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Page 1: OUTCOME OF A PILOT DEMENTIA TRAINING PROGRAM FOR PRIMARY CARE PHYSICIANS

This article was downloaded by: [Northeastern University]On: 26 October 2014, At: 20:33Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number:1072954 Registered office: Mortimer House, 37-41 Mortimer Street,London W1T 3JH, UK

Educational GerontologyPublication details, including instructions forauthors and subscription information:http://www.tandfonline.com/loi/uedg20

OUTCOME OF A PILOTDEMENTIA TRAININGPROGRAM FOR PRIMARYCARE PHYSICIANSMark T. Sizemore a , Belinda Vicioso a , Julia L.Lothrop a & Craig D. Rubin aa University of Texas Southwestern MedicalCenter at Dallas , Dallas, Texas, USAPublished online: 09 Jul 2006.

To cite this article: Mark T. Sizemore , Belinda Vicioso , Julia L. Lothrop &Craig D. Rubin (1998) OUTCOME OF A PILOT DEMENTIA TRAINING PROGRAMFOR PRIMARY CARE PHYSICIANS, Educational Gerontology, 24:1, 27-34, DOI:10.1080/0360127980240102

To link to this article: http://dx.doi.org/10.1080/0360127980240102

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Page 2: OUTCOME OF A PILOT DEMENTIA TRAINING PROGRAM FOR PRIMARY CARE PHYSICIANS

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OUTCOME OF A PILOT DEMENTIA TRAINING PROGRAMFOR PRIMARY CARE PHYSICIANS

Mark T. SizemoreBelinda Vicioso

Julia L. LothropCraig D. Rubin

University of Texas Southwestern Medical Center at Dallas,Dallas, Texas, USA

An intensive workshop on the management of Alzheimer's disease was implementedto train primary care physicians in the diagnosis and long-term care managementof patients with dementia and to provide communities with a professional source ofinformation on dementia issues. Before enrollment in the workshop, all participantswere asked to commit to training their community physicians and health careproviders in local educational activities on dementia. Effectiveness of the workshopwas assessed with a pre- and a postworkshop questionnaire and postworkshop tele-phone interviews. Twenty-eight primary care physicians attended: 25% wereinternists and 71% were family practitioners. Thirty-three percent practiced inrural communities, and 32% were nursing home directors. Twenty-one participantscompleted questionnaire pretesting, and fourteen completed posttesting. Seventeenresponded to a 6-month postworkshop telephone interview. Forty-one percent ofrespondents had used resource materials in didactic sessions with physicians andother health care providers in their own communities. All participants intervieweddescribed greater comfort in patient education settings, such as nursing home teamconferences, family meetings, and counseling sessions. Participants showed somegains in knowledge about available community resources and their use. There wasno difference in pretest and posttest Alzheimer's Disease Knowledge Test scores.Intensive workshops appear to be an effective and efficient means of disseminatinggeriatric training to primary care physicians and community health care providers.

Although the formal preparation of geriatricians has advanced over thelast decade, the ability of medical institutions to supply the physicianmanpower required to care for a growing frail elderly population is lim-ited (Kane, 1995). Consequently, a significant proportion of the care ofolder persons will be provided by physicians without extensive geri-

This research was supported by NIA grant number 1-P50-AG12300-02.Address correspondence to Dr. Mark T. Sizemore, Department of Gerontology, Uni-

versity of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Blvd., DallasIX 75235-8875, USA.

Educational Gerontology, 24:27-34, 1998 27Copyright © 1998 Taylor & Francis

0360-1277/98 $12.00 + .00

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28 M. SIZEMORE ET AL.

atrics training (Reuben et al., 1993). The National Institute of Aging(1987) has called for expanded continuing medical education to exposecurrent practitioners to advances in geriatric technology and care.

