LETTER TO THE EDITOR
Comparing content of dementia care after diagnosis: memory clinics versus general practitioners Introduction In dementia care, there are many different treatment options available, but success and quality depends on the ability to tailor individual needs. Besides symptomatic drug treatment, several studies have supported the effects of psychosocial interventions and adequate coordination of dementia care (Livingston et al., 2005; Spijker et al., 2008; Orrell, 2012). Mixture of all treatment options available results in a very heterogeneous dementia care practice. We investigated the contents of postdiagnosis dementia care in daily practice, when coordinated by either memory clinics or general practitioners. Methods The study was a pragmatic multicentre randomised trial with a follow-up period of 12 months. Details of the study design have been published elsewhere (Meeuwsen et al., 2009). Patients with very mild to moderate dementia (clinical dementia rating scale 0.5–2), newly diagnosed at the memory clinic, and their informal caregivers participated in the study. The patients with their informal caregiver were randomised to either the memory clinic or the general practitioner for follow-up care. We divided the interventions in three groups: The first group consisted of symptomatic dementia medication (cholinesterase inhibitors and memantine), the second group consisted of ‘basic needs’ such as home care, day care, nursing home admission and meals on wheels and the third group contained more specific advices such as keep a diary, wear an alarm or visit a patient organisation. Results In the 12 months of follow-up, 45% of the patients in the general practitioner group used a cholinesterase inhibitor (rivastigmine/galantamine) (Table 1). In the memory clinic group, this was 71%. Memantine was only used by patients in the memory clinic group who already had used galantamine and/or rivastigmine; this was the case in 10% of the patients. There was a Copyright # 2013 John Wiley & Sons, Ltd.
significant difference in the total use of medication between the two groups, p = 0.001 (Table 1). Both in the memory clinic group and in the general practitioner group, different interventions for basic needs of patients were started during the year of follow-up (Table 1). None of the differences in basic needs between the two groups were statistically significant. During the 12 months of follow-up, 10% of the patients in the memory clinic group and 9% of the patients in the general practitioner group were admitted to a nursing home. About the same number, 10% in the memory clinic group and 12% in the general practitioner group, were admitted to a home for the elderly. A number of special advices were given to the patients and their caregivers (Table 1). We received information about these advices from 125 participants, 79 in the memory clinic group and 46 in the general practitioner group. Memory clinics more often gave information and explained to caregivers about dementia than general practitioners did (p = 0.02). In the memory clinic group, patients were significantly more often advised to visit an Alzheimer café (p = 0.04). In the Netherlands, an Alzheimer café is a regional meeting for caregivers and patients with information about dementia.
Discussion A number of interventions were more often prescribed or advised by memory clinics compared with general practitioners during the first year after diagnosis. These differences reflect that memory clinics are more focussed on the dementia and have more experience in this field, whereas general practitioners take care of a limited number of dementia patients and also have to focus on patients’ other medical problems. In the memory clinic group, more patients received symptomatic dementia medication during the first year after the diagnosis. Also, memory clinics gave significantly more often information/explanation about dementia to caregivers, and they advised significantly more patients and caregivers to visit an Alzheimer café. Int J Geriatr Psychiatry 2014; 29: 437–438
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Letter to the Editor
Table 1 Use of different interventions by patients and caregivers (N) in the memory clinic and the general practitioners group
ChEI and/or memantine, ever used during FU Rivastigmine ONLY Galantamine ONLY Rivastigmine AND Galantamine Memantine and galantamine/rivastigmine ChEI and/or memantine use at 12 months FU Home care Domestic care Nursing care Day care Meals on wheels Nursing home) Home for the elderly Physiotherapy Occupational therapy
Information/explanation to the caregiver Visit an Alzheimer caféa Wear an alarm Medication structure Stop driving a car
Memory clinic (N = 83)
General practitioner (N = 77)
Chi-square
p-value
59 (71%) 31 (53% of 59) 16 (27% of 59) 6 (10% of 59) 6 (10% of 59) 46 (78% of 59)
35 (45%) 24 (69% of 35) 10 (29% of 35) 1 (3% of 35) — 29 (83% of 35)
10.8 0.7 1.2 — — 5.1
0.001 0.41 0.28 — — 0.02
13 (16%) 13 (16%) 20 (24%) 5 (6%) 8 (10%) 8 (10%) 5 (6%) 4 (5%)
13 (17%) 15 (19%) 25 (32%) 10 (13%) 7 (9%) 9 (12%) 4 (5%) 1 (1%)
(N = 79)
(N = 46)
50 (63%) 16 (20%) 7 (9%) 11 (14%) 18 (23%)
19 (41%) 3 (7%) 7 (15%) 8 (17%) 9 (20%)
0.04 0.4 1.4 2.3 0.01 0.2 0.05 1.6
0.83 0.53 0.24 0.13 0.91 0.67 0.82 0.20
5.7 4.3 1.2 0.3 0.2
0.02 0.04 0.28 0.60 0.67
ChEI, cholinesterase inhibitors; FU, follow-up. A regional meeting for caregivers and patients with information about dementia.
