Effectiveness of case management among older adults with early symptoms of dementia and their primary informal caregivers: a randomized clinical trial.

BACKGROUND: It is believed that timely recognition and diagnosis of dementia is a pre-condition for improving care for both older adults with dementia and their informal caregivers. However, diagnosing dementia often occurs late in the disease. This means that a significant number of patients with early symptoms of dementia and their informal caregivers may lack appropriate care. OBJECTIVES: To compare the effects of case management and usual care among community-dwelling older adults with early symptoms of dementia and their primary informal caregivers. DESIGN: Randomized controlled trial with measurements at baseline and after 6 and 12 months. SETTING: Primary care in West-Friesland, the Netherlands. PARTICIPANTS: 99 pairs of community-dwelling older adults with dementia symptoms (defined as abnormal screening for symptoms of dementia) and their primary informal caregivers. INTERVENTION: 12 months of case management by district nurses for both older adults and informal caregivers versus usual care. PRIMARY OUTCOME: informal caregiver's sense of competence. SECONDARY OUTCOMES: caregiver's quality of life, depressive symptoms, and burden, and patient's quality of life. Process measurements: intervention fidelity and caregiver's satisfaction with the quality of case management. RESULTS: Linear mixed model analyses showed no statistically significant and clinically relevant differences over time between the two groups. The process evaluation revealed that intervention fidelity could have been better. Meanwhile, informal caregivers were satisfied with the quality of case management. CONCLUSION: This study shows no benefits of case management for older adults with dementia symptoms and their primary informal caregivers. One possible explanation is that case management, which has been recommended among diagnosed dementia patients, may not be beneficial if offered too early. However, on the other hand, it is possible that: (1) case management will be effective in this group if more fully implemented and adapted or aimed at informal caregivers who experience more severe distress and problems; (2) case management is beneficial but that it is not seen in the timeframe studied; (3) case management might have undetected small benefits. This has to be established. Trial registration ISCRTN83135728.

Evaluating primary care research networks: a review of currently available tools.

BACKGROUND: An increasing number of primary care research networks (PCRNs) are being developed around the world. Despite the fact that they have existed for a long time in some countries, little is known about what they have actually achieved. There is an ongoing debate in the literature about the appropriate framework for the evaluation of PCRNs. Here, we aim to provide an overview of the tools that are currently available for measuring the performance of PCRNs and practices involved in PCRNs or research. METHODS: We performed electronic searches in bibliographic databases and several additional searches. We composed a checklist to evaluate the design, content, and methodological quality of the tools. RESULTS: We identified 4 tools for the evaluation of PCRNs or the measurement of primary care practices involved in PCRNs or research. CONCLUSIONS: The results of our study showed that various methods, areas of interest, dimensions, and indicators for the evaluation of PCRNs have been proposed. However, no generic and validated tool that enables meaningful comparison between different network models has been developed. It is, therefore, time to reflect on the appropriateness and effectiveness of PCRNs and determine the desired outcomes (ends) of PCRNs and how we can best achieve them in the future (means). To open up the "black box" of the effectiveness of the PCRNs, it may be relevant to observe the effects of network and research participation on those involved in networks.

Training GP's to use a minimal intervention for stress-related mental disorders with sick leave (MISS): Effects on performance: Results of the MISS project; a cluster-randomised controlled trial [ISRCTN43779641].

OBJECTIVE: To study the effects of a brief patient-stress management training on the performance of general practitioners (GPs). METHODS: After training in the Minimal Intervention for Stress-related mental disorders with Sick leave (MISS), the performance of 24 GPs was compared with the usual care provided by 22 GPs. Outcome measures in this intervention were: assignment of a diagnosis, taking an activating approach and monitoring the symptoms. RESULTS: Twenty-three GPs completed the training. Outcomes showed that the training added to a psychosocial diagnosis. Other skills (using a questionnaire to make a diagnosis, handing out information leaflets and monitoring the symptoms) were to some extent improved by the training. CONCLUSION: The result indicates limited adherence of GPs to the MISS. Only a few components of the training were actually applied after the training, and there is still ample room for improvement. PRACTICE IMPLICATIONS: More than the current 11h of training are probably needed to change the behaviour of GPs in general. Within educational programmes more attention should be given to the implementation of new behaviour, particularly when it concerns the treatment of patients with stress-related problems.

