NATIONAL AGEING RESEARCH INSTITUTE

An education program to improve

referral to Memory Services for
older people of Asian background
living in Melbourne

Literature Review

2010

Prepared by Dr. Dina LoGiudice, Ms. Betty Haralambous, Ms. Xiaoping

Lin, Ms. Freda Vrantsidis, Dr. Jean Tinney, Dr. Briony Dow, Prof. Nicola
Lautenschlager, Dr. Irene Blackberry

www.nari.unimelb.edu.au
Acknowledgements
The project team would like to acknowledge the J.O. & J.R. Wicking Trust for providing
funds for this research.
The project team would like to thank all members of the project advisory group for their
guidance, advice and feedback:
Professor Ed Chiu, St Georges Hospital
Ms Bich Ha, North Richmond Community Health Service
Ms Dominique Horne, Alzheimer‟s Australia Victoria (AAV)
Ms Marion Lau, Director, Management Consultants and Technology Services Pty Ltd and
former President of the Ethnic Communities Council of Victoria
Dr Sook Meng Lee, Western CDAMS
Ms Michelle Mew, Western CDAMS
Ms Trinh Nguyen (April 2010), Western Region Heath Centre
Ms Jenny Phillips, Alzheimer‟s Australia Victoria (AAV)
Professor Dimity Pond, Professor of General Practice, University Newcastle
Ms Grace Roberto, Alzheimer‟s Australia Victoria (AAV)
Dr Sam Scherer (Clinical Associate Professor), Eastern CDAMS and Montefiore Homes for
the Aged
Norminda Villanueva, Alzheimer‟s Australia Victoria (AAV)
Ms Anne Vu (till April 2010), Western Region Heath Centre

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Table of Contents
Acknowledgements ........................................................................................ 2
Table of Contents ........................................................................................... 3
List of tables.................................................................................................. 4
Acronyms...................................................................................................... 5
1. Introduction ............................................................................................ 6
1.1. Project aims and components ......................................................................... 6
2. Methods.................................................................................................. 7
3. Early diagnosis of dementia in primary care setting ...................................... 9
4. Factors impacting on early diagnosis of dementia in primary care ................ 12
5. Effective education programs for GPs ....................................................... 22
6. Effective education programs for older people from CALD backgrounds ......... 25
7. Conclusion ............................................................................................ 28
8. References ............................................................................................ 29

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List of tables
Table 1: GP related factors in early diagnosis of dementia ............................................. 12
Table 2: Carer-family related factors in early diagnosis of dementia ............................... 17

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Acronyms

ABS Australian Bureau of Statistics

CALD Culturally and Linguistically Diverse
CDAMS Cognitive Dementia and Memory Services
GP General practitioner
MMSE Mini-Mental State Examination
NARI National Ageing Research Institute
NESB Non-English speaking background
PN Practice Nurse

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1. Introduction
The National Ageing Research Institute (NARI) received funding in late 2009 from the J.O. &
J.R. Wicking Trust to develop education programs to improve referral patterns to Cognitive
Dementia and Memory Services (CDAMS) for older people of Chinese and Vietnamese
backgrounds living in Melbourne.
This 18 month project aimed to determine and implement the most effective methods of
improving early dementia detection rates in two Asian groups. The project targeted older
Vietnamese speaking people in the Western suburbs of Melbourne (the catchment area for
the Western CDAMS) and older Chinese speaking people in the Eastern suburbs of
Melbourne (the catchment area for the Eastern CDAMS). The project took into consideration
the cultural and linguistic diversity within these two groups.
1.1. Project aims and components
The aims of this project were to:
Determine the barriers and enablers for people with dementia and their families of
Chinese and Vietnamese backgrounds to accessing Memory Clinic services;
Determine the most useful available translated screening tools for cognitive
impairment/dementia and depression in these groups; and
Develop/implement two education programs (one for the community and one for health
professionals) and screening guidelines to improve detection of memory problems at an
earlier stage in these two communities.
To fulfil these aims, the project involved the following components:
a) Literature review;
b) Consultation with community workers and health professionals;
c) Development of evidence based dementia education programs/screening guidelines;
d) Revision of the dementia education programs/screening guidelines based on community
and health professional feedback;
e) Pilot use of the education programs/screening guidelines;
f) Evaluation of the project and refinement of the programs/guidelines.
The report details the literature review component. The literature review aimed to identify:
Barriers to early diagnosis of dementia in primary care, including barriers related to
health professionals and barriers related to older people and their families,
The most effective models of education programs for primary health professionals, and
The most effective models of education programs for people from CALD backgrounds.
The literature review informed the development of the education programs/screening
guidelines.

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2. Methods
Research questions
The research questions for the literature review included:
What are the barriers to early diagnosis for older Chinese and Vietnamese speaking
people with dementia?
What level of dementia literacy is there among older migrants, in particular older
Chinese and Vietnamese people, i.e. understanding of dementia within a cultural context
and the implications of early detection of dementia for the person and their carers?
What are the barriers and enablers to a diagnosis of dementia by general practitioners
(GPs) servicing these communities, in particular bilingual GPs?
What are the most appropriate screening tools (including cognitive and depression
scales) for these two groups?
What are the most effective models of education for primary health professionals, in
particular those working with people from Chinese and Vietnamese backgrounds?
What are the most effective models of education for older migrants, in particular older
Chinese and Vietnamese people?
Searching method
A comprehensive literature review was conducted using the following databases:
MEDLINE;
CINAHL PLUS (EBSCO);
PubMed.
To ensure optimal relevance and brevity, the search was restricted to research published
within the last 10 years (i.e. articles published after 1999).
The search used combinations of the following key words:
Dementia;
Education program;
Training program;
Health professional;
General practice;
Nurse;
Community;
Ethnic;
Cross cultural;
Cultural;
Chinese;
Vietnamese;
Screening;
Assessment.

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The reference lists of all included papers were also searched for additional articles.
The project team also consulted researchers and health professionals known to them, who
were involved in dementia assessment and/or provided dementia or other health education
to older people. Copies of grey literature, including reports and other unpublished literature
in this area were sought and included in this review.
In addition, the project team searched the websites of relevant government departments
(e.g., Australian Department of Health and Ageing), research centres (e.g., the Dementia
Collaborative Research Centres), and Alzheimer‟s Associations (e.g., Alzheimer‟s Australia)
to identify recent government policy, education programs and research projects in these
areas.
This literature review focused on early stage dementia and older people living in the
community (the focus of this study), therefore, research on moderate to severe dementia
and people in residential aged care facilities are not included in the review.

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3. Early diagnosis of dementia in
primary care setting
Prevalence of dementia in Australia
Dementia is the term used to refer to a large group of illnesses which cause a progressive
decline in a person‟s functioning, including memory, intellect, rationality, behaviour,
emotion and day-to-day functioning (Alzheimer‟s Australia, 2005a). The most common
cause of dementia is Alzheimer's disease, accounting for 50-70% of all cases.
Epidemiological studies have revealed that older age is the greatest risk factor for
dementia: the prevalence of dementia increases markedly with age, doubling every five to
seven years after the age of 65 (Hofman et al., 1991). However, it is important to
remember that most older people do not develop dementia.
The prevalence of dementia in Australia is projected to increase dramatically as the
population ages. Access Economics, commissioned by Alzheimer‟s Australia, has published
the most up-to-date estimates and projections of the prevalence and incidence of dementia
in Australia in 2009. Some key findings of this report include:
In 2009 the prevalence of dementia in Australia was 245,400 people and this number is
projected to increase over four-fold to around 1.13 million people by 2050;
Dementia is the leading single cause of disability in older Australians and is responsible
for one in every six years of disability burden for this group;
Dementia is one of the fastest growing sources of major disease burden. By the 2060s,
spending on dementia will outstrip that of any other health condition and is projected to
be $83 billion, representing 11% of the entire health and residential aged care sector
spending (Access Economics, 2009).
Prevalence of dementia in people from CALD backgrounds
The term Culturally and Linguistically Diverse (CALD) is currently used by Australian federal
and state government departments to refer to the diversity arising from a person‟s country
of birth, culture, language, race and/or religion. This term was developed because of
perceived limitations of the term non-English speaking background (NESB). NESB is a
categorisation based solely on language use, yet there are migrants who may speak English
well (e.g., Malaysians, Indians, Singaporeans) but have cultural backgrounds very different
from those of Anglo-Australians (Gibson et al., 2001). For the purposes of this study, the
term CALD will be adopted to be consistent with current policy.
Of the many variables that might be used to define people from CALD backgrounds,
including country of birth, culture, language, and religion, the most commonly used
variables are country of birth and language spoken at home. In 2008, among the estimated
resident population of Australians (21.4 million people), one quarter were born overseas
(5.5 million people) (Australian Bureau of Statistics, 2009). Of this group, the percentage of
people above the age of 65 (18%) is relatively higher than that of the Australia-born
population (11%), accounting for 36% of the total older Australian population (Australian
Bureau of Statistics, 2009). There are about 400 different languages spoken in homes
across Australia and there is a trend for fewer Australians speaking only English at home
(Australian Bureau of Statistics, 2007).
The Access Economics report uses the variable of language spoken at home to identify
people from CALD backgrounds, because there is some evidence that the loss of the most
recent language is often an early sign of dementia for people from CALD backgrounds
(Access Economics, 2006). The report estimated that the prevalence of dementia in people
from CALD backgrounds in 2009 is 35,000 people. This figure is projected to increase to