Studies reviewed by the Office of Technology Assessment (1990)underscore the multiple tasks physicians encounter in treating patientswith dementia: making a diagnosis; treating concurrent illness; man-aging medications; offering emotional support for caregivers; providingeducation and counseling to families about diagnosis, prognosis, andcaregiving techniques; and providing information about and referralsto services. However, the adequacy of preparation to play these key rolesin caring for patients with dementia and their families is questionable(National Institute on Aging, 1991; Office of Technology Assessment,1987). In some cases, the family members feel they are given a vaguediagnosis (e.g., "organic brain syndrome") rather than a more precisedefinition of the problem. Others are given a proper diagnosis but verylittle information regarding the course of the disease, what they canexpect and when, or where they can turn for help (Haley, 1992). Trainingin geriatrics lags far behind the need, leaving a knowledge gap in physi-cians' approach to chronic conditions that afflict the elderly.

This article describes the development and implementation of aninnovative seminar to train primary care physicians in the diagnosisand long-term care of persons with dementia. A secondary objectivewas to create a cadre of primary care physicians who could train healthcare providers in their communities and maximize dissemination of theinformation in the community. Evaluation results are also presented,and modifications for subsequent seminars are discussed.

METHOD

The concept of a seminar on Alzheimer's disease (AD) for primary carephysicians was developed by faculty from The University ofTexas South-western Medical Center at Dallas. Those who participated in the sem-inar planning included Alzheimer's Association representatives, geri-atric professionals from Dallas County Parkland Memorial Hospital,and professionals from the Veterans Affairs Medical Center in Dallas.

Seminar Planning

A committee consisting of faculty with geriatric expertise was orga-nized and assigned the task of planning the seminar. The nominalgroup technique (Delbecq, Van de Ven, & Gustofson, 1975) was used increative, idea-generating planning meetings to elicit and arrive at a

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DEMENTIA TRAINING PROGRAM 29

consensus on recommendations for the content and method of deliveryfor the seminar.

Seminar Content

The seminar content included eight topics on AD and related caregiverissues. The topic of recent advances in AD provided a brief overview ofthe most current scientific research on Alzheimer's disease. A section ondiagnosis of AD provided information on the tests and informationneeded to make an accurate premorbid diagnosis of AD. The third topic,behavioral management, presented information on the various problembehaviors exhibited by patients with AD and nonpharmaceutical waysto assist the family in managing those behaviors. The medicationsand AD portion offered information on medications that can be used tomanage the health and behaviors of the patient with AD. It also pro-vided information on new medicines under development for AD. Gen-eral medical issues were also discussed, including issues regarding con-current disease processes in people with AD. Another subject, caregiverburden, presented information from the family's point of view regardingthe diagnosis and management of AD. This session also presented infor-mation on the differences in coping abilities of family members andhealth issues regarding the caregiver. Finally, a section on identifyingcommunity resources offered information on what Alzheimer's Associ-ation chapters might offer and information on other support services incommunities and how to access them.

Training Materials

A training manual was provided to each participant. The manualincluded reprinted articles covering the seminar content, slides, andinformation on the participant's local community resources.

Learning Objectives

Learning objectives were developed for the seminar. At its conclusion,participants were expected to be able to

Discuss the most recent research on AD;Describe procedures for diagnosing AD;Identify medications for AD and discuss a frame of reference for bal-

ancing psychopharmacological and psychosocial measures forbehavior and emotional problems in AD;

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30 M. SIZEMORE ET AL.

Describe caregiver burden and the associated stress to caregivers;Identify community resources and their benefit to families and

patients; andUse seminar training materials in educational programs for other

health care providers.

Seminar Participants

Primary care physicians with significant geriatric practices were tar-geted as a group most likely to encounter dementia patients and mostlikely to benefit from the training. Participants were recruited by abrochure mailing to Texas Geriatric Society members and the TexasMedical Directors Association. Recruitment materials were mailed 6months before the training with a reminder postcard mailed 4 monthsbefore the event. Participants were asked to register for the training 4months in advance so that pretests for the seminar evaluation could becompleted and the program content could be adjusted according to theparticipants' specific needs. Eight hours in category one AmericanMedical Association continuing medical education credits and 8 hoursAmerican Medical Directors Association credits were awarded toattending physicians. As a condition for enrollment in the seminar,physicians were required to commit to disseminating the seminarinformation to health care providers in their communities.