Test-retest reliability of the PRIME-MD: limitations in diagnosing mental disorders in primary care.

BACKGROUND: The primary care evaluation of mental disorders (PRIME-MD) can be seen as characteristic for successive refinements of criteria and structured interview techniques for diagnosing psychiatric disorders in primary care. It is one of the most widely used instruments, but there is no evidence to support its test-retest reliability. METHODS: With 1-week intervals between interviews, a test-retest study of the PRIME-MD was conducted in a general practice population of 100 distressed patients (20- to 60-years old) who were on sick leave. RESULTS: Almost everyone (89%) received one or more diagnoses at both measurements, and there was fair total agreement (kappa = 0.27). The best agreement was found for more severe threshold disorders [major depressive disorder (kappa = 0.58), dysthymia (kappa = 0.57), and generalized anxiety disorder (kappa = 0.59)], while we found indefinite results for the sub-threshold disorders [anxiety disorder not otherwise specified (NOS) (kappa =.30), minor depressive disorder (kappa = -0.03), and somatoform disorder NOS (kappa = 0.11)]. CONCLUSION: The PRIME-MD is one of the few instruments in primary care that actually diagnoses specific mental disorders according to the DSM criteria. However, there was a failure to adequately classify sub-threshold disorders. Mental disorders, as seen in primary care, encompass important specific symptoms and clinical syndromes that vary in duration and severity over time, but they also encompass an admixture of somatic and psychological symptoms that do not match current diagnostic systems. This most likely resulted in methodological uncertainty about the level of agreement. Diagnostic criteria in psychiatry need to be operationalized for use in primary care and require further evaluation.

Somatic chronic diseases and 6-year change in cognitive functioning among older persons.

The influence of seven highly prevalent somatic chronic diseases on changes in cognitive functioning is investigated in older persons in a prospective design covering a 6-year follow-up period. The data were collected as part of the Longitudinal Aging Study Amsterdam (LASA). The associations between chronic diseases and cognitive functioning during 6 years of follow-up were analyzed among 1358 respondents (age 62-85) using generalized estimated equations (GEE). Cognitive tests were used to assess: general cognitive functioning, fluid intelligence, information processing speed and memory performance. In the fully adjusted models diabetes mellitus, stroke and peripheral artherosclerosis were associated with cognitive decline during a 6-year follow-up period in older persons. In the unadjusted models cardiac disease was negatively associated with memory function. However, after the correction for possible confounders this association became positive. Cancer was also associated with better memory function. A faster decline in especially memory function was found for diabetes mellitus, stroke, cancer, and peripheral artherosclerosis. The study shows that in older persons specific chronic diseases (diabetes mellitus, stroke, cancer, and peripheral artherosclerosis) are associated with decline in one or more domains of cognitive functioning during a 6-year follow-up period. These findings further stress that careful clinical evaluation of cognitive functioning in older persons with these diseases is required in order to provide adequate care.

Self-reports on the IQCODE in older adults: a psychometric evaluation.

The Informant Questionnaire on Cognitive Decline (IQCODE) has been successful in identifying demented persons in a general population. In this study, this questionnaire was used as a self-report screening for dementia symptoms. The object was to investigate the feasibility, homogeneity, and construct validity of self-reports on the IQCODE. Participants were 4823 community-dwelling older adults who received an IQCODE-SR. Feasibility was assessed on the basis of response rate, the proportion of missing data for each item, and the number of persons who received help in completing the questionnaire. Homogeneity was checked with Cronbach's alpha. To investigate construct validity, hypotheses on performance of the IQCODE-SR were tested. Feasibility was acceptable, with a response rate of 58.9%. Missing answers per item ranged from 2.5% to 7.3%, and 915 of 2841 participants received help in completing the questionnaire. Homogeneity was good, with Cronbach's alpha = .94. The majority of hypotheses on construct validity were confirmed. It was concluded that the IQCODE-SR meets the basic requirements of a good measurement instrument.

Are psychological treatments for depression in primary care cost-effective?

