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Dementia Education Strategy for BC Physicians 2007-2010 Final Report

Submitted by: Dr. Brenna Lynn, PhD Director of Research, and Director, Division of Continuing Professional Development Ms. Deirdre Maultsaid, M. Ed Project Manager, Division of Continuing Professional Development Dr. Bob Bluman, MD, CCFP, FCFP Assistant Dean, Division of Continuing Professional Development, and Principal Investigator, Dementia Education Strategy Evaluation

Dementia Education Strategy for BC Physicians 2007-2010 Final Report

Submitted by: Dr. Brenna Lynn, PhD, Director of Research, and Director, Division of Continuing Professional Development Ms. Deirdre Maultsaid, M. Ed, Project Manager, Division of Continuing Professional Development Dr. Bob Bluman, MD, CCFP, FCFP, Assistant Dean, Division of Continuing Professional Development, and Principal Investigator, Dementia Education Strategy Evaluation

December 15, 2010

Table of Contents 1

GLOSSARY & ABBREVIATIONS ........................................................................................................ 1

2

EXECUTIVE SUMMARY ...................................................................................................................... 2

3

INTRODUCTION .................................................................................................................................. 4

4

RATIONALE FOR THE STRATEGY .................................................................................................... 5

5

PROJECT DESCRIPTION ................................................................................................................... 7

6

EDUCATION DEVELOPMENT AND DELIVERY ................................................................................ 8 Learning Needs Assessments ...................................................................................................... 8 6.1 Educational Development and Delivery ........................................................................................ 9 6.2 Web-based Resources ................................................................................................................ 10 6.3 Podcasts/Vodcasts ...................................................................................................................... 10 6.4 Videoconferences ....................................................................................................................... 11 6.5 Regional Conferences ................................................................................................................. 12 6.6 Community Workshops ............................................................................................................... 12 6.7 Learning Objectives ............................................................................................................ 13 6.7.1 Education Principles ............................................................................................................ 13 6.7.2 Workshop Case-Based Content.......................................................................................... 14 6.7.3 Workshop Facilitators .......................................................................................................... 14 6.7.4 Workshop Delivery .............................................................................................................. 15 6.7.5 Other UBC CPD Conferences with dementia-related topics ...................................................... 15 6.8 Listserv Discussion ..................................................................................................................... 16 6.9

7

EVALUATION ..................................................................................................................................... 17 7.1 7.2 7.3 7.4

Community Workshops ............................................................................................................... 17 Regional Conferences: Evaluation Findings ............................................................................... 30 Other Related Educational Events .............................................................................................. 30 Online Resources ........................................................................................................................ 31

8

KNOWLEDGE DISSEMINATION....................................................................................................... 32

9

CONCLUSION.................................................................................................................................... 33

10

REFERENCES ................................................................................................................................... 35

11

ACKNOWLEDGEMENTS .................................................................................................................. 37

12

APPENDICES .................................................................................................................................... 40 Appendix A: Summary of UBC CPD Needs Assessment 2007 Survey of BC physicians ..................... 40 Appendix B: Education Log of Dementia Education Strategy Events 2007-2010 .................................. 45 Appendix C: UBC CPD – Dementia Education Strategy Webpages Screenshots ................................ 46 Appendix D: Dementia Vodcast Scripts and Promotional Material ........................................................ 49 Appendix E: UBC CPD – Videoconference “Cholinesterase Inhibitors for Alzheimer’s Disease” .......... 51 Appendix F: Regional Conference Agenda and Curriculum ................................................................... 52 Appendix G: UBC CPD – Regional Conference “Dementia Update 2008” ............................................ 54 Appendix H: UBC CPD – Dementia Community Workshop Case Studies Sample ............................... 55 Appendix I: Dementia Community Workshop Binder ............................................................................. 56 Appendix J: UBC CPD- CME on the Run Lecture Series “Psychiatry & Dementia” Agenda ................. 60 Appendix K: UBC CPD- Dementia Listserv Welcome Email, July 2009 ................................................ 61 Appendix L: Dementia Education Strategy Research Map .................................................................... 62 Appendix M: Dementia Workshop Evaluation Survey ............................................................................ 63 Appendix N: Dementia Community Workshop Participant Follow up Survey ........................................ 65 Appendix O: UBC CPD – Community Workshop Post-Workshop Interview Protocol for Participants .. 69 Appendix P: UBC CPD- Dementia Community Workshop Attendance & Facilitator Feedback Form ... 71

Appendix Q: Community Workshop Post-Workshop Interview Protocol for Facilitators ........................ 72 Appendix R: Regional Conference Evaluation Survey ........................................................................... 74 Appendix S: Publication in BC Academic Health Collaboration (November 2009) ................................ 77 Appendix T: Presentation at BC Psychogeriatric Association Conference ............................................ 78 Appendix U: Presentation at Canadian Conference on Medical Education and UBC CPD Leader’s Workshop (May 2010) ............................................................................................................................ 80 Appendix V: Presentation at 2nd Conference on Positive Aging (November 2010) .............................. 81

1 GLOSSARY & ABBREVIATIONS ADTI AD ASBC BC BCMA BC MOH CCCDTD3 CFPC ChEI CME CPD DES GDS GP GPAC LHA MoCA RCPSC SA SGP SMMSE SRPC UBC CPD

BC Ministry of Health Services, Pharmaceutical Services Division, Alzheimer’s Drug Therapy Initiative Alzheimer’s Disease Alzheimer’s Society of British Columbia British Columbia British Columbia Medical Association British Columbia Ministry of Health Services Third Canadian Consensus Conference on Diagnosis and Treatment of Dementia College of Family Physicians of Canada Cholinesterase Inhibitors Continuing Medical Education Continuing Professional Development Dementia Education Strategy Global Deterioration Scale General Practitioner/Family Physician BC Ministry of Health Services and the BC Medical Association Guidelines and Protocols Advisory Committee Local Health Area Montreal Cognitive Assessment Royal College of Physicians and Surgeons of Canada Special Authority Form Society of General Practitioners of British Columbia Standardized Mini-Mental State Examination Society of Rural Physicians of Canada University of British Columbia Faculty of Medicine, Division of Continuing Professional Development

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2 EXECUTIVE SUMMARY The Alzheimer’s Drug Therapy Initiative (ADTI) began in 2007 as a three year program in which the BC Ministry of Health Services (BC MOH) provided coverage for cholinesterase inhibitors (ChEI). The initiative also included clinical trials, a caregiver appraisal study, and an educational component for physicians developed and implemented by the University of British Columbia, Faculty of Medicine Division of Continuing Professional Development (UBC CPD). The education program was coined the “Dementia Education Strategy” (DES), and was designed for physicians and other healthcare professionals with the mission to help achieve optimal care for patients with dementia.

This final report outlines the main components and results for the Dementia Education Strategy. The findings underscore the value of the multi-modal educational programming for the physician learner. The evaluation highlights the effectiveness of the education in promoting physician behaviour change and practice improvement in the management of dementia.

At the outset of this project in 2007, UBC CPD implemented a needs assessment to determine the current state of knowledge and learning needs of general practitioners/family physicians (GPs) in British Columbia (BC) related to their ability to diagnose and manage dementia, and to their skill in prescribing pharmacological treatments. After the learning needs were determined, a variety of educational offerings and centralized information resources were developed by content experts and educational specialists to meet those needs. This involved the use of web material, vodcasts, videoconferences, regional conferences and community workshops. A multi-faceted educational strategy was used to effectively promote learning, and to support a variety of learning styles and preferences. The program incorporated effective engagement strategies and continuing medical education (CME) and adult learning principles to optimize physician performance improvement. The education was delivered to just over a thousand participants (some participated more than once). A robust data-driven evaluation, using mixed methods, was designed to assess the educational effectiveness. Self-report data was triangulated with that of the BC MOH in order to provide insight into health care delivery and physician prescribing patterns.

Our project evaluation showed that the small group interactive learning format provided an exceptional learning experience, and was rated highly by facilitators and participants. Physicians had varied baseline comprehension of issues about dementia, and did not necessarily have a strong background in this area.

Many identified barriers for BC physicians underscore the challenges in providing dementia management.

Findings confirm that physicians appreciated a variety of educational formats including community based resources. The program was shown to improve collaborative practice and relationships between family physicians and specialists. Also, findings showed that local community physicians can learn to be facilitators, and thus be a valuable community resource.

Measuring physician behaviour change and actual outcomes can be difficult due to issues of data availability, privacy laws, and ability to demonstrate a change with individual physicians. Despite these challenges, we were able to measure a significant impact, as our evaluation findings suggest that the workshop influenced both physician ADTI enrolment and prescribing patterns. This demonstrated that the workshops were effective in promoting a positive change in physicians’ behaviour. This is consistent with the workshop participants’ survey responses in which respondents self-reported that they were following BC Clinical Practice Guideline on Cognitive Impairment in the Elderly (the Clinical Practice Guidelines) more frequently after the workshop. As well, the results show a consistency between self-perceived learning and actual physician behaviour.

Descriptions of the Strategy and the preliminary evaluation results have been presented to a variety of healthcare professional and stakeholder audiences in the last 18 months via posters, conference presentations and newsletters. Now that the implementation and evaluation are complete, UBC CPD plans to compose several research articles in order to explain the positive findings about educational effectiveness.

In recognition of the success and value of this initiative, the BC MOH has generously provided funding

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through the ADTI to continue the education program until 2012. It is our hope that this successful model of education can be replicated for future similar government initiatives.

In summary, this program allowed UBC CPD and the ADTI to show leadership in educational outreach and community engagement in guiding physicians to performance improvement in the area of dementia management. The strategy promoted low barrier education, which fostered improved physician confidence and practical skills, thereby enhancing their management of dementia, and promoting better patient care and healthcare outcomes.

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3 INTRODUCTION GPs play a significant role in the provision of dementia care. However, they face many challenges in providing dementia management in the scope of their busy family practice. GPs need patient-focused practice guidelines and available consultation with specialists. They also need relevant and practical continuing medical education (CME) in order to improve their clinical practices in dementia care, to stay current with health and health policy issues, and to carry out the current recommended chronic disease management approach to patients with dementia.

The physician need for CME on dementia is paralleled by the evolving circumstances in which physicians practice. Not only are new practice guidelines now available, but there is also emerging knowledge about best practices in the management of dementia (1). The Clinical Practice Guidelines by the BC MOH and the BC Medical Association (BCMA) Guidelines and Protocols Advisory Committee (GPAC) were released in 2007 (2). The release of the Clinical Practice Guidelines coincided with the establishment of the ADTI. Part of the mandate of the ADTI was to provide funding for dementia education for physicians; the Ministry requested of UBC CPD to develop and implement a dementia education program for physicians (the Dementia Education Strategy) over a three year period, starting in 2007, on its behalf.

The DES was mandated to work for and with physicians to help achieve optimal care for patients with dementia. The DES assessed the current state of knowledge and learning needs of GPs in British Columbia (BC) in order to develop this high quality program. After the learning needs were determined, a variety of educational events and centralized information resources were tailored to fulfill those needs, and furthermore, to teach physicians about the Clinical Practice Guidelines.

The DES intended to be comprehensive and to provide education on issues along the entire continuum of care, from diagnosis to end of life planning, using multiple educational formats to meet a diverse variety of learning needs and to encourage improvement in medical practice. The DES used specialist experts as teachers, coordinated peer learning, and facilitated individual learning. UBC CPD provided education on best practices, according to the provincial Clinical Practice Guidelines, and expert opinion, in the prevention, screening, diagnosis and management of dementia, pharmacological and nonpharmacological approaches to symptom management, and use of community, government and legal resources.

For the above education programs, UBC CPD engaged in a robust evaluation process. Through onsite evaluation forms at educational events, post-education surveys, and interviews with workshop participants and facilitators, the evaluators listened to physician perceptions of the education to determine if it met their expressed learning needs. The evaluation process also assessed the self-reported impact of the education on physician practice, and confirmed these assessments with secondary data sources available through the BC MOH. The evaluation process has confirmed that the DES has been a successful education program, and was effective at promoting physician behaviour change and practice improvement. Additionally, the evaluation provided the research and evaluation team at UBC CPD with many insights on what has contributed to that success. The goal of this report is to describe the development and delivery of the Dementia Education Strategy, and to demonstrate the effectiveness of the education, so that this education can be replicated for future educational initiatives.

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4 RATIONALE FOR THE STRATEGY Dementia is a degenerative condition, which is characterized by a decline in intellectual and functional abilities marked by symptoms of memory loss, confusion, and agitation. It erodes a person’s cognitive abilities, and therefore, their ability to cope and function with everyday life. People with dementia require care and support from their families, other caregivers, and the health care system. Due to the aging population, there will be a large increase in the number of patients who have dementia in Canada in the coming decades (1, 3).

GPs play a critical role in the provision of dementia care, as they are most often the first point of contact when memory loss is suspected, and will generally have extensive contact with patients (4). However, physicians face many challenges in dementia care especially with the uncertainty of diagnoses, the complexities of managing patients, and the necessary coordination within the healthcare system between physicians, specialists, other healthcare professionals, caregivers, and healthcare institutions (5).

It is true that there are many barriers to practice improvement: health system weaknesses (e.g., lack of access to specialists); practice difficulties (e.g., demands of new information systems); and patient care challenges (e.g., cultural barriers), that can hinder physician improvement despite the best of intentions.

Nonetheless, it is expected that CME in general can foster physician confidence and practical skills. If improved approaches to patient care are compatible with the existing values, attitudes and experiences of physicians, if compelling evidence is presented, if physicians are positively influenced by colleagues and, most notably here, if Clinical Practice Guidelines—as presented in education—are relevant and valuable, then CME can be effective in helping to improve physician practice. This process would be as below.

Multifaceted CME opportunities are provided to physicians

Physicians are satisfied: Personal learning needs are met

Physicians demonstrate competence in managing patients with dementia

Physicians commit to improved performance in managing patients with dementia

Several studies assert that GPs have identified dementia as a priority for educational needs and/or have expressed strong interest in learning more about Alzheimer’s disease (AD) and other forms of dementia, and in augmenting their confidence in treating patients with dementia. A Canadian study revealed that many GPs felt inadequately prepared to diagnose and treat dementia (6). In this study, physicians identified a need for more comprehensive guidelines for diagnosis, treatment, and follow-up with patients.

Two American needs assessments on geriatric knowledge identified that physicians reported AD and dementia as the top clinical areas of interest needing further education (7, 8). Other large scale needs assessments of BC physicians by UBC CPD (e.g., a survey of all rural BC physicians in 2005) have confirmed that physicians express a need to learn more about psychiatric and geriatric issues.

Other needs assessments and education program evaluations informed the UBC CPD Dementia Education Strategy (9). Similarly, the publication of several influential documents and the commencement of a new BC government program were precursors to the creation of the Strategy. In 2004, the BCMA’s Council on Health Promotion published a call for a coordinated dementia strategy in BC. Amongst their recommendations: 1) make care for dementia a priority; 2) govern dementia care as a chronic disease, using chronic disease management principles; 3) support the provision of comprehensive care; and 4) provide coverage for dementia medications. The report also requested that BC physicians (through guidelines and protocols) be provided with ongoing information on dementia pharmacotherapy and effective drug utilization (10).

The Clinical Practice Guidelines were released in 2007 by GPAC. (2) The Clinical Practice Guidelines hold as their primary care objectives “to encourage early recognition and assessment of cognitive impairment and to support GPs in the development of a comprehensive care plan”. The Clinical Practice Guidelines recommend that physicians understand and use appropriate pharmacotherapy, and note that UBC CPD Dementia Education Strategy Final Report

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age associated medical diseases are likely the cause of reduced driving competence in the elderly; physicians are instructed to broach this subject with patients, to order driving assessments and to follow the relevant laws as necessary. Overall care planning is recommended (including dealing with legal and ethical issues early in the onset of dementia). Physicians are expected: to assess risks to the patient; to encourage patients to appoint legal and financial representatives; and to encourage patients to make their wishes known.

