Multidisciplinary Doctor ’ s Clinical Practice , Confident And Difficulties To Diagnose , Manage And Care For Dementia In Remote Area Hospital

Objectives: To examine multidisciplinary doctor’s clinical practice, confident and difficulties to manage and care for dementia in remote area hospital. Method: A structured self-completed questionnaire, purposive sampling method with 18 multi-specialist doctors from united mission hospital. Results: Key findings are dementia is a complex condition to diagnose and management that takes time to diagnose and current dementia assessment process is conflict between GPs and other professionals. As well as specialist did not consider that diagnosing dementia was benefited, nor current applied diagnostic methods are appropriate and they are skeptical about the advantages of dementia medications and methods which they have practice on primary care. Similarly, GPs detection is not final decision therefore better to make collaboration with others specialist professionalsneither confident to diagnose nor easy to get medicine in the local market. Likewise, neither social support nor day care and memory clinic services are available in the community. Lack of epidemiology knowledge, practice and experience, cost of dementia care, no governmental policy, no early diagnosis are additional barriers aspects to reach accurate diagnosis. Conclusions: Still the diagnostic methodology and practice has not similar to screening dementia so it does not seem significantly benefit in screening. Rather early diagnosis, collaboration with multi specialist doctors, appropriate referral pathways, diagnostic guideline and refined MMSE tool is far better. It is not only issue of primary care doctors’and not possible to detect the dementia without collaboration of multi experts group. The burden impact of dementia prevalence has been underestimated in developing countries. DOI : 10.14302/issn.2474-9273.jbtm-16-1376 Corresponding author: Krishna Prasad Pathak, Macedonia University, Thessaloniki. Email: krishnapathak32@gmail.com


Background
Dementia is a complicated disease to diagnose, management and care for health professionals due to its a dozen of overlapping signs and symptoms. Therefore, the universal question is significantly arising who is dementia specialist (GP, neuropsychiatric, geriatric and neurologist, psychiatrist of older age or later life)? Or who has the pivotal role in dementia diagnosis, management, and care? Also, is there essential of multidisciplinary team's combination to diagnose, management and care? Is this fact that due to the gap of appropriate knowledge the misdiagnosing rate is increasing? Therefore, we aimed to find the above mentioned and facts and to give a message on this issue.
Dementia is a progressive disease affecting various higher cortical functions and resulting in physical dependency, psychological affective and it is recognized as a crucial part of the dementia syndrome that remains an important for institutionalization [1]. Dementia can show vary from one person to another but over longer periods it makes the person more disabled [2]; [3] and challenges for primary care to detect for both caregivers and general practitioner and multidisciplinary team in their practice. It is a rapidly increasing as common public health issue all over the world that is under recognized in primary care settings [4]; [5] finds that primary care physicians fail to recognize, findings & proper managements. Therefore, dementia and related disorder disease pose a significant public health issue.
Also, it takes longer duration to diagnose due to its vague signs and symptoms and slowly it is going to be a future crisis. It is estimated that the number of people with dementia will double every 20 years to 81.1 million by 2040 [6].
In the current practice the final decision goes on the neurologist. However, physician/family doctors, geriatrician, psychiatrists can diagnose others complication out of memory clinic. First visit to the GP or physician can help for more confirmation because patients may have some insight any kinds of medical hidden changes may occurring that cannot diagnose by the other experts [7]. Further, the neurologist should collaborate with multidisciplinary team in primary care as well as should facilitate the development of multidisciplinary teams for appropriate diagnose [8]. [9] finds that to screen the dementia the mini-mental state examination is important test due to its more reliability and validity than other scale. Generally, in the clinical practice the mini-mental test clock drawing test(verbal)