BACKGROUND: Depression is a highly prevalent condition that is associated with high levels of work absenteeism and high health care costs. Most patients are treated in primary care. A large group of patients prefers psychological treatments to antidepressants. AIMS OF THE STUDY: To systematically review the evidence for the cost-effectiveness of psychological treatments, psychotherapy and counselling, in comparison with usual care or antidepressant treatment in adult primary care patients with depression. METHODS: A computer-assisted search of MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Library was carried out. Two independent reviewers selected studies for the review, extracted data and assessed the methodological quality of the included studies. RESULTS: Seven studies were included in the review. Forms of psychotherapy that were evaluated were cognitive behavioural therapy, interpersonal psychotherapy and couple therapy. Usual care generally consisted of care as usually provided by the general practitioner. No conclusion can be drawn on the cost-effectiveness of the above mentioned forms of psychotherapy in comparison with usual care or antidepressant treatment. The cost-effectiveness of counselling in comparison with usual care and antidepressant therapy is yet to be established. Meta-analyses showed that psychotherapy was significantly more expensive than usual care, but not significantly more expensive than antidepressant treatment. Counselling was associated with no statistically significant differences in costs and effects in comparison with usual care in the pooled analysis. DISCUSSION: Based on this review, no firm conclusions on the cost-effectiveness of psychotherapy and counselling in primary care can be drawn. Most studies had methodological shortcomings, which limit the generalisibility of the results. IMPLICATIONS FOR HEALTH POLICIES: Given the reluctance of patients to use antidepressants and the large economic impact of depression, policy makers have a need for well designed and sufficiently powered economic evaluations of psychological treatments. The available evidence seems to indicate that psychotherapy has more substantial clinical effects than counselling. Therefore, the emphasis should be on economic evaluations of forms of psychotherapy that have proved to be clinically effective. IMPLICATIONS FOR FURTHER RESEARCH: There are indications that the cost-effectiveness of depression treatment on the whole may be improved by incorporating psychological treatments into enhanced care models, tailored to the needs of individual patients and/or by providing them by trained nurses instead of psychologists or psychotherapists. Further research should investigate these patient tailored, stepped care treatment modalities for depression treatment.

Development and feasibility of a patient feedback programme to improve consultation skills in general practice training.

OBJECTIVE: To develop an attractive and effective patient feedback training programme for general practice trainees (GPTs). METHODS: First, an exploratory study was conducted in which patients and GPTs were interviewed after they had worked with patient feedback. This contributed to the development of the patient feedback training programme. Subsequently, in a feasibility study, first-year GPTs asked patients to give feedback on their consultation skills by completing a questionnaire. The outcomes of group discussions with the GPTs and the results of the evaluation forms filled in by the GPTs were analysed. RESULTS: Forty-eight GPTs collected 878 questionnaires. GPTs and patients alike expected patient feedback to be a major tool for acquiring consultation skills. The GPTs encountered several obstacles in the organisation of this programme in their practice. They reported that the learning effects were more limited than they had expected because patients gave positively biased answers and because not all consultations provided an appropriate source of patient feedback. CONCLUSION: The new patient feedback programme on consultation skills is feasible for patients and GPTs. PRACTICE IMPLICATIONS: To optimise the educational potential and benefits of patient feedback, GPTs should ask for feedback from patients after challenging consultations, and should stimulate patients to be critical in their answers.

Cost-effectiveness of usual general practitioner care with or without antidepressant medication for patients with minor or mild-major depression.

BACKGROUND: Minor depression is common in primary care and associated with increased health care costs. Many mildly depressed patients are prescribed antidepressants, although there is insufficient information on the cost-effectiveness of antidepressants for these patients. The objective of this study was to evaluate whether usual care without antidepressants is equivalent to (i.e. as effective as and as expensive as) usual care with antidepressants in patients with minor or mild-major depression. METHODS: Severity of depression was measured using the Montgomery Asberg Depression Rating Scale (MADRS) and quality-adjusted life-years (QALYs) using the EuroQol. Resource use was measured from a societal perspective using cost diaries. Bootstrapping was used to analyze the cost-effectiveness data. RESULTS: Equivalence could not be shown for improvement in MADRS score or QALYs gained at 52 weeks. The mean (95% CI) difference in total costs between usual care without antidepressants and usual care with antidepressants was -euro751 (-3601; 1522). Using an equivalence margin of euro500 equivalence in costs could not be shown. In the cost-effectiveness analyses equivalence also could not be shown. LIMITATIONS: This study was underpowered for economic outcomes. Another limitation was the loss-to-follow-up. CONCLUSIONS: Although equivalence could not be shown in the costs and cost-effectiveness analyses, 95% confidence intervals also did not show that usual care without antidepressants was vastly superior or inferior to usual care with antidepressants. Therefore, we recommend general practitioners to show restraint when prescribing antidepressants to mildly depressed patients.