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120,000 in 2050. Although the projected growth of people with dementia from CALD
backgrounds is not expected to grow as fast as for people with dementia who speak English
at home (a 3.4-fold increase compared to a 4.8-fold increase), the tripling in the absolute
number of people with dementia from CALD backgrounds represents a significant increase in
the future demand for dementia related services (Access Economics, 2009).
The target group for this project is older Chinese and Vietnamese people in Victoria. The
Chinese population has been in Australia for a long time and there is great diversity within
this group, both in languages spoken (Cantonese, Mandarin, Hokkien, Shanghai and other
Chinese dialects) and country of origin (mainland China, Hong Kong, Taiwan, Singapore,
and other South Asian countries) (Guo, 2005). The great diversity can be explained by the
diversity within the Chinese culture itself, but is also related to the history of migration of
this group. The Chinese population came to Australia during two main periods: the gold rush
time (the latter half of the 19th century) and the years after 1973 (Guo, 2005). The people
who came during the gold rush time were mostly from impoverished areas in southern
China, particularly the Guangdong province, and most of them spoke Cantonese (Museum
of Chinese Australian History Inc.). The Chinese population decreased gradually after the
gold rush period due to the restriction on Chinese immigration. It was not until 1973 when
the White Australia Policy was abandoned that the Chinese population began to expand
(Department of Immigration and Multicultural Affairs, 2001). Most of the Chinese
immigrants arriving in the 1970s and early 1980s were from Cambodia, Hong Kong,
Malaysia, Singapore and Vietnam (Department of Immigration and Multicultural Affairs,
2001) and spoke Cantonese. It was in the mid-1980s that the number of people from
mainland China, most of whom speak Mandarin, increased rapidly.
In contrast, Vietnamese immigration has a relatively short history (Department of
Immigration and Multicultural Affairs, 2001). Most of the Vietnamese migrants came as
refugees after the Vietnam War and then through family reunion in the 1980s (Department
of Immigration and Multicultural Affairs, 2001). It is important to know there is a mix of
Vietnamese and Chinese ethnicities among the Vietnamese immigrants (Museum Victoria
Australia). Immigration patterns can be associated with hardship and trauma of refugee
camps (Sims, Nguyen, LoGiudice, & Smith, 1999). It has been reported that there is an
increased incidence of depressive syndromes among refugees (Garcis-Peltoneiemi, 1987);
this includes our current Vietnamese older people (Sims et al., 1999).
In 1996, the Chinese languages and Vietnamese were ranked as 4th and 11th languages
spoken by older people from CALD backgrounds across Australia (Gibson et al., 2001).
These languages are projected to experience a fast proportional growth in the next 20
years. The Chinese languages and Vietnamese are projected to be the 1st and 4th
languages spoken by older people from CALD backgrounds by 2026, representing 10.5%
and 4.5% of the Australian CALD population, respectively (Gibson et al., 2001). This trend
is also evident in Victoria. In 1996, neither of these two languages were among the top ten
languages spoken by people from CALD backgrounds (Gibson et al., 2001). However, by
2026, the Chinese and the Vietnamese will be ranked as the third and fourth languages for
older Victorians from CALD backgrounds, respectively (Gibson et al., 2001). A recent
publication by the National Seniors Productive Ageing Centre reported that in 2006, Victoria
had the second highest number of immigrants born in CALD countries aged 50+ (33.4%)
following NSW (37.4%). In comparison, 23.4% of people born in Australia aged 50+ reside
in Victoria. Of the people aged 50+ from Vietnam, China, Hong Kong, and Singapore, a
large proportion reside in Victoria (35.3%, 25.1%, 21.8%, and 20.6%, respectively) in 2006
(National Seniors Productive Ageing Centre, 2011)
Early diagnosis of dementia in primary care setting
Early diagnosis for people with dementia is important to both the person with dementia and
their family. An early diagnosis allows the person and their family to plan ahead and gain
early access to support services and subsidised medication (Alzheimer‟s Australia, 2007;

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Brodaty, 2006; Derksen et al., 2006). An early diagnosis also means the person with
dementia is more likely to be able to participate in the future planning process to ensure
their wishes are considered (Iliffe et al., 2009). Furthermore, there is also evidence that the
currently available medications for Alzheimer‟s disease may be more beneficial if given early
in the disease process (Brodaty, 2006; Perry et al., 2008).
GPs and other health professionals in the primary care setting have a key role in early
diagnosis of dementia. Most older people in Australia live in the community (Australian
Bureau of Statistics, 2006) and the GP (also referred to as family physician, or primary
physician) is usually the first contact for older people with medical concerns (Australian
Bureau of Statistics, 2004). In an Australian focus group study with GPs, participants
described the role of GPs in diagnosis as “the primary gate keeper” where the GPs “organise
investigations, all specialist referrals and … then put the whole lot together seeing the
patients as a whole" (Dementia Collaborative Research Centres & The University Newcastle,
2007). However, there is evidence that dementia is probably under-diagnosed and
diagnosed at a late stage in the primary care setting. A recent review found about half of
older people met the criteria for dementia without GPs‟ knowledge of dementia or dementia
documentation in their medical record (Boustani, Peterson, Hanson, Harris, & Lohr, 2003).
Leifer (2003) concluded that GPs consistently failed to diagnose dementia in 24%-72% of
cases. Typically, the lag between symptom onset and diagnosis takes between 18–30
months and can be up to 4 years (Iliffe et al., 2009).
The issue of late diagnosis is particularly true for people from CALD backgrounds. It is well
documented that this group of older people often present to health professionals at a much
later stage for diagnosis, and when family and the person with dementia do present for
assistance, it is often in crisis mode (Cheng et al., 2009; LoGiudice, Hassett, Cook, Flicker,
& Ames, 2001; The Cultural and Indigenous Research Centre Australia, 2008). This pattern
is consistent with the finding of under-utilisation of all types of mainstream government and
non-government aged care services by people from CALD backgrounds in Australia (Black,
Osborne, & Lindeman, 2004; Johnstone & Kanitsaki, 2008; Lister & Benson, 2006).
Victoria is unique in providing regional multidisciplinary CDAMS services that offer early
diagnosis, advice, support and referral for people with cognitive difficulties and for those
who support them. Referrals are received predominantly from GPs and local aged care
services. Best practice guidelines include the need for cultural and linguistic sensitivity, and
use of interpreters is paramount. Part of the CDAMS role is to provide education on
dementia to community services and health professionals. In terms of the target groups for
this project, anecdotal reports indicate while the older Vietnamese population represents a
significant percentage of the older population over 70 in the western suburbs of Melbourne
(4.8% in Brimbank and 7.5% in Maribyrnong); few Vietnamese patients present to the
Western CDAMS per year. Similarly, the largest numbers of Chinese older people in
Melbourne reside in the eastern suburbs, including the City of Whitehorse (3.1% of the
population 70+) and the City of Manningham (4.4% of the population 70+), but there are
few Chinese older people attending the Eastern CDAMS.

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4. Factors impacting on early diagnosis
of dementia in primary care
The literature identified a number of factors related to GPs and older people and their
families that impacted on early diagnosis of dementia in primary care.
GP related factors
The review identified few articles focusing on GPs working with people from CALD
backgrounds therefore information was mainly drawn from the general literature on GPs
working with older people. GP related factors affecting early diagnosis of dementia include
GPs‟ uncertainty in diagnosis, their attitudes towards dementia, and other factors such as
disclosure difficulty and time pressures (see Table 1). The issue of cultural appropriateness
of common screening tools for patients from CALD groups was also raised in the literature
(see “An education program to improve referral to Memory Services for older people of
Asian background living in Melbourne: Dementia Screening Tools - Discussion Paper” for
more information on screening tools used in the education program.
Table 1: GP related factors in early diagnosis of dementia

Factor Related issues

Uncertainty about diagnosis of Complexity of dementia

dementia
Lack of education on dementia diagnosis
“Watchful waiting process” in diagnosis

Attitudes towards early Therapeutic nihilism

diagnosis of dementia
Scepticism about the usefulness of medications for
dementia
Concerns about the impact of the diagnosis of
dementia on people with dementia
Perception that physical problems take precedence
over cognitive problems
Ageist attitudes that give low priority to the health
needs of older people
Views about local services for people with
dementia

Other factors Difficulty in disclosure

Time pressure

Uncertainty about diagnosis of dementia

Many studies have found that GPs‟ uncertainty about a diagnosis of dementia is an
important reason for the delayed diagnosis of dementia in primary care (e.g., Iliffe et al.,
2005; Pimlott et al., 2009).
The main reason for this uncertainty is probably the complex nature of dementia (van Hout,
Vernooij-Dassen, Bakker, Blom, & Grol, 2000). Dementia is a progressive disease and its
early signs are often very subtle and vague (Alzheimer‟s Australia, 2005b). GPs often find it
difficult to differentiate normal ageing from symptoms of dementia (Cahill, Clark, Walsh,