Twenty-eight primary care physicians attended the seminar. Theparticipants' practices had on average 58% (range 10-100%) geriatricpatients. Participant characteristics included the following: 25% wereinternists; 71% were family practitioners; 33% were in rural practice;and 33% were nursing medical directors.

Evaluation

The evaluation used a pretest and a posttest design. Data on effective-ness were collected by 4-month pre- and posttest mailed questionnairesand a 6-month posttest telephone interview. Pretest and posttest ques-tionnaires were identical and six pages in length. Complete anonymityof response was assured to encourage a high response rate.

Mail Questionnaires

Twenty-one participants completed a mailed pretest questionnaireand 14 participants completed a mailed 4-month posttest question-naire. Questionnaire components included a modified version of TheAlzheimer's Disease Knowledge Test (ADK) (Dieckman, Zarit, Zarit, &Gatz, 1988) (the item on lecithin was deleted); a vignette describing a

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DEMENTIA TRAINING PROGRAM 31

patient with early-stage AD (a 70-year-old man, recently widowed,living alone, requiring treatment for hypertension, who was increas-ingly forgetful and easily irritated); and items assessing physicians'inclinations to refer to community services in response to the vignette.

Telephone Interview

Seminar participants were interviewed by telephone at 6 months toassess participant satisfaction with seminar resource materials, edu-cational activities by participants in their communities, and partici-pants' global assessment of the seminar's usefulness.

Data Analysis

Pretest and posttest means on the ADK total scores were comparedwith the independent samples t test (Loether & McTavish, 1974). Nom-inal level variables were examined with the Fisher exact probabilitytest (Siegel, 1956). Treatment of the data as independent samples wasdictated by the anonymity of response.

RESULTS

Questionnaire Responses

No significant differences were found for pretest and posttest compar-isons. The total scores were calculated as percentage of correctresponses on the ADK (see Table 1). Pretest and posttest means werenearly identical (approximately 73%). Individual ADK test items thatassessed knowledge of services covered by Medicare and the function ofthe Alzheimer's Association also were examined (see Table 1). Manyseminar participants were unable to correctly identify services for theAlzheimer's patient covered by Medicare (43%) on both pretest (43%)and posttests (43%). Nearly all participants correctly identified the

TABLE 1 Comparisons for seminar participants on the Alzheimer's DiseaseKnowledge Test

Pretest (re = 21) Posttest (n = 14)

Tbtal ADK score (M, SD) 73.2 (12.9) 73.3 (10.7)Individual ADK items (% correct)

Services covered by Medicare 43 43Function of Alzheimer's Association 76 93

Note. ADK = Alzheimer's Disease Knowledge Test.

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32 M. SIZEMORE ET AL.

function of the Alzheimer's Association on the posttest (93%), a slightimprovement over pretest responses (76%).

Most seminar participants were inclined to refer the vignette patientand family to community resources on both pretest and posttest ques-tionnaires, with the exception of the participants' indicated inclinationto refer to the area agency on aging on the posttest (see Table 2).Change in the predicted direction was noted for nursing home referralsand respite care, whereas change opposite to the anticipated directionwas found for the Alzheimer's Association and Area Agencies on Aging.In addition, whereas referrals to the Alzheimer's Association werenearly unanimous, the lowest percentages were indicated for areaagencies on aging.

Telephone Interview Responses

An attempt was made to contact all participants for a brief telephoneinterview. A total of 17 seminar participants were contacted by a physi-cian faculty member and interviewed (a response rate of 61%). Forty-one percent of the interview respondents reported having usedresource materials in didactic sessions with some physicians, but mostof the audiences were nursing home staff. All interview respondentsreported greater comfort as a result of the seminar in patient educationsettings, such as nursing home team conferences, family meetings, andcounseling sessions. Physicians also reported that the educationalmaterials were useful in training community health care providers,and they unanimously expressed an interest in continuing educationon dementia-related topics.

