Adi2017 junichiro toya

The factors of delayed diagnosis and intervention of primary care services

for people with dementia

Junichiro Toya, M.D., Chie Katayama, Kumiko Murashima, Daisuke Kiuchi, Hirotoshi Niikawa

Sakura-shinmachi urban clinic

Tokyo, Japan

32nd International Conference ofAlzheimer's Disease International

26-29th Apr. 2017

IPIST’s role:• Making an initial assessment by outreach to subject’s home• Planning for a comprehensive and intensive support• Liaising with local healthcare and social care services• Facilitating early diagnosis of dementia • Promoting social care involvement

Initial-Phase Intensive Support Team of dementia (IPIST)

• IPIST is one of the key policy priorities in the national dementia strategy.

• A specialist team consisting multidisciplinary professionals in dementia(nurses, health visitors, occupational therapists, GP and psychiatrics).

• A targeting population: People who are suspected to have dementia, but have no medical or care intervention.

Home visit to a patient Multidisciplinary team meeting

Research question• One of the major difficulties in the IPIST is how to identify

the subjects who are suspected to have dementia but have no medical or care intervention.

Why do the people with dementia tend to delay their access to health and social care services?

It may give people opportunities for early awareness and detection of dementia.

Are there any common features in subjects of IPIST?

• Theme; the factors contributing to delayed dementia diagnosis

and supportive care interventions in primary care setting.

• Keywords;

“early-stage”, “dementia”, “delay diagnosis” and “primary care”

“barriers”, “refuse”, “care services”

• Age, gender, household information, social life

• ADL, IADL, levels of cognitive impairment and disability

• Presence or absence of family doctor, frequency of regular visit to Dr.

• A duration since the symptom’s onset

• Information on how the person was identified

• Reasons why the person refused care services

Methods1. Data analysis from the IPIST’s subjects (n=52)

2. Literature search and review on prior studies

• Assessment scales using in IPIST

• CDR: Clinical Dementia Rating

• DASC: Dementia Assessment Sheet in Community-based integrated care system. This score is original and established for IPIST. It can assess about cognitive function, ADL and IADL all in one.

• DBD13: Dementia Behavior Disturbance scale

Demographics of the IPIST’s subjectsThe subjects who were referred to the IPIST in Setagaya ward, Tokyo 2013-2014 (n=52)

Age/Gender Over 75 year old (91%) male (31％), female (69％)

Household Living alone (40％), Living with spouse only (25％)

ADL Able to go out independently (77%)

Cognitive impairment

Marked disability in IADL (77%)

Family Doctor Regular visit in every two months (67.3％)

Goals Before intervention After intervention

Dementia diagnosis 30% 73%

Approved for the long term care insurance

36.5% 75%

Use for the long term care insurance

1% 57.7%

Outcomes of IPIST’s intervention

Result 1: the factor of the disease

Since people with AD present with memory loss and disorientation in time and place from the early stages, they tend to avoid meeting with people or to find it difficult to go outside and to isolate themselves from society. [22][23]

• Types of dementia:

AD (81％), VaD (2%), DLB (6%), FTD (2%), others (8%)

• The reasons why people did not have any intervention

Lack of insight into disease (63.9％)

Refusal of social contact (31.1％)

• Lack of social interaction (72%)

• Who detected the subject?:

family (50％), district welfare officer (19％)

Results of IPIST’s data analysis

Results of reviewing articles [22] P. A. Pollitt,2009, [23] A. J. Newens,1994

Result2: the factor of patient and family caregivers

ADL CDR DASC DBD13

Living alone(n=23) living with family(n=31)

*

*

**

ADL CDR DASC DBD13

The scores of ADL and dementia were significantly higher (worse) in those who lived with family.

The reasons of avoiding access to medical and care services [34][37][38]

・Stigma and misunderstandings of dementia

・Difficulty for the family to face up to reality

・Difficulty for the family to communicate with a doctor and care services

Results of reviewing articles


[34] L. Boise (1999), [37] S. B. Wackerbarth (2002), [38]D. Knopman (2000)

p-value were determined by Mann-Whitney U-test. *p<0.05, **p<0.01

Result3-1: the factor of primary care physician (PCP)

Current issues on primary care physician• It has taken between 18 to 30 months to confirm the diagnosis of

dementia. [21]

• Diagnostic sensitivity is lower in mild dementia (0.09-0.41) than in severe dementia (0.60-1.00). [30],[52]

• PCP who knew about patient support systems: 45% [57]

• PCP who knew about the details of local memory clinic: 53% [57]

ADL DASC DBD13 periods

Having GP (n=35) Not having GP (n=17)

Results of reviewing articles

ADL DASC DBD13 Periods

Prior to IPIST, having a Primary care physician did not have any impact on the subject’s dementia symptoms.