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Connell, & Lawlor, 2006; Hansen, Hughes, Routley, & Robinson, 2008). Furthermore, people
who have dementia are more likely to be older and have other chronic diseases,
complicating the clinical picture and making diagnosis more difficult (Boise, 2005). In
addition, the aetiology of dementia is undefined (Iliffe, Manthorpe, & Eden, 2003) and
people present with various symptoms of dementia (Access Economics, 2009). For these
reasons, GPs view dementia as more complicated and difficult than other chronic conditions
that they encounter in general practice (Pimlott et al., 2009; Wilkinson, Stave, Keohane, &
Vincenzino, 2004).
GPs‟ uncertainty about diagnosing dementia could also be linked to their lack of education
on dementia (Bradford, Kunik, Schulz, Williams, & Singh, 2009). Some UK studies have
found that most GPs have never had any dementia specific training (Cahill et al., 2006) and
current undergraduate and postgraduate curricula were seen to include insufficient training
in this area. Another study found that over half of GPs felt insufficiently trained to diagnose
dementia adequately (Woods et al., 2003). These results are consistent with Boise‟s (2006)
paper on dementia education among GPs. This paper found that there is a great need for
dementia education among GPs and that Alzheimer‟s disease was ranked by GPs as the top
geriatric topic that they would like to learn more about (Boise, 2006). A literature review by
Williams, Byrne, and Pond (2008) also suggested that educational programs for GPs may be
of assistance to improve GPs‟ knowledge of dementia.
Due to this uncertainty, GPs are often slow and cautious about making a diagnosis (Hansen
et al., 2008). They tend to observe patients over a long period of time (Hansen et al., 2008)
and take on a „watchful waiting process‟ with people presenting with possible symptoms
(Iliffe et al., 2009). They also expressed a desire for experts either to make or verify the
diagnosis of dementia (Pimlott et al., 2009). This pattern in the process of diagnosis is
consistent with the finding by Wilkinson et al. (2004), which reported that although the
majority of patients with dementia might consult their GPs first, the diagnosis was more
likely to be made by a specialist.
Attitudes towards early diagnosis of dementia
There is some evidence that GPs have negative, or at least, ambivalent attitudes towards
early diagnosis of dementia. Boise et al. (1999) found that although most of the GPs
considered dementia a serious condition, many of them questioned the importance of early
diagnosis. Similarly, a UK study found that half of the GPs interviewed did not believe it was
beneficial to make an early diagnosis of dementia (Renshaw, Scurfield, Cloke, & Orrell,
2001). These negative or ambivalent attitudes towards early diagnosis of dementia have
been linked to under-diagnosis of dementia in primary care (Bradford et al., 2009). Boise et
al. (1999) argued that it is GPs‟ attitudes, rather than their knowledge, that determines
whether GPs will conduct a full assessment for people presenting with possible dementia
(Boise, Camicioli et al., 1999).
There are several explanations for these negative or ambivalent attitudes towards early
diagnosis. Of these, therapeutic nihilism is probably the most frequently cited. Therapeutic
nihilism, the perception that nothing could be done for patients with dementia, has been
reported in many studies with GPs (Boise, 2005; Hansen et al., 2008; Vernooij-Dassen et
al., 2005; Wilkinson et al., 2004). In a study with 741 carers of people with dementia across
five countries (Australia, France, Italy, Spain and the UK), it was found that about one third
of those with dementia were not receiving any medication for dementia at the time of the
study (Wilkinson et al., 2004). One of the main reasons given by doctors for not
recommending treatment was that “there is no cure for Alzheimer‟s Disease” . Therapeutic
nihilism gives rise to the common argument that in the absence of effective treatment,
there is no benefit in early diagnosis of dementia (Boise, Morgan, Kaye, & Camicioli, 1999;
Woods et al., 2003).

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GPs‟ negative attitudes towards early diagnosis of dementia could also be linked to their
views about local dementia services. A recent review found that GPs were uncomfortable
with the limited range of advice and support activities they can offer to people with
dementia (Williams et al., 2008). Furthermore, some studies found that GPs‟ negative views
towards early diagnosis can be explained by their dissatisfaction with local dementia
services (Renshaw et al., 2001) and pessimistic views about the capacity of local services to
respond to the needs of people with dementia (Iliffe et al., 2003). However, GPs‟ attitudes
towards local services could also be an enabler in the early diagnosis of dementia. Hansen
et al. (2008) found that if GPs thought a diagnosis of dementia might assist their patients in
accessing services, they would consider the diagnosis important and pursue a formal
diagnosis. This study concluded that GPs‟ “perception of few desirable options for people
with dementia” … and “lack of knowledge about existing community-based dementia
support services” are two key factors in under-diagnosis of dementia in primary care
(Hansen et al., 2008). Consistent with this view, Iliffe and Wilcock (2005) suggested that
“the „failure‟ to recognise dementia early in general practice can be a conscious decision on
the part of the practitioner, who … takes into account the perceived lack of care for people
with dementia and their families”.
GPs‟ ambivalent attitude towards early diagnosis of dementia might also be related to their
concerns about the impact of the diagnosis on the person with early dementia, and the
potential adverse effects of labelling and stigmatising (Bradford et al., 2009; Cahill et al.,
2006; De Lepeleire et al., 2008; Iliffe et al., 2003). Other factors identified include GPs‟
perception that physical problems take precedence over cognitive problems (Bradford et al.,
2009; Hansen et al., 2008; Iliffe et al., 2003), and possible ageist attitudes that result in
their giving low priority to the health needs of older people with dementia (Boise, Camicioli
et al., 1999; Bradford et al., 2009).
While most of the above studies have focused on GPs‟ negative attitudes towards early
diagnosis of dementia, there is some evidence of improvements. Milne, Hamilton-West, and
Hatzidimitriadou (2005) compared the attitudes of GPs in the UK towards early diagnosis of
dementia in 1997 and 2001. They found that in 2001, there were more GPs holding positive
attitudes towards early diagnosis and considering early diagnosis to be beneficial. There
were also fewer GPs regarding early diagnosis as having negative consequences in 2001.
Furthermore, there was a significant increase in GPs‟ commitment to early diagnosis
between 1997 and 2001. This study stated that these changes can be explained by
increased access to dementia services in the UK during this period, including more support
from psychiatric professionals for GPs and increased investment in dementia care services.
However, as stated above, there has been limited research undertaken that looks at issues
related to GPs working with older people with dementia from CALD backgrounds.
Other factors
Disclosure difficulty in dementia has been identified as a barrier in early diagnosis in many
studies (Bradford et al., 2009; Iliffe et al., 2009). A review by Bamford (2004) found that
between 28 to 58% of practitioners reported difficulty with disclosing the diagnosis. It was
rated as one of the most difficult aspects of dementia management by GPs (Bamford et al.,
2004; Iliffe et al., 2009) and regarded as involving more time and effort than that of other
diagnoses (Bamford et al., 2004). Disclosure difficulty is also related to GPs‟ attitudes
towards breaking the bad news about dementia diagnosis (Williams et al., 2008), as well as
their negative attitudes towards early diagnosis of dementia. For example, a recent
Australian study found that many GPs did not see benefits in disclosing the diagnosis,
because they believed that dementia is an incurable disease (Dementia Collaborative
Research Centres & The University Newcastle, 2007). It is not surprising that only one fifth
of GPs often or always disclose a diagnosis of dementia and about 40% never or rarely do
(Cahill et al., 2006).

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Time pressure is another factor that impacts on GPs‟ practice of early diagnosis of dementia
(Boise, 2005; Boise, Camicioli et al., 1999; Dementia Collaborative Research Centres & The
University Newcastle, 2007; Iliffe et al., 2009; van Hout et al., 2000). This factor is related
to both the complex nature of dementia and the current reward system for GPs. As
discussed above, dementia is a complex disease and GPs observe the symptoms over a long
period of time before making a diagnosis. Furthermore, there are many tests involved in
diagnosing dementia. However, the current reimbursement system in most countries limits
the time GPs can spend with each patient (van Hout et al., 2000). A review by Williams,
Byrne, and Pond (2008) also identified inadequate time and poor remuneration as important
factors in GPs‟ identification, assessment and management of dementia. Consistently, Iliffe
et al. (2009) argued that “the problem of under-diagnosis is probably not due to lack of
diagnostic skills, but rather to the interaction of case-complexity, pressure on time and the
negative effects of reimbursement systems”.
In Australia, practice nurses (PNs) also play an important role in early diagnosis of
dementia. GPs often have limited time with each patient, and as a result, it is often the role
of the practice nurse to be the first contact for older people with medical concerns and to
perform various health assessments. Many of the above issues raised by GPs regarding
early diagnosis of dementia are also reported by the PNs (Dementia Collaborative Research
Centres & The University Newcastle, 2007) .
Screening tools and issues related to people from CALD backgrounds
A review of suitable screening tools for dementia and depression in the primary care setting
and their appropriateness for CALD groups generally, and in particular to those from
Chinese and Vietnamese backgrounds, was also conducted. A summary of the findings of
this review are included below. Full details of the review are included in a separate
document titled: An education program to improve referral to Memory Services for older
people of Asian background living in Melbourne: Dementia Screening Tools. Discussion
Paper.
Most screening tools have been developed and validated in Western cultures and concerns
have been raised in the literature about their adequacy for screening dementia in patients
from CALD groups. For example, the Mini-Mental State Examination (MMSE), a tool used
widely throughout the world and in Australia, has been well documented to be influenced by
age, education, language, ethnicity and socio-economic status (Anderson, Sachdev,
Brodaty, Troller, & Andrews, 2007; Escobar et al., 1986). Therefore outcomes can be
misleading (the presence of dementia may be overestimated) in patients from CALD
backgrounds, low socio-economic status and with high illiteracy.
Some examples of specific issues related to screening/assessment tools and CALD groups
include:
Some literal translations may have different meanings (e.g. in Italian „memorise‟ is often
translated to mean „learn‟);
Several words may be required to convey a concept and this can be problematic when a
single word is required to be read out;
There are differences in the number of syllables in words, e.g. in Spanish counting
(backwards) mostly involves double syllables, whereas in Vietnamese they are single
syllables;
“No ifs, and or buts” (MMSE) is not easily translated into other languages and it loses its
“articulatory complexity”, and the term may be unfamiliar to many CALD groups;
Chinese elders who have used brushes (not pens) may have a different form of motor
control (Sansoni et al., 2007);

