Knowledge of dementia and Alzheimer's disease among healthcare professionals in PeruAbstract
Background Primary care physicians and other healthcare providers report feeling unprepared to treat persons with dementia (PWD), especially in developing countries
Objective We aimed to assess the knowledge of dementia and Alzheimer's disease (AD) among health professionals in both primary and tertiary care in Peru.
Methods We conducted an in-person and virtual survey of healthcare professionals trained in Peru throughout the year 2020. The survey was developed based on a previously published one and reviewed by an expert panel. We compared groups using a Chi-squared test. A Bonferroni corrected p-value of 0.008 was used for statistical significance.
Results Out of 804 surveys, we excluded 56 due to incomplete data. A total of 41.6% of respondents were doctors and 21.8%, nurses. One fifth of participants did not recognize AD as a cause of dementia and over half considered "senile dementia" a valid clinical entity. Scores were higher among those with postgraduate training, multiple patients with dementia, or those who had practiced for over 10 years.
Conclusion There is a low level of knowledge of dementia and AD among health professionals in Peru, which worsens outside of Lima. Pernicious ideas, such as senile dementia, are still significantly present among respondents.
Keywords
Dementia; Peru; Allied Health Personnel; Alzheimer Disease
Resumen
Antecedentes Los médicos de primer nivel de atención y otros profesionales de la salud no se consideran cómodos tratando pacientes con demencia, especialmente en países en vías de desarrollo.
Objetivo Buscamos evaluar el conocimiento sobre demencia y enfermedad de Alzheimer entre profesionales de la salud en centros de atención primaria y terciaria en Perú.
Métodos Realizamos una encuesta virtual y presencial a trabajadores de la salud entrenados en Perú en el año 2020. La encuesta fue desarrollada con base en una previamente publicada y revisada por un panel de expertos. Comparamos los grupos por medio de una prueba de Chi-cuadrado. Un valor de p de 0.008, obtenido por una corrección de Bonferroni, fue usado para determinar la significancia estadística.
Resultados De 804 encuestados, excluimos 56 debido a datos incompletos. En total, 41.6% de los encuestados eran médicos y 21.8%, enfermeras. Un quinto no reconocía a la enfermedad de Alzheimer como una causa de demencia, y más de la mitad consideraban a la "demencia senil" una entidad clínica válida. Los puntajes fueron mayores para aquellos con entrenamiento de posgrado, experiencia con pacientes con demencia, o más de 10 años de experiencia.
Conclusión Existe un bajo nivel de conocimiento sobre demencia y enfermedad de Alzheimer entre profesionales de la salud en Perú. Este es aún más bajo fuera de Lima. Ideas dañinas como la "demencia senil" aún están significativamente presentes entre los encuestados.
Palabras clave
Demencia; Perú; Técnicos Medios en Salud; Enfermedad de Alzheimer
INTRODUCTION
Dementia is a neurological syndrome characterized by cognitive impairment severe enough to impede independent living. There are reversible and irreversible etiologies of dementia. Although neuroimaging and other biomarkers may help ascertain specific etiology or type of dementia, the diagnosis remains clinical and is based on three core evaluation components: cognitive history, brief cognitive tests (BCTs) or complete neuropsychological evaluation, and functional assessments.1,2
Dementia affects 50 million people globally, over 60% of whom are from low- or middle-income countries.3 In Latin America, the prevalence of dementia sits around 9 to 10%, with an increase of over 20 million new patients with cognitive disorders expected by 2050.4-6 In Lima, Peru, dementia prevalence is close to 7%.
Those who take care of patients with dementia, mostly informal, female caregivers, are also affected. They report decreased working time and a self-perception of impaired health. There are financial burdens as well, with total caregiving costs exceeding 1,500 USD a month.7,8
However, in these countries, primary care physicians (PCPs) face significant barriers to diagnosis and treatment of persons with cognitive impairment, such as limited time for evaluation and care, difficulty accessing tertiary care for dementia, and scarce specialized testing.9 Moreover, research suggests that PCPs may not be properly prepared to manage persons with dementia (PWD). In Peru, PCPs, psychologists, and nurses describe feeling unprepared to treat PWD, and less than a third of physicians report adequately learning about dementia during medical school.10,11 However, these studies focused primarily on frontotemporal dementia and only tangentially assessed knowledge of dementia and Azheimer disease (AD). Likewise, their sample was limited to the country's largest city, which may not be representative of primary care in more resource-limited settings.
