107 https://doi.org/10.1590/0004-282X-anp-2020-0051 ARTICLE ABSTRACT Background: Alzheimer’s disease (AD) is the leading cause of dementia worldwide. Despite alarming evidence on dementia prevalence, the condition is still underdiagnosed by general practitioners (GPs) in primary care. Early detection of the disease is beneficial for patients and relatives, who should be provided comprehensive guidance on dealing with dementia complications, covering medical, family and social aspects, thereby providing an opportunity to plan for the future. Objective: The objective of this study was to assess the knowledge of and attitudes toward dementia held by GPs from a city in the interior of São Paulo State, Brazil. Methods: A non-randomized intervention study was conducted involving six lectures about dementia. Before and after the intervention, the participating physicians completed two quizzes about knowledge of and attitudes towards dementia. The study was carried out in the primary care services of the town and a total of 34 GPs participated in the study. Results: The mean age of the sample was 33.9 (±10.2) years and the majority (76.5%) of the sample had not undertaken medical residency training. The mean number of correct answers on the Knowledge Quiz about dementia before and after the training intervention was 59.6 and 71.2% (p<0.001), respectively. The comparison of the mean responses on the Attitude Quiz revealed no statistically significant difference between the two applications of the instrument, before and after intervention (p=0.059). Conclusions: More training for GPs on dementia should be provided. Keywords: Aged; General Practitioners; Knowledge; Attitudes; Dementia. RESUMO Introdução: A doença de Alzheimer é a principal causa de demência em todo o mundo. Apesar das evidências alarmantes sobre a prevalência de demência, a condição ainda é subdiagnosticada por clínicos gerais na atenção primária. A detecção precoce da doença é benéfica para pacientes e familiares, que devem receber orientações abrangentes sobre como lidar com as complicações relacionadas às demências, abrangendo aspectos médicos, familiares e sociais, proporcionando assim uma oportunidade de planejar o futuro. Objetivo: O objetivo deste estudo foi avaliar os conhecimentos e as atitudes em relação à demência por parte de clínicos gerais de uma cidade do interior de São Paulo, Brasil. Métodos: Foi realizado um estudo de intervenção não randomizado, envolvendo seis palestras sobre demência. Antes e depois da intervenção, os médicos participantes completaram dois questionários sobre conhecimentos e atitudes em relação à demência. O estudo foi realizado nos serviços de atenção primária da cidade e um total de 34 clínicos gerais participaram do estudo. Resultados: A idade média da amostra foi de 33,9 (±10,2) anos e a maioria (76,5%) da amostra não havia realizado treinamento em residência médica. O número médio de respostas corretas no Questionário do Conhecimento sobre demência antes e após a intervenção de treinamento foi de 59,6 e 71,2% (p<0,001), respectivamente. A comparação das respostas médias no questionário de atitudes não revelou diferença estatisticamente significativa entre as duas aplicações do instrumento, antes e após a intervenção (p=0,059). Conclusões:  Deve  ser fornecido mais treinamento sobre demência para os clínicos gerais. Palavras-chave: Idoso; Clínicos Gerais; Conhecimento; Atitude; Demência. Knowledge and attitudes in dementia held by general practitioners in the primary care setting of Botucatu, São Paulo, Brazil Conhecimentos e atitudes em demência por parte de clínicos gerais do setor de atendimento primário de Botucatu, São Paulo, Brasil Vânia Ferreira de Sá MAYORAL1, Paulo José Fortes VILLAS BOAS1, Alessandro Ferrari JACINTO2,3 1Universidade Estadual Paulista “Júlio de Mesquita Filho”, Faculdade de Medicina de Botucatu, Departamento de Clínica Médica, Botucatu SP, Brazil. 2Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Medicina, Disciplina de Geriatria e Gerontologia, São Paulo SP, Brazil. 3Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Medicina Preventiva, Ambulatório de Medicina Geral e Familiar, São Paulo SP, Brazil. Vânia Ferreira de Sá MAYORAL https://orcid.org/0000-0002-9228-6338; Paulo José Fortes VILLAS BOAS https://orcid.org/0000-0001-9876-3222; Alessandro Ferrari JACINTO https://orcid.org/0000-0002-1977-5880 Correspondence: Alessandro Ferrari Jacinto; E-mail: alessandrojacinto@uol.com.br Conflict of interest: There is no conflict of interest to declare. Authors’ contribution: VFSM: designed the study, collected and analyzed data and wrote the manuscript. PJFVB: revised the study. AFJ: designed the study, analyzed data and wrote the paper. Received on February 18, 2020; Received in its final form May 18, 2020; Accepted on June 8, 2020. https://doi.org/10.1590/0004-282X-anp-2020-0051 https://orcid.org/0000-0002-9228-6338 https://orcid.org/0000-0001-9876-3222 https://orcid.org/0000-0002-1977-5880 mailto:alessandrojacinto@uol.com.br 108 Arq Neuropsiquiatr 2021;79(2):107-113 INTRODUCTION The aging of the population has led to a substantial rise in the number of older people with cognitive decline and dementia. By 2050, there will be an estimated 152 million per- sons with dementia globally1. Every year, another 10 million people will develop dementia, of which 6 million are from low- to middle-income countries, such as Brazil1,2. The esti- mated global cost of the condition in 2015 was 818 billion USD, a figure set to rise to 2 trillion USD by 20303,4. Dementia is a syndrome whose main risk factor is age. In most cases, the disease is progressive and marked by cognitive decline, which impacts the individual’s indepen- dence and autonomy5. Alzheimer’s disease (AD) accounts for 50–70% of all dementia cases6. Although AD demen- tia is a clinical condition with major personal, family and social impacts and no curative treatment, early detection is believed important because diagnosis allows patients and their carers to discuss future care plans, helping to reduce psychic distress and costs7,8,9,10. In many countries, including Brazil, general practitioners (GPs) play a central role in the health of older people and espe- cially in detecting individuals with dementia. However, the literature shows that dementia is underdiagnosed in primary care, delaying diagnosis and leading to unfavourable out- comes for patients and their relatives11,12,13. A systematic review showed that the main barrier to GPs establishing a diagnosis is lack of training and education on dementia. Moreover, lack of training leads to doubts and limited confidence among cli- nicians in confirming a dementia diagnosis and managing symptoms14. Other studies have shown that unclear guide- lines on screening for cognitive decline, misunderstandings regarding drug therapy, and difficulties talking with patients and their relatives about the disease and its complications, can preclude early diagnosis of dementia in primary care15,16,17. Since 1988, following the creation of the Brazilian National Health System (SUS), primary care has become the main entry point to the public health system. Currently, 73% of older peo- ple are treated solely by the SUS and most of them receive care provided by GPs18,19. Studies on dementia detection involving medical students and physicians on the first year of medical residency programs in Brazil have shown the need to pro- vide more in-depth education and training in the detection and diagnosis of cognitive impairments in older people20,21,22. This lack of training may be due to the teaching method used by medical schools, which until recently, focused on training students about serious illnesses involving hospital inpatients, with little emphasis on outpatient treatment, i.e., primary care. However, recent curriculum models now engage students in primary care practice. Nevertheless, studies point to the need for continuous teaching and training of newly graduated physi- cians in the practice of medicine, given the rapid demographic and epidemiological shifts that have taken place in the last few years. This limited professional training in internal medicine has prompted the present study assessing the knowledge and attitudes in dementia held by GPs from a primary care service of a city in the interior of São Paulo State, Brazil. METHODS Study design and setting A quasi-experimental intervention study was conducted involving six lectures (60 minutes each) about dementia and/ or a presentation script. The lectures were delivered, and the scripts were written by a geriatrician with experience in dementia (VFSM). The lectures/presentation script covered the definition, epidemiology, diagnosis and management of dementia syndromes. Before and after the intervention, the participating physicians completed two quizzes about knowledge of and attitudes towards dementia18. The coordi- nation of the health system of Botucatu held monthly meet- ings from 2 pm to 5 pm with GPs from the primary care ser- vice to deliver updates on health topics