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 Spelling WORLD backwards and counting back by 7s (MMSE) may be less relevant to
some cultural groups (Rowland et al., 2007);
“Close your eyes” (MMSE) can imply death in the Chinese culture (Steis & Schrauf,
2009).
There is also great individual variability within groups, culturally, socio-economically, and in
their level of acculturation (modification of one‟s culture, behaviour, beliefs, and values by
adapting to another culture) (Ganguli & Hendrie, 2005; Sansoni et al., 2007; Steis &
Schrauf, 2009). In addition those of CALD background have little test experience and
anxiety can be related not only to concerns about their own performance but also about
creating a negative stereotype for their cultural group, a term referred to as “stereotype
threat” (Hargrave, 2006).
Chiu and Lam (2007) outlined the desired process for the cultural adaptation of
instruments. This included paying attention to the linguistic aspects, conceptual validity and
cultural relevance of items when translating existing instruments, which was best
established through expert review and field testing. Normative data and the discriminating
characteristics of a test need to be recalibrated in local populations based on population
studies and not small convenient samples. In order to establish comparable data,
administration and scoring methods need to be standardised because different scores may
have different meanings in different populations (probable dementia in one group compared
to cognitive decline in another). For performance results to be meaningfully interpreted,
tests need to be “harmonised” to the local context and local norms (norms for age, sex,
education/literacy, racial/ethnic and language groups).
A lack of awareness of available screening tools and training were key issues identified in a
survey of GPs in the UK (Milne, Culverwell, Guss, Tuppen, & Whelton, 2008). The survey
results indicated that GPs felt there were few screening tools available, other than the
MMSE, and that more information was required about the full range of instruments
available. Training and advice on dementia screening and national guidance was also
identified as a need by these GPs in primary practice.
Similar cultural concerns have been reported in relation to screening tools for depression.
For example, the widely used Geriatric Depression Scale includes items that contain
Western value judgments and for some cultures disclosing this information to others may be
culturally inappropriate (Sansoni et al., 2007). It is more common for Asians with
depression to present with somatic complaints because of the perceived stigma, linguistic
difficulties and a cultural understanding of depression that integrates mind and body
experiences (Dinh, Yamada, & Yee, 2009). A literature review conducted by the National
Ageing Research Institute (Haralambous et al., 2009) found that older people from CALD
backgrounds were one of the groups most at risk of depression and anxiety, yet there was
limited research looking at the prevalence of depression in older CALD people and limited
research investigating the validity of common screening tools in CALD groups.
There was little information available specific to the appropriateness of assessment tools for
CALD groups in the primary care setting. Information from this review, primarily based on
the general literature, and the professional expertise of project staff, informed the selection
of the cognitive assessment tools included in the resources packs that were developed as
part of this study.
Patient/family factors
A number of patient/family related factors were identified that impact on early diagnosis of
dementia of older people from CALD backgrounds, in particular, older Chinese and
Vietnamese people. The factors have been organised around Levkoff, Cleary, Wetle, and
Besdine (1988)‟s health-seeking behaviour model of older people. This model describes
older people‟s help seeking behaviours for an illness in four stages:

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 Stage 1: symptom experience and recognition;
Stage 2: symptom appraisal;
Stage 3: decision to seek care;
Stage 4: medical care contact.
Each of these stages represents a potential transition point in older people‟s journey of help-
seeking behaviour and has been used in theoretical discussions about behaviours of older
people with various illnesses, including depression and dementia (Lawrence et al. 2006;
Lawrence et al. 2006; Levkoff, Levy, & Weitzman, 1999). In particular, Levkoff, Levy, and
Weitzman (1999) use these stages to understand how ethnic factors influence help seeking
behaviours in dementia. Table 2 provides a summary of the factors that might affect older
people‟s decisions at each stage.
Table 2: Carer-family related factors in early diagnosis of dementia

Stage Factors related to the older Chinese and

Vietnamese communities

Stage 1: Symptom experience Living arrangement/filial piety

and recognition

Stage 2: symptom appraisal Knowledge of dementia

Interpretations of symptoms of dementia:
normal ageing and mental illness
Perceptions of psychosocial stressors and
personal characteristics

Stage 3: decision to seek care Respect for older people

Definition of self
Perception about local services
Fear of the consequences of a diagnosis

Stage 4: medical care contact Language barriers

Availability of bilingual GPs

Stage 1: Symptom experience and recognition

The first stage, the disease and symptom experience stage, refers to the initial onset of
dementia symptoms that initiate diagnosis seeking behaviours. There is evidence, e.g.,
Levkoff, Levy, and Weitzman (1999) and Ikels ((2002), that most of the dementia
symptoms experienced by people from CALD backgrounds, such as cognitive problems and
behaviour changes, are not different from the symptoms experienced by people from
European backgrounds. However, some recent studies (Shah, 2007; Ajit Shah, Dalvi, &
Thompson, 2005) have found that the types and nature of signs and symptoms of
dementia, in particular, behavioural and psychological symptoms of dementia, may vary
between different ethnic groups. For example, delusions in Nigerians were one fifth of those
of African Americans in Indianapolis, and more common in African compared to white
Americans in dementia care centre groups (Shah, 2005).
In the case of dementia, older people‟s families play an important role in the recognition
process of Stage 1. Many studies have found that, in most cases, it is the family, rather

- 17 -
than the patients themselves or the GPs, that first notice the symptoms of dementia
(Dementia Collaborative Research Centres & The University Newcastle, 2007; Hansen et al.,
2008; Wilkinson et al., 2004). As discussed above, dementia is a progressive disease and
the early signs of dementia are very subtle. It is very difficult for GPs to pick up these subtle
signs of dementia during a brief consultation. Additionally, people with possible dementia
might not have the insight to notice the changes in their cognition or behaviour. These
factors put the family in the central role for early recognition of dementia. However, some
studies have found that families may compensate for older people‟s loss of function in daily
life and that the early symptoms of dementia may be ignored until they significantly affect
an older person‟s ability to function in daily life (Antonelli Incalzi, Marra, Gemma,
Capparella, & Carbonin, 1992; Iliffe et al., 2009). For example, family members often
unconsciously take over social roles from their older relatives, which not only protects the
older person from decompensation in daily life but also delays the recognition of dementia
by offsetting impairments (Iliffe et al., 2009).
This finding is of particular relevance to older Chinese and Vietnamese people due to the
strong influence of Confucianism, filial piety. Obedience, devotion and care towards one‟s
parents and older family members is regarded as one of the main components in an
individual‟s morality. Although filial piety can take many forms, at the most basic level,
children should provide material support and daily care for their older parents (Ikels, 2002).
As a result, older Chinese and Vietnamese people, with or without a spouse, tend to live in a
multi-generational environment with their children and receive daily care from their children
(Alzheimer‟s Australia Victoria, 2008a; Ikels, 2002). In contrast, the majority of people in
Western countries are more likely to live independently from their children, which requires
higher levels of functioning in activities of daily life and makes it easier to notice the
changes in older people‟s cognition and behaviour (Ikels, 2002). From this perspective, the
higher percentage of co-residence and the higher level of help that older Chinese and
Vietnamese people receive from their children might adversely affect the family‟s ability to
notice the early symptoms of dementia, and result in delayed diagnosis of dementia in these
two groups. It is not clear what the effect of migration is on these patterns.
Stage 2: Symptom appraisal
The second stage, the symptom appraisal stage, is when older people and their families
evaluate and interpret the experience of the illness. There are different ways that older
people and their families might attribute the symptoms of dementia. The first possibility is
that older people and/or their families correctly attribute these symptoms to dementia.
However, this requires some knowledge of dementia, and evidence suggests that
community knowledge about dementia and its causes and symptoms is lacking (Boise,
Morgan et al., 1999; Bradford et al., 2009). This is particularly true for older people from
CALD backgrounds (Alzheimer‟s Australia Victoria, 2008b), including older Chinese and
Vietnamese people and their families and carers (Alzheimer‟s Australia Victoria, 2008a).
Viewing the symptoms of early dementia as part of “normal ageing” is probably the most
common interpretation across different cultures. This perception has been found in studies
with the general population (Bradford et al., 2009; Iliffe et al., 2003; Iliffe et al., 2009;
Valcour, Masaki, Curb, & Blanchette, 2000; Vernooij-Dassen et al., 2005) and different
CALD groups (The Cultural and Indigenous Research Centre Australia, 2008). In particular,
there is evidence that this perception is prevalent in the Chinese and the Vietnamese
communities (Alzheimer‟s Australia Victoria, 2008a; Sue Levkoff et al., 1999; Liu, Hinton,
Tran, Hinton, & Barker, 2008; Sims et al., 1999). A recent study by Alzheimer‟s Australia
Victoria (2008a) found that the symptoms of dementia are not recognised by older Chinese
and Vietnamese people as an illness and that these symptoms are most commonly
considered a normal part of ageing. One implication of this view is that no treatment or help
will be sought or perceived as required (Mackenzie, Bartlette, & Downs, 2005). This
inaccurate perception of normal ageing is an important factor in a delayed diagnosis of

