This work was conducted in united mission hospital, where 90 percent are working as full-timer. This hospital is only one hospital in remote area from capital city and oldest, that was first established before 50 years. Twenty-nine were working (including trainees) and 10 mission appointees from six different countries, who work mostly as senior doctors in a teaching role, or in other support roles, at the movement. A purposive sampling approach identified 18 multidisciplinary from twenty-three experts (response rate 5.2 %). Questionnaires were given a self-completed structured with multiple choice items in English version. The medical division comprises the doctors and paramedical departments, Laboratory, Physiotherapy, Occupational Therapy, Dental, Anaesthesia, Out Patient Department, and Pharmacy. As well as, 6 posts for surgeons, at present two are trained orthopaedic surgeons, and 8 posts for senior medical officers, who are general practitioners, paediatricians, an anaesthetist, and medical officers with special training in obstetrics and gynaecology and internal medicine. They were not involved as expert of dementia neither in community nor hospitals. Approximately 70% of its patients come from the surrounding nine districts, Western Nepal, and from nearby parts of North India and total bed capacity is 165.

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.

These question set were distributed for those specialists only who were wishing to fill-up questionnaire. The disciplines (numbers of specialist doctors) were only eighteen from the following clinical areas; General psychiatry; general practitioners; pediatrics; gynecologists; orthopedic; (BDS) Dental surgeon as full timer and 6 doctors were from different countries like; 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.

The questionnaires were covering demographic questions, dementia quiz: diagnosis, medication, epidemiology, and management. It was on multiple choice items for each question as well as in the aspect of dementia quiz there was “do not know” option on the questions. In first part of questionnaire; awareness of local support, dementia care, confident and attitudes, current practices of dementia, difficulties, current diagnostic tools, management and caring process, common sign and symptoms, diagnostic confidence, diagnostic facing problems was measured with 40 questions and in second part: dementia knowledge was measured with 21 questions. These questions were included with anatomy and physiology of dementia, medication effects and its efficacy, perceived difficulties and some remaining questions were open type to measure the specialist doctors’ view, perception and their experiences in the dementia. There were measured the common sign and symptoms on the basis of “Yes”, “No” and “Do not know” option. For Aspects of the difficulties of dementia care was measured with Not at all difficult, extremely difficult and do not know options, similarly, regarding with attitudes to dementia care was measured ranking on scale of agreement (strongly agree, agree, neither agree nor disagree, disagree, strongly disagree and cannot say. There were open types of questionnaires also to measure of theirs view, need and current situation and suggestions.

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.

This paper describes diagnosis practices, confident, management and difficulties with multi-specialist doctors on the basis of result.Overall 18 multidisciplinary doctors’ data are collected on the basis of their response and analyzed. The practice confidences, management difficulties to diagnose, diagnostic place, screening tools, sources of dementia updating knowledge and its treatment procedure was measured with the multidisciplinary doctors in remote area hospital. These respondents’ minimum age was 28 and maximum 52 (mean age 39.10/ S.D.7.26). Majority experts (12) were received their final degree from the aboard university like; European Union 2(11.1%), Asia 4(22.2%), Africa 1(5.6%), Nepal 6(33.3%), Australia 1(5.65), Russia 1(5.6%), China 2(11.1%), USA 1(5.65) and among of them 6 were foreigner specialist from UK, Australia, Africa, USA, Germany and China, who were working in that hospital since long years ago.

The proportion of female number is nearly 50%; that was equal with the male experts. We could not find the diagnostic and management experiences difference between the male and female respondents. More than eighty percent doctors were full timer and the diagnosis process handling by them in the out-patient’s department. Neither there was Geriatric service nor dementia specialist in the hospital settings even though they could handle up to 13 suspected patients in a specific month. The duration of detection of dementia was 1-3 months to the suspected dementia patients. But they do not have taken any kind of dementia training which helps for their betterment diagnostic service.

Of 18 specialist doctors’ overall knowledge was very poor (Mean 12.83, SD= 2.8). See Table 1. It shows that dementia is very poorly focused disease than other types of disease in the hospitals.

Dementia diagnosis process is not similar globally also, nor medication is. The currently used clinical practice guidelines can be a worthy tool in the diagnose and management of dementia, though some professionals do not agree with their importance in clinical aspects.Even though there is a common agreement with the diagnostic strategies. Examination recommended to start with first signs and symptoms of cognitive deterioration. The majority of the doctors 15(83.3%)were reported to ask about the mental history at first of their clinical diagnosis process then systemic illness: Cancer, Connective tissue 15(83.3%), Trauma 12(66.7%), Check renal function 13(72.2%), Check glucose 12(66.7%) etc. SeeTable 2.

