Primary Dementia Care Capacity Building: Practice Nurse

1. Primary Dementia Care Capacity Building: Practice Nurse / Community Dementia Nurse Integration Nurses making a difference Helga Merl & Karen Collins 2011

2. Today Background � why? Integration project - How? Evaluation Acknowledgements Tony Maher (CEO), Lisa Craig, Deb Rushworth, GPAccess Louise Lazic CACS manager Community Dementia Nurses HNELHN Dr John Ward Geriatrician

3. Community Dementia Nurse (CDN) program Aim: Produce benefits for the client; carer and significant other through a series of evidence based and clinically supported therapeutic interventions. This �Person Centred Dementia Care� model: Identifies clients at risk of dementia, Support diagnosis and management, Conducts comprehensive assessment, (cog screens), Provides episodic case management for PWD, Facilitates Advance Care Planning Ameliorates disease progression & functional decline, Controls symptoms and provides comfort care throughout the career path of dementia. The first principle of Dementia Care principles within CDN is; Diagnosis and management. The diagnosis of uncomplicated dementia can be made by the GP with complicated cases best addressed through Geriatrician clinics; both can be supported by the CDN. The CDN can provide comprehensive assessment in the clients� home environment, involving carers and family or support as indicated in the geriatrician clinics. The CDN provides episodic case management for those people diagnosed with dementia in partnership with the GP[1]. [1] Ward, Filiptschuk, Golvers, Hughes, Korzinski, Lazic, McMinn, Mearitt, Oakey, Schofield, Searras, Ticehurst, Hunter Area Health, draft dementia plan 2001 � 2006 The first principle of Dementia Care principles within CDN is; Diagnosis and management. The diagnosis of uncomplicated dementia can be made by the GP with complicated cases best addressed through Geriatrician clinics; both can be supported by the CDN. The CDN can provide comprehensive assessment in the clients� home environment, involving carers and family or support as indicated in the geriatrician clinics. The CDN provides episodic case management for those people diagnosed with dementia in partnership with the GP[1].

