General Practitioners and postgraduate education in the northern region: occasional paper 9 J Royal Coll Gen Practitioners, London. Schon D (1987). Educating the reflective practitioner. Jossey Bass San Francisco. Scottish Intercollegiate Guidelines Network (1998). Interventions in the management of behavioural and psychological aspects of dementia: A national clinical guideline recommended for use in Scotland by the Scottish Intercollegiate Guidelines Network, February. Spencer JA, Jordan RK (1999). Learner centred approaches in medical education. British Medical Journal, 318:1280-3 Toner H (1992). What do we mean by assessment? in Haxby D (ed) Dementia: diagnosis and assessment. Dementia services development centre, Stirling. Van den Broucke J P (1999). Case reports in an evidence based world. J Royal Soc Med: 92(4): 159-163 Wilcock J, Iliffe S, Walters K, Rait G, Austin T, Turner S, Bryans M, Downs M, O'Carroll R, E, Keady J (2003) The development of an evidence-based curriculum for dementia care training in general practice. Education and Ageing, Vol. 17, no 2/3. Willis SL & Dubin SS (eds) (1990). Maintaining professional competence. Jossey Bass, San Francisco. Yeo GT, Deburgh SPH, Letton T, Shaw J, Donnelly N, Swinburn ME, Phillips S, Bridgeswebb C, Mant A. (1994). Educational visiting and hypnosedative prescribing in general-practice. Family Practice, 11 (1): 57-61 14