Thus, given the rising importance of dementia as a cause of morbidity and mortality worldwide, especially in Latin America, and the need for accessible multidisciplinary care, in this study, we aimed to determine the level of knowledge of dementia and AD—the most common irreversible etiology of dementia worldwide—among a diverse sample of Peruvian health professionals.
METHODS
Study design
We carried out a descriptive, observational, cross-sectional multicenter study. We used a survey which was handed both in-person and virtually during 2020 to healthcare professionals including doctors, nurses, nursing assistants, dentists, obstetricians, and psychologists among various centers around the country (Supplementary Material: https://www.arquivosdeneuropsiquiatria.org/wp-content/uploads/2024/06/ANP-2023.0070-Supplementary-Material.docx). We included only those professionals who had received their training in Peru and consented to participate in the study. The centers were selected by convenience sampling among five different regions in the country: Lima, San Martin, Tacna, Piura, and Trujillo. They included both primary care centers and tertiary care hospitals; likewise, professionals working at home healthcare assistance programs at both public and private institutions were included. These were Centro Médico Naval, Clínica Centenario Peruano Japonesa, Hospital de Collique, Hospital María Auxiliadora, Hospital Nacional Cayetano Heredia, Programa de Atención Domiciliaria (PADOMI), Palliative care at OncoSalud, Red Asistencial Moyobamba, and Centro de Atención Primaria III Metropolitano de Tacna.
For the sample size, we used the study of dementia knowledge in Lima by Custodio et al.11 For a population of around 100 thousand healthcare workers, with an expected frequency of respondents that had insufficient knowledge of dementia of 72.1%, confidence limit at 95%, design effect at 1, and drop rate of 25%, we estimated a required sample size of 387 healthcare professionals. However, we doubled this number by handling 804 surveys.
Instrument
We developed our study survey based on surveys previously used by Custodio et al. and Olavarría et al.11,12 Our study survey was reviewed by an expert panel composed of three neurologists with expertise in dementia. The first section includes demographic data such as age, gender, training, and professional experience with dementia. The second part was composed of 19 questions covering general topics, such as types of dementia and BCTs, and AD specific questions, including risk factors, symptoms, diagnosis, and treatment.
Statistical analysis
We used the Stata 16 software (StataCorp LLC, College Station, TX, USA). We first summarized descriptive variables using frequency measures or central tendency. We dichotomized some of them according to expert consensus to facilitate analysis. That is, number of years practicing (< 10 or ≥ 10), number of patients attended per month (< 5 or ≥ 5), known types of dementia (0 or ≥ 1), known BCTs (0 or ≥ 1), and dementia symptoms (< 4 or ≥ 4). We then obtained the average number of correct answers and classified it into low (0–1.9), medium (2.0–3.9), or high (4.0–6.0) according to expert consensus.
Finally, we evaluated factors associated with a lower number of correct answers using the Chi-squared test. Values with p < 0.008 were considered statistically significant, after performing a Bonferroni correction to avoid multiple test bias.
Ethics
Participation in the study was voluntary and anonymous. We used an informed consent form, which was signed prior to the start of the survey. The research protocol was approved by the Ethics Committee of Universidad Científica del Sur, with certificate no. 350-CIEI-CIENTIFICA-2020. All methods were carried out in accordance with the relevant guidelines and regulations in the Declaration of Helsinki.
RESULTS
We included 748 surveys out of 804, as 56 had incomplete data. Most respondents were male (69.5%) and worked in Lima (74.6%). The average age was 41 years old, and 41.6% were doctors and 21.8%, nurses. Of all participants, 53.9% had been practicing for less than 10 years.
More than 1/3 of survey respondents (36.8%) regularly cared for patients with dementia. However, less than a third considered themselves capable of diagnosis and treating a patient with dementia. Of those who did, most reported having only undergraduate knowledge of the disease (Table 1).
