Evaluation of Dementia Education at the Early Stages of Professional Training: Impact on Knowledge and Attitudes

The demographics of human population are changing worldwide with disproportionate increase in the oldest old, particularly those affected by Alzheimer's disease and other forms of cognitive impairment [1]. This has been linked to unprecedented challenges for the national heath guidance, public health and health policy and planning [1]. Acute hospital admission for a person with dementia can be very distressing and could result in decline in cognitive and functional ability. Furthermore, dementia care relating to clinical assessment, available resources, staffing levels, training and discharge planning is sub-optimal [2], which could result in poor clinical outcomes [2]. People with dementia have the right to fair and equitable treatment but may not be able to communicate their needs. The physical symptoms and underlying hardships are not easily recognised and are often misinterpreted to be manifestations of dementia itself. Therefore, caring for people with dementia, many of whom will have multiple co-morbidities, will be a challenge to healthcare systems. This inevitably places pressure on hospitals to provide safe inpatient stays for older patients, given that up to one in four of acute in-patients in the UK could have cognitive impairment [3]. Furthermore, older people with associated cognitive impairment have significantly higher incidence of inpatient falls and adverse outcomes including discharge to a new care home and prolonged length of stay when compared to those with no cognitive impairment [4,5]. With this growing number and associated adverse clinical outcomes, training of our future healthcare professionals in the care of older people is needed. 

Our current medical training not only generates relatively low numbers of geriatricians and specialists with interest in dementia, but also there is a lack of appropriate training in assessment and management of dementia among most health care professionals [6,7]. The appropriate training and support to health care staff not only result in a reduction in the stress level at the workplace [8] but also provide safe, holistic, dignified and person-centred dementia care [9,10]. The understanding and training on dementia will need to evolve in accordance with the exponential increase in ageing population and needs of people with dementia. The National Dementia Audit (2012-13) reported a lack of appropriate dementia care, which could be due to lack of awareness and training during medical school or during early stages of professional training [11]. 

A comprehensive review of the literature to determine the current dementia training for pre-registration healthcare students supported the potential to improve students' knowledge, attitude and comfort level with dementia training, but there are very few reports on the teaching methods and evaluation of such training [12]. This not only has an impact on reproducibility of the dementia teaching but make it difficult to replicate such training by other health care providers. 

There is a limited evidence about the most effective ways to deliver and evaluate dementia training to medical students or newly qualified doctors and further research is required to explore how organisations can deliver dementia training [13]. A pilot study was conducted with 40 Foundation Year 2 (FY-2) doctors in 2014-15 [14]. The overall feedback was to continue dementia teaching for all foundation doctors and also include fourth year medical students.

The objective of this study was to determine medical students and doctors attitudes towards older people with dementia and to evaluate the impact of a structured, dedicated dementia training workshop on these pre-existing attitudes, knowledge and competence when caring for these patients.

Study design and setting

The total sample over three years of teaching (2014-2017) consisted of 201 year-4 medical students and FY doctors. All medical students and FY doctors were asked to participate voluntarily in the study and complete the pre- and post-training questionnaires. There were no inclusion and exclusion criteria to participate.

Measurement

Data and statistical analysis:

A total of 201 year-4 medical students and foundation doctors attended the dementia training sessions over three years. A total of 173 questionnaires were returned before training out of a cohort of 201 (response rate 86.1%) and 167 participants completed post-training questionnaires (response rate 96.5%). All the questionnaires were completed appropriately.

The attendees were asked to express their responses following the drawing a penny coin. One of the attendees was asked to write all the responses on an A0 flipchart pad which were later taken by the trainer and have been shown in table 1. More than 90% students and FY doctors felt stressed, anxious and found it difficult to complete the task. Although they have been familiar with a penny coin since childhood they found it challenging to draw it from memory. Students could appreciate from this task the problems faced by the older person with dementia.

Table 1: Emotions reported following the first exercise - Drawing a penny coin from memory.

Similarly responses were collected following the second group exercise which was formulating a spider diagram has been shown in table 2. Most students suggested key components of good care which included ‘help people feel valued’; ‘make time to listen and be involved with activities together’; ‘offer them real support, don’t just brush their concerns aside’; ‘offer them simple choices and try not to confuse them’; ‘maintain respect, privacy, independence, appearance’; ‘understanding how the person feels and treat them as you would want your loved one to be treated’.

Table 2: Results following formulating a spider diagram.

The overall pre-training mean UCLA GAS score was 3.77 ± 0.48, suggesting a generally positive attitude. There was no significant change in the post-training mean UCLA GAS score following dementia training. The overall pre-training mean SCIDS score was 2.42 ± 0.40 and there was a significant change in the perceived competence following the dementia training (Table 3). The details of the sub-analysis of the UCLA GAS total, positive and negative scores and SCIDS score are shown in table 3. The overall mean pre-training and post-training SCIDS scores are also shown in the Box-and-whisker plot representing a significant mean change in the perceived competence following the training (Figure 1).

Table 3: UCLA GAS score and SCIDS score.

Figure 1: Box-and-whisker plot representing overall mean SCIDS scores before and after training.

The devised training program we used aimed to increase knowledge of the bio-psycho-social aspects of dementia and to promote the person-centred approach to care. In this study, duration of each training session was 1.5 hours, which would be classed as low intensity [21]. The previous study showed that there was no relationship between a higher intensity of training and outcome [21]. The person-centered approach adopted by a pervious study showed improvements in communication, staff knowledge and reduction in staff burnout although we did not assess these in this case[22].