to these professionals. The primary care service of the city of Botucatu comprises 4 basic health units (UBS), 2 health centres (CS), 2 polyclin- ics and 12 family health units (USF). All 40 GPs of the city of Botucatu primary health service were invited to take part in the study, most of whom were newly graduated physicians. Data collection Data collection took place between August 2016 and January 2017, gathering sociodemographic data (name, age, gender), responses to questions about time since graduation from medical school, completion of medical residency and specialty, and also about previous training in dementia dur- ing medical school: (“How long have you been a practicing physician?”, “Did you have any classes on dementia during your medicine course?”, “Have you done a Medical Residency program?”; If so, in which specialty?”, “Would you like to have refresher courses on dementia?”). Participants All GPs of the primary health service of Botucatu (n=40) commenced the study. Six physicians were excluded because they began classes but failed to complete the content and thus did not take part in the 2nd application of instruments. Physicians wishing to take part in the study, but who could not be away from their posts at health units, were provided with a script containing the topics presented in the lec- tures. After completing the 2 quizzes in the presence of the researcher, 10 physicians received the intervention based on this script. Thirty days later, the same group completed the quizzes a second time. Instruments The instrument Knowledge and Attitudes Quiz about Dementia was developed in the United Kingdom in 2004 109Mayoral VFS et al. Knowledge and Attitudes on Dementia by GPs with the purpose of measuring GPs’ knowledge of, confi- dence with and attitudes to the diagnosis and manage- ment of dementia in primary care16. In 2015, these instru- ments were translated and culturally adapted for use in the Brazilian setting20.The Knowledge Quiz contains 14 multi- ple-choice questions, each with five possible answers, only one of which is correct, with all questions including the response option “I don´t know”. The instrument is divided into 3 sub-items addressing aspects of dementia related to epidemiology (3 questions), diagnosis (8 questions) and management (3 questions). The Attitude Quiz contains 10 sentences about physi- cians’ thoughts on the management of patients with demen- tia, scored on a Likert-type scale with the following possible answers: “strongly agree”, “agree”, “neither agree nor disagree”, “disagree” and “strongly disagree”16. The first five sentences relate to positive attitudes: “1. Much can be done to improve the quality of life of carers of people with dementia. 2. Families would rather be told about their relative’s dementia as soon as possible. 3. Much can be done to improve the quality of life of people with dementia. 4. Providing diagnosis is usually more helpful than harmful. 5. Dementia is best diagnosed by specialist services”, whereas the other sentences relate to negative atti- tudes: “6. Patients with dementia can be a drain on resources with little positive outcome. 7. It is better to talk to the patient in euphemistic terms. 8. Managing dementia is more often frus- trating than rewarding. 9. There is little point in referring fami- lies to services as they do not want to use them.10. The primary care team has a very limited role to play in the care of people with dementia”16. Statistical analysis The data were analysed using the IBM-SPSS 21 statisti- cal software. Numerical variables were expressed as mean and standard deviation, while categorical variables were expressed as frequency and percentage. Student’s t-test was used to compare means. The level of significance adopted was 0.05. Ethics committee This study and the free and informed consent form were analysed and approved by the Research Ethics Committee of the Clinical Hospital of the Botucatu School of Medicine-UNESP. RESULTS The mean age of the sample was 33.9 (±10.2) years, where the majority (18 subjects — 52.9%) were 20–30 years old. Race consisted of thirty-two self-declared white, one black and one yellow. Sixteen (47%) of the physicians were female and 21 (61.8%) had been practicing for up to 5 years. Six (17.6%) physicians aged 47–59 years had been practicing for 18 years or longer. Of the 8 (23.5%) GPs who had undertaken medi- cal residency training in the overall sample, 5 were >47 years old, 1 was aged 28 years and 2 aged 37–39 years. The majority of the sample