Characteristics of the surveyed health professionals and level of knowledge about Alzheimer's disease
Knowledge about dementia and Alzheimer's disease
Less than a quarter of respondents knew more than 1 type of dementia and most (51.4%) described "senile dementia" as a valid type. A substantial proportion of respondents (19.5%) did not recognize AD as a type of dementia; among the respondents who did, 78.3% were able to recognize more than 4 of its symptoms and 71.3% more than 2 AD risk factors (Table 2).
Although more than half of respondents (55.9%) correctly indicated that BCTs allow for an early diagnosis of AD, only 27.5% were able to recognize more than 1 BCT from a list of commonly used BCTs; 44% identified more than 2 auxiliary exams that contribute to diagnosis. Over 80% of respondents could not identify how to definitively diagnose AD, and over 60% could not identify the role of available AD treatments (Table 3).
Factors associated with increased knowledge
Age and gender were not significantly associated with a higher number of correct responses. Respondents from Lima had a higher average of correct responses compared to those located outside the capital city (p = 0.002) (Figure 1). Doctors and psychologists had higher average correct responses compared to other healthcare professionals.
Among physicians, those who considered themselves experienced in the diagnosis and treatment of patients with dementia had statistically significant higher scores than those who did not (p < 0.001). Similarly, respondents who actively cared for patients with dementia during our study obtained a statistically significant higher average of correct responses compared to those who did not (p < 0.001), especially if they took care of more than 5 patients per month (p = 0.003). Additionally, those with postgraduate studies and those who trained in specialized institutes had a statistically significant higher number of correct responses (p < 0.001). Additionally, doctors with more than 10 years of clinical practice obtained the highest average of correct answers (p < 0.001). Finally, doctors practicing in Lima had higher averages compared to those outside of Lima (p < 0.001) (Table 4).
DISCUSSION
We found a surprisingly low level of knowledge of dementia, generally, and AD, specifically, among the surveyed health professionals in Peru. The surveyed population consisted mainly of physicians, followed by nurses and other health professionals in both primary and tertiary care in private and public institutions in 5 different cities of the country.
We found that only 27% of all surveyed professionals and 39% of physicians considered themselves fully capable of diagnosing and managing persons with dementia (PWDs). Another Latin American country, Chile, reported a similar frequency of 40% in a recent study.12 Likewise, two studies in Brazil described diagnosis of dementia as the most challenging aspect for PCPs in managing PWDs.13,14 As detection of dementia usually occurs at the PCP setting, these findings translate in low rates of appropriate referral to subspeciality care.15,16 This, added to the lack of subspeciality care availability in low-resource settings of Peru and Latin America as a whole, constitutes an obstacle for early diagnosis, which limits the possibility to preserve and improve the quality of life of patients and caregivers.4,17
Additionally, we found that only 25% of the health professionals surveyed managed to list one or more types of dementia. The majority of these indicated "senile dementia" as a valid type of dementia. The concept of senile dementia is considered obsolete and non-scientific; hence, in this regard, our study findings suggest there is an urgent need to update the knowledge of dementia among healthcare professionals at the national level. Although dementia is significantly more common in old age, it is not an inevitable consequence of aging. Likewise, people younger than 65 years can also suffer from dementia. It appears, based on our study findings, that knowledge of these key concepts is lacking among a substantial proportion of health professionals in Peru.
Lastly, we found higher correct responses among those with postgraduate training. Similarly, another study in Peru found that geriatricians and other specialists had increased capacity for dementia diagnosis compared with general practitioners.11 This suggests healthcare professionals are not sufficiently exposed to dementia during their training and highlights the importance of interventions in the undergraduate curriculum. Workshops of less than a day have showed significant improvement in dementia knowledge both in Australia and Brazil; however, attitude toward dementia did not seem to improve in the Brazilian population.18,19 Alternatively, a Canadian program of three days also found improvement in dementia knowledge.20 Instituting a program of this kind or increasing the emphasis on mild cognitive impairment (MCI) and AD in the medical school curriculum could result in increased knowledge of the disease in healthcare professionals in the country.
Of note, a higher rate of correct responses was found among physicians and other healthcare workers based in Lima, compared to those in other regions of the country. It is important to consider that Lima's gross domestic product (GDP) is more than double the GDP of the next richest region. Further studies with a larger sample size could compare the responses of different regions to identify if there is an association between the regions GDP and the knowledge of dementia among healthcare providers.