The release of Clinical Practice Guidelines coincided with the establishment of the ADTI. Part of the mandate of the ADTI is to support clinical research on dementia pharmacotherapy, as well as sociological research on caregivers and the health delivery system. The ADTI tracks the BC PharmaCare coverage for medications, coverage which was already available in other provinces. Notably here, the ADTI also committed to provide funding for dementia education for physicians; therefore, the BC MOH requested UBC CPD to develop and implement a comprehensive provincial dementia education program.

This strategy intended for the ADTI and UBC CPD to show collaborative leadership in providing accredited and unbiased education to address a clinical knowledge gap, and to guide physicians towards performance improvement in medical practice in diagnostic skills and prescribing patterns. One goal of the education strategy was to raise awareness of the ADTI, thus encouraging the participation of clinicians in helping to evaluate the rational and appropriate use of Cholinesterase Inhibitors (ChEIs) in dementia management. The strategy would encourage physicians to improve their skills in dementia management, including their support of patients participating in medical coverage programs.

UBC CPD took a strategic approach to the question of “how to educate physicians about dementia?� UBC CPD set a long-term direction for all the education: primary care physicians would learn to manage patients with dementia and furthermore, care for them with a chronic disease management approach over the entire continuum of care from initial diagnosis to end of life planning.

CME fosters physician self-perceived efficacy, confidence, reasoning, and clinical skills. If physicians are skilled and confident, this enhances their ability to diagnose early and improves dementia management (treating dementia as a chronic condition that is frequently re-assessed). Patients, as partners and part of the healthcare team, are able to have comprehensive care planning over the long term. If primary care physicians perform better at dementia management, this can potentially allow patients to stay in their own homes and communities longer. This lessens the financial burden on the residential care system (11), improves the quality of life of those with dementia, and enables persons with dementia to have greater personal autonomy, and to continue being contributors to their communities.

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5 PROJECT DESCRIPTION UBC CPD is a Division of the Faculty of Medicine of the University of British Columbia. The Division’s mandate is to design, provide and evaluate accredited high quality unbiased educational programming to support the identified CME and Continuing Professional Development (CPD) needs of physicians.

UBC CPD, with support from the ADTI, developed this program to assist physicians by giving them the tools and the knowledge that they need to optimally care for patients with dementia, and, furthermore, to teach physicians about the Clinical Practice Guidelines. The strategy offered education in multiple learning formats over three years, on best practices in the diagnosis and management of dementia, pharmacological and non-pharmacological approaches to symptom management, driving cessation, and issues surrounding representation agreements.

In addition to its role as an education provider, the DES was also a research/evaluation program. The DES has continually and systematically evaluated program and education effectiveness and desired learning outcomes, in order to determine whether the strategy has led to an increase in knowledge and clinical skills related to dementia, increased best practice guideline compliance, and improved physicians practice.

The DES Planning Committee consisted of physician experts in dementia and geriatric care, as well as project members from UBC CPD, and a member of the target audience (a GP). This committee met consistently since November 2007, with new members joining in at various stages, and bringing with them a host of expertise to develop the strategy designed to support a multi-faceted learning strategy to more completely support the physician learner. Please see acknowledgements below on page 37, for a full list of those who helped with the strategy.

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6 EDUCATION DEVELOPMENT AND DELIVERY 6.1

Learning Needs Assessments

In order to provide accredited high quality CME, based on the requirements of the Royal College of Physicians and Surgeons of Canada (RCPSC) and the College of Family Physicians of Canada (CFPC), the planning committee needed to assess current learning needs in the area of dementia care. The committee also wanted to uncover any barriers to physicians improving their practices in this area of medicine. The committee assessed the current state of knowledge and learning needs of GPs in BC, including the physicians’ ability to diagnose dementia, their confidence level in prescribing pharmacological and non-pharmacological treatments, and their skill in dementia management.

Physicians were also asked with whom and from whom they would like to learn about dementia care.

A national CME survey based on Third Canadian Consensus Conference on Diagnosis and Treatment of Dementia (CCDTD3) was conducted under the auspices of the CFPC. UBC CPD subsequently conducted an online survey targeted to BC GPs only, based on CCCDTD3 results. Together, these results helped to inform the types and content of DES education programs for BC GPs. See Appendix A for a summary of findings from these needs assessments.

The results indicated a learning need of BC physicians in the area of dementia care, particularly regarding the use of medications. For example, when asked about their level of understanding of ChEIs on a 4point Likert scale from “good” to “poor”, 79% of GPs perceived their knowledge to be “poor” or “moderate.” These results, together with the rest of the survey findings, suggested a need for further CME. Of the 25 possible CME workshop topics listed in the survey, BC physicians chose the following top eight topics for possible education programs: 1.

2.

3.

4.

5.

6.

7.

8.

What is mild cognitive impairment and how do I test for it?

What treatments are useful for patients with mild cognitive impairment?

What investigations should I do on a patient suspected of having mild dementia?

What screening cognitive tests should I use to diagnose dementia and who should be referred for neuropsychological testing?

What is an organized and practical way for a family doctor to assess a patient with a suspected dementia? Who should be referred to a specialist?

Which patients with Alzheimer’s disease should stop driving? How do I best assess driving ability and risk?

How should patients with severe dementia be managed (non-pharmacologically and pharmacologically)?

What is the best approach to managing the behavioural problems of the severe stages of Alzheimer’s Disease?

Physicians were asked to suggest other topics that they would like to see in workshops and conferences.

In their answers, physicians presented a range of topics including the following: end of life care, communication skills, behaviour management, both pharmacological and non-pharmacological treatments, diagnosis, community resources, legal concerns of competency and driving, family support, quality of life, assessment, and different types of dementia. Sixty four percent of physicians stated that they would prefer to be provided with CME by a specialist (geriatric psychiatrist, geriatrician or neurologist).

It should be noted that in 2007, UBC CPD conducted a focus group of GPs on behalf of the ADTI so that physicians could preview the clinicians’ package to be issued by the ADTI. Included in the package were instructions, flow charts, cognitive assessments and Special Authority (SA) forms on patient status (including assessment scores), which physicians would fill out to enrol their patients for coverage in the medication coverage program. The recommendations of the focus group were delivered to the ADTI. Among other recommendations, the physicians recommended clarification on the coverage criteria; they requested the Global Deterioration Scale (GDS) be more specific, and the purpose of the accompanying UBC CPD Dementia Education Strategy Final Report

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flow sheet be clarified. Focus group participants recommended that the ADTI give physicians prior notice before launching the whole initiative. These suggestions were taken up by the ADTI. The clinicians’ package, with explanations of the assessment tools and screening process, was later included as part of the education strategy (in the small group workshops).

6.2

Educational Development and Delivery

To encourage performance improvement in the practice of physicians, education should be evidence based, relevant, be integratable into practice, and take into account physician experience and knowledge.

As well as being practical, relevant CME should set out learning objectives that will be achieved by the participants from the education. As a result of the dementia education program, physicians would be able to achieve the following learning objectives: 1. Screen patients appropriately; 2. Recognize the onset of dementia; 3. Provide a subtype diagnosis (i.e., between MCI, Alzheimer’s, Vascular Dementia, Lewy Body Dementia, etc.) to aid in treatment planning; 4. Be able to apply Clinical Practice Guidelines, including recommended cognitive and other assessments; 5. Take a chronic disease management approach (including doing frequent reassessments and tracking, establishing a relationship with patient and caregivers to make decisions and plan care, and involving allied health professionals); 6. Be more familiar with appropriate pharmacological and non-pharmacological options; 7. Believe that maintenance or a slowing in the rate of decline of cognition be acceptable as a standard of efficacy in the pharmacological treatment of dementia; 8. Be able to differentiate between acceptable and unreasonable risks to the patient and others; 9. Know how to balance respect for the patient’s wishes with their risks; 10. Understand the legal and ethical issues related to patient selection of representatives and placement in long term care; 11. Understand processes for patients with conditions incompatible with safe driving; 12. Understand ways to broach the driving topic with patients, and apply the relevant legislation on driving cessation; and 13. Be familiar with resources in their own communities and province.

Multiple educational formats and events are necessary to meet a variety of learning needs, and to ensure that the education is accessible to physicians practicing over a large and diverse geographic region like BC. The DES involved the use of podcasts, web material, videoconferences, seminars, urban and regional conferences, community workshops.

The videoconferences gave physician groups, located in various hospitals across BC, an opportunity to connect with each other and learn together through a BC wide educational technology. The vodcasts and web resources promoted individual self-directed learning, and were totally accessible to any computer, whether at home or work. Regional conferences in BC provided healthcare practitioners with a forum in which to network with others in their own regions, learn to retrieve or refer to local resources later, and most importantly, spend a concentrated period of time focused on learning various dimensions of one topic area, such as pharmacotherapy. The presentations on dementia-related themes within the offerings of a much larger conference on psychiatry allowed dementia to be considered in the context of mental health. The “CME on the Run” program based in the largest acute care hospital (Vancouver General) allowed busy urban medical professionals to quickly glean key pearls and guidance on their practices.

The rural outreach case-based workshop format allowed physicians to teach and learn together, using their own experience and practice as learning material in a problem-based learning setting.

Educational programs on Dementia care have been delivered to 1009 participants since the start of this project. See Education Log, Appendix B.

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Below are the detailed explanations of each of the educational programs as part of the DES. 6.3

Web-based Resources

Many physicians prefer to be autonomous and self-directed for some of their learning; this is supported by adult learning theories. Physicians prefer to access web resources at their own convenience. The first step taken by the education planning committee, in 2007, was the creation of a webpage, through UBC CPD, to make available enduring resources and links for physicians on dementia. See Appendix C for a preview of the website.

6.4

Podcasts/Vodcasts

Podcasts are a valuable learning tool, because they meet the needs of physicians who seek individual, practical learning, wherein material is available that can be instantly useful in their day to day work. In this program the material was available online in a video format with sound (a “vodcast”). This online platform allows for accessibility of technology enabled learning. Leading medical journals/websites, such as the Lancet and the Journal of the American Medical Association, offer podcasts/vodcasts on topical health issues. The rich media (video and audio) makes the subject matter more interesting and interactive.

The purpose of the vodcasts was to disseminate important new science to professionals most active in the treatment of dementia. The vodcasts, which could be viewed online at any time (complemented with downloadable PowerPoint slides or an MP3 file), evaluated the evidence for the use of ChEIs in the treatment of mild-to-moderate dementia and identified and clarified the special authority process for getting patient coverage in BC. The vodcasts were accredited and allowed for questions in a discussion forum. After watching the vodcasts, physicians should have been better able to:    

Provide a succinct review of the evidence for the use of ChEIs in the treatment of mild-tomoderate dementia (Alzheimer's disease); Summarize the controversy in the use of ChEIs for this therapy; Summarize any data comparing efficacy of the three therapeutic agents; and Identify and clarify the special authority process for getting patient coverage in BC.

The following two vodcasts were offered: 

“Cholinesterase Inhibitors in the Treatment of Mild-to-Moderate Alzheimer's Disease for Patients in British Columbia: A Clinician's Role” by Marilyn Bater, MD, FRCPC, Vancouver Island Health Authority, Victoria, British Columbia



A New Treatment Option for Patients in British Columbia: Cholinesterase Inhibitors for Mild-to-Moderate Alzheimer's Disease by Kiran Rabheru, MD, CCFP, FRCP, ABPN, University of British Columbia, Vancouver General Hospital/Riverview Hospital, Vancouver, British Columbia nd

The vodcasts were launched on November 2 , 2007. Two hundred and ninety seven GPs (9% of those invited) engaged in the program online after 89 days. (Participation was measured at the 90 day mark, since the effects of marketing would diminish thereafter.) See Appendix D for a sample of the vodcast script and to view the promotional postcard. (Note that after the discussion forum was closed, no further evaluation was conducted on the vodcasts).

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6.5

Videoconferences

A videoconference allows physicians to learn together as a group, and to hear the perspectives and practices of colleagues from the various participating sites around BC. Participants in a hospital-based videoconference do not have to travel to participate in this interactive discussion. They are able to use a rurally available technology. Therefore, videoconferences are convenient and accessible learning formats. Two such videoconferences were delivered.

The first videoconference, which took place on November 14, 2007, was a response to anecdotal feedback from physicians regarding the ADTI package of instructions on receiving PharmaCare coverage for medications for their patients. As many physicians apparently discarded the ADTI package without understanding or reading it, the education planning committee created the first province-wide videoconference to offer an overview of the processes and the forms. The session was made available through the hospital videoconference network at no charge to participants on site.

The videoconference was broadcast from Prince George, BC. Dr. Douglas Drummond presented a onehour seminar on the treatment of Alzheimer’s disease with ChEIs. See Acknowledgements on page 37 for Dr. Drummond’s roles. See Appendix E for a preview of the presentation.

The presentation covered the following topic areas:   

“Best Practices: what should we really be doing for our patients with Dementia (current guidelines) The dreaded SA form: I’ve decided to fill out the form anyway, what tips and tricks are there to getting this done quickly? (ADTI process) Fitting this into a busy family practice – do I get paid for any of this? (Does this work, should I bother)”

This session connected with the following twelve sites: 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

Alert Bay Castlegar Invermere Kamloops Kaslo Logan Lake New Denver Prince George Princeton Surrey Vancouver Williams Lake

Vancouver Island Health Authority also conducted a videoconference in partnership with UBC CPD in January, 2008, presented by Dr. Ted Rosenberg, on “Distinguishing Mild Cognitive Impairment from Early Dementia in the Elderly”.

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6.6

Regional Conferences

Following the implementation of web resources and podcasts/vodcasts, UBC CPD produced six regional conferences on the theme of cognitive impairment. The conferences intended to build upon local physicians’ previous knowledge and practices of dementia care, while meeting the evolving learning needs of BC physicians. The conferences were also distinct in that they were linked directly to an interactive resource fair for participating health professionals, with the resource fair as a place for physicians to meet regional supports for people with dementia, and to understand the resources of the Alzheimer’s Society of BC (ASBC), and other local community groups (which provide support and public education on AD and related dementias).

Each regional conference was based on a template program developed by the committee but changed to reflect the local needs and situation. Therefore, key players in each health region were identified early on for their engagement and participation. Like other components of the education strategy, the conferences were designed based on the Clinical Practice Guidelines and on the needs assessment data collected in 2007 by UBC CPD. In accordance with teaching the Clinical Practice Guidelines, a general curriculum was set. Presentations and workshops were to include issues along the continuum of care including:      

Making the diagnosis Practice management (early dementia) Pharmacotherapy (ChEIs) Practice management (moderate to severe) Patient/family supports Risk factors

Six highly successful regional conferences were held around BC.      

Victoria, February 22, 2008 Cranbrook, May 1, 2008 Prince George, June 6, 2008 Coquitlam, June, 2008 Kamloops, September 20, 2008 Nelson, October 8, 2008

The conferences employed a mix of didactic presentations and interactive workshop sessions to educate physicians (and a small subset of allied health care professionals) about best practices in the diagnosis and management of dementia. The conferences covered diagnosis of dementia, pharmacological and non-pharmacological approaches to symptom management, driving cessation, and issues surrounding representation agreements. The resource fair featured organizations and groups that are in place, within each region, to provide supports to health professionals, care-givers, and patients. The program featured local speakers and local experts, and was tailored to showcase local resources. See Appendix F for the conference agenda and curriculum, and Appendix G for the promotional material.

6.7

Community Workshops

To complement previous education offerings and to further expand the Dementia Education Strategy in its fourth stage, the education planning committee, in April 2008, committed to offer community workshops to physicians around BC. The purposes of the workshops were:

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1. To make explicit and relevant clinical practice recommendations on early diagnosis and care planning, based on current clinical evidence, and relevant law; 2. To promote the uptake and adherence to the Clinical Practice Guidelines on Cognitive Impairment; 3. To provide a thorough learning experience for those involved in the primary care of patients with dementia; and 4. To provide a learning experience to those communities that had not been necessarily served by the larger regional conferences.