had not undertaken medical residency train- ing (76.5%). With regard to the question on having received classes on dementia during medical training, 29  (85.3%) stated “yes”. Of the participants who reported “no”, 3 had been practicing for 1–5 years and 1 for 18 years. All of the physicians (100%) stated that they wished to have a refresher course on dementia. Knowledge about dementia The Knowledge Quiz about dementia with response options and number of correct answers, before and after the training intervention of presentation class and/or script is given in Table 1. The mean number of correct answers before Table 1. Knowledge Quiz about Dementia with response options and number of correct answers, before and after training intervention, of general practitioners from the primary care system of Botucatu city, São Paulo state. Questions Response options Before After Epidemiology A general practitioner with a list of 1,000 people aged 60 years or older can expect to have the following number of people with dementia on the list A.10 B.500 C.200 D.70 E. I don’t know 13 (38%) 13 (38.0%) From 65 years of age, the prevalence of dementia is expected to: A. Double every 5 years B. Double every 10 years C. Double every 15 years D. Double every 20 years E. I don’t know 9 (26.4%) 21 (61.8%) One of the risk factors for the development of Alzheimer’s disease is: A. Hardening of arteries B. Age C. Nutritional deficiencies D. Exposure to aluminium E. I don’t know 25 (73.5%) 25 (73.5%) Continue... 110 Arq Neuropsiquiatr 2021;79(2):107-113 Questions Response options Before After Diagnosis All of the following are potentially treatable etiologies of dementia except: A. Hypothyroidism B. Normal pressure hydrocephalus C. Creutzfeldt–Jacob disease D. Vitamin B12 deficiency E. I don’t know 24 (70.6%) 26 (76.5%) A patient suspected of having dementia should be evaluated as soon as possible as: A. Prompt treatment of dementia may prevent worsening of symptoms B. Prompt treatment of dementia may reverse symptoms C. It is important to rule out and treat reversible disorders D. It is best to institutionalise a dementia patient early in the course of the disease  E. I don’t know 20 (58.8%) 27 (79.4%) Which of the following procedures is required to definitively confirm that symptoms are due to dementia? A. Mini-Mental State Exam B. Postmortem C. CAT scan of the brain D. Blood test E. I don’t know 7 (20.6%) 18 (52.9%) Which of the following is not a necessary part of the initial evaluation of a patient with possible dementia? A. Thyroid function test B. Serum electrolytes C. Vitamin B and foliate levels D. Protein electrophoresis E. I don’t know 29 (85.3%) 29 (85.3%) Which of the following sometimes resembles dementia? A. Depression B. Acute confusional state C. Stroke D. All of the above E. I don’t know 27 (79.4%) 26 (76.5%) When a patient develops a sudden onset of confusion, disorienta tion, and inability to sustain attention, this presentation is most consistent with the diagnosis of: A. Alzheimer’s disease B. Acute confusional state C. Major depression D. Vascular dementia E. I don’t know 27 (79.4%) 31 (91.2%) 10. Which of the following is nearly always present in dementia? A. Loss of memory B. Loss of memory and incontinence C. Loss of memory, incontinence and hallucinations D. None of the above E. I don’t know 28 (82.3%) 31 91.2%) 11. Which of the following clinical findings best differentiates vascular dementia from Alzheimer’s? A. Word-finding problems B. Short-term (2-minute span) visual memory loss C. Stepwise disease course D. Presence of depression E. I don’t know 23 (64.7%) 26 (76.5%) Management 12. The effect of anti-dementia drugs is to: A. Temporarily halt the disease in all cases B. Temporarily halt the disease in some cases C. Temporarily halt the disease in some cases but often causing liver damage D. Permanently halt the disease in some cases  E. I don’t know 25 (73.5%) 29 (85.3%) 13 Which statement is true concerning the treatment of dementia patients who are depressed? A. It is usually useless to treat them for depression because feelings of sadness and inadequacy are part of the disease B. Treatments of depression may be effective in alleviating depressive symptoms C. Anti-depressant medication should not be prescribed D. Proper medication may alleviate symptoms of depression and prevent further intellectual decline E. I don’t know 13 (38%) 11 (32.3%) 14. What is the function of the ABRAZ, the Brazilian association that provides patients and carers with information? A. Help people understand the disease and cope better with the symptoms and treatment B. Provide outpatient medical treatment C. Recruit people with dementia for research studies D. All of the above E. I don’t know 15 (44%) 22 (64.7%) Table 1. Continuation. 