Impact of physical symptoms on perceived health in the community.

OBJECTIVE: Physical symptoms, such as musculoskeletal pain, dizziness, or headache, are common. People with more symptoms are reported to use more healthcare and have higher sickness absenteeism. We studied the impact of the number of symptoms on perceived health in a community sample. METHODS: Between June 2005 and March 2006, a random sample of 4741 adults was selected from the records of five general practices in The Netherlands. They were sent a questionnaire regarding the frequency and impact of physical symptoms, and other factors that may influence health (potential confounders or modifiers), including lifestyle factors, childhood illness experiences, and psychological factors. We studied the association between increasing number of physical symptoms and perceived health using the SF-36 as the outcome measure. RESULTS: Response rate was 53.5% (n=2447). Fatigue was the most commonly reported symptom with a prevalence of 57%, followed by headache (40%) and back pain (39%). More than half of responders reported three symptoms or more. Responders with multiple symptoms were more often female, had lower educational level, less often paid work, higher body mass index, more negative childhood health experiences, and higher scores for anxiety and depression. Multiple symptoms were strongly associated with perceived health, especially among responders with negative illness perceptions, more anxiety, or those reporting family members with a chronic illness during childhood. CONCLUSION: Physical symptoms are common and often seem to be mild. However, increasing number of symptoms is strongly associated with poorer physical, emotional, and social functioning. Different somatization processes may explain our findings.

Depression in old age (75+), the PIKO study.

BACKGROUND: Old people (75+) are underrepresented in studies on the prevalence of and risk factors for depression while the number of elderly people suffering from this mood disorder may be considerably higher than previously assumed. The role--if any--of age and gender in 'Geriatric Depression' is still unclear. METHODS: In this community-based study, prevalence of depressive symptomatology and risk indicators were assessed in 2850 participants aged 75 years or more. A clinically relevant level of depressive symptoms was defined as a score of > or =16 on the Centre for Epidemiologic Studies Depression scale (CES-D). Demographic data and questions related to physical and psychological health were recorded. Simple and multiple logistic regression techniques were used to determine the risk indicators (Odds Ratios, OR, with 95% confidence intervals, CI) with apparent importance to this population. RESULTS: The prevalence of depressive symptoms was assessed to be 31.1%. This is considerably higher than what has been found in younger elderly samples. The bivariate age effect was OR 1.05 (95% CI=1.03 to 1.07). Controlling for confounding, the effect of gender and age on depressive symptoms disappeared. CONCLUSIONS: Depressive symptoms are highly prevalent in the elderly population and increase with age. This increase seems to be attributable to age-related changes in risk factors rather than to ageing itself. With regard to the risk factors found, attention should perhaps be paid to functional disability, loneliness and apprehensiveness for falling since these risk indicators are amenable for improvement.

Interdisciplinary cooperation of GPs in palliative care at home: a nationwide survey in The Netherlands.

OBJECTIVE: To investigate the occurrence and predictors of interdisciplinary cooperation of GPs with other caregivers in palliative care at home. DESIGN: In a prospective study among 96 general practices, the GPs involved identified all dying patients during the study period of 12 months. The GPs received an additional post-mortem questionnaire for each patient who died during the study period, and registered the healthcare providers with whom they cooperated. Multivariable logistic regression analysis was used to identify the predictors of GP cooperation with other caregivers. SETTING: Second Dutch National Survey in General Practice. SUBJECTS: A total of 743 patients who received palliative care according to their GP. MAIN OUTCOME MEASURES: Interdisciplinary cooperation between GP and other healthcare providers. RESULTS: During the study period, 2194 patients died. GPs returned 1771 (73%) of the questionnaires. According to the GPs, 743 (46%) of their patients received palliative care. In 98% of these palliative care patients, the GP cooperated with at least one other caregiver, with a mean number of four. Cooperation with informal caregivers (83%) was most prevalent, followed by cooperation with other GPs (71%) and district nurses (63%). The best predictors of cooperation between GPs and other caregivers were the patient's age, the underlying disease, and the importance of psychosocial care. CONCLUSION: In palliative care patients, GP interdisciplinary cooperation with other caregivers is highly prevalent, especially with informal caregivers and other primary care collaborators. Cooperation is most prevalent in younger patients, patients with cancer as underlying disease, and if psychosocial care is important.