a
Still, heterogeneity between individual patients was large—also within the memory clinic setting—and the dementia care provided by memory clinics did not impress as strictly following international treatment guidelines or including the latest, stateof-the-art, (psychosocial) intervention available. As a result the difference in dementia treatment between memory clinics and general practitioners was less than anticipated, possibly explaining the lack of difference in effectiveness that we found earlier (Meeuwsen et al., 2012). Ethics statement The study was approved by the Medical Ethics Committee of Radboud University Nijmegen Medical Centre. Acknowledgements This work was supported by ZonMw (Netherlands Organization for Health Research and Development; grant no 945-07-703) and by Radboud University Nijmegen Medical Centre.
Copyright # 2013 John Wiley & Sons, Ltd.
References Livingston G, Johnston K, Katona C, Paton J, Lyketsos CG. 2005. Systematic review of psychological approaches to the management of neuropsychiatric symptoms of dementia. Am J Psychiatry 162(11): 1996–2021. Meeuwsen EJ, Melis RJ, Adang EM, et al. 2009. Cost-effectiveness of post-diagnosis treatment in dementia coordinated by multidisciplinary memory clinics in comparison to treatment coordinated by general practitioners: an example of a pragmatic trial. J Nutr Health Aging 13(3): 242–248. Meeuwsen EJ, Melis RJ, Van Der Aa GC, et al. 2012. Effectiveness of dementia followup care by memory clinics or general practitioners: randomised controlled trial. BMJ 344: e3086. Orrell M. 2012. The new generation of psychosocial interventions for dementia care. Br J Psychiatry 201(5): 342–343. Spijker A, Vernooij-Dassen M, Vasse E, et al. 2008. Effectiveness of nonpharmacological interventions in delaying the institutionalization of patients with dementia: a metaanalysis. J Am Geriatr Soc 56(6): 1116–1128.
ELS J. MEEUWSEN*, RENÉ J. F. MELIS, OLGA MEULENBROEK AND MARCEL G. M. OLDE RIKKERT ON BEHALF OF THE AD-EURO STUDY GROUP Department of Geriatrics/Radboud Alzheimer Centre, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands *E-mail: [email protected] Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/gps.4064
Int J Geriatr Psychiatry 2014; 29: 437–438
Comparing content of dementia care after diagnosis: memory clinics versus general practitioners Introduction In dementia care, there are many different treatment options available, but success and quality depends on the ability to tailor individual needs. Besides symptomatic drug treatment, several studies have supported the effects of psychosocial interventions and adequate coordination of dementia care (Livingston et al., 2005; Spijker et al., 2008; Orrell, 2012). Mixture of all treatment options available results in a very heterogeneous dementia care practice. We investigated the contents of postdiagnosis dementia care in daily practice, when coordinated by either memory clinics or general practitioners. Methods The study was a pragmatic multicentre randomised trial with a follow-up period of 12 months. Details of the study design have been published elsewhere (Meeuwsen et al., 2009). Patients with very mild to moderate dementia (clinical dementia rating scale 0.5–2), newly diagnosed at the memory clinic, and their informal caregivers participated in the study. The patients with their informal caregiver were randomised to either the memory clinic or the general practitioner for follow-up care. We divided the interventions in three groups: The first group consisted of symptomatic dementia medication (cholinesterase inhibitors and memantine), the second group consisted of ‘basic needs’ such as home care, day care, nursing home admission and meals on wheels and the third group contained more specific advices such as keep a diary, wear an alarm or visit a patient organisation. Results In the 12 months of follow-up, 45% of the patients in the general practitioner group used a cholinesterase inhibitor (rivastigmine/galantamine) (Table 1). In the memory clinic group, this was 71%. Memantine was only used by patients in the memory clinic group who already had used galantamine and/or rivastigmine; this was the case in 10% of the patients. There was a Copyright # 2013 John Wiley & Sons, Ltd.
significant difference in the total use of medication between the two groups, p = 0.001 (Table 1). Both in the memory clinic group and in the general practitioner group, different interventions for basic needs of patients were started during the year of follow-up (Table 1). None of the differences in basic needs between the two groups were statistically significant. During the 12 months of follow-up, 10% of the patients in the memory clinic group and 9% of the patients in the general practitioner group were admitted to a nursing home. About the same number, 10% in the memory clinic group and 12% in the general practitioner group, were admitted to a home for the elderly. A number of special advices were given to the patients and their caregivers (Table 1). We received information about these advices from 125 participants, 79 in the memory clinic group and 46 in the general practitioner group. Memory clinics more often gave information and explained to caregivers about dementia than general practitioners did (p = 0.02). In the memory clinic group, patients were significantly more often advised to visit an Alzheimer café (p = 0.04). In the Netherlands, an Alzheimer café is a regional meeting for caregivers and patients with information about dementia.