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dementia (Bradford et al., 2009; Iliffe et al., 2003; Iliffe et al., 2009; Valcour et al., 2000;
Vernooij-Dassen et al., 2005).
The symptoms of dementia might also be interpreted as a type of mental illness (Mackenzie
et al., 2005). Studies with the Chinese and the Vietnamese communities in Victoria
(Alzheimer‟s Australia Victoria, 2008a; Liu et al., 2008) have found that this perception of
dementia is prevalent in some sections of these communities. Mental illness is extremely
stigmatised in these two cultures (Liu et al., 2008). Furthermore, the stigma not only
adversely affects older people with dementia, but extends to the family of the older person
(Liu et al., 2008; Mackenzie et al., 2005). Shame and “loss of face” are two common
experiential themes for family carers of people with dementia in these two cultures (Liu et
al., 2008). The tendency to view dementia as a type of mental illness has a major
implication for older people‟s health-seeking behaviour. Due to feelings of shame and “loss
of face”, older people and their families often try to conceal the symptoms (Liu et al., 2008;
Mackenzie et al., 2005). They are also more likely to be socially isolated and to approach a
therapist in traditional medicine rather than a GP to seek advice and help (Liu et al., 2008;
Mackenzie et al., 2005).
Many older Chinese and Vietnamese carers might also attribute dementia to psychosocial
stressors (i.e. earlier traumatic experience, migration, intergenerational conflict) and
personal characteristics (i.e. personality and substance abuse) (Liu et al., 2008). These
perceptions also delay people‟s help seeking behaviour, because people with dementia are
often associated with varying degrees of individual incapacity and moral failure (Levkoff et
al., 1999; Liu et al., 2008).
Stage 3: Decision to care
After the individual interprets his/her symptoms, he/she needs to decide whether or not to
seek care from a health care provider.
As discussed above, older people and their families‟ perceptions of dementia will affect their
decision to seek advice. For example, if the symptoms are considered a normal part of
ageing, this means that the person and the family are less likely to seek help.
Other factors relevant to Chinese and the Vietnamese cultures that might affect people‟s
decisions to seek help relate to the respect for older adults in these two cultures (Ikels,
2002; Liu et al., 2008). Due to the influence of Confucianism, respect and care for parents
is regarded as the centrepiece of an individual‟s morality in these two cultures. Therefore,
even when the family notices changes in an older person and thinks they might be
symptoms of dementia, families may feel it is disrespectful to tell the older person they
might have dementia and that they need to go to see the GP (Alzheimer‟s Australia Victoria,
2008a). In the Chinese and Vietnamese cultures, there is a strong cultural attitude towards
care giving and it is often perceived as the family‟s responsibility to care for the older
person (Alzheimer‟s Australia Victoria, 2008a; Ikels, 2002; Liu et al., 2008; Sims et al.,
1999; The Cultural and Indigenous Research Centre Australia, 2008). To seek help outside
the family might not be viewed as appropriate (The Cultural and Indigenous Research
Centre Australia, 2008).
Another factor relevant to these two groups is the Confucian concept of the self. According
to Confucians, social relationships rather than cognition are the most important factors in
the definition of self (Ikels, 2002). Therefore, the early signs of dementia, the initial
memory problems, are “less salient and less significant for contemporary elderly Chinese
and their family members than the later stages of personality change that disrupt the
correct performance of social roles” (Ikels, 2002). From this perspective, older people and
their families might notice the early signs of dementia but not consider it a serious issue
and therefore not seek a diagnosis from their GPs.

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Similar to GPs‟, older people and their families‟ perceptions about local services for people
with dementia might also influence their decision to seek a diagnosis (Boise, Morgan et al.,
1999). For people from CALD backgrounds, lack of awareness and lack of culturally
appropriate services might be an important factor in the delay of diagnosis (Alzheimer‟s
Australia Victoria, 2008b), because older people and their families may think that there is
no help available or the help is not culturally appropriate. Furthermore, there is clear
evidence that older people have a strong desire to sustain autonomy (Boise, Morgan et al.,
1999) and to stay at home as long as possible (The Cultural and Indigenous Research
Centre Australia, 2008). Therefore, the fear of the consequences of a diagnosis (Antonelli
Incalzi et al., 1992), such as losing control of their life and entering residential aged care,
might also contribute to the decision to not seek a diagnosis of dementia.
Stage 4: Medical care contact
Contact with medical professionals, the final stage, occurs after the decision to obtain help
is made. Levkoff et al. (1999) identified language as a key barrier for older Chinese people
with dementia. Studies have found that there is not only a lack of English language
proficiency but also low literacy levels in their first language among the older Chinese and
Vietnamese groups (Alzheimer‟s Australia Victoria, 2008a, 2008b; The Cultural and
Indigenous Research Centre Australia, 2008). Therefore, many older people often rely on
children for contacting and communicating with health professionals (Alzheimer‟s Australia
Victoria, 2008a, 2008b; The Cultural and Indigenous Research Centre Australia, 2008).
However, due to work and other family commitments, children might not always be
available to do this (The Cultural and Indigenous Research Centre Australia, 2008).
Furthermore, the use of informal interpreters such as a family member might also be
“dangerous” in health care settings, because of personal interpretations of the situation.
Children may also wish to protect their parents from bad news or to conceal embarrassing
personal issues (Szczepura et al., 2005). A survey with Australian GPs found that it is
uncommon for GPs to use formal interpreters for patients from CALD backgrounds and that
about one-third of GPs reported that they would not arrange an interpreter even if asked to
do so (Bird, 2008). As a result, older people from CALD backgrounds rely heavily on
bilingual GPs for their primary care (Alzheimer‟s Australia Victoria, 2008a) and the
availability and location of bilingual GPs becomes an important factor in early diagnosis of
dementia for these cultural groups.
Summary
A range of GP and patient/family related factors impact on the early diagnosis of dementia.
GPs are uncertain about the diagnosis of dementia, due to the complex nature of dementia,
limited education about the condition and the full range of screening tools available. GPs are
also dubious about the benefits of early diagnosis, because of therapeutic nihilism, concerns
about the impact of the diagnosis on people with dementia, views about local dementia
services, perceptions that physical problems take precedence over cognitive problems, and
ageist attitudes. Lack of time and disclosure difficulties also contribute to under-diagnosis of
dementia in primary care.
For older people and their families, their journey to seeking a diagnosis of dementia involves
four stages: symptoms experience and recognition, symptoms appraisal, decision to seek
care and contacting health professionals. There are many factors, particularly important to
older Chinese and Vietnamese people and their family, that impact on this journey,
including living arrangement, knowledge of dementia, interpretations of the symptoms of
dementia, respect for older people, definition of the self, language barriers and availability
of bilingual GPs.
These findings, related to GP and patient/family barriers, informed the development of the
two education programs for the current project. For GPs, education programs/guidelines
need to include information on the many benefits of early diagnosis of dementia to improve

- 20 -
their attitudes towards early diagnosis and information about the most appropriate tools to
use. Programs also need to consider the various perceptions of dementia among the two
groups and include information on culturally appropriate services to enhance GPs and older
people‟s perceptions about the benefits of diagnosis. The following section related to the
characteristics of effective education programs also informed the development of the
education programs.

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5. Effective education programs for GPs
This component of the review aimed to identify effective training strategies for health
professionals, with a focus on education of GPs and education in the area of dementia. The
review identified few articles focusing on education programs for health professionals
working with people from CALD backgrounds and the chapter is mainly drawn from the
literature regarding the general population.
Characteristics of effective education programs for GPs
NARI has recently completed a project for the Victorian Department of Human Services to
develop education strategies to support the implementation of the Council of the Australian
Governments Long Stay Older Patients (COAG LSOP) Initiative (Cyarto, Dow, Hempton,
Renehan, & Jones, 2009). This project included a literature review on key characteristics of
effective education and training programs for health service staff and the findings of this
review are categorised into three groups:
General characteristics of education programs (focusing on education methods);
Detailed aspects of education programs (focusing on content of the education
programs); and
Factors external to the education program itself (focusing on organisational factors).
In terms of educational methods, the review found that active techniques such as
interactive workshops, small group activities, role modelling and one-on-one training, are
successful education strategies (Cyarto et al., 2009). Multi-faceted education programs such
as a program consisting of a lecture, group discussion and analysis of case studies, are
more successful than single-faceted programs (Cyarto et al., 2009). The use of passive
strategies, such as didactic, instructive lectures, handouts or clinical guidelines, were not
effective when used alone, but can be a useful component of an education program (Cyarto
et al., 2009). Computer-based education is another possible option for health professionals
and has many advantages over instructor-led sessions, such as easier access and greater
flexibility (Cyarto et al., 2009).
In terms of content, problem-based learning, where the education materials are presented
in a format that involves solving a problem or finding a solution to an issue, are successful
education strategies for health professionals (Cyarto et al., 2009). Education programs are
also more likely to be successful if the materials are presented in a local context and
provide feedback to participants (Cyarto et al., 2009).
Factors external to the education program that increase the likelihood of success include
strong leadership support, a health service culture that supports practice change and
education, and providing continuous education to staff with follow-up sessions (Cyarto et
al., 2009).
These findings are supported by other reviews in this area. Davis et al. (1999) reviewed the
effect of continuing medical education on physician performance and health care outcomes
in 14 studies. This review found that an exclusively didactic education method had little or
no effect on physicians‟ performance. In contrast, education programs that used interactive
strategies, such as case study, role-play, or hands-on practice sessions, are more effective
in changing physicians‟ performance. Longitudinal education programs which provide “learn-
work-learn” opportunities and which incorporate enabling strategies to facilitate
implementation of changes in practice also appear to be effective.
Cauffman et al. (2002) conducted a review of 20 randomised controlled trials evaluating
continuing medical education. This paper also found that the use of interactive and multiple
education methods are important characteristics of a successful education program. The use
of printed and graphic materials with a personal explanation and using locally respected