22.9m 21.9m


[18] M. Ólafsdóttir,(2001),[21] C. Bamford(2007),[30] J. A. Eefsting,(2009),[52] S. Borson(2006), [57] S. Turner(2004)

Periodsfrom onset

Result3-2: the factor of primary care physician

Key reasons why PCP has difficulty in dementia practice

• A lack of skills and relevant training about dementia diagnosis [45]

• Perceived difficulty in disclosing the diagnosis and on-going monitoringand management of people with dementia [50]

• Limited time and inadequate financial incentives [43]

• Poor awareness and lack of network with specialists and care resources [51]

• Anxiety caused by prejudice and the sense of burden against dementia [51]

Results of reviewing articles (These studies were done in UK and USA)

[45] M. Downs (2002),[50] D.P. Harris (200),[43] S. Iliffe,(2005),[51] S. Turner(2004)

• There is no registration system of GP in Japan.• People can access any healthcare provider and therefore

directly see a specialist.• Most physicians in clinic lack the skills or a sense of

responsibility of comprehensive patient management.

Conclusion; The factors of delayed diagnosis and intervention of primary care services for people with dementia

• “Lack of insight into disease” and “Refusal of social contact” in people with dementia, particularly Alzheimer disease

• Due to having no GP system, primary care is not well developed

• Poor partnership between PCP and local care services

• Lack of PCP’s skills of dementia diagnosis and practice

• Stigma and misunderstandings of dementia in public

The factor of disease

The factor of primary care physician

The factor of patients and caregivers

• Implementation of regular community patrol and support for the elderly

• Raising awareness of dementia in people• Spreading the IPIST service nationwide

with a quality assurance system

• More training opportunities for PCP to improve their skills of dementia practice

• Better partnership between healthcare and social care services

• Evaluation of dementia care strategies and long-term cost effectiveness

Next step; Recommendations from the study to improveearly diagnosis and intervention of dementia

Conclusion; The factors of delayed diagnosis and intervention of primary care services for people with dementia

• “Lack of insight into disease” and “Refusal of social contact” in people with dementia, particularly Alzheimer disease

• Due to having no GP system, primary care is not well developed

• Poor partnership between PCP and local care services

• Lack of PCP’s skills of dementia diagnosis and practice

• Stigma and misunderstandings of dementia in public

The factor of disease

The factor of primary care physician

The factor of patients and caregivers

Next step; Recommendations from the study to improveearly diagnosis and intervention of dementia

• Implementation of regular community patrol and support for the elderly

• More training opportunities for PCP to improve their skills of dementia practice

• Better partnership between healthcare and social care services

• Evaluation of dementia care strategies and long-term cost effectiveness

• Raising awareness of dementia in people• Spreading the IPIST service nationwide with a quality

assurance system

The factor of disease “Lack of insight into disease” and “Refusal of social contact”

The factor of primary care physician “Lack of skills of dementia practice”

The factor of patients and caregivers “Stigma and misunderstandings”

• Primary care physicians are expected to take a central role in the early detection and diagnosis of dementia.

• It is hoped the early detection of dementia provides a positive experience for the person with dementia and family to be empowered and to regain hope for future.

認知症の方へのプライマリケアサービスの診断や介入が

遅れる要因について

遠矢純一郎、片山智栄、村島久美子、

木内大介、新川祐利

桜新町アーバンクリニック

第32回国際アルツハイマー病協会国際会議2017年4月26-29日

認知症初期集中支援チーム ; IPIST• 日本の認知症施策推進5カ年計画(2012-2017)における重要施策の１つ

• 認知症状がありながら、未だ医療や介護の介入が無く、生活に支障を来し、本人や家族の不安や負担がある方が対象

• 地域包括ケアセンターに相談された認知症疑いケースの中から、専門チームの介入が必要なケースが抽出・紹介される

• 地域毎に設置された専門チーム*が対象者宅に訪問して行なう

• 認知症や生活の包括的アセスメントとプランニングを約半年間行い、地域ケアに引き継ぐ。早期の診断やケア導入支援するのが目的

患者宅に訪問して実施多職種によるチーム員会議* チーム員；看護師、作業療法士、心理士、認知症専門医らで構成

リサーチクエスチョン• 認知症早期で未介入の対象者をどうやって抽出するか？

• 認知症早期中期における診断率は、約５０％と低い*

そもそもなぜ認知症の早期検出や介入が遅れるのか？

*A. Bradford, 2009

積極的にアプローチすべき対象者を抽出しやすくし、より効果的な支援や啓発活動につながるのではないか

初期集中支援対象者の特徴や共通点を検証する

ことで、診断や介護の介入遅れの要因を検証したい

• 「プライマリケアにおける認知症診断や支援的ケア介入の遅れ」に関する

研究論文を検索。

• 主にMedlineを用いて、early-stage, dementia, diagnosis, delay, barriers, refuse,

primary careなどのキーワードの組み合わせで検索し、システマティックレビューや

オリジナル文献を中心に収集、その参考文献についても調査した。

• 2013-2014年度初期集中支援の支援終了者

(n=52)の情報を集計、分析

内容；年齢、世帯、ADL、IADL、認知症タイプと重

症度、BPSDの程度や介護負担度のスコア、社会

性の有無、かかりつけ医の有無や定期通院の頻

度など

• データの解析にはSPSSを用い、Mann-Whitney

U-testで検定した。

方法1. 初期集中支援対象者のデータ分析

2. 先行研究の文献レビュー

• Assessment scales using in IPIST

• CDR: Clinical Dementia Rating

• DASC: Dementia Assessment Sheet in Community-based integrated care

system. This score is Japanese original and specialized for IPIST.

