Kristin Casady, Editorial Director, Geriatrics & Aging.

A recent study examined the effectiveness of educational interventions in improving detection and management of dementia in the primary care setting (BMJ 2006;332:692-6). Achieving improved detection rates and advances in the provision of ongoing care for demented individuals is facilitated by the integration of decision support systems and practice-based workshops, the study’s authors concluded.

Introduction
Primary care practitioners play a role of fundamental importance in diagnosing dementia as they are the point of patients’ first medical contact. Practitioners must deliver prompt intervention and provide ongoing care for their patients receiving the diagnosis, yet inadequate detection and management have been widely documented. Further, it is observed that clinicians often face profound obstacles in executing this role. There may be difficulty in assessing the presence of dementia (for a recent discussion of the diagnosis and treatment of the older adult with cognitive complaints, see Myronuk L. Pitfalls in the diagnosis of dementia. Geriatrics Aging 2006;9:12-9). Challenges are reported to include such barriers as a lack of resources and insufficient cooperation among the general practitioner’s team, involved specialists, and community services.

Assessing Effective Diagnosis and Management: Study of U.K. Practices
Thirty-six general practices in the United Kingdom (central Scotland and London) were recruited as settings for an unblinded, cluster randomized, before-and-after controlled study organized around the provision of three educational interventions: one, a CD-ROM tutorial; two, decision-support software built into the practices’ electronic medical records; and three, practice-based workshops for the general practitioners (the curriculum used is available for download from the U.K.’s Alzheimer’s Society website, www.alzheimers.org.uk). Eight practices were randomly assigned to the electronic tutorial; eight to decision-support software; 10 to practice-based workshops; and 10 to control. Results were obtained from 450 valid and usable records. The design of the interventions was modeled to reflect different approaches to adult learning: the electronic tutorial for self-directed learning; decision-support software for real-time investigations of actual cases; and workshops to facilitate peer communication about the cases under consideration.

Based on searches of the record system for the terms dementia, confusion, memory loss, and cognitive impairment, all practices identified registered patients aged 75 and over who were diagnosed as having dementia or had been assessed as having probable dementia by a general practitioner or specialist.
Investigators audited detection rates prior to and approximately nine months after the intervention. Analysis was conducted of differences in baseline concordance scores with best-practice guidelines for the diagnosis and management of dementia, repeating the analysis for postintervention scores. The ten-item diagnosis concordance score gathered data on items that included whether clinicians took measures such as requesting blood tests at index consultation, took full histories, undertook cognitive testing, and completed scans, both at index consultation and then secondarily after index consultation (before diagnosis). Management concordance scores tracked items such as concerns of caregivers, behaviour problems, depression screening/treatment, referrals to social services, and initiation of pharmacological treatment regiments.

Outcome: Improved Rates of Detection
Regarding changes in rates of detection, diagnosis, and management, the study’s authors noted improved rates of detected dementia with decision-support software and practice-based workshops compared with control: individuals identified as having dementia after the interventions represented 31% of all cases diagnosed in the practice-based workshops arm, 20% in the electronic tutorial arm, 30% in the decision support software arm, and 11% in the control arm. Authors reported the positive effect of the decision-support software as particularly encouraging, with practitioners describing software as simple and practical to implement. However, no difference in concordance with guidelines regarding the management of dementia was noted. This outcome was ascribed to the modest number of cases identified after the intervention and the relatively few cases in the control arm. The result was also described as traceable to the investigators relying on the medical record for evidence of practice; they postulated that practitioners may have improved their practice but not noted it. The authors highlighted the value of focussed educational interventions directed at improving clinical record-keeping.

Conclusion
Successful management of dementing illnesses depends first on effective detection. This study affirms that interventions such as decision-support software and practice-based workshops can improve those rates. The authors highlight that future interventions aimed at improving concordance with recommended diagnosis or management may be furthered by the effect of combining locality initiatives with practice-based interventions, such as ones that incorporate local opinion leaders as well as encourage the direct involvement of patients and caregivers.

Deborah Radcliffe-Branch, PhD, University of Montreal, Centre de Recherche, Institut universitaire de gériatrie de Montréal, Montréal, QC.
Cara Tannenbaum, MDCM, MSc, Assistant Professor, Department of Medicine, Division of Geriatrics, University of Montreal, Centre de Recherche, Institut universitaire de gériatrie de Montréal, Montréal, QC.