In our study, 20% of all health professionals surveyed (including 15% of physicians) indicated that AD is not a type of dementia. This finding is astounding, as it suggests that a significant proportion of Peruvian health professionals conceptualize dementia and AD as distinct and unrelated entities. This finding alone represents a strong indicator of the lack of awareness and misunderstanding among Peruvian health care professionals regarding dementia and its causes, and the importance of launching meaningful educational efforts to address this gap.
Almost one third of the health professionals surveyed identified fewer than two risk factors for the development of AD. This is a concerning finding, as it implies that healthcare professionals in Peru are not aware that up to 40% of cases of AD and other causes of dementia may be prevented via public healthcare approaches focused on addressing key modifiable medical and lifestyle risk factors.21
Furthermore, although most health professionals surveyed for this study correctly identified more than four AD symptoms, they were unable to identify diagnostic procedures and tests that should be included in the clinical evaluation of persons with cognitive impairment. It is important to mention that in Peru there are nine validated BCTs, among them are: the Clock Drawing Test, Manos version (CDT-Mv), frontal assessment battery (FAB), INECO frontal screening test (IFS), Memory Alteration Test (M@T), Peruvian Money Test (PMT), Addenbrooke's cognitive examination (ACE), Verbal-Language/Orientation-Memory Ratio (VLOM), Mini-Mental State (MMSE) and Rowland Universal Dementia Assessment Scale (RUDAS).22-24 However, most respondents were unable to identify these BCTs.
In terms of treatment of AD, 62.2% of those surveyed indicated they did not know the function of the medications currently indicated for persons with AD. Similar results have been found among other Latin American countries.4,12 This is worrisome as PWDs may already question the benefit of seeking treatment. A recent meta-analysis showed that, contrary to evidence, the general public does not belief dementia treatment can delay functional or cognitive de- cline.25 If healthcare professionals are not prepared to challenge these beliefs, it will limit the access of PWDs to appropriate care.
Finally, these findings shed light on the importance of targeted educational interventions directed at healthcare professionals, especially during their undergraduate training, to increase their exposure to dementia and, thus, their diagnostic capacity.26
In conclusion, the primary limitation to the present study was that participants were selected in a non-randomized fashion. However, inclusion and exclusion criteria were established that allowed us to reduce selection bias. Furthermore, we did not use the validated and widely applied Alzheimer Dementia Knowledge Scale (ADKS) as our instrument. This was because we wished to explore knowledge related to all types of dementia, not just AD. Thus, we adapted an instrument previously used by our team in the Peruvian population.
Another significant limitation is the relatively small percentage of surveyed healthcare workers outside of Lima. Although this is sufficient for larger comparisons, as we have presented above, it would be too small of a sample size to compare different regions in Peru. Further studies aimed at identifying the most vulnerable regions in the country can power their studies accordingly.
Despite these limitations, our study establishes a starting point to identify the causes of low level of knowledge of dementia among healthcare professionals in Peru, which could guide important interventions to reduce this problem here and in other Latin American countries.
In conclusion, there is a low level of knowledge of dementia and AD among health professionals in Peru. This improves among those who practice in Lima, have postgraduate studies, and frequently manage dementia patients. Pernicious ideas such as senile dementia are still significantly present among respondents. We recommend considering implanting targeted interventions at the undergraduate level to increase exposure to dementia among all healthcare professionals.