It can assess about cognitive function, ADL and IADL all in one.

• DBD13: Dementia Behavior Disturbance scale

初期集中支援対象者のプロフィール

東京都世田谷区（人口89万人、高齢化率19％)において2013-2014年に認知症初期集中支援を実施、終了した52症例が対象

年齢／性別 75歳以上 91％男性 31％, 女性 69％

世帯状況独居 40％、夫婦のみ 25％

ADL 独りで外出可能な生活自立レベル* 77%

認知障害 IADL障害が顕著なレベル** 77%

かかりつけ医あり 67.3％（平均2か月毎に定期通院）

認知症診断介入前 30％（ほとんどがかかりつけ医以外で診断）

*障害高齢者日常生活自立度; J1+J2, **認知症日常生活自立度; Ⅱa+Ⅱb

目標項目介入前介入後

認知症診断 30% 73%

介護保険認定 36.5% 75%

介護保険利用 1% 57.7%

初期集中支援の成果

結果１疾患の要因

ADは病初期から記憶障害や見当識障害が生じるため、人と会うことを避けたり、外出がおっくうになり自宅に引きこもる傾向がある

• 対象者の疾病割合アルツハイマー病 81％, 血管性認知症 2%, レビー小体型認知症 6%, 前頭側頭型認知症 2%, その他 8%

• これまで医療やケアの介入が無かった主な理由

病識のなさ 63.9％

対人拒否 31.1％

• 社会性がない方 72%

• 対象者の把握家族 50％、民生委員 19％

特にアルツハイマー病は、早期には身体症状がほとんどなくADLが保たれることから、本人の病識が無く、医療への接触がなされないことが多くなる可能性が高い。

初期集中支援からのデータ解析による結果

文献レビューによる結果

結果2 患者・家族の要因

ADL CDR DASC DBD13

独居(n=23) 家族同居(n=31)*

*

**

ADL CDR DASC DBD13

独居より家族同居の方が、認知機能やADLのスコアがより悪化していた

医療やケアへのアクセスを遠ざける理由 [34][37][38]

・認知症へのスティグマや誤解・家族が患者と直接向き合う事の難しさ

・医師とのコミュニケーションの難しさ・社会サービスとの関わりについての不安



[34] L. Boise (1999), [37] S. B. Wackerbarth (2002), [38]D. Knopman (2000)

Mann-Whitney U-testにて検定 *p<0.05, **p<0.01

結果と考察3-1 プライマリケア医の要因

プライマリケア医の実際（複数の研究より）

• 認知症診断にかかる期間平均18-30ヶ月間

• 認知症の診断精度は軽症の方が低下診断感度軽度0.09-0.41、重度0.60-1.0

• 患者支援サービスについて知っている 45%

• 地域のメモリークリニックの詳細を知っている 53%

• 必要な社会支援サービスを組織することが難しい 56%

ADL DASC DBD13 periods

かかりつけ医あり(n=35) なし(n=17)


ADL DASC DBD13 Periods

かかりつけ医の存在は、介入時の認知症やADLの程度や介入までの期間に寄与していない

22.9m 21.9m


Result3-2: かかりつけ医による要因

文献レビューによる結果（主に欧米での研究による）

[45] M. Downs (2002),[50] D.P. Harris (200),[43] S. Iliffe,(2005),[51] S. Turner(2004)

• 日本にはGP制度がなく、病院専門医へのフリーアクセスが一般的。• 開業医でさえも、かかりつけ医として包括的な診療や役割へのスキル

や責任意識が乏しく、地域ケアとのつながりも弱い。

プライマリケア医が認知症診断やマネジメントを避けたがる理由

• 認知症診療スキル不足と教育の不十分さ [45]

• 認知症診断の告知やその後のマネジメントへの苦手意識 [50]

• 限られた診療時間や不適切な診療報酬 [43]

• 専門医紹介や地域支援リソースへの知識や繋がりの不足 [51]

• 認知症への偏見や負担感による不安 [51]

Next step; 認知症早期診断とケア介入を改善する方策

• 高齢者世帯への定期的な見守りの実施

• プライマリケア医の認知症診療スキル向上

• 医療介護連携による包括的ケアマネジメント

• 認知症ケア戦略と長期的費用対効果の評価

• 国民に対する認知症の理解のための啓蒙活動• 初期集中支援の全国的普及と質の維持向上

疾病による要因 “Lack of insight into disease” and “Refusal of social contact”

かかりつけ医による要因 “Lack of skills of dementia practice”

患者や家族介護者による要因 “Stigma and misunderstandings”

• かかりつけ医は認知症の早期検出や診断において中心的役割を担うことを期待されている。

• 認知症の早期発見が、患者さんや家族にとって、将来への希望を取り戻すための良い機会となりますように。

Adi2017 junichiro toya

Healthcare

Transcript of Adi2017 junichiro toya