Diagnosing dementia with confidence by GPs.

BACKGROUND: Earlier reports suggest limited clinical reasoning and substantial uncertainty of GPs in assessing patients suspected of dementia. OBJECTIVE: To explore the predictors of GPs to decide on the presence and absence of dementia as well as the predictors of diagnostic confidence of GPs. DESIGN: An observational study was set up among 107 patients of 64 GPs. The GPs were instructed to use the Dutch national dementia guideline on consecutive patients newly suspected of dementia and to register their assessment on a detailed form. The predictors of the presence and absence of dementia according to the GPs and their diagnostic confidence were explored by logistic regression analyses. DEPENDENT VARIABLES: (i) presence and absence of dementia according to GPs and (ii) diagnostic confidence. INDEPENDENT VARIABLES: clinical (cognitive, behavioural, somatic, functional), applications of recommendations, patient related and GP related. RESULTS: Dementia was diagnosed in 67% of the suspected patients. The presence of dementia according to the GPs was positively associated with observed impairment of the higher cognitive functions, absence of depression and female gender of patients. The GPs expressed diagnostic confidence in 58% of the cases. This was positively associated with application of recommendations, ADL dependency, longer duration, informant availability, restless behaviour and a patient's female gender. Use of the Mini Mental Status Examination was not associated with confidence. CONCLUSIONS: GPs seem to base the diagnosis of dementia on rational grounds. Application of the dementia guideline's recommendations may contribute to more diagnostic confidence.

Symptoms in patients receiving palliative care: a study on patient-physician encounters in general practice.

Most people with an incurable disease prefer to stay and die at home, cared for by their general practitioner (GP). This paper aims at describing the prevalence of symptoms in patients receiving palliative care at home. Within the framework of a nation wide survey of general practice in the Netherlands, GPs received a questionnaire for all patients who died within the 1-year survey period to determine whether patients received palliative care (n = 2,194). The response rate was 73% (n = 1,608), and 38% of these patients received palliative care until death. Information regarding encounters during the last 3 months of life was derived from the records kept by the GPs. Digestive symptoms (59%) and pain (56%) were the most prevalent. The total number of symptoms per patient was higher in cancer patients (11.99) than in non-cancer patients (7.62). Not reported in previous studies were musculoskeletal symptoms (20%) and chronic ulcer (18%). Concluding, this showed that Dutch GPs encounter a diversity and wide range of symptoms in palliative care. To face these complex challenges in patients receiving palliative care at home, GPs have to be trained as well as supported by specialized palliative care consultants.

Survey among 78 studies showed that Lasagna's law holds in Dutch primary care research.

OBJECTIVE: Research in general practice has grown considerably over the past decades, but many projects face problems when recruiting patients. Lasagna's Law states that medical investigators overestimate the number of patients available for a research study. We aimed to assess factors related to success or failure of recruitment in general practice research. STUDY DESIGN AND SETTING: Survey among investigators involved in primary care research in The Netherlands. Face-to-face interviews were held with investigators of 78 projects, assessing study design and fieldwork characteristics as well as success of patient recruitment. RESULTS: Studies that focused on prevalent cases were more successful than studies that required incident cases. Studies in which the general practitioner (GP) had to be alert during consultations were less successful. When the GP or practice assistant was the first to inform the patient about the study, patient recruitment was less successful than when the patient received a letter by mail. There was a strong association among these three factors. CONCLUSION: Lasagna's Law also holds in Dutch primary care research: many studies face recruitment problems. Awareness of study characteristics affecting participation of GPs and patients may help investigators to improve their study design.