6.7.1

Learning Objectives

After the workshop, the physicians would be able to:       6.7.2

Be more confident and prepared to recognize, screen and diagnose patients; Be able to apply Clinical Practice Guidelines, including recommended cognitive assessments; Be more familiar with appropriate pharmacotherapy options; Consider discussing issues of driving, dementia management and care planning with patients and care team; Be able to understand and apply relevant legislation for driving and for care planning; and Be familiar with resources in their own communities and province.

Education Principles

The community-based workshops were carefully designed and guided by the following education principles: 1. Conducted as small group learning UBC CPD and much medical education research have shown that there are many benefits to small group learning. Small group learning provides an environment where participants feel comfortable, where rich discussion and active learning can occur, and where focus is maintained on the particular learning needs of participants. Besides encouraging participants to think critically about clinical issues, small group learning is collegial. Learning is improved when participants are actively learning and offering solutions from their own experiences, and when others are offering alternative solutions.

2. Geographically accessible Some barriers to proper dementia management are complexity of care, lack of resources, and lack of access to specialists (especially for rural physicians). Thus, it is important to offer low barrier CME, so that all the cited inconveniences, such as no time, and too much paperwork, are removed. Physician learners are more likely to participate in community-based, close to home educational programming, due to problems of getting locum coverage and leaving their practice to travel. Geographical accessibility is a particular issue for rural physicians.

3. Community-based Learning in context— wherein the learners can apply the learning to their own unique situation, with their own resources and their own team— is extremely valuable and authentic. Rather than learning in the abstract and then having to package up and “carry home” their learning, learners can apply the new material to their own situation immediately. Also, physicians will change their practice if they see observable results from others; the experiences and successes of their own colleagues will influence them for the better. A collegial atmosphere also allows physicians to safely challenge their ways of thinking, and support each other in practice change.

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4. Using original case-based content The four cases (see below) were designed to reinforce best practices in dementia by using a collaborative, problem-based approach to learning, and using realistic and representative clinical scenarios that physicians would encounter in their practice. Problem based learning helps the physicians create knowledge and solutions together as a group. Problem based learning uses open-ended, challenging practical problems that enable participants to learn in context, use higher-order thinking, activate prior knowledge, and encourage clinical reasoning and reflection on their own experience.

5. Encouraging pre workshop activities Pre-reading was provided to the participants, including the Clinical Practice Guidelines, so that the participants were focused on the topics at hand and had a common base of knowledge with which to solve the cases presented.

6.7.3

Workshop Case-Based Content

Workshop content, including the pre-reading material, was developed by the education planning committee under the guidance of dementia experts, Dr. Martha Donnelly and Dr. Doug Drummond, and the assistance of educational consultants (see Acknowledgements on page 37). The education content was designed to support the Clinical Practice Guidelines, and to be flexible enough to be adapted based on the specific learning objectives of the participating community. The four case topics are as follows: 1.

2.

3.

4.

Case One: Mild Cognitive Impairment and Progression of Symptoms Case Two: Dementia and Driving Case Three: Dementia and Living at Risk Case Four: Late Stage Dementia and Admission to a Nursing Home

With the assistance of the program planning group, UBC CPD provided a Workshop-In-A-Box “toolkit” to the facilitators so that they could do their own implementation on site. The standardized workshop binder included the cases, pertinent pre-reading and supplemental reading, including important enduring resources for physicians and their patients. The facilitator binder contained “talking points” to guide the participants through the cases. Along with the facilitator binder, a participant binder was developed that included pre-reading, the content (cases), and learning resources. The participant binders were similar to the facilitator’s binder except that the facilitator binders contained some of the suggested answers to the cases in order to help guide the discussion.

See Appendix H for case study examples, and Appendix I for a listing of the full workshop content.

6.7.4

Workshop Facilitators

Although in the original needs assessment, sixty four percent of physicians stated that they would prefer to be provided with CME by a specialist (geriatric psychiatrist, geriatrician or neurologist); GPs also facilitated some of the workshops.

Three approaches were used to organize facilitation of the workshops: 1. Run workshops in areas where there were identified specialists or “experts”— GPs with interest, a certificate, in or experience in the clinical area of geriatrics.

2. Run workshops in areas to which outreach psychiatrists were traveling, or 3. Work with local CME coordinators to implement workshops in areas without identified “experts”, using local GPs, for peer to peer learning.

The first two approaches relied on expert-based facilitation, whereas the third approach used a peerbased facilitation style, where no known expert was available. A particular strength of this model was that all three approaches engaged the direct involvement of a community leader— whether that community leader was a local expert, an outreach psychiatrist who was also the referring consultant psychiatrist for the community, or a local CME coordinator. This approach fosters relationships between the “community UBC CPD Dementia Education Strategy Final Report

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leader” and the physicians in the community. With the use of the Train-the-Trainer model, the identified facilitators in each community received guidance from dementia experts, Drs Martha Donnelly and Doug Drummond, via telephone, prior to leading the workshops.

6.7.5

Workshop Delivery

By holding workshops in the physician’s communities, the education planning committee intended to bring this important CME opportunity directly to physicians, removing any geographic barriers. While not exclusively available to smaller communities, the intent was to engage GPs at the level of the practice community – whether that be a geographic community or a portion of a larger area where professionals are working together closely. The workshops were at no cost (minimal barrier to attendance) for the participants. The workshops were designed to meet the educational needs of smaller audiences (8-12 participants), and used a case-based approach. Since there were four cases available, each discussion group, in consultation with the facilitator, was able to choose the cases that they wanted to discuss based on group interest and learning need. Most groups chose to discuss Case One on recognition and diagnosis and Case Two on driving issues, although there was certainly interest in the other cases.

Eighteen workshops took place from March to July 2009. With the success of this first workshop round, the planning committee decided to extend workshop offerings into the following fall and winter season; twenty one more workshops were offered between November 2009 and April 2010. Based on facilitator commentary and under the direction of the education planning committee, revisions in the workshop material were made in order to refine content. More background explanations for relevant legislation and driving issues were added. See participation summary in the educational log, Appendix B, as mentioned above.

6.8

Other UBC CPD Conferences with dementia-related topics

During the course of the DES, UBC CPD hosted several other events with dementia-related topics.

Presenters were invited to speak at the “Hot Topics in Psychiatry” conference (January 2008). One of the workshops at this conference was “Cholinesterase Inhibitor Use in Dementia”, presented by Dr. Martha Donnelly.

The “CME on the Run” program, based in the largest acute care hospital (Vancouver General) allows busy urban medical professionals to quickly glean guidance on their practices. In November, 2008, the “CME on the Run” session was on “Psychiatry & Dementia”. Four of the specific topics related to the Dementia Education Strategy were presented.

Dr. Martha Donnelly, spoke on: 1. “When to stop cholinesterase inhibitors” 2. “Tools to assess dementia: practice tips for the busy GP”.  To use a simple informant questionnaire  To understand the importance of the SMMSE as a basic tool  To know when and how to do a MoCA  To state what clock drawing assesses with respect to higher level functions  To differentiate different types of dementia by a simple checklist of symptoms Dr. Bonnie Dobbs, an expert in driving cessation spoke on: 1. “How to get your patient to give up their driver’s license” and 2. “Key issues physicians should know when assessing fitness to drive” See Appendix J for the session agenda.

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6.9

Listserv Discussion

The Dementia Education Strategy initially intended to include “an online discussion board” for physicians and other health care professionals to discuss the ADTI, the Clinical Practice Guidelines, the DES and other dementia-management related issues. However, after careful consideration and realization that this discussion board would not be accredited CME, it was decided that the simple UBC listserv system would be most suitable for a listserv discussion. Other listservs have enabled some discussions amongst participants (i.e., from CFPC or SRPC). Email alerts are the quickest way to provide updates for fairly stable materials (e.g. BC Driving Guidelines) The listserv was launched in June 2009. It was decided that the participants in the Dementia Education Strategy educational activities would be subscribed and able to participate, to discuss issues of dementia management. It was intended to be moderated by the DES physician leads – Dr. Doug Drummond and Dr. Martha Donnelly. It appeared that this was not the type of forum in which physicians wanted to discuss their views. In 2010, the listserv was closed due to insufficient uptake to engender worthwhile discussions. See Appendix K for an invitation to the listserv.

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7 EVALUATION In order to assess physician learning and practice change, education evaluations must be conducted in an ongoing and comprehensive manner. This section addresses the evaluation findings of the following four educational events: 1) community workshops, 2) regional conferences, 3) other related education events, and 4) online resources. For a detailed research map, see Appendix L. The Dementia Education Strategy Program Evaluation sought to:   

listen to physician perceptions of the impact of this carefully designed strategy; seek greater understanding of any surmountable obstacles that physicians experience when involved in managing patients with dementia; and characterize and explain o physicians’ self-perceived increased knowledge and skills o best practice guideline adherence increases o practice pattern improvements.

The following questions were addressed in the evaluation strategy: How effectively do the educational interventions:    

Meet the expressed learning needs of the target audience?

Lead to a self-perceived increase in knowledge and clinical skills specific to dementia?

Impact Dementia guideline compliance / practice patterns of physicians?

Appropriately promote knowledge uptake and translation by physicians educated on the DES?

Since the educational programs of the DES were multi-faceted, data from the following multiple sources was collected for the program evaluation: 

  

Community Workshops evaluation; o On site evaluation surveys completed by workshop facilitators and participants; o Interviews with workshop facilitators; o Interviews with workshop participants; o 2-month post workshop surveys completed by workshop participants; Evidence of physician behaviour change from secondary BC MOH (ADTI-PharmaNet) data on Local Health Areas (LHA); Regional conferences - on site evaluation surveys; and Physician visits to relevant online resources – count of webpage views.

The evaluation study was approved by UBC Behavioural Research Ethics Board.

There were a total of 723 evaluation respondents, although it should be noted that some respondents were involved in evaluating more than one program.

7.1

Community Workshops

Evaluation of community workshops included two components: 1) Secondary BC MOH (ADTIPharmaNet) data; and 2) participant and facilitator perspectives. Both quantitative and qualitative feedback were gathered from participants and facilitators regarding workshop process, workshop content, general learning, and application of learning into practice.

The rigorous evaluation of community workshops was designed to determine the benefits of a small group learning format in helping to overcome barriers to appropriate dementia management (physician compliance with Clinical Practice Guidelines and proper use of assessments). The evaluation would also inform on the best CME to help physicians be in a process of continuous improvement over their UBC CPD Dementia Education Strategy Final Report

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professional careers. UBC CPD used mixed methods to provide a comprehensive portrayal of the workshop experience as it related to physician learning and practice changes (improvements in care provided to patients).

BC Ministry of Health Services Secondary Data Analysis 1. Background As mentioned, the ADTI provides BC residents in the mild to moderate stages of Dementia with PharmaCare coverage of ChEIs. Patients’ cognitive abilities are assessed and reassessed to ensure they benefit from the treatment. In order for patients using ChEIs to receive and continue receiving coverage under ADTI, the physicians must submit the previously mentioned Special Authority forms to PharmaCare. One requirement in this SA form is to provide scores of the patient’s Standardized Mini Mental Status Exam (SMMSE) (12) and Global Deterioration Scale (GDS) (13), which are two of the cognitive tests in the Clinical Practice Guidelines. These assessments were included in the education workshops, thus, the submission of the SA forms is a proxy indicator to show how many physicians after the workshop implemented the ongoing cognitive assessments of their patients.

2. Objectives The UBC CPD research team aimed to assess the impact of the workshops on physicians’ practice in dementia recognition, diagnosis, and management. The team predicted that after the workshops, there would be increased awareness of the ADTI program and increased assessment of patients’ cognitive abilities by the physician participants.

Through an examination of monthly ADTI enrolment and SA form submission data at the community level, the team investigated if there were increased numbers of physicians that prescribed ADTI covered ChEls and increased numbers of SA forms that physicians submitted to the BC MOH. Since the SMMSE and GDS scores were mandatory in the SA forms, the increased submission of SA forms would reflect increased use of these two assessment tools. It was hypothesized that when comparing the control communities (matched on population, seniors and physician numbers and similar PharmaNet baseline data) to communities that have been exposed to the Dementia Education Workshops (“treatment” communities), the “treatment” communities would show more physicians submitting the SA forms and prescribing ADTI covered ChEIs following the education. A pre and post education comparison of “treatment” would show a similar trend as well.

3. Methods UBC CPD obtained the ADTI-PharmaNet data of monthly aggregated physician prescription and patient usage information of ChEIs in various local health authorities (LHAs) in BC during a specific time period.

The aggregate information between September 2007 and May 2010 of 88 LHAs was available in this dataset. Among the 33 month points, September 2007 was the month before the ADTI Initiative was launched and March 2009 was the month when UBC CPD started delivery of the education (Dementia Education Workshops). These were deemed critical time points to the DES evaluation process. The control/treatment and pre/post analyses were based on the critical time point (i.e., launch of the workshops) to assess effectiveness of this educational strategy.

UBC CPD selected 21 of 88 LHAs for the analyses. These 21 LHAs were matched based on community size, number of physicians and seniors in a community and divided into two groups: workshop (11 LHAs) vs. non-workshop (10 LHAs) communities. To make the data comparable among the LHAs, population ratio transformation was performed to divide the data by the number of seniors in the respective LHAs (i.e., per 100,000 seniors). For pre/post analysis, the 33 time points were categorized into pre-workshop (September 2007 – February 2009) and post-workshop (March 2009 – May 2010). Data analyses were performed using SPSS 17.0, with α level set at a significance level of 0.05. Firstly, two-way ANOVA was used to pre-assess the effect of factors of community and time on the outcome measures. Secondly, oneUBC CPD Dementia Education Strategy Final Report

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way ANOVA was used to detect the difference between workshop and non-workshop groups of LHAs, and the difference between pre- and post- workshop exposure (in time).

4. Findings It was observed that during September 2007 to February 2009 (before the workshops), there was no difference between workshop and non-workshop communities in the mean amount of physicians prescribing ADTI covered ChEls and mean amount of SA forms submission (p>0.05; see the ‘Preworkshop’ panels in Figure 1 & 2). This showed that there was no difference between the treatment and control group at baseline (or before the start of the workshop education).

During March 2009 to May 2010 (after the workshops), workshop communities had significantly more physicians prescribing ADTI covered ChEls (330/100,000 seniors vs. 290/100,000 seniors, respectively; p=0.006; see the ‘Post-workshop’ panel in Figure 1). Also, workshop communities had more SA forms submissions compared to non-workshop communities (meaning there was no workshop delivered to this community) (150/100,000 seniors vs. 120/100,000 seniors; p=0.021; see the ‘Post-workshop’ panel in Figure 2). This demonstrated that the workshop was effective in promoting a change in physicians’ behaviour.

Mean of monthly # of physicians prescribing ADTI covered ChEIs (per 100,000 seniors)

These findings provide evidence that the Dementia Education Workshops had apparent impact on the physicians’ practice resulting in more ADTI enrolment and more patient assessments undertaken. This was consistent with the workshop participants online survey responses in which respondents selfreported that they were following the Clinical Practice Guidelines and using the GDS more frequently after the workshop (see further survey results below). p = 0.302

p = 0.006

Figure 1: Comparisons of monthly numbers of physicians prescribing ADTI covered ChEIs Values were presented as mean ± 1SE. The post-workshop difference between workshop and non-workshop communities was statistically significant (p<0.05).

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p = 0.021

Mean of monthly # of SA form submission (per 100,000 seniors)

p = 0.603

Figure 2: Comparisons of monthly numbers of SA form submissions Values were presented as mean ± 1SE. The post-workshop difference between workshop and non-workshop communities was statistically significant (p<0.05).

