There have been a number of studies which have examined the prevalence of dementia in people accessing GP services (Albert et al., 2002; Eaker et al., 2002; Geldmacher et al., 2013a; Richards et al., 2000; Taylor & Sloan, 2000b; Zhao et al., 2008).However, the following article is the first to analyse the use of GP services by people with any Mild Cognitive Disorder (MCD) in Australia over eight years. To the authors knowledge it is also the first paper to analyse GP use of MCD participants when they have either a physical or mental comorbid condition, depression or arthritis. We chose arthritis and depression as our two comorbid conditions as both are highly prevalent in the elderly population, they are associated with increased disability and they are frequently
managed in GP clinics. Finally, this article is the first to evaluate the effect of financial problems and access to social networks on the use of GP services by people with MCD.
Statement of authorship
A longitudinal analysis of general practitioner service use by patients with mild cognitive disorders in Australia. (2016). Dementia and Geriatric Cognitive Disorders, 41:324-333. doi: 10.1159/000447123.
This is the accepted manuscript version of an article published by S.Karger AG in Dementia and Geriatric Cognitive Disorders, 2016, 41, 324-333 including DOI and available from
www.karger.com/Article/Fulltext/doi.
Lily O’Donoughue Jenkins (PhD candidate)
Developed study concept and design; analysed and interpreted data; drafted and edited the manuscript; acted as corresponding author. I certify that the statement of contribution is accurate
Signed……… Date……….
Peter Butterworth (Co-author)
Drafted and provided critical revision of the article; assisted in interpretation of data analysis. Provided final approval of the manuscript to be published. I certify that this statement of
contribution is accurate and permission is given for Lily O’Donoughue Jenkins to include this paper in this thesis for examination towards the Doctor of Philosophy
Signed……… Date……….
Kaarin J. Anstey (Principal supervisor)
Assisted in developing the study concept and design; drafted and provided critical revision of the article; assisted in interpretation of data analysis; provided final approval of the manuscript to be published. Anstey is Principal Investigator on the PATH Through Life Study. I certify that this statement of contribution is accurate and permission is given for Lily O’Donoughue Jenkins to include this paper in this thesis for examination towards the Doctor of Philosophy
Signed……… Date……….
5.3 Summary
We found that individuals in Australia with MCD were visiting their GP significantly more than individuals who were classified as cognitively healthy. This usage significantly increased if MCD participants had a comorbid condition, arthritis or depression. This article highlights the increasing need for public health strategies to deal with the increased use of GPs in the future. The manuscript reflects, and confirms previous research findings of the increasing need for GPs by older individuals in the community. The importance of GPs for individuals with early signs of memory impairment is discussed in the literature review (Chapter 2).
Due to the increase in the ageing population and the corresponding rise in cognitive
impairments, it is anticipated that there will be an increased need in future for GP or similar services. This may result in longer waiting times for patients, insufficient time spent with patients and care needs not being met. For example, in 2013 Canberra residents waited an average of 6.73 days to see their usual GP (Boddy, 2014). To overcome these prolonged waiting times individuals may present to an emergency department or visit a different GP who is not aware of the patient’s history. The Australian government and GPs in ACT should develop new approaches to meet this increased need or change or modify services currently provided to ensure that they are appropriate for these patients (ACT Health Directorate, 2011; Comijs et al., 2005).
Paper 3 highlights the issue that individuals with a cognitive impairment are more likely to visit a GP if they have a comorbid condition (physical or mental). Use of services may be indirectly related to cognitive impairment, or individuals may be using these services for conditions that are
exacerbated by the presence of cognitive impairment. For example, evidence has found that is more frequent in people with dementia and MCI compared to cognitively healthy individuals (Ellis et al., 2009; Shahnawaz et al., 2013). Depression has also been shown to contribute to impairment in several cognitive domains, including executive function, attention and psychomotor skills (Gonda et al., 2015) and low memory performance has been shown to be a reliable predictor of depression
three years later (Airaksinen, Wahlin, Forsell, & Larsson, 2007). The association between depression and mild cognitive disorders can be clinically challenging and cognitive dysfunction in depressed patients is largely unrecognised and unmonitored by clinicians (Gonda et al., 2015; McAllister- Williams et al., 2017). Further research examining the presence of comorbidities, such as depression, and effect on cognitive impairment is required, particularly regarding the nature and treatment of cognitive impairment.
In the process of conducting research for paper 3 a number of gaps were identified. MCI is an unstable condition - individuals may stabilise, revert back to normal cognition or progress to dementia. However, there has been little or no research examining the effect that changes in cognitive status over time have on health service use. Future research could use linked longitudinal data, such as that used in the article, to examine the multiple exposures, determinants and
outcomes of cognitive status changes and GP use. Previous research has examined the impact of comorbid conditions on dementia and health service use, for example Griffith et al. (2016) and Browne et al. (2017). However, very little research has examined comorbid conditions in people with MCI/MCD. Given this gap, future research should examine whether particular comorbid conditions are associated with MCI/MCD or lead to increased service use. Previous research has largely focused on individuals from a clinical sample. Future research examining the association between MCI/MCD and primary care should focus on community-dwelling individuals as they tend to have more medical problems and their cognitive impairment is rarely identified (Fowler, 2013). Results in paper 3 indicate that increased health service use can be used as a proxy for health costs with even mild cognitive disorders. Future research which examines the reason for increase will enable the development of appropriate public health policy.
Research findings discussed in this chapter highlight the importance of examining the impact of cognitive impairment on GP use. However, the impact of cognitive impairment on hospital services
appears to be relatively greater than that on GPs (Australian Institute of Health and Welfare, 2004). The next chapter discusses the relationship between cognitive impairment and hospital use.