Low back pain in general practice: cost-effectiveness of a minimal psychosocial intervention versus usual care.

An intervention that can prevent low back pain (LBP) becoming chronic, may not only prevent great discomfort for patients, but also save substantial costs for the society. Psychosocial factors appear to be of importance in the transition of acute to chronic LBP. The aim of this study was to compare the cost-effectiveness of an intervention aimed at psychosocial factors to usual care in patients with (sub)acute LBP. The study design was an economic evaluation alongside a cluster-randomized controlled trial, conducted from a societal perspective with a follow-up of 1 year. Sixty general practitioners in 41 general practices recruited 314 patients with non-specific LBP of less than 12 weeks' duration. General practitioners in the minimal intervention strategy (MIS) group explored and discussed psychosocial prognostic factors. Usual care (UC) was not protocolized. Clinical outcomes were functional disability (Roland-Morris Disability Questionnaire), perceived recovery and health-related quality of life (EuroQol). Cost data consisted of direct and indirect costs and were measured by patient cost diaries and general practitioner registration forms. Complete cost data were available for 80% of the patients. Differences in clinical outcomes between both the groups were small and not statistically significant. Differences in cost data were in favor of MIS. However, the complete case analysis and the sensitivity analyses with imputed cost data were inconsistent with regard to the statistical significance of this difference in cost data. This study presents conflicting points of view regarding the cost-effectiveness of MIS. We conclude that (Dutch) general practitioners, as yet, should not replace their usual care by this new intervention.

Sense of competence questionnaire among informal caregivers of older adults with dementia symptoms: a psychometric evaluation.

BACKGROUND: The Sense of Competence Questionnaire (SCQ) was originally developed for informal caregivers of patients with diagnosed dementia. In order to study the validity and usefulness of the SCQ when applied to informal caregivers of older adults with dementia symptoms (i.e. cognitive impairment, pre-diagnostic dementia or dementia in its early stages), we investigated the construct validity, feasibility, subscales, homogeneity, and floor and ceiling effects in this new target population. METHODS: A psychometric evaluation was performed among 99 informal caregivers. To investigate construct validity, hypotheses were tested, concerning the association between sense of competence and burden, mental quality of life, depressive symptoms, and mastery. To investigate feasibility, response rate and the proportion of missing data were explored for each item. An exploratory principal component analysis was used to investigate whether the SCQ comprises the three subscales established in previous studies. Homogeneity was assessed for each subscale with Cronbach's alpha and item-total correlations. Floor and ceiling effects were explored. RESULTS: Most hypotheses on construct validity were rejected. Only the subscale 'consequences of involvement in care' was found to be partly valid. Feasibility: 93 out of 99 persons completed the SCQ. The proportion of unanswered items per item ranged from 0-3%. Subscales: the SCQ comprises the three expected subscales. Homogeneity: Cronbach's alpha and item-total correlations of the three subscales were satisfactory. A ceiling effect occurred on the subscale 'satisfaction with the care recipient'. CONCLUSION: The three subscales of the SCQ showed good homogeneity and feasibility, but their validity is insufficient: only the subscale 'consequences of involvement' was found to be partly valid. The two other subscales might not be relevant yet for the new target population, since many of the items on these scales refer to problem behaviour and problematic interactions. Our message to clinicians is not to use these subscales.

A cluster-randomised trial evaluating an intervention for patients with stress-related mental disorders and sick leave in primary care.

OBJECTIVE: Mental health problems often affect functioning to such an extent that they result in sick leave. The worldwide reported prevalence of mental health problems in the working population is 10%-18%. In developed countries, mental health problems are one of the main grounds for receiving disability benefits. In up to 90% of cases the cause is stress-related, and health-care utilisation is mainly restricted to primary care. The aim of this study was to assess the effectiveness of our Minimal Intervention for Stress-related mental disorders with Sick leave (MISS) in primary care, which is intended to reduce sick leave and prevent chronicity of symptoms. DESIGN: Cluster-randomised controlled educational trial. SETTING: Primary health-care practices in the Amsterdam area, The Netherlands. PARTICIPANTS: A total of 433 patients (MISS n = 227, usual care [UC] n = 206) with sick leave and self-reported elevated level of distress. INTERVENTIONS: Forty-six primary care physicians were randomised to either receive training in the MISS or to provide UC. Eligible patients were screened by mail. OUTCOME MEASURES: The primary outcome measure was duration of sick leave until lasting full return to work. The secondary outcomes were levels of self-reported distress, depression, anxiety, and somatisation. RESULTS: No superior effect of the MISS was found on duration of sick leave (hazard ratio 1.06, 95% confidence interval 0.87-1.29) nor on severity of self-reported symptoms. CONCLUSIONS: We found no evidence that the MISS is more effective than UC in our study sample of distressed patients. Continuing research should focus on the potential beneficial effects of the MISS; we need to investigate which elements of the intervention might be useful and which elements should be adjusted to make the MISS effective.