Participant and Facilitator Perspectives UBC CPD conducted surveys and interviews. In addition to on-site evaluation surveys, UBC CPD conducted follow-up surveys online (n=82) two months after the respective workshops in order to measure the participants’ self-reported compliance with Clinical Practice Guidelines and use of assessment tools (SMMSE and GDS). The evaluation team waited for two months after any participation in a workshop before sending out the survey link. This allowed the team to measure practice changes after physicians had a period of reflection on learning, and a period of implementation of any improvements. Also, eight workshop participants attended a 30-minute telephone interview two months after the workshops. They were asked about impressions of the workshop, perceived learning and perspectives on practice improvement (See Appendices M, N, and O for protocols). All the workshop facilitators completed on-site evaluation surveys (See Appendix P). Some workshop facilitators (n=14) attended a 30-minute telephone interview within two weeks after the workshop. Facilitators were asked about workshop impact on their own and other physician practice patterns (See Appendix Q).

The Likert scale ratings from the two-month post workshop survey were analyzed using descriptive statistics. A sample t test was used to compare the respondents’ attitude and practices before vs. after the workshops. The analyses were performed using SPSS 17.0, with α level of 0.05 as the significance level.

1. Quantitative survey findings Workshop participants rated their self-perceived learning using a Likert scale. They also ranked their behaviours on following the Clinical Practice Guidelines and using assessment tools. The results are highlighted in the following tables.

Tables 1 and 2 show participant feedback from on-site evaluations. As a result of the workshop, the majority of the participants felt more confident in working with dementia patients. Participants highly rated the case discussion and the binder of resources.

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Table 1: Participant perceptions on the session and self-perceived learning (n=309) * Participant Statement

%

As a result of this workshop, I feel more confident in working with dementia patients

67%

The discussion of cases was an effective way to learn about diagnosis and treatment

88%

The binder of materials is a useful resource

86%

Overall, I learned a lot from this workshop

83%

* Aggregates of rating scales 4 & 5 (“True” & “Very true”) were reported.

Table 2: 2009-2010 workshop participant self-perceived knowledge increase (n=47) * Before

After

%

workshop

workshop

increase

GPAC Guidelines

29%

81%

52%

Alzheimer’s Drug Therapy Initiative

34%

73%

39%

48%

83%

35%

Power of Attorney Guidelines

34%

70%

36%

Representation Agreement Guidelines

24%

66%

42%

Participant Statement

Determining medical fitness to operate a motor vehicle

* Aggregates of rating scales 3 & 4 (“Quite a bit” & “A lot”) were reported.

Participants’ self-perceived learning was also examined based on the type of facilitator who facilitated the workshop. ANOVA was performed to detect any differences in participant ratings. In total, there were 37 facilitators. Below are the facilitator demographics: • • • •

Thirty facilitators were local (teaching 81% of the participants); and seven were outreach/visiting (teaching 19% of participants).

Among all the facilitators, there were 13 GPs (35%); five GP “experts” (14%); and 19 specialists (51%; including psychiatrists and geriatricians).

Among local facilitators, there were 13 GPs (43%); five GP “experts” (17%); and 12 specialists (40%).

Outreach facilitators were all specialists.

Whether the workshops were led by any one of the three types of facilitators, namely GPs, GP “experts”/ specialists or led by a local versus outreach facilitator, there was no difference in participant ratings in terms of self-perceived overall learning and increase of confidence in dementia management (p<0.05).

These findings were not surprising because the workshop content and the guide to workshop facilitation were both standardized for education delivery. Although in the original needs assessment, sixty four percent of physicians stated that they would prefer to be provided with CME by a specialist (geriatric psychiatrist, geriatrician or neurologist), these results might suggest that the local GP facilitators contributed to the community workshops, and helped increase confidence and learning of their peers as much as the workshops that were facilitated by a specialist.

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Tables 3, 4, and 5 show participant feedback from the post workshop surveys. The majority of the participants felt the workshop met their learning needs. They stated that the workshop enhanced their clinical skills and knowledge. Participants reported that they would follow the Clinical Practice Guidelines more frequently after the workshop. They reported more use of the SMMSE and GDS in patient original and re-assessments.

Table 3: Participant perceived workshop effectiveness (n=82) Participant Statement

%

The educational intervention effectively addressed my learning needs

a

78% a

The educational intervention enhanced my clinical skills and knowledge in the following areas : Diagnosis

61%

Management of mild to moderate dementia

69%

Pharmacotherapy

63%

Management of Severe Stage Dementia

60%

Overall rating of this educational intervention

b

74%

a

Aggregates of rating scales 4 & 5 (“Moderately” & “To a great extent”) were reported. b Aggregates of rating scales 4 & 5 (“Very good” & “Exceptional”) were reported.

Table 4: Participant perceptions on following the Clinical Practice Guidelines (n=82) * Participant Statement I currently adhere to cognitive impairment clinical practice guidelines

% 73%

I intend to follow the educational intervention’s outlined practice guidelines

81%

* Aggregates of rating scales 4 & 5 (“Frequently” & “Always”) were reported.

Table 5: Participant perceptions on using assessment tools Item

a

Before

After

Workshop

Workshop

% increase

2009 workshops (n=35) Original assessment

66%

77%

11%

Re-assessment

54%

71%

17%

Original assessment

14%

37%

23%

b

Re-assessment

11%

40%

29%

b

Using SMMSE

Using GDS 2009-2010 workshops (n=47) Original assessment

66%

71%

5%

Re-assessment

60%

76%

16%

Original assessment

22%

28%

6%

Re-assessment

22%

32%

10%

Using SMMSE b

Using GDS a b

b

b

Aggregates of rating scales 4 & 5 (“Frequently” & “Always”) were reported. p<0.05 UBC CPD Dementia Education Strategy Final Report

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2. Qualitative findings from surveys and interviews To provide a comprehensive and well-documented portrayal of the perceptions of the facilitators and participants, content analysis was performed (14). Nvivo 8 qualitative software was used to organize the multilayered data. To understand, organize, and identify recurring themes in the perceptions of physicians, UBC CPD used content analysis of the comments and used constant comparison and teamwork to confirm emerging coding categories, and predominant themes. Facilitator and participant feedback on workshop experience (including workshop process and workshop content) and comments on the application of learning into practice are highlighted as follows.

Physician perceptions on applying the learning in practice Most facilitators themselves had used the Clinical Practice Guidelines in practice; therefore, they did not change their behaviour after the workshop. However, facilitators believed the workshop made the physician participants more aware of the Clinical Practice Guidelines. Facilitators found that the participants were not familiar with the flow sheet in the Clinical Practice Guidelines. They felt the busy GPs might not follow the Clinical Practice Guidelines very closely.

Some of the participants stated that they implemented the Clinical Practice Guidelines more consistently than they did before the workshop. They also mentioned that the Clinical Practice Guidelines were complex. 

“Like with most guidelines, if they are not at your fingertips it is hard to remember what you are to do.” – A physician participant

Facilitators believed it was good to see that participants thought of dementia as a chronic disease, requiring management. They noticed participants’ increased awareness of the holistic approach to dementia care. They expected that the participants would feel they had more to offer the patients and their families after the workshop.

Participants expressed some challenges in dementia care. Participants felt that they were facing pressure from care aids to control patient behaviour with pharmaceutical “restraints”. They mentioned the time constraints for dementia care, the availability of community resources and patient/family factors as some of the major challenges. After the workshop, some participants stated they performed a more comprehensive review of the daily functions of their dementia patients. Participants stated that they learned about approaching patients with early cognitive impairment, about the differential diagnosis of various types of dementia, and understanding the progression of cognitive decline. 

“I think they [participants] become much more comfortable with that and then choosing initial treatments and the local resources available for support; they came away with a good understanding of the initial approach to managing dementia in a comprehensive way.” – A facilitator



“After attending the workshop I had a plan on how to approach dementia and before that I was all over the place and now I think I know what to do for step number 1, step number 2, step number 3 and I think I’m covering most of the points now. Before I was missing a few things when I was dealing with patients who were having memory problems.” – A participant

Facilitators felt that participants became much more comfortable with making a diagnosis. They believed that the workshop made the participants more aware of diagnostic classifications and diagnosis issues. However, they mentioned that when there was very limited time to spend with the patients, it was a challenge for the GPs to make a diagnosis. Participants felt that the reviewing process for diagnostic criteria of dementia was valuable, in the workshop. They said the most difficult thing was to recognize the disease when it is very incipient; the workshop helped with that concept. Facilitators believed workshop information about the different levels of investigation and prognosis was very informative to the UBC CPD Dementia Education Strategy Final Report

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participants. Facilitators were surprised that some participants were not familiar with either Montreal Cognitive Assessment (MoCA) or SMMSE. Facilitators believed that from the workshop, the participants would realize that they had to perform the assessment tools in order to get ADTI coverage and to confirm the diagnosis.

Participants said they learned that they had to use assessment tools regularly for the ADTI initial coverage and renewal. They learned how to use the GDS effectively, an assessment tool they did not frequently use before. They said they were more aware of various assessment tools and the correct use of these tools; and after the workshop, they assessed patients more regularly for cognitive concerns:   

“The workshop increased my confidence to assess for cognitive changes.” “[I] brought patients back the following week to do MoCA/SMMSE.” “I now administer the MoCA as well as improved the flow of administering the SMMSE.”

Facilitators were surprised at the participants’ knowledge gap in medications for dementia. They noticed that the participants definitely wanted to learn about the medications. 

“They knew about the medications for dementia but they wanted more details about when to use them, what we thought were the benefits that we’d seen with the medications and the realistic benefits. They know that it works for some people and actually we had a couple of GPs that said ‘I’ve used these medications and I’ve had a few successes’ and that was actually just as beneficial as talking to us to have their peers talking about these medications and saying ‘this worked for my patients’ and this case was very helpful for them to see. And then we talked about some of the patients and the medications.” - A facilitator

Facilitators expected that the workshop discussion would:   

Change physicians’ perception on medications for dementia and the value of investigation and treatment; Encourage participants to be more open to medication use as an option rather than thinking that there is no hope for the patients; and Increase physician’s confidence in using the medications, switching between them, and stopping them.

Participants reported that they learned the proper prescriptions for different medications and dosages.

They appreciated that they had a chance to listen to geriatric experts talking about ChEI use. Some participants had noticed that there were patients prescribed the medications (without ADTI coverage).

Now they learned that ADTI coverage would benefit these patients and enable patients financially to stay on these medications as long as indicated. Participants learned about the criteria for ADTI coverage, and about decision making for initial use, switching, and stopping of medications. They said they would manage medications differently. Some participants mentioned that they would start prescribing the medications more by themselves, rather than by consulting the specialists.

Facilitators believed the participants would be a little more open to using medications as one of the options rather than thinking there was no hope for the patients; the participants would feel more comfortable dealing with any cases that might be similar with the workshop cases; the workshop made the GPs more aware of details of the practice. 

“Impact means that you can review what the physicians are doing and have a comparison/assessment of before vs. after the workshop. Therefore it’s hard to tell the impact on the participants from the facilitators’ perspective. However, it was the impression that the participants did learn from the workshop, from the discussion and were more aware of the guidelines. Participants left with different perceptions of the value of dementia care, especially some specific, important concerns.” – A facilitator

Participants thought the workshop information on prognosis was helpful. They believed they were now UBC CPD Dementia Education Strategy Final Report

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able to inform the patient’s family where the patient is along the continuum of cognitive decline. The participants reported current and future practice changes such as:    

“My attitude; more assertive in dealing with resistant elderly clients; more focus on family teaching & referral to support groups”; “Earlier intervention with medications”; “Collaborate more with other health professionals” and; “More discussion about driving and end of life planning”.

The participants stated that they were more aware of legal issues (i.e., representation agreement) around dementia. They learned: 

“Discuss representation agreements with families; ensure that family members are aware of the progress of dementia and can take appropriate steps to ensure safety.” – A participant

Facilitators became more familiar with information and resources for driving issues. They found the participants struggled to discuss driving with their patients, and some preferred to send the patients somewhere else to get their driving assessed, without fully engaging the patient in discussion about this issue.

Participants now were more aware of driving restrictions and resources for driving issues. They were reminded that the driving re-assessment needed to be done for dementia patients. In the post-workshop survey, some participants reported that they had held more discussions about driving with their patients.

They reported sending more patients for “Driveable” driving assessments as well. 

“I think knowing that there’s a cognitive driving testing facility around in Kelowna will be helpful for us.” – A participant

Facilitators and participants gave positive comments on the small group learning format and casebased discussion of the workshop. The facilitators felt inspired to prepare more for this face to face small group; thus, this helped the learning tool to be even more effective. The participants thought that small group learning required higher commitment from all participants. They found the open sharing and the back and forth dialogue on many issues very helpful, especially for a topic as complex as dementia, for which there were not always obvious solutions. Because of the open discussion, participants stated that they were able to get their own learning needs met. Further, the discussion brought about changes in perception. 

“It’s just helpful for people to discuss what their challenges are in a group setting and then have others give suggestions and I think people come away from that with much more understanding of what other people struggle with but also other solutions that they may not have thought of.” – A facilitator



“I was a bit surprised at some of the initial assumptions of the physicians regarding medications for dementia and the value of investigating and treating it and I think following the discussions it seemed that they held a very different view and they’re much more willing to entertain the value and the subtleties of dementia care and so I think there was a real changed perception following the discussion.” – A facilitator

Comments on workshop content Facilitators and participants thought the pre-reading was relevant and important, and was seen as good background and reference material. They thought the pre-reading was at an appropriate level for GPs as it was simplified enough yet provided enough content. The participants felt the pre-reading reminded them of their “commitment to learning”.

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

“I don’t know how much the doctors did the pre-reading, but I got the impression that quite a few had done so I think it was all very relevant.” – A facilitator

Both facilitators and participants thought the case-based content was excellent. The facilitators thought that the case-based content inspired a rich discussion, and inspired the participants to talk about their own clinical experiences. They believed it led to a deeper level of learning. The participants thought the cases were representative of physicians’ daily practice situations. 

“It was just helpful for them as a starting point so that they could ask the questions that they had been deliberating over for a long time and they hadn’t ever talked to anybody about it so it was very much a conversation starter.” – A facilitator



“It was case based so we were enjoying it because the cases are usually received in our day to day practice and it was good to deal with those cases in the workshop and especially listening to how other people deal with those types of cases.” – A participant

Facilitators and participants thought the workshop binders were “well-organized” and “excellent resources”. 

“It was actually really nice that you had such a big binder of information for people… It was nice to provide people with kind of a resource manual and I actually took my binder and I’ve lent it to one of my colleagues at work who wasn’t able to attend. But it’s become a bit of a kind of a resource for the community as well which is good.” – A participant

Facilitators and participants thought the workshop increased their awareness of resources available in their communities.

Perceptions on general learning Facilitators thought that dementia was a condition that should be and was largely managed by the GPs. They thought GPs’ referrals had been improving over time, becoming more and more appropriate. They believed the GPs were doing a good job with limited resources available in rural communities. 

“It gave me a chance to know where my colleagues are and that would definitely influence my consultation report because when you know where people are at then you tailor your concentration to that and definitely gave me a chance to learn it a bit more about resources in the community that they may not have been aware of because we discussed those things” – A facilitator

The workshop provided facilitators with a unique opportunity to listen to the GPs and to seek a better understanding of the GPs’ beliefs and attitudes about dementia care, and of their practice patterns.

Furthermore, the workshop was a chance for the facilitators to have a conversation with a group (instead of providing consultation to individuals). The facilitators became more aware of the challenges that the GPs were facing. From this point of view, the relationship between the facilitators (specialists) and the GPs was improved, in the communities wherein the workshop was facilitated by a specialist. 

“I was actually quite surprised at some of the assumptions held by the physicians and it was different than what I would have expected including their views of medications for Alzheimer’s disease. It was quite pessimistic and so a presentation simply for promoting the benefits might not have met their needs.” – A facilitator

Facilitators felt they themselves did not learn that much emerging knowledge from the workshop.

However, some of them learned about dementia care practice in isolated communities. Some of them enjoyed the knowledge reinforcement and gaining great experience from doing a lot of reading beyond the content of the workshop.