CONCLUSION

The seminar participants had relatively high levels of knowledge aboutAD at baseline and also indicated a general willingness to referpatients with early-stage disease and their families to community ser-

TABLE 2 Comparisons for seminar participants on inclination to referpatients with early-stage Alzheimer's to community services

Would refer to: (%) Pretest (re = 21) Posttest (re = 14)

Nursing home 19 7Alzheimer's Association 95 86Area Agency on Aging 62 43Respite care adult day care 71 79

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DEMENTIA TRAINING PROGRAM 33

vices over nursing home placement. Although significant gains inknowledge from seminar participation were difficult to demonstratebecause of the high baseline measurements and a low posttest responserate, areas for increased attention in subsequent seminars were iden-tified.

Most seminar participants incorrectly indicated that Medicare cov-ered nursing home and homecare services for patients with AD. Inaddition, fewer physicians considered referrals to Area Agencies onaging compared with other community services. As the public is gener-ally unaware of what services are covered by Medicare and that somearea agencies on aging provide services for homebound elderly, accu-rate information and appropriate referrals by primary care physiciansare significant elements of caregiver support. Increased emphasis willbe given to this information in subsequent seminars by emphasizingphysician interactions with caregivers after the diagnosis has beenmade (Cooper, 1991).

Modification of the evaluation approach also was indicated. The ADKcontributed little to the assessment of effectiveness, and the deletion ofthe ADKin a redesigned questionnaire of shorter length should increaseresponse rates. In addition, verification of referrals and documentationof continuing education presentations will be obtained from communitysources, providing direct evidence of desired seminar outcomes.

Continuing education for practicing physicians on geriatric topics,especially dementia, has been advocated by numerous medical experts.Despite the limitations discussed here, the participants' subjectivereactions to the seminar obtained by telephone interview indicatedthat the information benefited clinical practices. Participants also usedseminar materials in training other professionals. The preponderanceof evidence is consistent with the interpretation that intensive work-shops are effective means of extending geriatric training to primarycare physicians and community health providers.

REFERENCES

Cooper, J. K. (1991). Alzheimer's disease: Answering questions commonly askedby patients' families. Geriatrics, 46 (3), 38-47.

Delbecq, A., Van de Ven, A., & Gustofson, D. (1975). Group techniques for pro-gram planning. Glenview, IL: Scott, Foresman, and Co.

Dieckmann, L., Zarit, S. H., Zarit, J. M., & Gatz, M. (1988). The Alzheimer's Dis-ease Knowledge Test. The Gerontologist, 28 (3), 402-407.

Haley, W., Clair, J., & Saulsberry K. (1992). Family Caregiver satisfaction withmedical care of their demented relatives. Gerontologist, 32, 219-226.

Kane, R. L. (1995). Health care reform and the care of older adults. Journal ofthe American Geriatric Society, 43 (6), 702-706.

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34 M. SIZEMORE ET AL.

Loether, H. J. & McTavish, D. G. (1974). Descriptive statistics for sociologists.Boston: Allyn and Bacon.

National Institute on Aging. (1987). Personnel for the health needs of the elderlythrough year 2020. Washington, DC: U.S. Department of Health and HumanServices.

National Institute on Aging. (1991). Second report of the Advisory Panel onAlzheimer's Disease (DHHS Publication No. ADM 91-1791). Washington,DC: U.S. Department of Health and Human Service.

Office of Technology Assessment. (1987). Losing a million minds: Confrontingthe tragedy of Alzheimer's disease and other dementias (OTA Publication No.BA-323). Washington, DC: U.S. Congress.

Office of Technology Assessment. (1990). Confused minds, burdened families:Finding help for people with Alzheimer's and other dementias (OTA Publi-cation No. BA-403). Washington, DC: U.S. Congress.

Reuben, D. B., Bradley, T. B., Zwanziger, J., Fink, A., Vivell, S., Hersch, S., &Beck, J. C. (1993). The critical shortage of geriatrics faculty. Journal of theAmerican Geriatrics Society, 41(5), 560-569.

Siegel, S. (1956). Nonparametric statistics for the behavioral sciences. NewYork: McGraw-Hill.

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