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AbstractObjective To test the effectiveness of educational interventions in improving detection rates and management of dementia in primary care.Design Unblinded, cluster randomised, before and after controlled study.Setting General practices in the United Kingdom (central Scotland and London) between 1999 and 2002.Interventions Three educational interventions: an electronic tutorial carried on a CD Rom; decision support software built into the electronic medical record; and practice based workshops.Participants 36 practices participated in the study. Eight practices were randomly assigned to the electronic tutorial; eight to decision support software; 10 to practice based workshops; and 10 to control. Electronic and manual searches yielded 450 valid and usable medical records.Main outcome measures Rates of detection of dementia and the extent to which medical records showed evidence of improved concordance with guidelines regarding diagnosis and management.Results Decision support software (P = 0.01) and practice based workshops (P = 0.01) both significantly improved rates of detection compared with control. There were no significant differences by intervention in the measures of concordance with guidelines.Conclusions Decision support systems and practice based workshops are effective educational approaches in improving detection rates in dementia.

Primary care is often the first point of contact for people with dementia (Briggs & Askham, 1999) and primary care practitioners are recognised as having an integral role to play in the diagnosis and management of dementia (Downs, 1996). Around 70 percent of people with dementia living in the community live with their carer. Most informal carers are the spouse of daughter of the person with dementia (Alzheimer’s Scotland, 2000). Previous research has shown that caring for people with dementia can be stressful, although it also has many positive aspects, and that carers need support systems in place for themselves and their relative. The aim of the current study was to explore the first reported signs of dementia by two groups known to be closely involved with individuals within the earlier stages of the condition, carers and primary care practitioners. Previously unanalysed data collected from carers and practitioners who participated in the Downs et al (2003) study “Improving the response of primary care practitioners to people with dementia and their families: a randomised controlled trial of educational interventions”, was used. A grounded theory approach (Strauss & Corbin, 1990) was adopted to explore the first signs of dementia reported by 122 carers and 204 primary care practitioners. Five main categories and thirty-two subcategories related to cognitive, emotional, behavioural, physical and other (non-categorised) signs of dementia were generated. Statistical analysis was carried out to explore the effect of sociodemographic and occupational variables on the first signs of dementia reported by carers and practitioners, and the effect of training on practitioner signs reported.

This article introduces findings from the first phase of a randomized controlled trial of educational interventions in primary care. The focus of the article is the knowledge, attitudes and confidence of primary care nursing staff to the diagnosis and ongoing management of dementia. A total of 78 nurses with a mean age of 46.4 years and a mean time since qualification of 23.0 years were recruited in 36 practices in central Scotland and in London. Disciplines represented by this sample were predominantly district nurses, health visitors, practice nurses and community staff nurses. Each practitioner was administered an extensive self-completion questionnaire before the educational interventions were introduced to measure baseline knowledge, confidence and perceived difficulties in dementia care management and attitudes. Results from the quiz indicate lower levels of knowledge about epidemiology and diagnosis, but slightly higher levels about management strategies. Self-reported ratings of confidence were also low and were directly related to ratings of difficulty in identifying dementia and dealing with coexisting behavioural and mental health problems. Lower scores on all domains were recorded for practice nurses than for district nurses or health visitors.

The emerging UK national research network in neurodegenerative diseases and dementias aims to promote large-scale community-based studies of therapeutic interventions, based in primary care. However, trials in primary care settings can be problematic, a common difficulty being the recruitment of a large enough sample. The article discusses recruitment issues in a multi-centre randomized controlled trial of differing educational approaches to improving dementia care in general practice. Sample size calculations based on community studies of prevalence may be misleading in intervention trials which may recruit practices with atypical demography. Recruitment rates for practitioners in this study were lower than expected. Professionals excluded themselves from the study mainly due to pressures of time and staff shortages, and we detected both ambivalent attitudes to primary care research and a perception that research into dementia care was not a high priority. Evaluation of the quality of care may be perceived as criticism of clinical practice, at a time when general practice is undergoing major administrative and contractual changes. Variations in Research Ethics Committee conditions for approval led to different methods of recruitment of patients and carers into the study, a factor which may have contributed to disparate levels of recruitment across study sites. Patient and carer levels of recruitment were lower than expected and were affected partly by carers' time pressures and other family commitments, but largely by problems in identifying patients and carers in the practices. The development of research potential in primary care is at an early stage and studies reliant on patient recruitment in general practice must allow for multiple obstacles to enrollment. This is particularly relevant for studies of dementia care, where the prevalence of dementia in a demographically average population is low and the incidence very low, compared with other disabilities. Professionals may give dementia low priority in allocating practice time for research projects, and strategies to address this problem are needed.

In the radiation sterilization arena, the question often arises as to whether radiation resistance of microorganisms might be affected by the energy level of the radiation source and the rate of the dose delivered (kGy/time). The basis for the question is if the microbial lethality is affected by the radiation energy level and/or the rate the dose is delivered, then the ability to transfer dose among different radiation sources could be challenged. This study addressed that question by performing a microbial inactivation study using two radiation sources (gamma and electron beam [E-beam]), two microbial challenges (natural product bioburden and biological indicators), and four dose rates delivered by three energy levels (1.17 MeV [gamma], 1.33 MeV [gamma], and 10 MeV [high-energy E-beam]). Based on analysis of the data, no significant differences were seen in the rate of microbial lethality across the range of radiation energies evaluated. In summary, as long as proof exists that the specified dose is delivered, dose is dose.