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Facilitators thought the participants went away with more understanding. Therefore, the facilitators thought the education might make the participants be willing to take on more cases of patients with dementia. Participants said they better realized their role in dementia care after the workshop. They reported they would encourage patients to plan ahead, and to discuss gradual loss of independence well ahead of time. For facilitators themselves, the workshop had an impact on some facilitators’ approach to patients living at risk, but not on their approaches to investigation and management of dementia, which had been informed by the Clinical Practice Guidelines. However, other facilitators thought the workshop impacted how they screen for cognitive problems, and how often they follow up with patients. The facilitators also mentioned they would provide more education in their written consultation with the GPs. Some facilitators mentioned that mixed professions and experiences among the workshop participants brought different points of view. Facilitators and participants had comments on interdisciplinary learning: 

“I think in geriatric care we try to encourage more interdisciplinary care and it was good for the physicians to see the partners that were providing this care. I think it’s the education for both sides, both the physician component as well as the interdisciplinary team.” – A facilitator



“These workshops seems to be slanted to a physician's perspective - which of course, is vital, but dementia is less a "drug-treatable" disease than a "management" disease - which needs a team approach - nursing, medical, family, community resources.” – A participant

However, one participant commented that one barrier in dementia care was nursing staff beliefs and a lack of implementation of non-pharmacological behaviour management in facility settings.

Perceptions on workshop process Both facilitators and participants thought the workshops were successful. They considered the local workshops in many communities around BC as a major strength in terms of delivery of the education.

Facilitators believed it was helpful that participants addressed their own learning needs by asking specific questions; furthermore, participants felt that they learned based on going through the cases and interacting with the facilitator and other participants. Facilitators thought the workshop was very practical and relevant; the materials were good, and discussion was fruitful to foster learning. The preworkshop training from the experts helped them facilitate the workshop efficiently and boosted participant engagement. Compared with formal lectures, facilitators preferred the dementia workshop format.

Facilitators enjoyed the conversation and questions from the participants; in general, the specialistprimary care physician partnership was enhanced. Facilitators emphasized the benefits of the workshop such as networking during the workshop and the physical presence of a facilitator for answering participants’ questions in a practical manner.

Participants also gave very positive comments on the workshop. They commented that interaction with an expert (i.e., the facilitator) was one of the most effective aspects of the workshop. They commented that the facilitators were “trusted”, “colleagues in our community”, knowledgeable and experienced, which made the content more applicable. Where workshops were delivered locally, participants stated that they also enjoyed the workshop in that it was local and participants knew each other, which made them feel comfortable to have discussion.

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Facilitator Perspectives “The biggest strength is actually having it in the physician’s Bringing us as facilitators to where they are rather Facilitator community…

Perspectives than having them come down to where we are.”

• •

• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

•

“The challenges [for facilitator included] covering the GPs, figuring out how to make it relevant to local GPs, being able to adjust the clinical recommendations for that community, dealing with aboriginal patients and figuring out how the community support system worked there.”

•

“…the collegiality, it was good to meet the family doctors that often refer to us to hear firsthand what their concerns are and what their, what they struggle with up there in the north.”

•

“I just love doing it and I consider that is some contribution on my part to the community.”

•

“It was just mostly the relationship

•

“I think I was energized by their [workshop participants] enthusiasm for the subjects and how they really wanted to understand given the cases that we had. I think they could relate a lot of their patients to those cases so they had lots of questions around them. It was really, it was very well received.”

•

“I think the nice part about the workshop [was] it wasn’t didactical. We discussed the cases, people offered suggestions about what they would do, and we had discussions around that, and then we as facilitators guided the discussion a little bit and then asked questions based on parts of the case or other points that people brought up so that we tried to cover all the material, not in a linear fashion by any means. It went back and forth but we seemed to cover all the material quite well.”

with family physicians that was improved through the workshop.”

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Participant Perspectives •

“[The workshop was a] great review with concise details of characteristics of dementia & testing. All applies to my

work.”

•

“a lot of ground covered regarding the breadth dementia”

of

•

“This is great because it’s face-to-face and you can ask questions and we can bring up specific cases that we encounter in our practice and there’s an expert in front of you. So certainly it’s more personal.”

•

“…knowledgeable and down-to-earth group leader who delivered education in a very practical kind of format without going into a lot of theory, provided just the very useful information that one can use

in any practice...”

•

“I think the biggest strength of this particular workshop is that all the participants knew each other. There’s more interaction and discussion with your colleagues, it’s much more, it’s much more interesting and more fun.”

•

“This was much more interactive. That was a definite strength.

Like you often go to CME events of that nature and you’re basically being talked to while you eat. And that you don’t apply the knowledge and you’re not pushed to think about everything as we did in this workshop. [This workshop] it was very good. You couldn’t have just gone there and not participated.”

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7.2

Regional Conferences: Evaluation Findings

From February to November 2008, UBC CPD delivered six Dementia Update Regional Conferences across BC, including five one-day conferences and one two-day conference. Participants were invited to complete a post-conference survey on the day of the conference. See Appendix R. The surveys contained nine questions, designed to examine participants’ opinions on the session effectiveness and gauge their intentions as to what they intended to do differently in their practice as a result of the conference. There were 140 of 365 participants (38.3% response rate) who completed and returned the evaluations. There were a variety of healthcare professionals in attendance at the conference who then provided evaluation feedback.

The data were analyzed using descriptive statistics and qualitative methods. The quantitative data analyses were performed using SPSS 17.0, with α level of 0.05 set as the significance level. One-way ANOVA, sample t test, and bivariate correlations were used to determine if there were differences between participants in different BC regions, participants from urban and rural areas, or participants with different levels of work experience.

More than 75% of the respondents rated the session effectiveness as “above average” or “excellent”. This included the respondents’ ratings on conference content, educational format, level of interactivity and overall rating. More than 65% of the respondents felt to a “moderate” or “great extent” that the conferences enhanced their dementia knowledge and clinical skills.

UBC CPD did not detect differences in the opinions of urban vs. rural health care practitioners (p > 0.05).

It appears that the session was effective regardless of the region in which it took place. In this case, Prince George, Cranbrook, and Nelson were grouped as rural (n = 52) while Victoria, Coquitlam, and Kamloops were grouped as urban (n = 88). Comparing the health care practitioners who had at least 20 years work experience (n = 86), with those who had less than 20 years experience (n = 54), those with less work experience perceived higher effectiveness of the session content (p < 0.05) and gave the conferences higher overall ratings (p < 0.05), likely because they were newer to the topics.

For four of the regional conferences, Victoria, Coquitlam, Cranbrook, and Prince George, participants were asked to what extent they felt that the educational intervention enhanced their clinical skills and/or knowledge. 75% felt that their skills in assessment of patients with dementia were enhanced “moderately” or “to a great extent”. 64% felt that their skills in the pharmacological management of AD and dementia were either improved “moderately” or to “a great extent”.

UBC CPD received very positive feedback in general on the conferences. The participants made the following statements about what they plan to do differently as a result of having attended the regional conferences:     

7.3

“More screening for cognitive problems” “Look more into driving assessment” “Increased comfort in starting Cholinesterase Inhibitors” “Change care plan depending on types of Dementia” “Take more time to listen to my clients and caregivers”

Other Related Educational Events

After the November 2007 videoconference, by Dr. Doug Drummond, wherein he gave the initial statements about how to do early diagnoses and explained the rationale for the ADTI, one physician commented, “feel more comfortable with diagnosis and SA process”. Another commented “Probably won't change it but gives me additional reinforcement of general AD - Dementias; and Stages, etc. Also, good UBC CPD Dementia Education Strategy Final Report

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reinforcement of which SMMSE form to use”.

Dementia education related sessions were also delivered within other major CME events provided by UBC CPD. In January 2008, one of the workshops in the “Hot Topics in Psychiatry” Conference was titled “Cholinesterase Inhibitor Use in Dementia”, presented by Dr. Martha Donnelly. The participants appreciated “expert opinion of specific topics” and “well-prepared, interactive workshop”. The participants became aware of ADTI coverage of ChEI and related SA forms. They committed to administer objective tests on dementia patients.

In November 2008, the UBC CPD “CME on the Run” session was on “Psychiatry & Dementia” and there were 89 participants. Four of the specific topics related to the Dementia Education Strategy. This session was well-received. A full 86% of the participants said that they would use the learning in their future practice. Many participants stated that they would use assessment tools such as SMMSE more frequently. Participants committed to “Screen more elders for Dementia”. Many participants committed to assess the patients’ driving ability. Participants stated that they learned a lot about “Fitness to drive [and to] be more vigilant”.

7.4

Online Resources

934

658 568

598 503 425 338

255

239 247 128 116

98

2008

156 62 53 76

2009

191

113 137

201 56 57 56

126 115

Jan Feb March April May June July Aug Sept

202 222

Jan Feb March April May June July August Sept Oct Nov Dec

1000 900 800 700 600 500 400 300 200 100 0

June July August Sept Oct Nov Dec

Page Views

UBC CPD used Google Analytics to determine the number of webpage views on the cognitive impairment resource links on the UBC CPD website (Figure 3). It should be noted that the page view analytics show physicians viewing resources, most notably in 2009 when the most physicians were engaged in the strategy. (Conclusions about the reading or application of these resources to practice are only speculative).

2010

Figure 3: Monthly page views of Cognitive Impairment resource links within UBC CPD website (June 2008-Sept 2010)

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8 KNOWLEDGE DISSEMINATION The evaluation process confirmed physician learning and practice improvement. Because of the comprehensive evaluation of the education program, UBC CPD and the planning committee have planned to disseminate the findings through peer-reviewed publications and conference abstracts. These findings are of interest to medical educators, healthcare professionals involved in the care of patients with dementia, advocacy and community groups, and other stakeholders.

Dissemination activities to date are listed as follows: Nov 2009 BC Academic Health Council Academic Health Collaborations Newsletter “Dementia Education through Community Workshops” See Appendix S Apr 2010 BC Psychogeriatric Association th 13 Annual Conference and Meeting Presentation: “Continuing Medical Education Effectiveness: Facilitated Small Group, Case-based Learning on Dementia” See Appendix T May 2010 “Standing Committee on Continuing Professional Development (SCCPD) retreat” Presentation: “Provincial Dementia Education Strategy: Measuring Physician Performance through Quantitative Approach” See Appendix U Nov 2010 UBC Interprofessional Continuing Education 2nd Conference on Positive Aging Poster: “Supporting BC Physicians’ Practice in Dementia Care: The UBC CPD Case-based Dementia Education Workshop” See Appendix V May 2011 Canadian Conference on Medical Education (Presentation abstract submitted) “Physician education in dementia: Using mixed methods to determine physician implementation of clinical practice guidelines”

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9 CONCLUSION Dementia is a complex condition about which knowledge is evolving. Primary care physicians are committed to the health of their patients. However, in order for physicians to provide optimal dementia care, they need sufficient self-confidence, specific knowledge, skills and tools, as well as the capacity to work collaboratively with others involved in the complex care and management for patients with dementia.

The UBC CPD Dementia Education Strategy designed, delivered and evaluated a province-wide, multifaceted educational program in order to help physicians acquire self-confidence and knowledge related to dementia management. The learning objectives listed below have been met. After participating in the Dementia Education Strategy, physicians were able to: 1.

2.

3.

4.

Screen patients, recognize the onset of dementia, and provide a subtype diagnosis; Be able to apply Clinical Practice Guidelines; Take a chronic disease management approach; Be more familiar with appropriate pharmacotherapy for the maintenance or a slowing in the rate of decline of cognition and use this as an accepted standard of efficacy in the treatment of dementia; 5. Be proactive in care of patients living at risk; 6. Understand the legal and ethical issues related to patients with dementia, including safe driving and placement in long term care; and 7. Be more familiar with resources in their own communities, and improve relationships and communication with physician colleagues.

The Dementia Education Strategy, through its configuration of resources, relevant education, and variable delivery formats, was designed to meet the perceived and unperceived needs of primary care physicians, and to provide education that is practical and applicable to clinical practice. The educational formats were useful and effective in their own ways. The vodcasts and web resources promoted individual learning, and were accessible from any computer, which mitigated geographical barriers. Videoconferences were convenient and allowed participation by physicians with minimal need for travel and locum coverage.

Regional conferences provided physicians with a forum in which to network with others in their own regions.

The final component of the Dementia Education Strategy included small group workshops held in communities around the province and involved case-based discussions. These community-based workshops allowed colleagues to learn together in a supportive and authentic setting. Although the workshop facilitators included local specialists, outreach specialists, or local GPs, the evaluation results showed that the participants perceived equal value in the overall learning and the acquired increase in confidence in dementia management. The workshop facilitators became more aware of the challenges that the GPs were facing in the management of dementia in their own communities. From this point of view, the relationship between the facilitators and the participants was improved in these communities wherein the workshop was delivered. Facilitators thought that dementia was a condition that should be, and was largely managed by the GPs. This awareness of the circumstances, challenges, and referral practices of GPs and specialists may help enhance physician communication, and coordination of care.

Additional results from the community-based workshops confirmed physician learning and performance improvement in guideline adherence. The secondary BC MOH data provided evidence that the community-based workshops had apparent impact on the physicians’ practice resulting in more ADTI enrolment and more patient assessments undertaken. This was consistent with the workshop participants’ online survey responses in which respondents self-reported that they were following the Clinical Practice Guidelines. After the workshop, participants indicated that they learned how to use the assessment tools more effectively and frequently. They also understood better the process for ADTI initial coverage and renewal. Thus, the small group, case-based workshops were perceived as valuable by the participants and facilitators. This type of “workshop” education is clearly effective in promoting physicians performance improvement, and should be offered whenever possible as part of CME strategies.

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The multifaceted CME opportunities provided through the Dementia Education Strategy have been shown to increase GP competence and confidence in providing full patient care in managing patients with dementia. This strategy provides further insight about the physicians’ experiences in managing this condition. The results from the program evaluation indicated that GPs have committed to improved performance in managing their patients with dementia, by following the best practice guidelines, doing more screening, taking more time with clients and caregivers, administering appropriate assessments, and starting medications when indicated. Physicians’ commitment to continuous quality improvement, as part of the healthcare team may help foster long term improvements in the health of their own communities.

The Dementia Education Strategy intended for the ADTI and UBC CPD to show collaborative leadership in providing CME to guide physicians towards performance improvement in the area of dementia care.

UBC CPD has presented information and preliminary results of the evaluation to a variety of healthcare professional and stakeholder audiences. There are plans for further dissemination, including research articles. The Strategy has been recognized by physician and stakeholder organizations including the Society of General Practitioners of BC. “The [Alzheimer’s Drug Therapy] initiative has changed, they now have an excellent educational component…”— Dr. Ralph Jones, President, Society of General Practitioners of BC (SGP) (17).

Excellent CME programs benefit the body of knowledge about continuing professional development, the learners (physicians), and the patients for which they care. This Dementia Education Strategy has provided a standard of excellence in continuing medical education. We hope it can be replicated for similar government initiatives, and for UBC CPD future education on dementia, and other important topics. This strategy strengthened physician to physician communication. These improved relationships not only have positive implications for dementia management, but may extend beyond to all patient care.

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10 REFERENCES 1. Chertkow H. Diagnosis and treatment of dementia: Introduction. CMAJ. 2008;178:316-9.

2. Guidelines and Protocols Advisory Committee, BC Ministry of Health and BC Medical Association.

Cognitive impairment in the elderly – recognition, diagnosis and management [Internet]. 2007 [cited 2010 Nov 22]; Available from: http://www.bcguidelines.ca/gpac/pdf/cognitive.pdf 3. Dudgeon S, editor. Rising tide: The impact of dementia on Canadian society. Alzheimer’s Society of Canada [Internet].

2010 [cited 2010 Dec 1]; Available from: http://www.alzheimer.ca/docs/RisingTide/Rising%20Tide_Full%20Report_Eng_FINAL_Secured%20v ersion.pdf 4. Boustani M, Sachs G, Callahan CM. Can primary care meet the biopsychosocial needs of older adults with dementia? J Gen Intern Med. 2007 Nov; 22(11):1625-7.

5. Pimlott N, Drummond N, Persaud M, Cohen C, Silvius J, Seigel K, et al. Family physicians and dementia in Canada: Part 2. Understanding the challenges of dementia care. Can Fam Phys. 2009 May; 55(5):508-9.e7.