.References
-
1 Dubois B, Hampel H, Feldman HH, et al; Proceedings of the Meeting of the International Working Group (IWG) and the American Alzheimer's Association on "The Preclinical State of AD"; July 23, 2015; Washington DC, USA. Preclinical Alzheimer's disease: Definition, natural history, and diagnostic criteria. Alzheimers Dement 2016;12(03):292–323. Doi:10.1016/j.jalz.2016.02.002
» https://doi.org/10.1016/j.jalz.2016.02.002 -
2 Custodio N, Montesinos R, Alarcón JO. Evolución histórica del concepto y criterios actuales para el diagnóstico de demencia. Rev Neuropsiquiatr 2018;81(04):235–250. Doi:10.20453/rnp.v81i4. 3438
» https://doi.org/10.20453/rnp.v81i4.3438 - 3 Prince M, Wimo A, Guerchet M, Ali GC, Wu YT, Prina M. World Alzheimer Report 2015. The Global Impact of Dementia. An Analysis of Prevalence, Incidence, Cost and Trends.; 2015
-
4 Parra MA, Baez S, Allegri R, et al. Dementia in Latin America: Assessing the present and envisioning the future. Neurology 2018;90(05):222–231. Doi: 10.1212/WNL.0000000000004897
» https://doi.org/10.1212/WNL.0000000000004897 -
5 Prince M, Bryce R, Albanese E, Wimo A, Ribeiro W, Ferri CP. The global prevalence of dementia: a systematic review and meta-analysis. Alzheimers Dement 2013;9(01):63–75.e2. Doi:10.1016/j.jalz.2012.11.007
» https://doi.org/10.1016/j.jalz.2012.11.007 -
6 Ribeiro F, Teixeira-Santos AC, Caramelli P, Leist AK. Prevalence of dementia in Latin America and Caribbean countries: Systematic review and meta-analyses exploring age, sex, rurality, and education as possible determinants. Ageing Res Rev 2022; 81:101703. Doi:10.1016/j.arr.2022.101703
» https://doi.org/10.1016/j.arr.2022.101703 -
7 Custodio N, Lira D, Herrera-Perez E, et al. Cost-of-illness study in a retrospective cohort of patients with dementia in Lima, Peru. Dement Neuropsychol 2015;9(01):32–41. Doi:10.1590/S1980-57642015DN91000006
» https://doi.org/10.1590/S1980-57642015DN91000006 -
8 Custodio N, Lira D, Herrera-Perez E, et al. Informal caregiver burden in middle-income countries: Results from Memory Centers in Lima - Peru. Dement Neuropsychol 2014;8(04):376–383. Doi:10.1590/S1980-57642014DN84000012
» https://doi.org/10.1590/S1980-57642014DN84000012 -
9 Custodio N, Wheelock A, Thumala D, Slachevsky A. Dementia in Latin America: Epidemiological Evidence and Implications for Public Policy. Front Aging Neurosci 2017;9:221. Doi:10.3389/fnagi.2017.00221
» https://doi.org/10.3389/fnagi.2017.00221 -
10 Gleichgerrcht E, Flichtentrei D, Manes F. How much do physicians in Latin America know about behavioral variant frontotemporal dementia? J Mol Neurosci 2011;45(03):609–617. Doi:10.1007/s12031-011-9556-9
» https://doi.org/10.1007/s12031-011-9556-9 -
11 Custodio N, Becerra-Becerra Y, Cruzado L, et al. Nivel de conocimientos sobre demencia frontotemporal en una muestra de médicos que evalúan regularmente a pacientes con demencia en Lima-Perú. Rev Chil Neuro-psiquiatr 2018;56(02):77–88. Doi: 10.4067/s0717-92272018000200077
» https://doi.org/10.4067/s0717-92272018000200077 -
12 Olavarría L, Mardones C, Delgado C, Slachevsky Ch A. Percepción de conocimiento sobre las demencias en profesionales de la salud de Chile. Rev Med Chil 2016;144(10):1365–1368. Doi:10.4067/S0034-98872016001000019
» https://doi.org/10.4067/S0034-98872016001000019 -
13 Costa GDD, Santos OGD, Oliveira MAC. Knowledge, attitudes, and qualification needs of primary health care professionals in the care of dementia. Rev Bras Enferm 2020;73(Suppl 3):e20200330. Doi:10.1590/0034-7167-2020-0330
» https://doi.org/10.1590/0034-7167-2020-0330 -
14 Steiner ABQ, Jacinto AF, Citero Vde AIdosos com demência: conhecimentos e atitudes dos médicos nas unidades de saúde. Rev Saude Publica 2020;54:137. Doi:10.11606/s1518-8787.2020054002451