4. Primary Care Reality Dementia is difficult to diagnose. 50% GPs routinely identify early stage dementia & 70% identify moderate dementia [7] Differentiate between depression and dementia Difficult [8] GPs reluctant to communicate a diagnosis [9] Gap first symptoms and diagnosis 10 - 32 months [10] Adherence to management guidelines, provision of information and referral on to community services and supports is low. [11] Capacity of primary & community care to meet the needs of PWD and their carers must improve. It is recognised that dementia is difficult to diagnose. Currently initial screening and assessment for dementia is initiated when a person or family member expresses concern about symptoms, or when the GP notices signs associated with dementia (Bridges-Webb, Wolk, Britt, & Pond 2003). This is problematic in that it requires GPs to be aware of signs and symptoms of dementia and that they are open to discussing these with patients and their families with referral to services for care and support and a specialist if the diagnosis is unclear. Here in lies the problem. Only approximately half of GPs are routinely able to identify early stage dementia with approximately 70% able to identify moderate dementia (Creasy & Brodaty 1998; Valcour, Masaki, Curb, & Blanchette 2000). Many GPs find it difficult to differentiate between depression in older people and dementia (Brodaty, Draper & Low 2004). The rates of formal cognitive testing by GPs are low, as are adherence to management guidelines, provision of information and referral on to community services and supports (Renshaw, Scurfield, Cloke & Orrell 2001). GPs are also reluctant to communicate a diagnosis of dementia to the patient and their carer (Van Hout, Vernooij-Dassen., Poels., Hoefnagels & Grol 2000). A variety of explanations for these problems have been given including; lack of confidence by GPs in diagnosing; a belief that the diagnosis is the domain of specialists and erroneous beliefs that nothing can be done or that a diagnosis would be harmful to the patient (Milne, Woolford, Mason, & Hatzidimitriadou 2000; Turner, Iliffe, Downs, Wilcock, Bryans & Levin 2004; Merl & Bauer 2007). Nevertheless consumers and carer groups report that they would prefer that the diagnosis was communicated clearly and as early as possible (Black, LoGuidice, Ames, Barber & Smith 2001) GPs also lack understanding of the services and supports required for PWD, their carers and families. Attitudinal barriers in PWD, carers and GPs, often lead to inadequate assessment of the PWD and carer problems (Abbey, Palk, Carlson & Parker 2008). Benefits of early diagnosis and support Being able to recognise symptoms and obtain an accurate diagnosis early means drug and medical treatments can be commenced which benefit people most in the early to moderate stages. Reversible conditions such as depression can be treated, improving prognosis. Financial and legal plans can be made including appointing an Enduring Power of Attorney and Enduring Guardians, and preparing Advance Care Directives with the full agreement of the PWD. The individual and family can adjust better to the diagnosis, understand the illness and learn how to cope through adequate counselling, support and education (Educational newsletter 2002). Surveys of local GPs conducted from 2002 - 2005 (Merl & Bauer 2007) identified that whilst GPs consider the diagnosis and management of PWD as an extremely important part of their role, they do not have the time required to spend in adequately addressing the points mentioned above. It is recognised that dementia is difficult to diagnose. Currently initial screening and assessment for dementia is initiated when a person or family member expresses concern about symptoms, or when the GP notices signs associated with dementia (Bridges-Webb, Wolk, Britt, & Pond 2003). This is problematic in that it requires GPs to be aware of signs and symptoms of dementia and that they are open to discussing these with patients and their families with referral to services for care and support and a specialist if the diagnosis is unclear. Here in lies the problem. Only approximately half of GPs are routinely able to identify early stage dementia with approximately 70% able to identify moderate dementia (Creasy & Brodaty 1998; Valcour, Masaki, Curb, & Blanchette 2000). Many GPs find it difficult to differentiate between depression in older people and dementia (Brodaty, Draper & Low 2004). The rates of formal cognitive testing by GPs are low, as are adherence to management guidelines, provision of information and referral on to community services and supports (Renshaw, Scurfield, Cloke & Orrell 2001). GPs are also reluctant to communicate a diagnosis of dementia to the patient and their carer (Van Hout, Vernooij-Dassen., Poels., Hoefnagels & Grol 2000). A variety of explanations for these problems have been given including; lack of confidence by GPs in diagnosing; a belief that the diagnosis is the domain of specialists and erroneous beliefs that nothing can be done or that a diagnosis would be harmful to the patient (Milne, Woolford, Mason, & Hatzidimitriadou 2000; Turner, Iliffe, Downs, Wilcock, Bryans & Levin 2004; Merl & Bauer 2007). Nevertheless consumers and carer groups report that they would prefer that the diagnosis was communicated clearly and as early as possible (Black, LoGuidice, Ames, Barber & Smith 2001) GPs also lack understanding of the services and supports required for PWD, their carers and families. Attitudinal barriers in PWD, carers and GPs, often lead to inadequate assessment of the PWD and carer problems (Abbey, Palk, Carlson & Parker 2008). Benefits of early diagnosis and support Being able to recognise symptoms and obtain an accurate diagnosis early means drug and medical treatments can be commenced which benefit people most in the early to moderate stages. Reversible conditions such as depression can be treated, improving prognosis. Financial and legal plans can be made including appointing an Enduring Power of Attorney and Enduring Guardians, and preparing Advance Care Directives with the full agreement of the PWD. The individual and family can adjust better to the diagnosis, understand the illness and learn how to cope through adequate counselling, support and education (Educational newsletter 2002). Surveys of local GPs conducted from 2002 - 2005 (Merl & Bauer 2007) identified that whilst GPs consider the diagnosis and management of PWD as an extremely important part of their role, they do not have the time required to spend in adequately addressing the points mentioned above.

5. Why target Practice Nurses (PNs)? Nursing in primary care is the most rapidly growing area of health care in Australia, increasing 15-17% per annum backed by the Australian Medical Association, the Royal College of General Practitioners and the Royal College of Nursing Australia [12] PNs could assist the GP in Dementia Care activities but they are not trained or supported to do this. It is an area we need to support in order to provide best practice dementia care to the community. 