Older women are one of the most rapidly growing segments of the Canadian population. This growth necessitates an evaluation of the quality and breadth of care women receive to promote successful aging in later life. Older women’s perceptions of health priorities being addressed by the current health care system and those for which improvements are required are reviewed. Recommendations include screening for memory loss, falls, muscle weakness, depression, and urinary incontinence. Guidelines for assessment and prevention as well as the adoption of a patient-centred approach to care are suggested to address the broader context of promoting physical, emotional, and social well-being for older women.
Key words: older women’s health, health priorities, patient-centred care, screening guidelines, primary care.

Marnin J. Heisel, PhD, C.Psych, Center for the Study and Prevention of Suicide, Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
Paul S. Links, MD, FRCP(C), Arthur Sommer Rotenberg Chair in Suicide Studies, Suicide Studies Unit, Department of Psychiatry, University of Toronto/St. Michael’s Hospital, Toronto, ON.

Older adults have high rates of suicide worldwide. Suicide rates increase with advancing age, and older adults typically use highly lethal means of self-destruction. In addition, suicidal older adults tend to pursue treatment in primary care rather than mental health settings, but current limitations in the primary care system potentially restrict suicide prevention in older patients. We briefly review the epidemiology of late-life suicide and suggest modifications in primary care to better address the psychosocial needs of at-risk older adults, supported by research on suicide risk and resiliency, clinical assessment and treatment options, and collaborative models of primary medicine and mental healthcare.
Key words: suicide, suicide ideation, suicidal behaviour, older adults, primary care.

Donna L. Algase, PhD, RN, FAAN, FGSA, School of Nursing, University of Michigan, Ann Arbor, MI, USA.

Wandering is among the most challenging behaviours associated with dementia. While research is progressing toward a fuller understanding of this phenomenon, the basis for deriving effective and tested interventions has not been fully developed. In this paper, wandering is defined from multiple perspectives, and its various outcomes and risks are discussed. Putative causes of wandering are summarized. Finally, an approach to aid clinicians in discovering effective strategies for managing an individual’s wandering is presented.
Key words: wandering, dementia, assessment, intervention, primary care.

Tessa L. Lewis, MD, General Practitioner, Carreg Wen Surgery, Church Road, Blaenavon, Torfaen, UK.

The NO TEARS structure can aid efficient medication review within a 10-minute consultation. It is a flexible system that can be tailored to the individual practitioner’s consultation style:
Need/indication
Open questions
Tests
Evidence
Adverse effects
Risk reduction
Simplification/switches

Key words: medication review, NO TEARS, primary care, older adults, polypharmacy.

Chanaka Wijeratne, MD, MB, BS, FRANZCP, Conjoint Senior Lecturer in Psychiatry, University of New South Wales, Sydney, AUS.

Somatic presentations such as fatigue, headache, and abdominal and joint pain are common in primary care, although investigation may not readily identify an underlying cause. Such “functional somatic syndromes” are best conceptualized within a multifactorial, inclusive illness model rather than as diagnoses of exclusion (that is, of medical pathology). For instance, the syndrome of fatigue occurs in up to 25% of older people and is predicted by factors as diverse as female gender, more severe medical illness, and concurrent anxiety and depression. Although the management of functional somatic syndromes is frustrating to the clinician, the importance of a multimodal management model is emphasized.

Key words: functional somatic syndromes, older adults, primary care.

Jennifer Pike, PhD, Neuropsychiatric Institute, Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles (UCLA), CA, USA.

Michael Irwin, MD, Cousins Center for Psychoneuroimmunology, Neuropsychiatric Institute,
Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles (UCLA), CA, USA.

Introduction
Depressive disorders are common in the geriatric primary care setting,¹ and are associated with considerable costs and human suffering.^2-4 In 1990, depression was ranked as the fourth leading cause of disability worldwide,⁵ with annual health care costs estimated at $44 billion in the United States alone. Much of this cost is a reflection of higher health care utilization rates in depressed individuals, irrespective of medical comorbidity and mental health visits.³

The prevalence of depressive disorders, defined by the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision; Table 1), in the elderly is high and ranges from 6.5-17% in the primary care setting.^1,6 The rates for dysthymia, minor depression or subsyndromal depressions are roughly double those for major depression. The functional impairments and medical burden of these minor depressed geriatric patients are comparable to those of younger patients with major depression.