» https://doi.org/10.11606/s1518-8787.2020054002451 -
15 Jacinto AF, Brucki S, Porto CS, Martins Mde A, Nitrini R. Detection of cognitive impairment in the elderly by general internists in Brazil. Clinics (São Paulo) 2011;66(08):1379–1384. Doi:10.1590/S1807-59322011000800012
» https://doi.org/10.1590/S1807-59322011000800012 -
16 Kaduszkiewicz H, Bachmann C, van den Bussche H. Telling "the truth" in dementia–do attitude and approach of general practitioners and specialists differ? Patient Educ Couns 2008;70(02): 220–226. Doi:10.1016/j.pec.2007.10.010
» https://doi.org/10.1016/j.pec.2007.10.010 -
17 Hansen EC, Hughes C, Routley G, Robinson AL. General practitioners’ experiences and understandings of diagnosing dementia: factors impacting on early diagnosis. Soc Sci Med 2008;67(11): 1776–1783. Doi:10.1016/j.socscimed.2008.09.020
» https://doi.org/10.1016/j.socscimed.2008.09.020 -
18 Tierney L, Mason R, Doherty K, Winbolt M, Long M, Robinson A. Workshops on diagnosis and management of dementia for general practitioners: a pre-post intervention study of dementia knowledge. BMJ Open 2019;9(04):e027804. Doi:10.1136/bmjopen-2018-027804
» https://doi.org/10.1136/bmjopen-2018-027804 -
19 Mayoral VFS, Villas Boas PJF, Jacinto AF. Knowledge and attitudes in dementia held by general practitioners in the primary care setting of Botucatu, São Paulo, Brazil. Arq Neuropsiquiatr 2021;79(02):107–113. Doi:10.1590/0004-282x-anp-2020-0051
» https://doi.org/10.1590/0004-282x-anp-2020-0051 -
20 Prorok JC, Stolee P, Cooke M, McAiney CA, Lee L. Evaluation of a Dementia Education Program for Family Medicine Residents. Can Geriatr J 2015;18(02):57–64. Doi:10.5770/cgj.18.148
» https://doi.org/10.5770/cgj.18.148 -
21 Livingston G, Huntley J, Sommerlad A, et al. Dementia prevention, intervention, and care: 2020 report of the Lancet Commission. Lancet 2020;396(10248):413–446. Doi:10.1016/S0140-6736(20)30367-6
» https://doi.org/10.1016/S0140-6736(20)30367-6 -
22 Custodio N, Herrera-Pérez E, Montesinos R, Lira D, Metcalf T. Brief cognitive tests validated in Peru for detection of cognitive impairment A systematic mapping of the scientific literature. Dement Neuropsychol 2020;14(02):134–144. Doi:10.1590/1980-57642020dn14-020006
» https://doi.org/10.1590/1980-57642020dn14-020006 -
23 Custodio N, Montesinos R, Lira D, et al. Validation of the RUDAS in Patients With a Middle-Level Education in Lima, Peru. Am J Alzheimers Dis Other Demen 2019;34(7-8):513–522. Doi: 10.1177/1533317519869709
» https://doi.org/10.1177/1533317519869709 -
24 Custodio N, Montesinos R, Diaz MM, et al. Performance of the Rowland Universal Dementia Assessment Scale for the Detection of Mild Cognitive Impairment and Dementia in a Diverse Cohort of Illiterate Persons From Rural Communities in Peru. Front Neurol 2021;12:629325. Doi:10.3389/fneur.2021.629325
» https://doi.org/10.3389/fneur.2021.629325 -
25 Cations M, Radisic G, Crotty M, Laver KE. What does the general public understand about prevention and treatment of dementia? A systematic review of population-based surveys. PLoS One 2018; 13(04):e0196085. Doi:10.1371/journal.pone.0196085
» https://doi.org/10.1371/journal.pone.0196085 -
26 Perry M, Drašković I, Lucassen P, Vernooij-Dassen M, van Achterberg T, Rikkert MO. Effects of educational interventions on primary dementia care: A systematic review. Int J Geriatr Psychiatry 2011;26(01):1–11. Doi:10.1002/gps.2479
» https://doi.org/10.1002/gps.2479
Publication Dates
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Publication in this collection
21 Oct 2024 -
Date of issue
2024
History
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Received
15 Sept 2023 -
Reviewed
09 June 2024 -
Accepted
16 June 2024