111Mayoral VFS et al. Knowledge and Attitudes on Dementia by GPs and after the training intervention was 8.35 (59.6%) and 9.97 (71.2%), respectively. The percentage of correct answers on the epidemiology, diagnosis and management subscales before intervention were 44.1, 68.3, and 50.9% versus 57.7, 79.7, and 61.7% after intervention, respectively. Results on Student’s paired t-test for comparisons of mean correct answers on the quizzes before and after the training showed a statistically significant difference only on the diagnosis sub- scale (p<0.001) (Table 2). Attitudes to dementia The comparison of the mean responses on the Attitude Quiz is presented in Table 3, revealing no statistically signifi- cant difference between the two applications of the instru- ment, before and after intervention (p=0.059). DISCUSSION This study employed two quizzes assessing the knowledge and attitudes of physicians about dementia. The mean total correct answers on knowledge before and after the inter- vention was 8.35 (59.6%) and 9.97 (71.2%) out of 14 points, respectively. Turner et al.16, used the same instruments in a single application to 127 GPs who had volunteered to join a randomized clinical trial of educational interventions to improve the detection and management of dementia. The GPs scored 67% overall on the quiz about knowledge of dementia and 48, 74 and 73% on the epidemiology, diagno- sis and management subscales, respectively. In the present study, the GPs exhibited a lower performance, scoring 59.6 versus 67% by British GPs. Brazilian scores on the epidemiol- ogy, diagnosis and management subscales also proved to be lower, at 44.1, 68.3 and 50.9%, respectively. The most common mistakes in the UK study involved questions on epidemiol- ogy, whereas Brazilian GPs erred most on epidemiology and management of dementia. However, both groups of GPs per- formed best on questions about diagnosis in dementia. A previous study by Jacinto et al. of 152 medical residents of a federal university hospital in São Paulo state applied the same two quizzes used in the present study21. The sample comprised 40.8% (n=61) residents in neurology, psychiatry, and geriatrics and internal medicine, and therefore probably had contact with older people with dementia during training. The remaining residents (59.2%) specialized in surgery and clinical subspecialties. Around 59.7% of residents embarking on their programs reported having received good training on cognitive impairments during medical school. Another study where 155 final-year medical students from two different universities participated, 92 (59.7%) considered that they had good training in cognitive alterations during their under- graduate medical course and 67 (58.8%) declared having only theoretical training22. However, this group of students scored an average of 6.9 (49.2%) on the Knowledge Quiz, pointing to the need for continued education, given that the workforce in the public health system in Brazil, akin to the UK, comprises very young doctors dealing with the population of older peo- ple users seeking public health services23. The study by Downs et al.24, assessing the effectiveness of educational interventions in improving detection and man- agement of dementia, concluded that GPs have difficulty detecting and managing dementia symptoms. Two inter- ventions showed positive results: a decision-support system built into the electronic medical records and practice-based workshops. There were improvements in detection and con- fidence of GPs in the diagnosis and management of demen- tia. A similar result was seen in the present study, where pri- mary care GPs showed improved performance, post-training, on the epidemiology diagnosis and management subscales. These results confirm that continued education may be effec- tive for improving detection of cognitive impairment and dementia in older adults in primary care. Several barriers, for both doctors and patients, to early diagnosis of dementia in primary care were outlined in the European Carers’ Report 201825: GPs believed forgetfulness was part of normal aging and so gave little importance in diagno- sis; and also due to the fact that no curative treatment exists, regarding patients and/or relatives, delay in seeking help at Table 2. Comparison