Discussion A number of interventions were more often prescribed or advised by memory clinics compared with general practitioners during the first year after diagnosis. These differences reflect that memory clinics are more focussed on the dementia and have more experience in this field, whereas general practitioners take care of a limited number of dementia patients and also have to focus on patients’ other medical problems. In the memory clinic group, more patients received symptomatic dementia medication during the first year after the diagnosis. Also, memory clinics gave significantly more often information/explanation about dementia to caregivers, and they advised significantly more patients and caregivers to visit an Alzheimer café. Int J Geriatr Psychiatry 2014; 29: 437–438
438
Letter to the Editor
Table 1 Use of different interventions by patients and caregivers (N) in the memory clinic and the general practitioners group
ChEI and/or memantine, ever used during FU Rivastigmine ONLY Galantamine ONLY Rivastigmine AND Galantamine Memantine and galantamine/rivastigmine ChEI and/or memantine use at 12 months FU Home care Domestic care Nursing care Day care Meals on wheels Nursing home) Home for the elderly Physiotherapy Occupational therapy
Information/explanation to the caregiver Visit an Alzheimer caféa Wear an alarm Medication structure Stop driving a car
Memory clinic (N = 83)
General practitioner (N = 77)
Chi-square
p-value
59 (71%) 31 (53% of 59) 16 (27% of 59) 6 (10% of 59) 6 (10% of 59) 46 (78% of 59)
35 (45%) 24 (69% of 35) 10 (29% of 35) 1 (3% of 35) — 29 (83% of 35)
10.8 0.7 1.2 — — 5.1
0.001 0.41 0.28 — — 0.02
13 (16%) 13 (16%) 20 (24%) 5 (6%) 8 (10%) 8 (10%) 5 (6%) 4 (5%)
13 (17%) 15 (19%) 25 (32%) 10 (13%) 7 (9%) 9 (12%) 4 (5%) 1 (1%)
(N = 79)
(N = 46)
50 (63%) 16 (20%) 7 (9%) 11 (14%) 18 (23%)
19 (41%) 3 (7%) 7 (15%) 8 (17%) 9 (20%)
0.04 0.4 1.4 2.3 0.01 0.2 0.05 1.6
0.83 0.53 0.24 0.13 0.91 0.67 0.82 0.20
5.7 4.3 1.2 0.3 0.2
0.02 0.04 0.28 0.60 0.67
ChEI, cholinesterase inhibitors; FU, follow-up. A regional meeting for caregivers and patients with information about dementia.
a
Still, heterogeneity between individual patients was large—also within the memory clinic setting—and the dementia care provided by memory clinics did not impress as strictly following international treatment guidelines or including the latest, stateof-the-art, (psychosocial) intervention available. As a result the difference in dementia treatment between memory clinics and general practitioners was less than anticipated, possibly explaining the lack of difference in effectiveness that we found earlier (Meeuwsen et al., 2012). Ethics statement The study was approved by the Medical Ethics Committee of Radboud University Nijmegen Medical Centre. Acknowledgements This work was supported by ZonMw (Netherlands Organization for Health Research and Development; grant no 945-07-703) and by Radboud University Nijmegen Medical Centre.
Copyright # 2013 John Wiley & Sons, Ltd.
References Livingston G, Johnston K, Katona C, Paton J, Lyketsos CG. 2005. Systematic review of psychological approaches to the management of neuropsychiatric symptoms of dementia. Am J Psychiatry 162(11): 1996–2021. Meeuwsen EJ, Melis RJ, Adang EM, et al. 2009. Cost-effectiveness of post-diagnosis treatment in dementia coordinated by multidisciplinary memory clinics in comparison to treatment coordinated by general practitioners: an example of a pragmatic trial. J Nutr Health Aging 13(3): 242–248. Meeuwsen EJ, Melis RJ, Van Der Aa GC, et al. 2012. Effectiveness of dementia followup care by memory clinics or general practitioners: randomised controlled trial. BMJ 344: e3086. Orrell M. 2012. The new generation of psychosocial interventions for dementia care. Br J Psychiatry 201(5): 342–343. Spijker A, Vernooij-Dassen M, Vasse E, et al. 2008. Effectiveness of nonpharmacological interventions in delaying the institutionalization of patients with dementia: a metaanalysis. J Am Geriatr Soc 56(6): 1116–1128.
ELS J. MEEUWSEN*, RENÉ J. F. MELIS, OLGA MEULENBROEK AND MARCEL G. M. OLDE RIKKERT ON BEHALF OF THE AD-EURO STUDY GROUP Department of Geriatrics/Radboud Alzheimer Centre, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands *E-mail: [email protected] Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/gps.4064
Int J Geriatr Psychiatry 2014; 29: 437–438