1-4 minute, GPCOG (verbal 4-5) minute & minute screen
(verbal-7 minute) memory impairment screen (verbal minute), mini cog (verbal 2-4-5 minute) are frequently using to assess the dementia [10]. Even though due to the lack of specific knowledge skills among the GPs, are not success to diagnose. However there remain others influencing factors such as: education, age and valuable tools these do not help to diagnose dementia properly [11]. So, early detection of dementia is more potential for both patients and HPs [12] who observes mostly in their primary care in hospital [13] because it helps to find accuracy detecting probability and to refer in the correct place in time.
A study stated that delaying process in the diagnosis of dementia is 35 % by the GP in Ireland and almost GP pointed out the some factors are the responsible to be late detection of dementia: 1) lack of time, 2) Lack of confidence 3) lack of education, 4) Lack of confidence [14]; [15]. In next study, only 47.6% of GPs received training in the diagnosis and management of dementia and only 43.9% used specific protocols to diagnosis. As well as rest of them focused some need for more support for families, more respite care, day centres and social activities for people with dementia [16]. A growing number of studies [17] show that the prevalence of dementia increases with age and affects approximately 5-8 percent of individuals over age 65, 15 approximately 15-50 percent of individuals over age 85.
Similarly, in Nepalese context the old age population number is increasing as worldwide. In 2011, 2.2 million accounting 8.3% of Nepal's total population [18].
Initially it is assumed that 78000 over 65 have suffered by any kind of dementia even though there is not any scientific study [19].
All the above-mentioned facts and figures brought the considerable attention to conduct this study because we already knew that burden for health institutions, multi-expert, GPs and nurses, those are facing difficulties in diagnosis, manage and care. Our queries were, "who is who" in the dementia diagnosis like; GPs, Neurologist, psychologist, psychiatrist, Geriatrician and other HPs? Does it necessary to have collaboration of other (support of) health professionals like-psychiatric nurses/admiral nurses, dentist, optometrist, audiologist, physiotherapist, occupational therapist, dieticians, clinical psychologist, speech and language therapist, caregivers and social care staff, optometrists etc.? Do they prepare to address the dementia issues? Therefore, this would not be argued that multidisciplinary service is not helpful. Also, this paper will be an initiative step to assess the dementia health profession condition and to prepare for looming epidemic disease.

Design
Purposive sampling method was used to achieve the objectives and it was conducted after the taking permission using self-completed question (English version) set with the specialist doctors in hospital. All these questions were both distributed and collected by the hospital director and it was collected after the information by the same director with in one months of the distributed date. There was not any bias to distribute the questions to the specialist. It was requested to complete questionnaire set according to their own current knowledge but not taking any support from out. UK., Germany, Africa, Nepal, Australia, and USA. The intension was to choose how do the multiple doctors regarding with dementia issues in their profession and are they aware with this issue or not and to assess the difficulties with the multi doctors to provide dementia services in the hospitals because a minimum survey was needed to create a new policy and increase public concerns. In clinical diagnose group work seems more suitable than individuals examining for better diagnose [20].

Measurement
The questionnaires were covering demographic questions, dementia quiz: diagnosis, medication,

Data analysis
The questionnaire format was similar with Turner's et al., (2004) [21]. These questions were coded according to the Statistical Package for the Social Sciences, SPSS version 20. Our data information was using frequencies information with percentages, mean, and standard deviation and we summarized open type of answer manually in descriptive way and analyzed with other related work.

Awareness of local services
In respect to awareness of day care services in living area fifty percent{no 9(50%)} knew there was day care services, accordingly about the memory clinic at living area one third said "no" 13(72.2%), 7(38.9%) respondents said "no" carer support group at living area, half percent {'No' -9(50%)} could name local support group for people with dementia and locate the name and very less percent were noted 6(33.3%) available to get the medicine for those dementia patients in the market. This result reflects the dementia care is still in shadow in hospital settings.

Confidence in Making Diagnosis Dementia
With the specialists were asked 'how confidence in making the diagnosis' of dementia {somewhat confident 7(38.9%)} nearly thirty-nine per cent were confident to prescribe medicine to suspected dementia patients themselves. Respondents were not confident to recommend medication on the time of diagnose but GPs are easily accessible [24]. The overall score reflects low confidence with the respondents. There were no significant differences with between received degree from aboard and native country practitioners' in total knowledge, confident, management and care.

Aspects of the Difficulties of Dementia Care
On the basis of dementia care difficulties, the important difficulty was noted "making a diagnosis"  Table 3  Huntington's disease means the inherited, degenerative brain disease which affects the mind and body.   [27].    : 10.14302/issn.2474-9273.jbtm-16 finding was the similar with our result. Also, we found, the general concept of dementia in not positive-it is considered a disease of elderly. GP has vital role although GPs felt the early diagnostic process is more challenging [41]) and they suggested for early diagnosis [12]. Even though majority experts were not concerned to take cognitive assessment/ screening to the patients [42] nor especial dementia training as like Sweden. We found majority respondents were interested to attain training for update the overall knowledge but, never get opportunities for raining. However, they were keep going practices own their efforts as like Irish and Swedish HPs [43]. Our limitations were no observational research in their clinical practice, less number from one hospital. This result may not represent true practice and management. Also, we have no national data to compare with dementia to yield reliable data.