6. Allen M, Ferrier S, Sargeant J, Loney E, Bethune G, Murphy G. Alzheimer’s disease and other dementias: An organizational approach to identifying and addressing practices and learning needs of family physicians. Educ Geront. 2005;31:521-39.

7. Goins R, Gainor S, Pollard C, Spencer S. Geriatric knowledge and educational needs among rural health care professionals. Educ Geront. 2003;29(3):261-72.

8. Robinson B, Barry P, Renick N, Bergen M, Stratos G. Physician Confidence and Interest in Learning More About Common Geriatric Topics: A Needs Assessment. J Am Geriatr Soc. 2001 Jul; 49(7):9637.

9. Davis D, Barnes B, Fox, editors. The Continuing Professional Development of Physicians. Chicago, IL: AMA Press; 2003.

10. British Columbia Medical Association. Building Bridges: A Call for a Coordinated Dementia Strategy in British Columbia [Internet]. 2004 Apr [cited 2010 Dec 1]; Available from: https://www.bcma.org/files/Dementia_Building_Bridges.pdf 11. Chappell NL, Dlitt BH, Hollander MJ, Miller JA, McWilliam C. Comparative Costs of Home Care and Residential Care. The Gerontologist. 2003; 44(3):389-400.

12. Mollloy D, Alemayehu E, Roberts R. Reliability of a standardized Mini-Mental State Examination compared with the traditional Mini-Mental State Examination. Am J Psychiatry. 1991; 148(1):102-5.

13. Reisberg B, Ferris S, de Leon M, Crook T. The Global Deterioration Scale for assessment of primary degenerative dementia. Am J Psychiatry. 1982; 139:1136-9.

14. Cohen L, Manion L, Morrison K. Research Methods in Education. 6th ed. New York, NY: Routledge; 2007.

15. McMillan J, Schumacher S. Research in Education: Evidence Based Inquiry. 6th Ed. Boston, MA: Pearson Education; 2006.

16. Bogdan R, Biklen S. Qualitative Research for Education: An Introduction to Theory and Methods.

2nd Ed. Needham Heights, MA: Allyn and Bacon; 1982.

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17. Jones R. Society of General Practitioners of British Columbia President's Letter [Internet]. 2010 Oct; Available from: http://www.sgp.bc.ca/download.php?section=news&id=249

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11 ACKNOWLEDGEMENTS We acknowledge the financial support of the Alzheimerâ&#x20AC;&#x2122;s Drug Therapy Initiative (ADTI), Pharmaceutical Services Division, BC Ministry of Health Services.

We acknowledge the input and advice from the ADTI project team, the ADTI Project Advisory Committee, the Education Working Group and the Study Design Working Group.

We would like to thank the participants of the following working groups and committees for guiding the design, development and implementation of the University of British Columbia, Division of Continuing Professional Development Dementia Education Strategy.

Planning Committee Members 2007-2008 Dr. Martha Donnelly Geriatric Psychiatrist, Geriatric Psychiatry Outreach Team, Vancouver Coastal Health Authority Program Director, Division of Geriatric Psychiatry, Department of Psychiatry, UBC Dr. Douglas Drummond Director, Geriatric Assessment and Treatment Centre, Prince George Regional Hospital Clinical Assistant Professor, Department of Family Practice, UBC Dr. David Evans Medical Consultant, Older Adult Mental Health and Addictions, VIHA Coordinator Family Medicine Continuing Professional Development, VIHA South Dr. Raymond Simkus Physician, Brookswood Family Practice, Langley, BC Special interest in medical informatics Dr. Shirley Sze, Family Physician, Associate Staff, Royal Inland Hospital, Kamloops Chair of the Royal Inland Hospital CME Committee Chair, BCMA Continuing Medical Education Nucleus Committee Mr. Luke Ferdinands Director, UBC CPD Mr. Terry Wintonyk Marketing and Business Coordinator, UBC CPD Coordinator Mr. Ryan Payne Project Manager, UBC CPD

Planning Committee Members 2008-2010 Dr. Martha Donnelly Geriatric Psychiatrist, Geriatric Psychiatry Outreach Team, Vancouver Coastal Health Authority Program Director, Division of Geriatric Psychiatry, Department of Psychiatry, UBC Dr. Douglas Drummond Director, Geriatric Assessment and Treatment Centre, Prince George Regional Hospital Clinical Assistant Professor, Department of Family Practice, UBC Dr. Kathryn Bell UBC CPD Dementia Education Strategy Final Report

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Geriatrician, Vancouver, Vancouver Coastal Health Authority Dr. John Soles Family Physician, Clearwater, Interior Health Authority Dr. Shirley Sze, Family Physician, Associate Staff, Royal Inland Hospital, Kamloops Chair of the Royal Inland Hospital CME Committee Chair, BCMA Continuing Medical Education Nucleus Committee Dr. Brenna Lynn Director, UBC CPD Ms. Deirdre Maultsaid Project Manager, UBC CPD

Project Consultants Mr. David Dunne Director, Road Safety, BCAA Dr. Bonnie Dobbs, PhD, Research Director, Division of Care of the Elderly, Department of Family Medicine, University of Alberta Denise Buote, Arbor Educational and Clinical Consulting Inc. David Hosick, Information Analyst, Pharmaceutical Services Division, Ministry of Health Services

Investigators/Research Team Members Dr. Sandra Jarvis-Selinger, Principal Investigator, 2007-2008 Dr. Robert Bluman, Principal Investigator, 2008-2010 Researchers: Ms. Jasmin Abizadeh, Ms. Elmira Chan, Ms. Rebekah Chapman, Ms. Mia Chung, Mr. Luke Ferdinands, Ms. Gurveen Grewal, Dr. Brenna Lynn, Ms. Deirdre Maultsaid, Mr. Ryan Payne, Ms. Katherine Wisener, and Ms. Chloe Wu.

Report Contributors Dr. Robert Bluman, Dr. Brenna Lynn, Ms. Deirdre Maultsaid and Ms. Chloe Wu. Thank you to UBC Cooperative Education Students (2009-2010) Ms. Gurveen Grewal and Ms. Tracey Ma for technical assistance.

Community Workshop Authors Martha Donnelly, MD, FRCPC Program Director, Division of Geriatric Psychiatry, Department of Psychiatry, UBC Geriatric Psychiatrist, Geriatric Psychiatry Outreach Team, Vancouver Coastal Health Authority Douglas C. Drummond, MD, FCFP Director, Geriatric Assessment and Treatment Centre, Prince George Regional Hospital Clinical Assistant Professor, Department of Family Practice, UBC The planning committee members and UBC CPD also made important intellectual contributions.

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We would like to acknowledge all of the speakers and physician educators from videoconferences, regional conferences and podcasts, the workshop facilitators, the local CME coordinators and hospital staff around BC, who assisted in the delivery of the Dementia Education Strategy. We appreciate all the survey and interview respondents for their willingness to share their insights, as part of the evaluation strategy; we recognize their commitment to continuous improvement in physician practice, improved dementia management and optimal patient care in BC. Thank you to all educational event participants.

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12 APPENDICES Appendix A: Summary of UBC CPD Needs Assessment 2007 Survey of BC physicians There were 161 survey respondents. This survey was based on the recommendations of the third Canadian Consensus Conference on Diagnosis and Treatment of Dementia (2006) Workshops: 1. Possible Workshop Topics

Not Interested

Some Interest

Very Interested

1. What are the risk factors for the development of Alzheimerâ&#x20AC;&#x2122;s disease (AD) and how can we prevent this disease?

15

54

92

2. What is known about genes for AD and when should I order genetic testing?

42

80

39

3. What is mild cognitive impairment and how do I test for it?

8

35

118

10

22

129

9

19

133

6. When should I order neuron imaging in the diagnostic workup of patients with mild dementia and what should I order?

12

31

118

7. What screening cognitive tests should I use to diagnose dementia and who should be referred for neuropsychological testing?

9

26

126

8. What blood tests are needed to evaluate dementia patients?

10

59

92

9. What is an organized and practical way for a family doctor to assess a patient with a suspected dementia? Who should be referred to a specialist?

6

28

127

10. What are the clinical criteria for some of the more common dementias: AD, frontotemporal dementia (FTD) and Lewy body dementia (LBD)?

11

49

101

11. Can blood, urine and cerebrospinal fluid (CSF) tests help in the diagnosis of dementia, including AD? How should I use these tests?

20

73

68

12. What non-pharmacological interventions are recommended for patients with mild to moderate AD?

10

44

108

4. What treatments are useful for patients with mild cognitive impairment?

5. What investigations should I do on a patient suspected of having mild dementia?

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13. What is recommended in terms of drug therapy for mild to moderate AD? How do I start and stop these medications?

10

44

107

14. Are there drugs that prevent the progression of AD? What is coming in the future?

9

45

107

15. Which patients with AD should stop driving? How do I best assess driving ability and risk?

9

34

118

16. How important are vascular risk factors in dementia?

How can I differentiate vascular dementia from AD? Is it important to differentiate between them?

9

56

96

17. What is the recommended therapy for patients with vascular dementia (VaD) or AD with cerebrovascular disease?

12

42

107

18. How should patients with severe dementia be managed (non-pharmacologically and pharmacologically)?

7

39

115

19. What is the best approach to managing the behavioral problems of the severe stages of AD?

10

39

113

20. When do AD/dementia patients lose their ability to give their consent for research, for therapy and for financial competence?

9

64

88

21. Should diagnosis be disclosed to all dementia patients?

How can I best disclose the diagnosis to patients and families?

15

69

77

22. What should I know about genetic screening in families with AD?

15

90

56

23. What are the clinical criteria for rarer dementias like progressive supranuclear palsy, normal pressure hydrocephalus and Creutzfeldt-Jakob disease?

32

71

59

24. What can physicians do to help caregivers of AD patients?

14

60

89

25. How could criteria for AD be improved in the future?

29

75

57

2. Other topics you would like to see covered •

Dementia in long term care facilities

•

Competency assessments

•

Psychotherapy with mild to moderate dementia diagnosis (for psychiatrists)

•

Alcohol related dementia: effects of chronic alcohol dependence on cognition in older adults

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• • • • • • • •

Community based resources and supports for shared or team based care of dementia patients End stage dementia: when to transfer to nursing homes, how to manage the transition, how to manage behavior How to be appropriately remunerated for your time with AD patients and care givers End of life care for dementia: medical, psychological and spiritual aspects, role and use/safety of the anti-psychotics, communication skills in dementia Dementia versus pseudo dementia Evidence based prevention and the role of nutrition: is there still a role for ibuprofen or Vitamin E? Should aluminum personal care products and cooking ware be avoided? Is there a role for anti-oxidants and Essential Fatty Acid supplements?

Different ways dementia can present.

Legal implications /guidelines relating to POA representation agreements and competency issues from a caregivers perspective.

Use of Cholinesterase Inhibitors: 3. My understanding is that the evidence for the use of cholinesterase inhibitors in the treatment of mild to moderate dementia is: (98% Response Rate) Rating Good Moderate Poor Don’t know

Response Percent 15.19% 48.73% 34.18% 1.90%

4. I have concerns with the use of cholinesterase inhibitors specifically with respect to: (check all that apply) Topic Switching medications

Response Percent 22.44%

Stopping medication

28.85%

Side effects

53.85%

Drug interactions

28.85%

Cost of medications

77.56%

Level of evidence

62.18%

Other

3.21%

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Conferences: 5. What topic areas would you like to have covered? (50% Response Rate) • •

Pharmacological and non-pharmacologic treatment options for mild dementia: initiation, monitoring, switching, stopping Diagnosis for various forms of dementia: cognitive assessment tools, lab work, CT scan

•

Referrals and consultation

•

•

Support for family: quality of life issues, care and support, consent, end of life decisions, care-giver burden Policy and program development to support primary care of dementia patients in the community Family counseling strategies

•

Red flags for less common forms of dementia

•

Causes of dementia

•

Role and use of ChEI

•

Community resources for patient and caregivers

•

Medico-legal aspects of patient care: capacity, POA, consent, driving

•

Prognosis with or without ChEI

•

Prevention

•

Behavioural interventions

•

Appropriate setting of care

•

Evidence and efficacy for different drugs

•

Polypharmacy

•

Allied health professionals availability for family support

•

Delirium vs Dementia

•

Resources: 6. Who in BC do you turn to for your dementia-related questions? Who is the best resource for dementia questions? (36% Response Rate) Resource Geriatric Psychiatrist/ Psychiatrist Geriatrician

Response Percent 28% 23% UBC CPD Dementia Education Strategy Final Report

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Neurologist Hospital Geriatric Clinics (incl. Alzheimer Clinic and Geriatric Assessment Units) Community Geriatric teams (incl. outreach teams) Reference material/ Medical literature Internet Other GPs Gerontologist Physicians with geriatric fellowships Mental health resources Other families Geriatric Courses Alzheimerâ&#x20AC;&#x2122;s Society Health Authority Division of Geriatric Psychiatry, UBC

13% 12% 5% 4% 4% 3% 3% 1% 1% 1% 1% 1% 1% 1%

7. How familiar are you with the patient provider resources provided by the Alzheimer Society of BC?

Very familiar Somewhat familiar Somewhat unfamiliar Unaware of the resources available

Response Percent 5.70% 24.05% 32.28% 37.97%

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Appendix B: Education Log of Dementia Education Strategy Events 2007-2010 Presentation by DES leader Dr Martha Donnelly - Cognitive Impairment Guidelines

UBC CPD- Community Workshop

Date

Location

Participant Count

Date

Location

Participant Count (% physician)

11-Oct-07

Vancouver (Geriatric Outreach Team)

20

5-Mar-09

North Vancouver

6 (100%)

12-Mar-09

Prince George

10 (40%)

1-Nov-07

Vancouver (UBC Dept of Family Practice-Div. of Community Geriatrics)

25-Mar-09

Trail

13 (85%)

15-Apr-09

Fort St. John

8 (75%)

16-Apr-09

Vernon

12 (83%)

21-Apr-09

Vancouver

9 (78%)

30-Apr-09

Revelstoke

6 (100%)

7-May-09

Vancouver

11 (67%)

13-May-09

Comox

11 (82%)

28-May-09

New Westminster

11 (27%)

10-Jun-09

Smithers

6 (50%)

11-Jun-09

Sechelt

8 (75%)

17-Jun-09

Duncan

10 (60%)

18-Jun-09

Port Hardy

6 (100%)

18-Jun-09

Clearwater

17 (24%)

18-Jun-09

Abbotsford

10 (60%)

25-Jun-09

Penticton

6 (83%)

26-Jun-09

Queen Charlottes

6 (83%)

Psychiatry

18

Vancouver (UBC Dept of Psychiatry, 1-Nov-07 Div. of Geriatric Psychiatry) 15 UBC CPD- Videoconference – Cholinesterase Inhibitors for Alzheimer’s Disease Date

Location Participant Count Alert Bay, Castlegar, Cormorat Island, Invermere, Kamloops, Kaslo, Logan Lake, New Denver, Princeton, Prince George, Surrey, Vancouver, Williams 14-Nov-07 Lake 20 UBC CPD- Podcast - CI in the Treatment of Mild-to-Moderate Alzheimer’s Disease Date Location Participant Count 2-Nov-07 to 297 2-Nov-08 Online (2 events) UBC CPD & VIHA- Videoconference – Distinguishing Mild Cognitive Impairment from Early Diagnosis in the Elderly Date

Location

Participant Count 90 (25% 15-Jan-08 Victoria physicians) UBC CPD- Hot Topics Conference – Workshop on “CI use in Alzheimer’s Disease”

5-Nov-09

Vanderhoof

11 (73%)

Date

Location

Participant Count

12-Nov-09

Williams Lake

9 (89%)

25-Jan-08

Vancouver

30

18-Nov-09

Invermere

11 (82%)

25-Nov-09

Squamish

7 (71%)

26-Nov-09

Cranbrook

6 (100%)

1-Dec-09

Victoria

6 (100%)