UCLA GAS was used to measure attitudes towards patients with dementia and self-perceived changes pre- and post-training. All the three groups demonstrated generally positive pre-training UCLA GAS scores prior to the intervention (scores > 3.5). This was also reflected in their responses during the brainstorming exercise to identify essential components of dementia care (Table 2). 

The intervention in this study did not reveal any significant change in attitudes towards people with dementia after training. A systematic review concluded that training had no significant impact on attitudes of care home staff either [21], mainly assessed using the Approaches to Dementia Questionnaire (ADQ) [23]. However other studies have shown improvement in hospital nurses attitudes after half day training sessions [24] and also after experiential learning in the form of clinical placements [25]. There also seems to be more success in changing students’ attitudes where teaching involves empathy fostering experiential learning which delivers insight into the lives of older patients which our training did employ in some aspects [26]. 

Negative societal attitudes towards older people have been reported [27] and very few medical students consider pursuing a career in geriatrics [28]. It would be beneficial for all doctors to have some experience in geriatrics, which could also build a more positive attitude. There may be potential for even earlier intervention, at A-levels or first-year medical students for example, in forming positive attitudes towards people with dementia. 

SCIDS scale was selected to assess the impact of training on the perceived competence in dementia care for its reliability [20]. The perceived pre-test competency scores (SCIDS) were found to be similar and above average (>2) at all levels of participants. Contrary to the insignificant change in their attitudes (UCLA GAS) following the intervention, the perceived competency scores (SCIDS) showed significant improvements (p> 0.01) in all groups of participants. Participants of higher training grades (FY-2 and FY-1) showed slightly better changes in their mean perceived competency scores as compared to medical students [17]. The fact that this study showed an increase in perceived competence suggests an increase in knowledge and could hint at the development of individual practical approaches and coping strategies in dementia care. 

The SCIDS has also been used to investigate the feasibility of implementing the Staff Training in Assisted Living Residences (STAR) program in UK care homes; this study showed improvements in sense of competence following training also [29] however another study that showed similar improvements in competence showed lack of sustainability of that competence over time [30]. 

We observed as part of this training that participants expressed their emotions and could appreciate the challenges experienced by older people with dementia. These emotions were reported by participants when they were asked to draw a penny coin. Sharing these emotions play a key role in providing empathetic and compassionate dementia care. We need to start building our future workforce now and develop integration between multidisciplinary members, community teams and various carer groups to improve the quality of life of those suffering from dementia. There are some extraordinary gaps in our research related to dementia training. Therefore we need to determine the best evidence-based practice to train everyone working with people with dementia in order to provide the most effective, holistic care. 

Our study has certain strengths. Validated scales were used to measure the outcomes of dementia training on change of attitude and perceived competence. We have made an attempt to address a very important area of dementia education during early stages of professional training which, so far, is explored and studied mainly in nursing colleagues [21,22,24,29,30]. Dementia training is likely to be a vital part of the medical curriculum in the future and rightly so, to meet the challenges of health care delivery for the ageing population. We have attempted to devise and test an effective dementia training model for the medical trainees at an earlier stage of career over a reasonable time period of 90 minutes. While doing so, we have encouraged Medical Schools and the University to include dementia training in the curriculum of medical training. 

We acknowledge the study's weaknesses. We did not record the gender of students or trainees, therefore we cannot comment on the gender difference in attitude scores towards older people with dementia. The training session was devised and has not been validated. We have not measured the sustainable effect on the competence of this educational intervention. We have also not measured the impact of this education on work related stress levels.

Dementia specific training workshop did not show any significant changes in medical students’ or FY doctors’ attitudes towards patients with dementia. However, there was a significant improvement in perceived competence in caring for patients with dementia amongst the group. This would suggest an increase in knowledge leads to development of practical approaches and coping strategies when providing dementia care.

We propose that dementia training should form a vital part of the medical curriculum in the future in order to meet the challenges of health care delivery for the ageing population. It is also vital that other healthcare professionals receive training with dementia specific learning outcomes to ensure patients with dementia receive a patient -centred holistic care approach across all health care services. We propose future studies could specifically address the reasons for negative attitudes towards older patients and study the factors that could result in positive attitudes.

The authors are grateful to all the members of the Department of Geriatric Medicine, Ysbyty Ystrad Fawr for their continued support for research activities. The authors would especially like to thank all the staff and members of the education centres within Aneurin Bevan University Health Board, Wales (UK) for helping us to deliver dementia training. The authors would also like to thank Jane Power for her immense contribution, as this project would have been impossible without her administrative support. Authors would also like to thank Dr Justin Okeke and Dr Bnar Talabani for their contribution. No external funding was applied.tudies could specifically address the reasons for negative attitudes towards older patients and study the factors that could result in positive attitudes.

I.S. designed the study. I.S and S.A. devised and delivered training sessions. M.K, L.E., L.R., S.A. contributed to data collection. C.E. performed statistical analysis. M.K., S.A. and I.S. completed data interpretation. I.S. wrote the first draft and M.K., L.E., L.R. and S.A. completed a critical revision of the article. All authors contributed to dementia training and approved the final version.

The authors declare no conflict of interest.

The pilot study was presented at British Geriatrics Society 2016 Spring Meeting on 11–13 May 2016 at ACC, Liverpool and the abstract has been published in British Geriatrics Society, Abstracts of work presented at the 2016 BGS Spring Scientific Meeting and Age and Ageing supplement issue.

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