6. Why else target PNs? 8 000 PWD & 10,000 carers Health (HNELHN) = 1 CNC Dementia, 5 CDNs, 6 Geriatricians Primary Care (GP Access) = 471 GPs and 325 PNs. support to the 145 General Practices in the Hunter Urban Area. This provides contact to the 471 General Practitioners and 325 Practice Nurses. By gaining the assistance of GP Access, we can better spread the information to GPs and Practice Teams about improved assessment, early detection, referral pathways, and benefits of the Dementia/ Memory Assistance Nurse for newly diagnosed patients and their families. Over the past five years the dementia advisory has held focus groups and surveyed our GP�s to determine they needs in regards to dementia care Biggest barrier to dementia care were gaps in education and confidence in diagnosing and managing dementia. And the time it takes to do this well, as a part of the development of a strategic plan for Central Coast consultation was conducted a division of GP with a large group of GP�s and they indicated that wanted a service to support them in dementia care. Focus area one of The National Framework for Action on Dementia 2006-2010: Care and Support, identifies that diagnosis, assessment, care and support are priority areas for action. Further the strategy goes on to state that evidence based, �networks of care and support� that are well coordinated with clear pathways that are responsive to changing needs are essential to improving Person Centred service delivery and a better quality of life for PWD, their carers and families. support to the 145 General Practices in the Hunter Urban Area. This provides contact to the 471 General Practitioners and 325 Practice Nurses. By gaining the assistance of GP Access, we can better spread the information to GPs and Practice Teams about improved assessment, early detection, referral pathways, and benefits of the Dementia/ Memory Assistance Nurse for newly diagnosed patients and their families. Over the past five years the dementia advisory has held focus groups and surveyed our GP�s to determine they needs in regards to dementia care Biggest barrier to dementia care were gaps in education and confidence in diagnosing and managing dementia. And the time it takes to do this well, as a part of the development of a strategic plan for Central Coast consultation was conducted a division of GP with a large group of GP�s and they indicated that wanted a service to support them in dementia care. Focus area one of The National Framework for Action on Dementia 2006-2010: Care and Support, identifies that diagnosis, assessment, care and support are priority areas for action. Further the strategy goes on to state that evidence based, �networks of care and support� that are well coordinated with clear pathways that are responsive to changing needs are essential to improving Person Centred service delivery and a better quality of life for PWD, their carers and families.

7. PN CDN integration project. Partnership: GPAccess, PNs & GPs, Geriatric Medicine, CDNs. Project Goal: To build the capacity of Primary Care to diagnose and manage PWD, their carers and families. Aims: Improve referral pathways Promote the multidisciplinary Primary Dementia Care team Increase PN knowledge and confidence in Primary Dementia Care Increase CDN referrals & consultations from Primary Care Target Group PNs in the inner Newcastle region (Pilot Site) and across the Greater Newcastle cluster (Port Stephens, Newcastle West , East & West Lakes) for the General role out. GPs were not excluded.

8. PN CDN Integration Project From rocky road To superior pathway

9. Education and information A multifaceted education approach was adopted The resources and information kit � brochures GP Clinical Pathway PN referral pathway E � learning; Dementia Care CD-ROM -14 CNE points proven to educate and empower Primary Dementia Care [13] Two face to face workshops with CNC Dementia, part of the over 75s health assessment training organised by GP Access. Met some areas of identified PN education needs. E � learning; Dementia Care CD-ROM -14 CNE points proven to educate and empower Primary Dementia Care to advocate for and initiate changes required (5). Two face to face workshops utilising andragogical principles including case discussion, were also conducted as part of the over 75s health assessment training organised by GP Access and facilitated by the CNC Dementia community, in order to meet some areas of PN education needs identified E � learning; Dementia Care CD-ROM -14 CNE points proven to educate and empower Primary Dementia Care to advocate for and initiate changes required (5). Two face to face workshops utilising andragogical principles including case discussion, were also conducted as part of the over 75s health assessment training organised by GP Access and facilitated by the CNC Dementia community, in order to meet some areas of PN education needs identified

10. Implementation The CDN organised meet and greet activities, educated PN and GP in the resource kit, CDN program and referral and clinical pathways. Discussed barriers to Primary Dementia Care and education requirements. Invited the PN to join an E-network and attend weekly multidisciplinary case conference for support with complex clients. Completed the visit evaluation.

11. Duration The pilot August 2009 - Feb 2010. Note: The project was delayed due to H1N1 vaccines which monopolised PN time during the later months of 2009. The general roll out was completed Mid Nov 2010

12. Evaluation Methodology Quantitative Pre and post project measures. Meet & greet evaluation forms Education evaluation forms Rates of GP & PN referral/ consultation Qualitative Survey / evaluation form Interviews conducted with 1 practice nurse 1 CDN 2 GP Access staff