1-Dec-09

Salmon Arm

13 (100%)

2-Dec-09

Port Alberni

9 (67%)

2-Dec-09

Powell River

12 (92%)

14-Jan-10

Langley

10 (80%)

21-Jan-10

Vancouver

10 (90%)

21-Jan-10

Kamloops

14 (100%)

28-Jan-10

Richmond

9 (89%)

4-Mar-10

Chilliwack

8 (38%)

4-Mar-10

Parksville

9 (89%)

18-Mar-10

Nelson

10 (50%)

UBC CPD- CME on the Run Lecture Series - Psychiatry & Dementia

18-Mar-10

Dawson Creek

9 (44%)

Date

Location

Participant Count

25-Mar-10

Quesnel

8 (100%)

28-Nov-08

Vancouver

89

25-Mar-10

White Rock

6 (67%)

25-Mar-10

Kamloops

3 (100%)

1-Apr-10

Kelowna

25-Jan-08 Vancouver 16 Presentation by DES leader Dr Martha Donnelly - Cognitive Impairment Guidelines Date

Location

Participant Count

15-Jan-08

Chilliwack

40

UBC CPD- Regional Conference – Dementia Update 2008 Participant Count Date Location (Total = 365) 22-Feb-08

Victoria

70

1-May-08

Cranbrook

51

6-Jun-08

Coquitlam

57

6-Jun-08

Prince George

29

20-Sep-08 9-Oct-08 10-Oct-08

Kamloops Nelson

48 110

UBC CPD- Web Resources Date 1-Apr-08 to31-Mar-09 1-Apr to 30Sept 10

Location

Participant Count

UBC CPD Website

88 views

UBC CPD Website

155 views

4 (100%) Total: 339 participants

Grand Total = 1009 Participants UBC CPD Dementia Education Strategy Final Report

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Appendix C: UBC CPD â&#x20AC;&#x201C; Dementia Education Strategy Webpages Screenshots

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UBC CPD Dementia Education Strategy Final Report

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Appendix D: Dementia Vodcast Scripts and Promotional Material

Scripts Presentation 1: Dr. Bater Cholinesterase Inhibitors in the Treatment of Mild-to-Moderate Alzheimer’s Disease for Patients in British Columbia: A Clinician’s Role Narrator: The Alzheimer's Drug Therapy Initiative will bring British Columbia into line with the other provinces in cholinesterase inhibitor therapy for mild-to-moderate Alzheimer’s disease. Eligible patients will receive coverage for the cost of the drugs, and at the same time, the initiative will gather long-term data on the effectiveness of CI treatment. Dr. Marilyn Bater discusses the use of CI therapy within the ADTI framework.

Dr. Bater: Now in British Columbia, we’re going to have funding available for individuals with mild-to-moderate Alzheimer’s disease for treatment with cholinesterase inhibitors. This is really important that this treatment is going to be supplied for them without the patient having to have all of the cost being borne, and being more in alignment with the other provinces within Canada. We do have specific guidelines now available regarding cognitive impairment, how to recognise, how to diagnose it, and how to manage, and this will give us some standardised approach while we continue to gather information about its usefulness and provide for Pharmacare some evidence in a larger group of individuals locally the benefits of the medication.

Narrator: According to Dr. Bater, although CIs are not effective for all patients, there is considerable clinical evidence that many with mild-to-moderate Alzheimer’s disease do experience symptomatic improvement, and about one quarter of patients improve enough to benefit their caregivers. However, until now, the ADTI did not provide coverage for these medications in British Columbia.

Presentation 2: Dr. Rabheru A New Treatment Option for Patients in British Columbia: Cholinesterase Inhibitors for Mild-toModerate Alzheimer’s Disease Narrator: The ADTI is the result of many months of collaboration between the provincial government, the Alzheimer Society of British Columbia, clinical experts, researchers, drug manufacturers, and practising clinicians.

Although cholinesterase inhibitors have demonstrated efficacy in mild-to-moderate Alzheimer’s disease, the effect size seen in studies is small, and long-term data are scarce. As a result, there is considerable debate about the cost effectiveness of this class of drugs.

Dr. Rabheru: There has been no other class of medications that has created this level of controversy. In British Columbia, Pharmacare has looked at this very carefully and the ADTI is really an excellent attempt to try and reconcile all of these problems, to make the medications available to the patients who need them, to track the improvement or lack of over the 3-year period and address some of these questions that have loomed over the scientific community, and lastly, the dearth of studies, including caregiver assessments, which is a critical aspect of care for persons with Alzheimer’s disease, has really not been addressed by any of the randomised, controlled data.

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Promotional Material

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Appendix E: UBC CPD – Videoconference “Cholinesterase Inhibitors for Alzheimer’s Disease” Presentation by Dr. Doug Drummond, November 2007

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Appendix F: Regional Conference Agenda and Curriculum UBC CPD- Regional Conference “Dementia Update 2008” Sample Conference Agenda

Time

Speaker

0745

Breakfast; Registration, & Resource Fair

0830

Opening Remarks

Dr. Martha Donnelly

0835

Making The Diagnosis

Dr. Bill Dalziel

0915

Management of Mild to Moderate Dementia

Dr. Duncan Robertson

1000

Refreshment Break/Resource Fair

1025

Pharmacotherapy – A Balanced Review of the Evidence

Dr. Martha Donnelly Dr. Glenda MacDonald

1100

Case Based Workshop- Mild to Moderate Dementia

Facilitated by Drs. Loomer, Donnelly, & Robertson

1200

Lunch (Provided) & Resource Fair

1300

Management of Severe Stage Dementia – A Family Physician’s Role

Dr. Frank Loomer

1345

Supporting your Patients: ASBC – Program & Services Driving with Dementia

Ms. Betty Sinclair, Mr. David Dunne & Dr. John McCracken

1430

Refreshment Break & Resource Fair

1450

Case Based Workshop -Severe Dementia

Facilitated by Drs. Loomer, Donnelly, & Robertson

1550

Risk Factors

Dr. D. Sam Williams

1620

Completion of Evaluations; Wrap Up

Dr. Martha Donnelly

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UBC CPD- Regional Conference “Dementia Update 2008” General Curriculum

1.

Making the Diagnosis a. Differential diagnosis (delirium, dementia, depression) b. The diagnostic work-up (symptoms, physical examination, lab, neuro-imaging, cognitive testing) c. Differential diagnosis of the dementia (Alzheimer’s, vascular, mixed, Parkinson’s dementia, Lewy Body dementia, frontal temporal dementia) d. Mild Cognitive Impairment (with the introduction of the Montreal Cognitive Assessment [MOCA])

2.

Practice management, early (mild to moderate) a.

Diagnostic disclosure b.

Staging, Global Deterioration Scale c.

Advanced directives (power of attorney, representation agreements and wills) d.

Chronic disease management approach e.

General care and support f.

Co-morbid conditions g.

Driving

3.

Pharmacotherapy for Dementia (Cholinesterase Inhibitors and Memantine) and future directions?

4.

Practice management, late (moderate to severe) a. Caregiver support b. Behavioural and Psychological Symptoms of Dementia (BPSDs) c. End of life issues d. Incapacity assessment

5.

Patient/Family practice supports a. Alzheimer’s Society (first link, etc) b. Community caregiver support groups c. Continuing care services as in home support, home nursing, dietary, day programs d. Specialty support through geriatric medicine, mental health clinics (or outreach teams) or research clinics like the Alzheimer’s clinic e. New academic detailing program in B.C.

6.

Risk factors and prevention following the Third Canadian Consensus Conference on Diagnosis and Treatment of Dementia guidelines

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Appendix G: UBC CPD – Regional Conference “Dementia Update 2008” Sample Poster

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Appendix H: UBC CPD – Dementia Community Workshop Case Studies Sample 1. Mild Cognitive Impairment & Progression of Symptoms of Dementia 2. Dementia & Driving 3. Dementia & Living at Risk 4. Late Stage Dementia & Admission to a Nursing Home “Case One: Global Dementia Case and Progressive Care: Participant Case for Discussion” Part One (of four) Mr. W. is a 66 year-old working executive whose wife and children have noticed his memory deteriorating progressively over the past year. “He forgets details of conversations we have” complains his wife. She began to notice this about a year ago and it seems to be getting worse. His past medical history is unremarkable other than treated hypertension. He takes ramipril 10 mg OD, hydrochlorothiazide 12.5 mg OD, ASA 81 mg OD….

What are your initial diagnostic considerations?

What additional information would you like on history?

How would your proceed from here?”

“Case Two: Driving with Dementia” Part One (of two) Ray M. is a 76 year-old retired accountant who was recently brought to you by his wife and daughter for assessment of memory problems. Over the course of several visits you complete a work-up and determine that Ray has early (Stage 4) Alzheimer’s disease. He is physically robust and plays golf regularly. His only meds are for hypertension and dyslipidemia. He scores 26/30 on MMSE. His 3-word recall is 1/3. His clock face was done well. Ray is independent for iADLs except that his wife has to check that he has remembered to take his evening medication. Ray thinks his memory is no worse than most of his golfing buddies. He is doubtful about your diagnosis of AD and says “If you say so, doc”.

At you meeting with Ray and his family to disclose and discuss the diagnosis, Ray’s daughter asks you “Is he still OK to drive?” Ray shoots her a withering look, and adds that he has been driving for 60 years and hasn’t yet had an accident. You ask his wife if she has any concerns about Ray’s driving and Ray silences her with one of his dirty looks. Later you get a chance to talk to her and their daughter alone.

They tell you that Ray has had no driving mishaps. Sometimes he drives a bit too slow for the ambient traffic and once he got lost when he drove his wife to her sister’s home in a distant city that he did not know well. Ray’s wife doesn’t drive. The daughter says she isn’t aware of any particular issues with Ray’s driving but she never actually sees him drive.

How would you approach the issue of Ray’s driving?

What are your obligations as a physician under the Motor Vehicle Act? What does the “BC Guide for physicians in determining fitness to drive” recommend?

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Appendix I: Dementia Community Workshop Binder Facilitator Binder (March to July 2009)

1. Facilitator Role Overview and tips for facilitating case discussions Workshop Pre-Reading 2. GPAC Guidelines (including CAM, GDS, SMMSE, MOCA, GDS, Flowsheet) 3. Diagnosing and Treating Alzheimer’s Disease Cases for Discussion (©2008, UBC-Continuing Professional Development) 4. Case One: Global Dementia case (progressive care) 5. Case Two: Driving Case 6. Case Three: Living at Risk 7. Case Four: Nursing Home Care Supplemental Materials 8. Alzheimer’s Drug Therapy Initiative Clinical Information Package (including diagnostic guidelines, prescribing guidelines and special authority forms) 9. Cognitive Impairment in the Elderly: A Guide for People with Dementia and their Caregivers 10. Determining medical fitness to operate a motor vehicle (selected sections only) 11. Driving Fitness Related Forms •

B.C. Motor Vehicles “Report of a Condition Form”

•

BCAA Mature Drivers Self Assessment

•

DriveABLE Research Overview

•

DriveABLE referral forms (Vancouver, Victoria, Kelowna)

12. Power of Attorney information booklet 13. Representation Agreement Information 14. Post workshop evaluation and instructions for return of evaluation forms 15. Cases (participant version)

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Participant Binder (March to July 2009) Note that participants were expected to have done the following pre-reading: • GPAC Guidelines (including CAM, GDS, SMMSE, MOCA, GDS, Flowsheet) • Diagnosing and Treating Alzheimer’s Disease 1. Overview of the Dementia Educational Strategy Cases for Discussion (©2008, UBC-Continuing Professional Development) 2. Case One: Global Dementia case (progressive care) 3. Case Two: Driving Cases (Two cases) 4. Case Three: Living at Risk 5. Case Four: Nursing Home Care Supplemental Materials 6. Alzheimer’s Drug Therapy Initiative Clinical Information Package (Section 1 -4; 7) 7. Cognitive Impairment in the Elderly: A Guide for People with Dementia and their Caregivers 8. Driving Fitness Related Forms 

Relevant Driving Weblinks



BCAA Mature Drivers Self Assessment



DriveABLE Research Overview



DriveABLE referral forms (Vancouver, Victoria, Kelowna)

9. Power of Attorney information booklet 10. Representation Agreement Information 11. Weblinks for Physicians and Patients and their Caregivers 12. Post workshop evaluation and instructions for return of evaluation forms

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Facilitator Binder (November 2009- April 2010) 1.

Facilitator Role Overview and tips for facilitating case discussions Workshop Pre-Reading

2. GPAC Guidelines (including CAM, GDS, SMMSE, MOCA, GDS, Flowsheet) 3. Diagnosing and Treating Alzheimer’s Disease Cases for Discussion (©2008, UBC-Continuing Professional Development) 4. Case One: Global Dementia case (progressive care) 5. Case Two: Driving Case 6. Case Three: Living at Risk 7. Case Four: Nursing Home Care Supplemental Materials 8. Alzheimer’s Drug Therapy Initiative Clinical Information Package (including diagnostic guidelines, prescribing guidelines and special authority forms) 9. ADTI Research Program Information Package and Sample Forms 10. Cognitive Impairment in the Elderly: A Guide for People with Dementia and their Caregivers 11. Notes on Driving and Dementia 12. Determining medical fitness to operate a motor vehicle (selected sections only) 13. Driving Fitness Related Forms •

B.C. Motor Vehicles “Report of a Condition Form”

•

BCAA Mature Drivers Self Assessment

•

DriveABLE Research Overview

•

DriveABLE referral forms (Vancouver, Victoria, Kelowna)

14. Notes on Living at Risk and Relevant Legislation 15. Power of Attorney information booklet 16. Representation Agreement Information 17. Post workshop evaluation and instructions for return of evaluation forms 18. Cases (participant version)

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Participant Binder (November 2009- April 2010) Note that participants were expected to have done the following pre‐reading: • GPAC Guidelines (including CAM, GDS, SMMSE, MOCA, GDS, Flowsheet) • Diagnosing and Treating Alzheimer’s Disease

1.

Overview of the Dementia Educational Strategy

2.

a) GPAC Guidelines b) Diagnosing and treating Alzheimer’s Disease Cases for Discussion (©2008, UBC-Continuing Professional Development)

3.

Case One: Global Dementia case (progressive care)

4.

Case Two: Driving Cases (Two cases)

5.

Case Three: Living at Risk

6.

Case Four: Nursing Home Care Supplemental Materials

7.

Alzheimer’s Drug Therapy Initiative Clinical Information Package

8.

ADTI Research Program Information Package and Sample Forms

9.

Cognitive Impairment in the Elderly: A Guide for People with Dementia and their Caregivers

10. Notes on Driving and Dementia 11. Driving Fitness Related Forms •

Relevant Driving Weblinks

•

BCAA Mature Drivers Self Assessment

•

DriveABLE Research Overview

•

DriveABLE referral forms (Vancouver, Victoria, Kelowna)

12. Notes on Living at Risk and Relevant Legislation 13. Power of Attorney information booklet 14. Representation Agreement Information 15. Weblinks for Physicians and Patients and their Caregivers 16. Post workshop evaluation (return to facilitator)

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Appendix J: UBC CPD- CME on the Run Lecture Series “Psychiatry & Dementia” Agenda Friday November 28, 2008 1:00 pm – 5:00 pm Paetzold Lecture Room, Vancouver General Hospital 1230

Final Registration

1300

Introduction

1305

When to stop cholinesterase inhibitors

Dr. Martha Donnelly

~ To be aware of the third CCCD Guidelines on stopping ChEIs ~ To understand the BC ADTI approach to stopping payment for ChEIs

1328

Tools to assess dementia: practice tips for the busy GP

Dr. Martha Donnelly

~ To use a simple informant questionnaire ~ To understand the importance of the MMSE as a basic tool ~ To know when and how to do a MOCA ~ To state what clock drawing assesses with respect to higher level functions ~ To differentiate different types of dementia by a simple checklist of symptoms

1351

A Critical Review - Antidepressants

Dr. Raymond Lam

~ learn the latest research on anti-depressant efficacy ~ choosing the right antidepressant for your patient ~ strategies for combining antidepressants

1414

How to get your patient to give up their driver's license

Dr. Bonnie Dobbs

~ how to navigate this sensitive topic and maintain rapport

1437

Key issues physicians should know when assessing fitness to drive

Dr. Bonnie Dobbs

~ review common medical conditions that may affect driving ability ~ physician reporting obligations

1500

Refreshment Break

1520

Assessment of ADHD in Adults

Dr. Derryck Smith

~ presentation of ADHD in adult patients ~ management guidelines and where to access resources

1543

Physician Mental Health: Should we be golfing more?

