Under-provision of medical care for vascular diseases for people with dementia in primary care: a cross-sectional review
ABSTRACT Vascular diseases contribute to the causation and progression of clinical dementia.
To evaluate the quality of medical care for vascular diseases provided to people with dementia, the patient and practice characteristics that influence quality, and to compare care with that provided to those without dementia.
Observational, cross-sectional review of primary care records of people with dementia from 52 general practices from five primary care trusts in the UK, and comparison with publicly available summary data on patients without dementia.
A total of 700 patients with ≥1 diagnosed vascular disease or risk factor were identified from dementia registers. Quality of care was measured on 30 indicators from the UK Quality and Outcomes Framework (QOF) for hypertension, coronary heart disease, stroke, diabetes mellitus, atrial fibrillation, heart failure, and smoking. Overall quality of vascular care was calculated for each patient with dementia.
Level of care received by people with dementia was significantly lower compared with those without dementia for 22 of 30 (73%) indicators; most notably for measurement processes such as peripheral pulses check and neuropathy testing for diabetes, and cholesterol measures for stroke. Among people with dementia, women, those in care homes, and those with fewer comorbid physical conditions and medications were associated with lower scores for overall quality of vascular care.
The quality of medical care provided to people with dementia with regard to vascular diseases is not concordant with quality, as defined by the QOF. Research is needed to improve access to high-quality care.
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ABSTRACT: Background Evidence suggests that amongst people with dementia there is a high prevalence of comorbid medical conditions and related complaints. The presence of dementia may complicate clinical care for other conditions and undermine a patient¿s ability to manage a chronic condition. The aim of this study was to scope the extent, range and nature of research activity around dementia and comorbidity.Methods We undertook a scoping review including all types of research relating to the prevalence of comorbidities in people with dementia; current systems, structures and other issues relating to service organisation and delivery; patient and carer experiences; and the experiences and attitudes of service providers. We searched AMED, Cochrane Library, CINAHL, PubMed, NHS Evidence, Scopus, Google Scholar (searched 2012, Pubmed updated 2013), checked reference lists and performed citation searches on PubMed and Google Scholar (ongoing to February 2014).ResultsWe included 54 primary studies, eight reviews and three guidelines. Much of the available literature relates to the prevalence of comorbidities in people with dementia or issues around quality of care. Less is known about service organisation and delivery or the views and experiences of people with dementia and their family carers. There is some evidence that people with dementia did not have the same access to treatment and monitoring for conditions such as visual impairment and diabetes as those with similar comorbidities but without dementia.Conclusions The prevalence of comorbid conditions in people with dementia is high. Whilst current evidence suggests that people with dementia may have poorer access to services the reasons for this are not clear. There is a need for more research looking at the ways in which having dementia impacts on clinical care for other conditions and how the process of care and different services are adapting to the needs of people with dementia and comorbidity. People with dementia should be included in the debate about the management of comorbidities in older populations and there needs to be greater consideration given to including them in studies that focus on age-related healthcare issues.BMC Medicine 10/2014; 12(1):192. DOI:10.1186/PREACCEPT-1961031831372106 · 7.28 Impact Factor
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ABSTRACT: Increasing evidence suggests vascular risk factors (VRF) play a role in the pathogenesis of Alzheimer’s disease (AD). Epidemiological studies have found associations between VRF and risk of AD. Treating VRF in patients with AD offers a potential treatment option but ineffective treatments should be avoided in this group who are frequently on multiple medications and in whom compliance may be challenging. Studies containing information on the treatment of VRF in patients with a diagnosis of AD were identified using a defined search strategy. Randomised controlled trials and observational studies were included. The pre-specified search strategy retrieved 11,992 abstract articles, and 25 papers including those identified on review of reference lists and reviews met the inclusion criteria. Of these, 11 were randomised controlled trials (RCTs) and 14 observational studies. Observational studies suggested that a VRF package and treatment of hypertension and statin therapy may be associated with improved outcome but these studies suffered from potential bias. The few RCTs performed were mostly small with short duration follow-up, and do not provide clear evidence either way. Observational data raises the possibility that treating VRF could alter the rate of decline in AD. However RCT data are not yet available to support this hypothesis and to alter clinical practice. RCTs in larger numbers of individuals with longer follow-up, ideally in the early stages of AD, are required to address this potentially important treatment question.BMC Medicine 12/2014; 12(1):160. DOI:10.1186/s12916-014-0160-z · 7.28 Impact Factor