13. Results No. Practice visited = 38 No. PNs interviewed = 41 No. GPs interviewed = 6

14. PN Results (N=41) Q 1. Did you find the information pack useful? 80% strongly agreed (all agreed) Q 2. Is dementia education a priority for you? 46% strongly agreed (all agreed) Q 3. How likely are you to contact the CDN? 66% strongly agreed (1 did not agree) Further assistance by CDNs All pilot and general roll out PNs believed they were likely to contact the CDN in the future with 70% of the pilot PNs stating they would definitely do so. Of the pilot PNs 8% were not interested in case conferencing difficult clients, 52% believed that it would be "good to be able to phone someone for a nursing opinion". This same number indicated the ability to attend the weekly multidisciplinary case conference to discuss a complex clients when necessary. GPs indicated that they were just as likely to contact the CDN in the future. Encouragingly one GP felt able to attend case conference when necessary with five GPs indicating that the clinical pathway "would be useful" including this response "Can you send the flow chart electronically?" Two GPs were interested in referral to the CDN acknowledging that it is "good to know there are Dementia Nurses to look after patients and families" Further assistance by CDNs All pilot and general roll out PNs believed they were likely to contact the CDN in the future with 70% of the pilot PNs stating they would definitely do so. Of the pilot PNs 8% were not interested in case conferencing difficult clients, 52% believed that it would be "good to be able to phone someone for a nursing opinion". This same number indicated the ability to attend the weekly multidisciplinary case conference to discuss a complex clients when necessary. GPs indicated that they were just as likely to contact the CDN in the future. Encouragingly one GP felt able to attend case conference when necessary with five GPs indicating that the clinical pathway "would be useful" including this response "Can you send the flow chart electronically?" Two GPs were interested in referral to the CDN acknowledging that it is "good to know there are Dementia Nurses to look after patients and families"

15. PN Results Q . Are you interested in attending multidisciplinary case conference with ACAT, CDN and Geriatrician for complex patients? 34% strongly agreed 8% were not interested 52% believed that it would be "good to be able to phone someone for a nursing opinion". Note: This same number indicated the ability to attend case conference when necessary. 12% would contact the CDN rather than attend case conference as it is "difficult to get away".

16. GP results (N=6) GPs just as likely to contact the CDN in the future. Encouragingly one GP felt able to attend case conference when necessary. 5 GPs indicated that the clinical pathway "would be useful" including this response "Can you send the flow chart electronically?� 2 GPs were interested in referral to the CDN acknowledging that it is "good to know there are Dementia Nurses to look after patients and families" GPs indicated that they were just as likely to contact the CDN in the future. Encouragingly one GP felt able to attend case conference when necessary. 5 GPs indicated that the clinical pathway "would be useful" including this response "Can you send the flow chart electronically?� 2 GPs were interested in referral to the CDN acknowledging that it is "good to know there are Dementia Nurses to look after patients and families" GPs indicated that they were just as likely to contact the CDN in the future. Encouragingly one GP felt able to attend case conference when necessary. 5 GPs indicated that the clinical pathway "would be useful" including this response "Can you send the flow chart electronically?� 2 GPs were interested in referral to the CDN acknowledging that it is "good to know there are Dementia Nurses to look after patients and families"

17. PN Results Confidence levels in supporting dementia diagnosis and management pre & post

18. GP results Question one. Rate your confidence in diagnosing and supporting people with dementia, carers and families prior to meeting the CDN? ? Poor 4 Fair 2 Good ? Excellent Question two. Rate your confidence in diagnosing and supporting people with dementia, carers and families after meeting the CDN? Poor ? Fair 6 Good ? Excellent Approx 66% of participating GPs indicated an increase in confidence after the CDN visit by 1 point on a 4 point scale, with all GPs indicating a good level of confidence in this area post visit.Question one. Rate your confidence in diagnosing and supporting people with dementia, carers and families prior to meeting the CDN? ? Poor 4 Fair 2 Good ? Excellent Question two. Rate your confidence in diagnosing and supporting people with dementia, carers and families after meeting the CDN? Poor ? Fair 6 Good ? Excellent Approx 66% of participating GPs indicated an increase in confidence after the CDN visit by 1 point on a 4 point scale, with all GPs indicating a good level of confidence in this area post visit.