The effectiveness of adding cognitive behavioural therapy aimed at changing lifestyle to managed diabetes care for patients with type 2 diabetes: design of a randomised controlled trial.

BACKGROUND: In patients with type 2 diabetes, the risk for cardiovascular disease is substantial. To achieve a more favourable risk profile, lifestyle changes on diet, physical activity and smoking status are needed. This will involve changes in behaviour, which is difficult to achieve. Cognitive behavioural therapies focussing on self-management have been shown to be effective. We have developed an intervention combining techniques of Motivational Interviewing (MI) and Problem Solving Treatment (PST). The aim of our study is to investigate if adding a combined behavioural intervention to managed care, is effective in achieving changes in lifestyle and cardiovascular risk profile. METHODS: Patients with type 2 diabetes will be selected from general practices (n = 13), who are participating in a managed diabetes care system. Patients will be randomised into an intervention group receiving cognitive behaviour therapy (CBT) in addition to managed care, and a control group that will receive managed care only. The CBT consists of three to six individual sessions of 30 minutes to increase the patient's motivation, by using principles of MI, and ability to change their lifestyle, by using PST. The first session will start with a risk assessment of diabetes complications that will be used to focus the intervention. The primary outcome measure is the difference between intervention and control group in change in cardiovascular risk score. For this purpose blood pressure, HbA1c, total and HDL-cholesterol and smoking status will be assessed. Secondary outcome measures are quality of life, patient satisfaction, physical activity, eating behaviour, smoking status, depression and determinants of behaviour change. Differences between changes in the two groups will be analysed according to the intention-to-treat principle, with 95% confidence intervals. The power calculation is based on the risk for cardiovascular disease and we calculated that 97 patients should be included in every group. DISCUSSION: Cognitive behavioural therapy may improve self-management and thus strengthen managed diabetes care. This should result in changes in lifestyle and cardiovascular risk profile. In addition, we also expect an improvement of quality of life and patient satisfaction. TRIAL REGISTRATION: Current Controlled Trials ISRCTN12666286.

Yield of a new method to detect cognitive impairment in general practice.

OBJECTIVE: To examine whether a new screening method that identified patients with cognitive impairment who needed further examination on the presence of dementia yielded patients who were not detected by their general practitioner (GP), and to identify factors associated with GPs' awareness of patients identified by the screening. METHODS: Cross-sectional comparison between two methods used to identify dementia symptoms: (1) usual identification of dementia by GPs; (2) a two-stage screening to identify cognitive impairment. The two methods were implemented on the same older general practice population. The study was set in primary care practices in the Netherlands. The participants were 44 GPs and 2,101 general practice patients aged 75+ who lived at home. The following measurements were used: (1) yield of the screening; (2) determinants of GPs' awareness of patients identified by the screening. RESULTS: The two-stage screening yielded 117 patients with cognitive impairment who needed further examination; in most cases (n = 82, 70.1%) their GP was unaware of the symptoms. Among patients identified by the screening, GPs' awareness was associated with co-morbidity of chronic diseases [odds ratio (OR) = 3.19; 95% Confidence Interval (CI) = 1.25 to 8.15], depressive symptoms (OR = 0.41; 95% CI = 0.17 to 0.99), and cognitive functioning (per point on the MMSE, OR = 0.88; 95% CI = 0.79 to 0.98). CONCLUSION: A two-stage screening method and increased alertness for cognitive impairment and dementia among patients with depressive symptoms may improve detection rate of dementia in general practice.