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health experts as educators also increased the likelihood of success of an education
program.
Characteristics of effective dementia education programs for GPs
The literature on dementia education for GPs is consistent with the findings of the general
characteristics of a successful education program. Rampatige, Dunt, Doyle, Day, and van
Dort (2009) reviewed the effect of continuing professional education on improving dementia
care outcomes. This review found that the most effective education methods for GPs are
those using intensive, interactive and multiple education methods.
Boise (2006) identified some challenges to improving dementia care through GP education,
such as, GPs‟ attitudes towards dementia, lack of time and other constraints in the primary
care setting. The study proposed that an effective dementia education program for GPs
should not only present sound evidence-based knowledge on diagnosis and management of
dementia, but also incorporate practical strategies to overcome these barriers. In terms of
education strategies, the paper suggested that “utilizing well-respected and credible
sponsors (educators) and incorporating tools and practice recommendations that can be
implemented within the primary care setting are two essential ingredients of effective
dementia education programs” (Boise, 2006).
Downs et al. (2006) used a cluster randomised controlled study to investigate the
effectiveness of different types of education interventions in improving detection and
management of dementia in primary care. These interventions included an electronic
tutorial carried on a CD Rom, decision support software built into the electronic medical
record, and practice-based workshops. This study found that decision support systems and
practice-based workshops are effective educational approaches in improving dementia
detection among GPs.
Cherry, Hahn, and Vickrey (2009) discussed two completed projects that used evidence-
based clinical practice guidelines to train GPs in the identification, diagnosis and
management of dementia. These studies also used innovative strategies, including GP
education (detailed below) and the introduction of dementia care managers, to help GPs
implement the guidelines. Both studies reported improvements in dementia care, including
an increase in the use of recommended tests and referrals to the Alzheimer‟s Association.
The second study found that the dementia care management component was a stronger
predictor of quality care than the GP education component. However, it is important to note
that the education component in this study was much simpler than that of the first one and
only consisted of education seminars and group discussions. In contrast, the training in the
first study was reinforced through educational detailing, tool kits, checklists and other
strategies. The results of these studies suggested that the training of GPs alone is not
sufficient to implement guidelines. Most importantly, training of GPs needs to be reinforced
through multiple strategies and endorsement from organisational leadership.
Lombardo, Wu, Hohnstein, and Chang (2002) reported a successful dementia education
course for Chinese American health care professionals. The course was developed by
academic researchers, executives of community service providers and consultants from
Alzheimer‟s agencies through a series of meetings. The aim of the course was to train
bilingual health care providers to identify, assess and service people with dementia and
their families, as well as to raise awareness of dementia in the Chinese American
communities. This course was based on the “Train the Trainer” program, which was a
training program focused on dementia awareness and services for African Americans.
Participants for this program were executives and staff of the service providers involved in
the development in the course. The course was perceived by the participants as highly
useful in both their professional and personal lives. At the ten-month follow-up, the study
found that the participants helped over 70 families and reached over 400 people in their

- 23 -
communities through presentations or workshops. The study attributed the success of the
program to four factors:
Comprehensive education components;
The use of train the trainer design;
Mutuality of exchanges of information, empowerment and resources among the
researchers, community agency and mainstream Alzheimer‟s agency; and
Two-way communication throughout the training course.
Other factors identified that may have contributed to the success of the program included:
class planning at a convenient time for the staff, offering the Dementia Specialist Certificate
on completion, and providing nurse and social work Continuing Education points. Based on
the participant feedback the study also provided recommendations for further
improvements, including:
Creating Continuing Education and Peer-Support services after the completion of the
course;
Providing information on alternative treatments for dementia;
Using more case studies in the course.
Summary
The use of intensive, interaction and multiple strategies are important characteristics of an
effective GP education program in dementia. The use of a problem-focused approach and
locally respected health experts as educators also increase the likelihood of the success of
an education program. In terms of content, the education program needs to prepare
materials in a local context and incorporate practical strategies to overcome the barriers
GPs might experience in this area. These characteristics were built into the education
program for GPs developed as part of this project.

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6. Effective education programs for
older people from CALD backgrounds
There are many community education projects for people from CALD backgrounds reported
in the literature, however, these projects are of varying quality and their outcomes are often
not evaluated. Therefore, this section focuses on review articles in community education
strategies and not individual projects.
Characteristics of effective education programs for older people from CALD
backgrounds
Angus, Feldman, and Sims (2006) completed a scoping study for Alzheimer‟s Australia to
identify and evaluate community education strategies that might be used in a dementia risk
reduction program by Alzheimer‟s Australia. This study involved a comprehensive literature
review on community education strategies for the prevention of chronic conditions such as
heart disease and diabetes. A key finding is the importance of engaging the target group in
the development of community education programs. Some key recommendations from this
study are:
The need to engage peak bodies, target community groups and volunteers from the
community in the development of community education strategies;
Mass media is likely to be most effective when complemented by efforts enabling
behaviour change, such as increasing access to health services;
Education materials should be developed and pilot tested with target communities;
Materials for CALD groups should use simple and culturally appropriate language;
Materials for people from CALD backgrounds should be provided in both English and
their own language so that they can learn English words for key terms.
Szczepura et al. (2005) conducted a review of the research evidence on ethnicity and
communication in healthcare. The review proposed that “effective communication is central
to safeguarding the quality of health care” , particularly for people from CALD backgrounds.
The paper reviewed various areas of communication in healthcare for people from CALD
backgrounds, such as translation of materials and providing interpreter services. Some
relevant key findings from the health promotion area of this study include:
Education needs to shift from “printed materials and passive dissemination towards
audio-visual presentation and active engagement” with CALD communities;
Single technological approaches may prove ineffective, particularly for people from
CALD backgrounds;
Communication needs not only an appropriate message and communication channel,
but also the active involvement of community agencies in spreading the message
and initiating the action;
The messenger is as important as the message itself. Working through health
experts, religious leaders and community leaders may raise acceptance of the
message;
For Asian people, video and verbal presentations are considered the most effective
format for information dissemination.
Bronheim and Sockalingam (2003), from the US National Center for Cultural Competence,
published a guide on how to choose and adapt culturally and linguistically competent health
promotion materials. The paper highlighted the importance of “honoring traditions and
beliefs of the intended audience, while recognising that some of those beliefs and practices

- 25 -
may not be congruent with emerging knowledge of what supports healthy outcomes” . It
also emphasised that health promotion efforts need to take the social, environmental and
political context into consideration. For example, the economic status of participants,
availability of community health supports and access to public transport can affect health
promotion efforts. Similar to Angus, Feldman and Sims (2006), this article highlighted the
importance of involving community members and key stakeholders in the health promotion
process. The authors proposed a ten-step model for choosing and adapting culturally and
linguistically competent health promotion materials:
1. Determine the need for the health promotion effort and materials to support it;
2. Identify and engage key community partners;
3. Determine the focus and intended audience for the health promotion effort and the
materials to support it;
4. Understand the intended audience;
5. Determine the mode of delivery;
6. Create criteria for choosing health promotion materials;
7. Gather and review existing materials;
8. Elicit reactions from the intended audience;
9. Develop and implement a plan for dissemination;
10. Create a mechanism for periodic review and modification.
NARI has recently completed a project that aimed to improve the availability and access to
quality assurance related information for community aged care consumers. This project
included a literature review on information provision to older people in the community. It
concluded that to provide information to older people, the service providers not only need to
consider the factors that influence older people‟s ability to obtain useful information, such as
literacy levels, sensory deficits, cognitive abilities and mobility problems, but also the
factors that influence the quality of the information provided, for example, modes of
information (oral vs. written information), readability, design and writing of information
(Moore, Dow, Vrantsidis, & Lin, 2009). This review also highlighted the importance of
involving older people at each stage of information provision, including design, production,
dissemination and evaluation (Moore et al., 2009). This review found that face-to-face
contact is the preferred means of receiving health information for older people. However,
older people still desired information in other formats, such as written material so they can
refer back to the information when needed. Readability and other characteristics that make
information easy or hard to understand are also key factors in information provision. The
review found that the readability levels of health information often exceeds the reading
ability of older people and suggested that materials be prepared at a grade five to six level
despite their cultural background to make the information easily understood by most health
consumers (Moore et al., 2009). Some recommendations about improving readability:
Key messages be highlighted and repeated with visual cues such as italics, bold text,
and boxes;
Use bigger font;
Use short sentences;
Use active rather than passive voice (Moore et al., 2009).
For people from CALD backgrounds, the review identified limited English competence as a
major barrier. Although providing information in their preferred languages is the most often
mentioned strategy, it is also important to include them in the process of information

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production. It was found that partnerships with the CALD community help to modulate the
protocols used in producing resources, the resource contents, and the provision of the
resources (Moore et al., 2009).
Characteristics of effective education programs for older people from Chinese and
Vietnamese backgrounds
Yang, Haralambous, Angus, and Hill (2008) explored the information needs of older Chinese
Australians in falls prevention. Focus groups were conducted with Chinese older people.
Participants reported that medical doctors were the main information source and there was
a clear preference for information in their first language. It was suggested by the
researchers that the local ethnic media, such as newspapers and radio, could be key
avenues in delivering health related information. In addition, participants preferred to
receive information locally, in places like local shops, medical clinics and their local
community which they visited regularly.
Similarly, research by the Cultural and Indigenous Research Centre found that GPs were the
most important point of contact for people seeking a diagnosis of dementia (The Cultural
and Indigenous Research Centre Australia, 2008). GPs play an important role in information
provision for people from CALD backgrounds. They are highly regarded as “professional”
and “trust worthy” (The Cultural and Indigenous Research Centre Australia, 2008) and are a
main contact for information and advice about dementia. In most cases the GP is from the
same cultural and language background to the person with dementia (The Cultural and
Indigenous Research Centre Australia, 2008). People from CALD backgrounds might also
access information from language specific organisations, Alzheimer‟s Australia and ethnic
media, such as community newspapers and ethnic radio programs (Alzheimer‟s Australia
Victoria, 2008b; Sims et al., 1999; The Cultural and Indigenous Research Centre Australia,
2008). Although written information about dementia is valued, there is a clear preference
for oral information in the older Chinese and Vietnamese groups (Alzheimer‟s Australia
Victoria, 2008a, 2008b).
Summary
Strategies for effective community education for older people from CALD backgrounds
identified in the literature include involving the target community in every stage of the
education program; providing oral information and information in the person‟s own
language. GPs, local community centres and ethnic media, such as ethnic radio and
community newspapers, are important avenues in delivering information in these
communities. These characteristics of education programs for older people from CALD
backgrounds were built into the community education program developed as part of this
project.