of mean correct answers on Knowledge Quiz about Dementia, before and after training intervention, of general practitioners (n=34) from primary care system of Botucatu, São Paulo. Sub-items Before intervention mean (SD) After intervention mean (SD) p-value* Epidemiology 1.41 (±0.85) 1.74 (±0.82) 0.07 Diagnosis 5.44 (±1.80) 6.32 (±1.55) <0.001 Management 1.53 (±0.92) 1.85 (±0.70) 0.09 Total correct answers** 8.35 (±0.74) 9.97 (±2.11) <0.001 *Student’s paired t-test; **out of 14. Table 3. Comparison of mean answers on Attitude Quiz towards Dementia, before and after training intervention, of general practitioners (n=34) from primary care system of Botucatu, São Paulo. Subscales Before training intervention mean (SD) After training intervention mean (SD) p-value* Positive attitude 14.68 (±2.92) 15.03 (±2.91) 0.59** Negative attitude 11.32 (±2.27) 12.35 (±2.20) 0.09# *Student’s paired t-test; **higher means: more positive attitudes; #higher means: less negative attitudes. 112 Arq Neuropsiquiatr 2021;79(2):107-113 the early stage of the disease is explained by fears of preju- dice among friends, at work and also amongst health profes- sionals26, where clear information is lacking on all aspects of dementia for physicians and for individuals who are aging26,27. Regarding attitudes towards dementia held by GPs, the present study showed that most of them agreed much can be done to improve the quality of life of people with dementia (82.3%) and of their carers (97.1%), but 50% believed demen- tia is best diagnosed by a specialist. Similar results were found in the study by Turner et al.16. These findings are alarm- ing because individuals are unable to get an appointment to see a specialist following the onset of symptoms because nei- ther patient nor relatives took the cognitive and functional impairments seriously, believing them to be part of normal aging. Another important finding of the study was that 20.6% strongly agreed with the statement that treating individuals with dementia is frustrating. In the study by Ahmad et  al.,28 assessing the attitudes, awareness and practice regarding early diagnosis of demen- tia of 1011 GPs, they found that older physicians were more confident diagnosing and advising about dementia. However, although these physicians believed early diagnosis of dementia was beneficial, they were more likely to feel that patients with dementia can be a drain on resources with little positive outcome. By contrast, younger physicians were more positive and felt that much can be done to improve the qual- ity of life of patients with dementia27. The World Alzheimer Report 2017–2025 warns of the global impact of AD dementia in the near future and emphasizes the urgent need for awareness of this problem by society, public authorities and healthcare professionals29. Banerjee et al.30 showed that programs that encourage the individual with dementia to share their experiences with stu- dents result in the deepening of knowledge about the cogni- tive decline by the student, favouring a change in attitude to deal with the manifestations of dementia. The study by Alzheimer’s Disease International (ADI) “World Alzheimer Report 2019 — Attitudes to dementia”31 showed that in Brazil, there is still a huge stigma and nega- tive attitudes towards people with dementia by health pro- fessionals and people in the community. The authors believe that changes in attitudes to eliminate stigma about demen- tia should have the direct participation of individuals with dementia. In addition, the inclusion of students in the health field from the beginning of graduation so that they share the early stages of the disease can be the path to ethical manage- ment in the management of dementia. The limitations of this study included the convenience sample and small sample size, all derived from a single location in Sao Paulo State. Future research should explore whether the same findings can be replicated in a larger, rep- resentative sample of GPs in Brazil. ACKNOWLEDGEMENTS We thank the GPs who kindly agreed to participate in this study. 1. Bastos LFCS. OPAS/OMS Brasil - Demência: número de pessoas afetadas triplicará nos próximos 30 anos | OPAS/OMS. Pan American Health Organization / World Health Organization; 2017. Available from: https://www.paho.org/bra/index.php?option=com_content& view=article&id=5560:demencia-numero-de-pessoas-afetadas- triplicara-nos-proximos-30-anos&Itemid=839 2. Kalache A. Coping with the longevity revolution. 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