19. Q. How can the CDN further assist you? 26% PNs wanted the CDN to provide them with "ongoing education" and information. PN response GP response

20. PN Education needs assessment Q. What education are you interested in? e.g. BPSD, Cognitive screening, legal issues, Advance Care Planning, community supports or other. What format face to face vs online? 75% face to face and 25% combination of face to face and online e.g. �either is okay�. Note: No preference for purely online. 15 responses for BPSD with a preference to discuss actual "cases with the Dementia Nurse". 14 responses expressed an interest in Advance Care Planning e.g. "sometimes patients ask me about ACPlanning and I am not sure what to tell them" and "is it legal?" 14 responses indicated they would be interested in further cognitive assessment training if offered by Helga in the future at GP ACCESS (Note Helga provided cognitive assessment as part of the over 75s assessment training for Practice Nurses in Aug 09). Two responses for everything e.g. "everything valuable". Two responses for Dementia Care 15 responses for BPSD with a preference to discuss actual "cases with the Dementia Nurse". 14 responses expressed an interest in Advance Care Planning e.g. "sometimes patients ask me about ACPlanning and I am not sure what to tell them" and "is it legal?" 14 responses indicated they would be interested in further cognitive assessment training if offered by Helga in the future at GP ACCESS (Note Helga provided cognitive assessment as part of the over 75s assessment training for Practice Nurses in Aug 09). Two responses for everything e.g. "everything valuable". Two responses for Dementia Care

21. 1st PN Workshop evaluation N=19 Increased confidence in Dementia Care All PNs increased their knowledge of Dementia Care �Having not attended an update in recent years I found the dementia topics really interesting and helpful� and �I learnt a lot about dementia and plans that can be put into place�. Most important new learning�s. Advanced Care Directives, referral pathway, CDNs �what dementia nurses can offer�, �accessing help and understanding why I�m doing certain things�, �everything so I can now improve�. New resources available to patients e.g. CCRC Most enjoyable. �dementia education�, �cognitive screening tools�, �hallucinations in dementia patients�, �referral systems� and �contact numbers� Future PN dementia education needs were identified Four responses wanting more on dementia including cognitive screening, dementia assessment and behaviours in dementia. One wanted more on referral pathways and one Advance Car Planning PN Workshop evaluation. 19 completed evaluations were received with the data collated in Attachment 6. Figure 4 below shows that prior to the workshop 11% of PN described their confidence levels in Dementia Care as poor. Confidence levels rose post workshop with almost half the participants describing it as good and 37% indicating excellent levels of confidence. All PNs increased their knowledge of Dementia Care in areas themed and ranked below. Eleven responses indicated increased knowledge in Dementia topics including �Having not attended an update in recent years. I found the dementia topics really interesting and helpful�, �anatomy and physiology�, �Determining types of dementia� and �I learnt a lot about dementia and plans that can be put into place�. Two responses indicating the CDN Dementia referral pathway was most valuable e.g.�what dementia nurses can offer �and �contact details and other resource centres to network with�. One PN responded that Advanced Care Directives was the most important new learning. 12 separate responses were themed and ranked below to indicated what the PN enjoyed most. Five enjoyed general �dementia education�, including discussion of cognitive screening tools and �hallucinations in dementia patients�. Four enjoyed learning about the �referral systems� and �contact numbers� to improve confidence in �accessing help and understanding why I�m doing certain things�, �so I can now improve�. Three enjoyed learning about new resources available to patients e.g. �commonwealth carers resource centre� (Commonwealth carer respite centre) Future PN dementia education needs were identified Four responses wanting more on dementia including cognitive screening, dementia assessment and behaviours in dementia. One wanted more on referral pathways and one Advance Car Planning PN Workshop evaluation. 19 completed evaluations were received with the data collated in Attachment 6. Figure 4 below shows that prior to the workshop 11% of PN described their confidence levels in Dementia Care as poor. Confidence levels rose post workshop with almost half the participants describing it as good and 37% indicating excellent levels of confidence. All PNs increased their knowledge of Dementia Care in areas themed and ranked below. Eleven responses indicated increased knowledge in Dementia topics including �Having not attended an update in recent years. I found the dementia topics really interesting and helpful�, �anatomy and physiology�, �Determining types of dementia� and �I learnt a lot about dementia and plans that can be put into place�. Two responses indicating the CDN Dementia referral pathway was most valuable e.g.�what dementia nurses can offer �and �contact details and other resource centres to network with�. One PN responded that Advanced Care Directives was the most important new learning. 12 separate responses were themed and ranked below to indicated what the PN enjoyed most. Five enjoyed general �dementia education�, including discussion of cognitive screening tools and �hallucinations in dementia patients�. Four enjoyed learning about the �referral systems� and �contact numbers� to improve confidence in �accessing help and understanding why I�m doing certain things�, �so I can now improve�. Three enjoyed learning about new resources available to patients e.g. �commonwealth carers resource centre� (Commonwealth carer respite centre)

22. Advance Care Planning � PR, ACDs & EPOA, EG WWW.planningwhatiwant.com.au WWW.planningwhatiwant.com.au

23. Suggested comments: The unexpected happens in life. There may be a time when any of us are unable to communicate our choices for health care. Our families are not always available, informed or willing to make difficult health care decisions for us.Suggested comments: The unexpected happens in life. There may be a time when any of us are unable to communicate our choices for health care. Our families are not always available, informed or willing to make difficult health care decisions for us.