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7. Conclusion
There is evidence that dementia is under-diagnosed and diagnosed at a late stage in
primary care. This is particularly true for older people from CALD backgrounds who present
to health professionals at a later stage of diagnosis and often in crisis mode.
Factors found to contribute to this delayed, or missed, diagnosis include both GP and
patient/family related barriers. GPs are uncertain about the diagnosis of dementia, due to
the complex nature of dementia, limited education about this condition and the available
screening tools. GPs are also dubious about the benefits of early diagnosis, because of
therapeutic nihilism, concerns about the impact of the diagnosis on people with dementia,
views about local dementia services, perceptions that physical problems take precedence
over cognitive problems, and ageist attitudes. Lack of time and disclosure difficulties also
contribute to under-diagnosis of dementia in primary care.
For older people and their families, there are many factors that are particularly important to
older Chinese and Vietnamese people and their families in their journey to seek a diagnosis.
This includes: living arrangement, knowledge of dementia, interpretations of the symptoms
of dementia, respect for older people, definition of the self, language barriers and
availability of bilingual GPs.
This review also investigated the characteristics of effective education programs for GPs and
older people in the community. For GPs, they included the use of intensive, interactive and
multiple strategies, the use of a problem-focused approach and locally respected health
experts as educators. For people from CALD backgrounds, there is a clear message from the
literature that involving the target community in every stage of the education program was
vital for the success of the program. There is also a clear preference for oral information and
information in the person‟s own language. GPs, local community centres and ethnic media,
such as ethnic radio and community newspapers, are important avenues in delivering
information in these communities.
These characteristics of education programs for GPs and older people from CALD
backgrounds were built into the two education programs that were developed as part of this
project. For GPs, information was included on the many benefits of early diagnosis to
improve attitudes towards early diagnosis of dementia and information about the most
appropriate tools to use. Both programs considered the various perceptions of dementia
among the two groups and included information on culturally appropriate services to
enhance GPs‟ and older people‟s perceptions about the benefits of diagnosis.

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8. References
Access Economics. (2006). Dementia prevalence and incidence among Australians who do
not speak English at home: Access Economics Pty Limited for Alzheimer's Australia.
Access Economics. (2009). Keeping dementia front of mind: incidence and prevalence 2009-
2050: Access Economics Pty Limited for Alzheimer's Australia.
Alzheimer‟s Australia. (2005a). About dementia 1.1: What is dementia. Retrieved 20th
January, 2010, from http://www.alzheimers.org.au/content.cfm?infopageid=326
Alzheimer‟s Australia. (2005b). About dementia 1.2: Diagnosing dementia. Retrieved 20th
January, 2010, from http://www.alzheimers.org.au/content.cfm?infopageid=326
Alzheimer‟s Australia. (2007). Early diagnosis of dementia Alzheimer’s Australia Paper 10.
Retrieved 20th January, 2010, from
http://www.alzheimers.org.au/content.cfm?infopageid=4384#pri
Alzheimer‟s Australia Victoria. (2008a). Perceptions of dementia in ethnic communities.
Melbourne.
Alzheimer‟s Australia Victoria. (2008b). Perceptions of dementia in ethnic communities:
Project Report. Melbourne.
Angus, J., Feldman, S., & Sims, J. (2006). Dementia Risk Reduction Community Education
Strategies Scoping Project - Report to Alzheimer’s Australia Vic. Melbourne.
Antonelli Incalzi, R., Marra, C., Gemma, A., Capparella, O., & Carbonin, P. (1992).
Unrecognised dementia: Sociodemographic correlates. Aging (Milano), 4, 327-332.
Australian Bureau of Statistics. (2004). 4827.0.55.001 - The Health of Older People,
Australia, 2001 Canberra.
Australian Bureau of Statistics. (2006). 4833.0.55.001 - Health of Older People in Australia:
A Snapshot, 2004-05. Canberra.
Australian Bureau of Statistics. (2007). Australians overall claim more than 250 ancestries,
speak 400 languages at home: Census. In A. B. o. Statistics (Ed.). Canberra.
Australian Bureau of Statistics. (2009). 3412.0 Migration Australia 2007-2008 Canberra:
Australian Bureau of Statistics.
Bamford, C., Lamont, S., Eccles, M., Robinson, L., May, C., & Bond, J. (2004). Disclosing a
diagnosis of dementia: a systematic review. International Journal of Geriatric
Psychiatry, 19(2), 151-169.
Bird, S. (2008). Lost without translation. Australian Family Physician, 37, 1023-1024.
Black, K., Osborne, D., & Lindeman, M. (2004). Access to Local Government HACC services
for people speaking a language other than English at home. Australian Journal of
Primary Health 10, 9-15.
Boise, L. (2005). Improving dementia through physician education: some challenges.
Clinical Gerontologist, 29(2), 3-10.
Boise, L. (2006). Improving dementia through physician education: some challenges.
Clinical Gerontologist, 29(2), 3-10.
Boise, L., Camicioli, R., Morgan, D. L., Rose, J. H., & Congleton, L. (1999). Diagnosing
dementia: Perspectives of primary care physicians. Gerontologist, 39, 457-464.

- 29 -
Boise, L., Morgan, D. L., Kaye, J., & Camicioli, R. (1999). Delays in the diagnosis of
dementia: Perspectives of family caregivers. American Journal of Alzheimer's Disease
and Other Dementias, 14(1), 20-26.
Boustani, M., Peterson, B., Hanson, L., Harris, R., & Lohr, K. N. (2003). Screening for
dementia in primary care: a summary of the evidence for the U.S. Preventive
Services Task Force. Annals of Internal Medicine, 138, 927 - 937.
Bradford, A., Kunik, M. E., Schulz, P., Williams, S. P., & Singh, H. (2009). Missed and
delayed diagnosis of dementia in primary care: prevalence and contributing factors.
Alzheimer Disease & Associated Disorders, 23, 306-314.
Brodaty, H. (2006). 10 Reasons Why an Early Diagnosis of Dementia is Important. Life,
April, 10.
Bronheim, S., & Sockalingam, S. (2003). A guide to choosing and adapting culturally and
linguistically competent health promotion materials. Washington, D.C.: National
Center for Cultural Competence, Georgetown University Center for Child and Human
Development.
Cahill, S., Clark, M., Walsh, C., Connell, H. O., & Lawlor, B. (2006). Dementia in primary
care: the first survey of Irish general practitioners. International Journal of Geriatric
Psychiatry, 21, 319-324.
Cauffman, J. G., Forsyth, R. A., Clark, V. A., Foster, J. P., Martin, K. J., Lapsys, F. X., et al.
(2002). Randomized controlled trials of continuing medical education: what makes
them most effective? Journal of Continuing Education in the Health Professions, 22,
214 - 221.
Cheng, A., Cruysmans, B., Draper, B., Hayward-Wright, N., Jeon, Y., LoGiudice, D., et al.
(2009). Report on strategic directions in CALD dementia research in Australia.
Sydney: Dementia Collaborative Research Centres - The University of New South
Wales.
Cherry, D. L., Hahn, C., & Vickrey, B. G. (2009). Educating primary care physicians in the
management of Alzheimer's disease: using practice guidelines to set quality
benchmarks. International psychogeriatrics, 21(SupplementS1), S44-S52.
Cyarto, E., Dow, B., Hempton, C., Renehan, E., & Jones, C. (2009). Education Strategy to
support implementation of the COAG LSOP Initiative: Implementation Resource
Toolkit. Melbourne: National Ageing Research Institute for Victorian Department of
Human Services.
Davis, D., O'Brien, M. A., Freemantle, N., Wolf, F. M., Mazmanian, P., & Taylor-Vaisey, A.
(1999). Impact of formal continuing medical education: do conferences, workshops,
rounds, and other traditional continuing education activities change physician
behavior or health care outcomes? Journal Of the American Medical Association, 282,
867 - 874.
De Lepeleire, J., Wind, A. W., Iliffe, S., Moniz-Cook, E. D., Wilcock, J., González, V. M., et
al. (2008). The primary care diagnosis of dementia in Europe: An analysis using
multidisciplinary, multinational expert groups. Aging & Mental Health, 12(5), 568-
576.
Dementia Collaborative Research Centres, & The University Newcastle. (2007). Dementia
focus group report.
Department of Immigration and Multicultural Affairs. (2001). Immigration: Federation to
Century’s End. Canberra: Department of Immigration and Multicultural Affairs.