Dr. Andrew Clarke

~ how to recognize signs of burnout and psychiatric illness ~ how and when to get help

1606

Traumatic Brain Injury Effects - dealing with the sequelae

Dr. Hugh Anton

~ brief overview of the types of traumatic brain injury a GP may see in the office ~ the short and long term complications of such injuries ~ what the GP can do to maximize recovery (what to look for in follow up, referrals, resources etc.)

1629

New Mental Health Codes: Using them to your advantage

Dr. Cathy Clelland

~ SGP will provide tips on how to bill the new mental health codes

1652 1655

Discussion Program Day Ends UBC CPD Dementia Education Strategy Final Report

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Appendix K: UBC CPD- Dementia Listserv Welcome Email, July 2009 Welcome!

This listserv is open to all physicians who are participating in the 2-year UBC Division of Continuing Professional Development Dementia Education Strategy. If you are invited to this listserv, you are one of the 450 physicians across BC who have taken part in one of our Dementia Management education programs in the last 18 months. This is a forum to discuss ideas, and exchange information about Dementia Management in a peer-to-peer setting. All physician experiences and input are welcome. Please pose questions and challenging problems and offer solutions and advice to others.

The BC Dementia CME Strategy is an initiative that is working for and with physicians and other health professionals to give you the tools and knowledge to help achieve optimal care for patients suffering from Dementia. For more information on the Dementia Education Strategy, with links to the clinical practice guidelines, and other resources, and current educational offerings, please see our website at: http://www.cpd.med.ubc.ca/Projects/DementiaCME.htm This listserv will run for 6 months, subject to reassessment on the level of your interest.

The input of any physician is welcome and can in no way be construed as advice or a specialist consultation on particular patient care. This is a discussion forum only.

To send a message to the group: • write to cpd-dementia-education@interchange.ubc.ca To hide your email address: • send your post to owner-cpd-dementia-education@interchange.ubc.ca and they will post for you To remove yourself from this mailing list: • you can send mail to <Majordomo@interchange.ubc.ca> with the following command, "unsubscribe" followed by the list name,"cpd-dementia-education" in the body of your email message.

• To avoid warning messages from MajorDomo, please don't include a signature block (it thinks it is a command).

To have information about this listserv appear in your email: • please choose the "plain text" format in your email program.

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Appendix L: Dementia Education Strategy Research Map

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Appendix M: Dementia Workshop Evaluation Survey UBC CPD- Dementia Community Workshop Evaluation Form (March to July 2009) Thank you for taking the time to evaluate your experience at this workshop. Your feedback is important to the ongoing efforts that we are making in offering these workshops across the province. Once you have completed this survey, please place it in the envelope provided and hand it in to the facilitator.

Date: ________________________________ Number of years as a practicing physician: ____________________ Current number of patients in your practice who have Dementia: _________________ Please circle the answer that best describes how much knowledge you had about the following topics/resources prior to the workshop.

1.

2.

3.

4.

5.

Statement Dementia GPAC guidelines Alzheimerâ&#x20AC;&#x2122;s Drug Therapy Initiative Determining medical fitness to operate a motor vehicle Power of Attorney guidelines Representation Agreement guidelines

None 1 1 1 1 1

A little 2 2 2 2 2

Quite a bit 3 3 3 3 3

A lot 4 4 4 4 4

Please circle the answer that best describes how true the statement is for you.

Statement

Not at all true 1

A little bit true 2

Somewhat true 3

Quite true 4

Very true 5

2. The discussion of cases was an effective way to learn about the diagnosis and treatment of Dementia.

1

2

3

4

5

3. The binder of materials is a useful resource.

1

2

3

4

5

4. Overall, I learned a lot from this workshop.

1

2

3

4

5

1. As a result of this workshop, I feel more confident in working with patients with Dementia.

Are there things that need to be added to this workshop to improve learning?

What was the most helpful part of this workshop?

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UBC CPD- Dementia Community Workshop Evaluation Form (November 2009- April 2010) Thank you for taking the time to evaluate your experience at this workshop. Your feedback is important to the ongoing efforts that we are making in offering these workshops across the province.

Once you have completed this survey, please place it in the envelope provided and hand it in to the facilitator.

Date: ______________________ Number of years as a practicing physician: ____________ Current number of patients in your practice who have Dementia: ____________________ 1. Please circle the answer that best describes how much knowledge you had about the following topics: i. a. b. c. d. e. ii. a. b. c. d. e.

prior to the workshop: Statement Dementia GPAC guidelines Alzheimerâ&#x20AC;&#x2122;s Drug Therapy Initiative Determining medical fitness to operate a motor vehicle Power of Attorney guidelines Representation Agreement guidelines

None 1 1 1 1 1

A little 2 2 2 2 2

Quite a bit 3 3 3 3 3

A lot 4 4 4 4 4

after the workshop: Statement Dementia GPAC guidelines Alzheimerâ&#x20AC;&#x2122;s Drug Therapy Initiative Determining medical fitness to operate a motor vehicle Power of Attorney guidelines Representation Agreement guidelines

None 1 1 1 1 1

A little 2 2 2 2 2

Quite a bit 3 3 3 3 3

A lot 4 4 4 4 4

2. Please circle the answer that best describes how true the statement is for you.

Statement Not at all A little bit Somewhat true true true 1 2 3 a. As a result of this workshop, I feel more confident in working with patients with Dementia.

1 2 3 b. The discussion of cases was an effective way to learn about the diagnosis and treatment of Dementia. c. The binder of materials is a useful 1 2 3 resource. d. Overall, I learned a lot from this 1 2 3 workshop.

Quite true 4

Very true 5

4

5

4

5

4

5

3. Do you feel that there was any industry bias in the workshop?

Yes ____ 4. Are there things that need to be added to this workshop to improve learning?

5. What was the most helpful part of this workshop?

No ____

Please provide any other comments on the back of this page.

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Appendix N: Dementia Community Workshop Participant Follow up Survey UBC CPD- Dementia Community Workshop Participant Follow Up Survey

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Appendix O: UBC CPD – Community Workshop Post-Workshop Interview Protocol for Participants UBC CPD- Community Workshop Post-Workshop Interview Protocol for Participants Thank you for agreeing to help us. We would like to better understand your perceptions of the Dementia Education workshops. We will discuss the perceived impact on your knowledge, clinical skills and practice patterns, and the overall perceived strengths and weaknesses of the workshop. Your perceptions are very important to us.

This interview should not take longer than 30 minutes in total.

General Impressions Let’s discuss your general impressions of the workshop.

You registered for a spot in the free workshop. You discussed the cases over a complimentary dinner, in a neutral location (a restaurant or board room). The workshop was offered in a variety of communities.

1. What were the most positive aspects of your participation?

2. Did you experience any barriers in attending the workshop?

3. How did you overcome these barriers?

Educational content Let’s discuss educational content and format. The workshop was a facilitated case-based small group discussion.

4. Did you feel engaged in the workshop?

Prompt: What parts of the workshop engaged you?

Prompt: What did not engage you?

5. In terms of Dementia Management, what do you think you need to learn?

6. Do you feel that the workshop met your learning needs?

Prompt: What specific areas met and did not meet your learning needs?

7. From your perspective, what are the benefits of receiving this case-based small group learning compared to other educational methods? (i.e. books, conferences, etc).

The workshop included two articles for pre-reading--an article on Dementia by Dr. Doug Drummond and the Clinical Practice Guidelines on Cognitive Impairment, including all the assessment tools. The workshop also included supplementary materials on Driving, Power of Attorney, Representation Agreements, and web links.

There were four cases on Dementia.

1.Mild Cognitive Impairment & Progression of Symptoms of Dementia 2.Dementia & Driving 3.Dementia & Living at Risk 4.Late Stage Dementia & Admission to a Nursing Home 9. What do you think of the content included in the workshop?

Prompt: What, if anything, do you think is missing at this stage?

Perceived impact on the participants Let’s discuss the impact of the workshop on your practice.

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10. Do you think the workshop affected your ability to manage patient or caregiver concerns about Dementia?

Prompt A: Can you please explain?

Prompt B: What specific concerns?

11. Do you think the workshop has affected/is affecting your practice (i.e. using the clinical practice guidelines)?

Prompt: Can you please describe how it has affected your practice?

Probe: Did you experience any barriers when trying to change your practices in dementia management? If so, was the education helpful for you to overcome the barriers? How? 12. After the workshop, are you using the assessment tools – the Standardized Mini Mental State Examination (SMMSE) and the Global Deterioration Scale (GDS) more – frequently in original and/or re-assessments?

Prompt: Can you please explain?

Overall Perceived Strengths and Weaknesses of the Workshops Let’s discuss the perceived strengths and weaknesses of the workshop…

The workshops were designed to help physicians discuss the best practices for the management of Dementia. The workshops are a component of the Dementia CME Strategy, which targeted an increase in physician uptake of and adherence to the BC Clinical Practice Guidelines on Cognitive Impairment.

13. In terms of the Dementia Education Strategy, what do you think were the most and least effective parts of the workshop?

Prompt: The most?

Prompt: The least?

14. In comparison to other CME workshops you have attended, what are the strengths of this case-based workshop?

Prompt: What is the greatest strength?

15. In order to deliver more effective Dementia Management education in the future, what suggestions or recommendations would you make?

Any last thoughts? Thank you for your time!

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Appendix P: UBC CPD- Dementia Community Workshop Attendance & Facilitator Feedback Form UBC CPD- Dementia Community Workshop Attendance & Facilitator Feedback Form

Date

Facilitator:

Name of Venue:

City/Town:

Please check attendance against the registration list provided and return the registration list.

Attendance:

Physicians:

(please indicate total for each)

Other health care professionals:

1.

Overall how did the workshop go? (Circle) Not well

2.

Physiotherapist Occupational Therapist Nurse Nurseâ&#x20AC;&#x2122;s Aide Psychiatrist Other:

Okay

Good

Very Good

Excellent

Very Good

Excellent

Overall how engaged were the participants? (Circle) Not well

3. What

would

Okay make

the

workshop

Good more

meaningful

and/or

practical

for

participants?

4. What worked well?

5. What did not work well? What were the challenges/barriers?

6. Suggestions for improvement?

7.

Other comments?

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Appendix Q: Community Workshop Post-Workshop Interview Protocol for Facilitators UBC CPD- Dementia Community Workshop Post-Workshop Interview Protocol for Facilitators Date: ________________________________________________________________ Interviewee: __________________________________________________________ FP:______________________Specialist: ___________Speciality:________________ Interviewer: ___________________________________________________________ Location and date of Workshop: ___________________________________________ Cases* discussed in workshop: ____________________________________________ Number of attendees at workshop: _________________________________________ Other co-facilitator name (if applicable) _____________________________________ Have signed consent form?** _____________________________________________ *Cases are: 1.Mild Cognitive Impairment & Progression of Symptoms of Dementia 2.Dementia & Driving 3.Dementia & Living at Risk 4.Late Stage Dementia & Admission to a Nursing Home **If no, remind facilitator to send it in and seek verbal consent Introduction Thank you for agreeing to help us. We would like to better understand your role in, and your perception of how effective the implementation of the Dementia Education Strategy has been for physicians. What you perceive can assist us in planning more iterations of the workshop or other educational programming.

I will ask your personal experience of facilitating the workshop and your overall perception of this educational intervention. I encourage you to contribute your honest opinions after listening to each question. Your answer will be digitally recorded and will be kept confidential, only accessible to members of the research team. This interview should not take longer than 35 minutes in total.

Opening questions I would like to ask some general questions about your experience facilitating the Dementia focused educational intervention…

1. Could you please briefly describe your roles in the Dementia Education Strategy 2. What were the most positive aspects of your involvement with the Dementia Education Strategy?

3. What challenges did you experience during the implementation of the workshop? (i.e., facilitator training, preparation, logistics, managing the group discussion, etc) 4. How were these challenges overcome?

Educational content I would like to ask some questions about your experiences in facilitating the workshop…

1. Do you feel that the workshop met the participants’ learning needs?

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a) What specific areas met and did not meet the participantsâ&#x20AC;&#x2122; learning needs?

2. What do you think of the content included in the workshop? (ie, pre-reading, the clinical practice guidelines, the four cases, the supplementary materials) (*If no answer, Interviewer suggests examples: comprehensive, relevant, useful, practical, meaningful, easy to understand) a) What, if anything, do you think is missing from the content at this stage?

3. In your opinion how well did all the participants engage in the workshop? a) What worked in terms of making the workshop process as smooth as possible? b) What did not work? What were the challenges or barriers?

Perceived impact on the participants I would now like to ask some questions about how useful you think the educational intervention has been for the participants....

1. From your perspective, what are the benefits for the participants to receive this educational intervention compared to other educational methods? (i.e. books, conferences, etc).

2. Do you think the intervention made the participants more aware of emerging knowledge about Dementia? a) No=Why not? b) Yes = What emerging knowledge?

Yes= What part of the workshop made the participants more aware?

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Appendix R: Regional Conference Evaluation Survey UBC CPD- Regional Conference â&#x20AC;&#x153;Dementia Update 2008â&#x20AC;?

Evaluation Survey Thank you for taking time to fill out the following survey. The purpose of this survey is to better understand the effect that the Dementia educational intervention has had on your knowledge and clinical skills. Your perceptions can assist us with improving the design of future Dementia educational interventions. Your answers will be kept strictly confidential.

1. What is your sex? Male

Female

2. How many years have you been in practice?

Less than 1

1-5

5-10

10-15

15-20

More than 20

3. Is there anything you plan to do differently as a result of having attended this program?

4. The key pearls I learned were:

5. Please rate how you think the following factors contributed (or did not contribute) to the effectiveness of the intervention:

Content

Extremely Poor

Below Average

Average

Above Average

Excellent

Session Format Facilitators/Presenters Audience Size Length of Session Level of interactivity

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6. To what extent do you feel the educational intervention enhanced your clinical skills and/or knowledge in the following areas?

Not at all

Very little

Somewhat

Moderately

Diagnosis

To a great extent

Mild Dementia and Communication Dementia and Driving ADTI Drugs/Cholinesterase Inhibitors Academic Detailing and Cholinesterase Inhibitors Capacity Assessments Moderate to Severe Dementias Non-Pharmacological Management of Severe Dementia Behaviors Preplanning RARC Case and Panel Discussions

7. Do you feel that there was any industry bias in any of the presentations? Yes

No

If yes, please describe

8. Is there any additional content that you feel should have been included?

9. What is your overall rating of this program?

Unsatisfactory

Weak

Satisfactory

Very Good

Exceptional

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Thank you for completing the survey!

Would you be willing to further discuss the Dementia educational interventions in a focus group No discussion? Yes Would you like to receive a summary of the survey findings? Yes

No

If you responded yes to any of the above questions, please provide us with your contact information according to your preferred method of correspondence. This information will not be associated with your responses. 1 Name: Email: Phone/fax: Mailing Address: Preferred method of correspondence: Phone

1

Fax

Email

This page will be separated from the rest of the survey in order to preserve anonymity.

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Appendix S: Publication in BC Academic Health Collaboration (November 2009)

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Appendix T: Presentation at BC Psychogeriatric Association Conference Presentation at BC Psychogeriatic Association Conference (April 2010)

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Appendix U: Presentation at Canadian Conference on Medical Education and UBC CPD Leaderâ&#x20AC;&#x2122;s Workshop (May 2010)

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Appendix V: Presentation at 2nd Conference on Positive Aging (November 2010)

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