24. Impact Pre project (2 mths) no GP referrals, no PN phone consults and no PN or GP attendance at case conference. Post project (2mths) significant increase in these indicators. Impact: Rates of referral and consultation by the PN and the GP to CDN program. The following graph indicates that Figure 2. CDN activity pre and post project Impact: Rates of referral and consultation by the PN and the GP to CDN program. The following graph indicates that Figure 2. CDN activity pre and post project

25. Interview Quotes 2 PNs �Pathway through Health was fantastic � really helps � able to use that to show GPs� Same PN told the GP �Use those Dementia Nurses, they are in a good position to help� From a PN that works with 5 GPs �I attend the meeting whenever I can, I am so grateful, I have a backlog of patients but I only present 1 or 2 patients so they don�t get sick of me� GP Access �Organisationally excellent to have a referral pathway and clinical guideline, it would be great if other Health services would do this� CDN �straight from the horses mouth � �my team now contact the PNs�

26. Time taken Practice visits averaged 30 minutes each. Approx. 2 hours extra for each CDN in project methodology education /compiling resources. Phone consults with PNs are typically short less than 5 minutes.

27. Sustainability Regular dementia education by Community Dementia CNC scheduled on GP Access education calendar for PNs. Phone contacts and case conference is now promoted to PNs for complex client trouble shooting e.g. Nelson Bay PN attends regularly to present 1-2 cases on behalf of the 5 GPs in her practice. All PNs included on an E -network potential to receive ongoing information, education and consultation.

28. The future Rural Project Submission attended for a National Alzheimer�s Quality Grant to build on this project by developing the role of the Primary Dementia Care nurse. Partnership with HNELHN, GPAccess, Wicking Institute, AANSW & AATas

29. Questions

31. References [1] Gaugler et al, 2005 [2] Banerjee et al 2007 [3] Bird 2003 [4] Mittelman et al 2007 [5] �Challis et al 2002). [6[ Brodaty & Donkin 2009 [7] Valour, VG., Masaki, KH., Curb, JD., & Blanchette, PL.The detection of dementia in the primary care setting. Archives of Internal Medicine, 2000. 160(19), 2964-2968. [8] Brodaty, Draper & Low 2004 [9] Van Hout, H., et al., Are general practitioners able to accurately diagnose dementia and identify Alzheimer's disease? A comparison with an outpatient memory clinic. British Journal of General Practice, 2000. 50(453): p. 311-312. [10] Bond et al. (2005). International Journal of Clinical Practice; 59:s146 [11] Renshaw, Scurfield, Cloke & Orrell 2001 General practitioners' views on the early diagnosis of dementia. British Journal of General Practice, 51(462): p. 37-8. [12 ] Watts I, Foley E, Hutchinson R, Pascoe T, Whitecross L, Snowdon T. General Practice Nursing in Australia. Royal Australian College of General Practitioners and Royal College of Nursing, Australia. May 2004 [13] Merl H & Bauer, L, Dementia Care Survey and evaluation of educational package NSW GPs. 2007 Bibliography Boustani, M., Peterson, B, Hanson, L, Harris, R, Lohr, KN, , Screening for Dementia in Primary Care: A Summary of the Evidence for the U.S. Preventive Services Task Force. Annals of Internal Medicine, 2003. 138(11): p. 927-937. Turner, S., et al., General practitioners' knowledge, confidence and attitudes in the diagnosis and management of dementia. Age & Ageing, 2004. 33(5): p. 461-7. Milne, A.J., et al., Early diagnosis of dementia by GPs: An exploratory study of attitudes. Aging & Mental Health, 2000. 4(4): p. 292-300. Alzheimers Association Australia. Black K, LoGuidice D, Ames D, Barber B, Smith R. Diagnosing Dementia: Reference paper. September 2001. Ward John et al. Dementia Care in New South Wales. Hunter New England Health. 2004 Ward, Filiptschuk, Golvers, Hughes, Korzinski, Lazic, McMinn, Mearitt, Oakey, Schofield, Searras, Ticehurst, Hunter Area Health, draft dementia plan 2001 � 2006