- 30 -
Derksen, E., Vernooij-Dassen, M., Gillissen, F., Olde, R. M., Scheltens, P., . Aging Ment
Health , et al. (2006). Impact of diagnostic disclosure in dementia on patients and
carers: qualitative case series analysis. Aging & Mental Health, 10, 525-531.
Downs, M., Turner, S., Bryans, M., Wilcock, J., Keady, J., Levin, E., et al. (2006).
Effectiveness of educational interventions in improving detection and management of
dementia in primary care: cluster randomised controlled study. British Medical
Journal, 332(7543), 692-696.
Garcis-Peltoneiemi, R. E. (1987). Psychopathology in refugees. Rockville, MD: National
Institute of Mental Health.
Gibson, D., Braun, P., Benham, C., & Mason, F. (2001). Projections of Older immigrants:
people from culturally and linguistically diverse backgrounds, 1996-2026. Canberra:
Australia Institute of Health and Welfare.
Guo, X. (2005). Immigrating to and ageing in Australian: Chinese experiences. Unpublished
PhD, Murdoch University, Perth.
Hansen, E. C., Hughes, C., Routley, G., & Robinson, A. L. (2008). General practitioners‟
experiences and understandings of diagnosing dementia: Factors impacting on early
diagnosis. Social Science & Medicine, 67, 1776-1783.
Hofman, A., Rocca, W. A., Brayne, C., Breteler, M. M. B., Clarke, M., Cooper, B., et al.
(1991). The prevalence of dementia in Europe:A collaborative study of 1980-1990
findings. International Journal of Epidemiology, 20(3), 736-748.
Ikels, C. (2002). Constructing and deconstructing the self: Dementia in China. Journal of
Cross-Cultural Gerontology, 17, 233-251.
Iliffe, S., De Lepeleire, J., van Hout, H., Kenny, G., Lewis, A., & Vernooij-Dassen, M. (2005).
Understanding obstacles to the recognition of and response to dementia in different
European countries: A modified focus group approach using multinational, multi-
disciplinary expert groups. Aging & Mental Health, 9(1), 1-6.
Iliffe, S., Manthorpe, J., & Eden, A. (2003). Sooner or later? Issues in the early diagnosis of
dementia in general practice: a qualitative study. Family Practice, 20(4), 376-381.
Iliffe, S., Robinson, L., Brayne, C., Goodman, C., Rait, G., Manthorpe, J., et al. (2009).
Primary care and dementia: 1. diagnosis, screening and disclosure. International
Journal of Geriatric Psychiatry, 24(9), 895-901.
Iliffe, S., & Wilcock, J. (2005). The identification of barriers to the recognition of, and
response to, dementia in primary care using a modified focus group approach.
Dementia, 4, 73-85.
Johnstone, M., & Kanitsaki, O. (2008). Ethnic aged discrimination and disparities in health
and social care: A question of justice? Australian J Ageing, 27, 110-115.
Lawrence, V., Banerjee, S., Bhugra, D., Sangha, K., Turner, S., & Murray, J. (2006). Coping
with depression in later life: A qualitative study of help-seeking in three ethnic
groups. Psychological Medicine, 1375-1383.
Lawrence, V., Murray, J., Banerjee, S., Turner, S., Sangha, K., Byng, R., et al. (2006).
Concepts and Causation of Depression: A Cross-Cultural Study of the Beliefs of Older
Adults. The Gerontologist, 46, 23-32.
Leifer, B. P. (2003). Early Diagnosis of Alzheimer's Disease: Clinical and Economic Benefits.
Journal of the American Geriatrics Society, 51(5s2), S281-S288.
Levkoff, S., Cleary, P., Wetle, T., & Besdine, R. W. (1988). Illness behavior in the aged:
Implications for clinicians. Journal of the American Geriatrics Society, 36, 622-629.

- 31 -
Levkoff, S., Levy, B., & Weitzman, P. F. (1999). The role of religion and ethnicity in the help
seeking of family caregivers of elders with Alzheimer‟s disease and related disorders.
Journal of Cross-Cultural Gerontology, 14, 335-356.
Lister, S., & Benson, C. (2006). Comparative analysis of dementia and ethnicity in the NSW
Aged Care Assessment Program. Australian J Ageing, 25, 24-30.
Liu, D., Hinton, L., Tran, C., Hinton, D., & Barker, J. C. (2008). Reexamining the
Relationships Among Dementia, Stigma, and Aging in Immigrant Chinese and
Vietnamese Family Caregivers. Journal of Cross-Cultural Gerontology, 23, 283-299.
LoGiudice, D., Hassett, A., Cook, R., Flicker, L., & Ames, D. (2001 ). Equity of access to a
memory clinic in Melbourne? Non-English speaking background attenders are more
severely demented and have increased rates of psychiatric disorder. International
Journal of Geriatric Psychiatry, 16, 327-334.
Lombardo, N. B. E., Wu, B., Hohnstein, J. K., & Chang, K. (2002). Chinese dementia
specialist education program: training Chinese American health care professionals as
dementia experts. Home Health Care Services Quarterly, 21, 67-86.
Mackenzie, J., Bartlette, R., & Downs, M. (2005). Moving towards culturally competent
dementia care: have we have been barking up the wrong tree? Reviews in Clinical
Gerontology, 15, 39-46.
May, T. (1993). Social research: Issues, methods and process. Buckingham: Open
University Press.
Milne, A. J., Hamilton-West, K., & Hatzidimitriadou, E. (2005). GP attitudes to early
diagnosis of dementia: evidence of improvement. Aging & Mental Health, 9, 449 -
455.
Moore, K., Dow, B., Vrantsidis, F., & Lin, X. (2009). Consumer information for aged care in
the community: Phase 1 - Final Report. Melbourne: National Ageing Research
Institute for the Australian Government Department of Health and Ageing.
Museum of Chinese Australian History Inc. History. Retrieved 15th February, 2010, from
http://www.chinesemuseum.com.au/history.html
Museum Victoria Australia. History of immigration from Vietnam Retrieved 15th February,
2010, from http://museumvictoria.com.au/origins/history.aspx?pid=97
National Seniors Productive Ageing Centre. (2011). The Ageing Experience of Austrlaians
from Migrant Backgrounds: National Seniors Australia.
Perry, M., Draskovic, I., van Achterberg, T., Borm, G. F., van Eijken, M. I. J., Lucassen, P.
L., et al. (2008). Can an EASYcare based dementia training programme improve
diagnostic assessment and management of dementia by general practitioners and
primary care nurses? The design of a randomised controlled trial. BMC Health
Services Research, 8(1), 71.
Pimlott, N. J. G., Persaud, M., Drummond, N., Cohen, C. A., Silvius, J. L., Seigel, K., et al.
(2009). Family physicians and dementia in Canada: Part 2. Understanding the
challenges of dementia care. Canadian Family Physician, 55(5), 508-5097.
Rampatige, R., Dunt, D., Doyle, C., Day, S., & van Dort, P. (2009). The effect of continuing
professional education on health care outcomes: lessons for dementia care.
International psychogeriatrics, 21(SupplementS1), S34-S43.
Renshaw, J., Scurfield, P., Cloke, L., & Orrell, M. (2001). General practitioners' views on the
early diagnosis of dementia. The BritishJournal of General Practice, 51, 37 - 38.

- 32 -
Shah, A. (2007). Can the recognition of clinical features of mental illness at clinical
presentation in ethnic elders be improved? International Journal of Geriatric
Psychiatry, 22, 277-282.
Shah, A., Dalvi, M., & Thompson, T. (2005). Behavioural and psychological signs and
symptoms of dementia across cultures: current status and the future. International
Journal of Geriatric Psychiatry, 20(12), 1187-1195.
Sims, J., Nguyen, H., LoGiudice, D., & Smith, R. (1999). Dementia care in the Vietnamese
community. Melbourne: National Ageing Research Institute for Victorian Department
of Human Services.
Szczepura, A., Johnson, M., Gumber, A., Jones, K., Clay, D., & Shaw, A. (2005). An
overview of the research evidence on ethnicity and communication in healthcare:
final report. Coventry: Warwick University, Commissioned by the Department of
Health.
The Cultural and Indigenous Research Centre Australia. (2008). CALD dementia strategic
model: Literature review, report, model. Sydney: New South Wales Department of
Ageing, Disability and Home Care.
Valcour, V. G., Masaki, K. H., Curb, J. D., & Blanchette, P. L. (2000). The detection of
dementia in the primary care setting. Archives of Internal Medicine, 160, 2964 -
2968.
van Hout, H., Vernooij-Dassen, M., Bakker, K., Blom, M., & Grol, R. (2000). General
practitioners on dementia: tasks, practices and obstacles. Patient Education and
Counseling, 39, 219 - 225.
Vernooij-Dassen, M. J. F. J., Moniz-Cook, E. D., Woods, R. T., Lepeleire, J. D., Leuschner,
A., Zanetti, O., et al. (2005). Factors affecting timely recognition and diagnosis of
dementia across Europe: from awareness to stigma. International Journal of Geriatric
Psychiatry, 20, 377-386.
Wilkinson, D., Stave, C., Keohane, D., & Vincenzino, O. (2004). The role of general
practitioners in the diagnosis and treatment of Alzheimer's disease: a multinational
survey. Journal of International Medical Research, 32(2), 149-159.
Williams, J. S., Byrne, J., & Pond, D. (2008). Dementia Identification, Assessment and
Management in Community-Based Primary Health Care: A review of the international
literature 1995-2006: Dementia Collaborative Research Centre,.
Woods, R. T., Moniz-Cook, E., Iliffe, S., Campion, P., Vernooij-Dassen, M., Zanetti, O., et al.
(2003). Dementia: issues in early recognition and intervention in primary care.
Journal of the Royal Society of Medicine, 96, 320 - 324.
Yang, X. J., Haralambous, B., Angus, J., & Hill, K. (2008). Older Chinese Australians'
understanding of falls and falls prevention: exploring their needs for information.
Australian Journal of Primary Health, 14, 36-42.

- 33 -