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.

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.

On the basis of dementia care difficulties, the important difficulty was noted “making a diagnosis” particularly in the early stages. Accordingly, establishing a diagnosis 13 (72.2%), telling the patient the diagnosis 8 (44.4%), telling the family the diagnosis 8 (44.4%),responding to the family's concerns 8 (44.4%),getting information about anti-dementia (cognitive enhancing) medications 7(38.9%) also expressed greater difficulties. Likewise, they added some extra barriers on open opinion like not having clinical research, the complexity of biological and psychological disorder, ethical nature of the condition, limited training to the physicians, neglect of elderly disease etc. ²⁵. See Table 3.

Dementia is gradually being burden issue to the practitioner in the hospital settings on the basis of survey data. Majority believed that dementia diagnosis is more frustrating issue than rewarding and felt that a diagnostic issue is not only with the general practitioners. Result shows that scale of response towards on dementia is nearly half percentage. Respondent reported in five categories for each statement. Finally, to all practitioners were asked to rate their own agreement of dementia diagnosis and management on a scale of “strongly agree” to “Cannot say” option about their experience in caring for dementia patients. SeeTable 4

Large majority respondents were reported that dementia is an umbrella term so there is no specific sign and symptom to determine that patients have dementias problem. There was given to choose 18 symptoms of dementias. However, the most common sign and symptoms identified the forgetfulness 18 (100%), memory loss, social skill loss and difficulty to recognize to the others and conduct disorder by the multi experts. The specialist group reported at least 10 warning symptoms are essential to declare the dementia disease to the suspected patients which are as following: Loss of interest in activities 8 (44.4%), loss of interest in activities 6(33.3%), loss initiative 12(66.7%), Memory loss 17 (94.4%), phobias 8(44.4%), Difficulty performing familiar task 7(38.9%), Recurring thoughts of death or suicide 18(0%), social skills loss 16(88.9%), change in appetites 6(33.3%), low self-stem 8(44.4%), difficulty to recognize 13(72.2%), Conduct disorder 10(55.6%), forgetfulness 18(100%), fatigue 3(16.7%), problems with language 9(50%),disorientation with time and date 11(61.1%), poor or decreased judgment 5(27.8%), Depression anxiety 6(33.3%).Above mentioned warning signs help to recognize at first stage of dementia for doctors ²⁶; ²⁷.

Table shows some barrier aspects regarding on their manage and care for dementia patient on the basis of multidisciplinary responses. Similarly, these barriers are: unsure how to refer patients to take available services, lack of team staff in the practice, unfamiliar with available services to help keep them at home, costs of dementia care,too busy: not enough time during surgery visit, lack of funding within the practice, unfamiliar with advances in the management of dementia-related symptoms and lack of social service support available to the practice dementia-related symptoms. Above mentioned are mainly barrier aspects to detect the dementia in their primary care practice. See Table 5.

There was most common agreement with all specialist doctors that dementia diagnosis is very less prioritized problem in Nepal than other public health issue and no adequate facility for screening dementia in the hospital even though the staff member are self-motivating to diagnose, management and care. Neither there was dementia care center, dementia specialist, nor admiral nurses in the hospital. The measuring criteria were as followings: strongly agree, agree, neither disagrees nor agrees, strongly disagree and can’t say.

In this last section, there was valuable comments/perceptions have on the drug treatment (Donepezil, Glantamine, Memantamine, Rivastigmine etc), diagnosis process/guideline, their perception satisfaction, further recommendation, education (internet, web, journal) and advices. One third multi-dimensional doctors reported that lees access with the internet and MRI, CT to make more confirm dementias diagnose but In North America there was 60-70% ²⁸), 72% of Norwegian doctors had Internet access ²⁹). They have desire to be updated Neuro-degenerative disorder and dementia, desire to cooperation and coordination with patients, caregivers and their loved one, multi-discipline working team and consultant, requesting to arrange social policy, further treatment and investigation and wanting to have access with CT/MRI as well. Efforts in Nepal need to be directed towards improving financial support, community support, family support, establishing day care home services, memory clinic services with geriatric services, a separate department of dementia in the hospital and in the community. Improvements in dementia knowledge and self-confidence for management and care should lead to an improvement in service delivery in Nepalese hospital and research is essential without delaying.