Dementia is a leading cause of disability and disease burden.1 There are currently 50 million people living with dementia and approximately 10 million new cases diagnosed each year.2 While dementia is not a normal part of aging, older age is the primary risk factor for dementia.2 With life expectancy increasing in most parts of the world, it is estimated the number of people with dementia will triple by 2050.2
Dementia poses a challenge to the person, as well as both health and aged care systems, due to the complex nature of its clinical presentation.3,4 There are many types of dementia (eg, Alzheimer's disease, vascular dementia, primary progressive aphasia) and the clinical presentation of dementia can vary. Symptoms include confusion, memory loss, communication difficulties, and changes in personality and behavior.5 In addition to the primary symptoms of dementia, people with dementia are at an increased risk of other debilitating health conditions. For example, Alzheimer's disease nearly triples the risk of hip fracture compared to those with normal cognition.6 There are large direct and indirect costs both economically and to quality of life, and these costs are expected to grow as the number of people with dementia increases.2
The clinical management of people living with dementia, as a primary diagnosis or comorbidity when a person seeks treatment for another condition (eg, hip fracture, respiratory infection), can be complex. Furthermore, there is a growing body of evidence to support the use of exercise and physical activity in the care of people with dementia in community, hospital, and residential aged care settings.4,7-11 Given the role that physiotherapists have in promoting physical activity, prescribing exercise, optimizing mobility, pain management, and falls prevention,12 it is important that they have positive attitudes and beliefs towards working with people with dementia. In addition, they require adequate knowledge and confidence in managing both the presenting clinical problem as well as any co-existing symptoms of dementia.
Knowledge, confidence, attitudes, and beliefs are important factors individually, yet in the management of people with dementia, they can be intertwined when providing clinical care. The results of prior studies have highlighted low levels of knowledge about dementia among residential care staff,13 community medical and nursing professionals,14 as well as in undergraduate social workers.15 In turn, low levels of knowledge is associated with reduced confidence in managing care for people with dementia,13 as well as negative attitudes and beliefs about the capacity of their health condition to improve.16-17 In contrast, greater self-confidence is associated with positive attitudes and beliefs,17 as well as with undertaking more dementia-specific education.16 Despite this, dementia-specific education and training opportunities have been noted as an unmet need in many professions.18,19
With the growing number of people living with dementia and the important role that physiotherapists have in optimizing function and quality of life,20 it is important to understand both physiotherapists’ and physiotherapy students’ attitudes, beliefs, knowledge, and confidence in working with people with dementia. Gaining a better understanding about the experiences of physiotherapists and physiotherapy students working with people with dementia will assist in identifying areas of concern and inform potential areas for future undergraduate and postgraduate education and training.
A preliminary search of MEDLINE, CINAHL, and PROSPERO has been undertaken and no existing or in-progress systematic review is currently being undertaken on the topic. The overall objective of this review is to explore what is known regarding the attitudes and beliefs of physiotherapists and physiotherapy students when working with people with dementia. Additionally, a second objective is to explore their knowledge and confidence in this clinical area. We will consider both qualitative and quantitative studies to ensure that we achieve a comprehensive account of this topic.21
- i) What are physiotherapists’ and physiotherapy students’ attitudes and beliefs on working with people with dementia?
- ii) How knowledgeable and confident are physiotherapists and physiotherapy students in working with people with dementia?
We include the PICo format where: P = Population of interest; I = Phenomena of interest, and Co = Context.22
This review will consider studies that include physiotherapists and physiotherapy students. Studies including physiotherapists with any clinical specialty (eg, gerontology, orthopedic, neurological, cardiorespiratory) will be considered. Physiotherapy student participants must have had at least one clinical placement for the study to be considered. Studies that include multiple professions will be included if findings can be extracted specific to physiotherapists or physiotherapy students. For example, for quantitative studies, survey findings must be able to be attributable to the physiotherapy profession, and for qualitative studies, themes and quotes must be attributable to the physiotherapy profession for the study to be included.
Phenomena of interest
This review will consider quantitative studies that include the following outcomes: physiotherapist or physiotherapy student knowledge (eg, Knowledge of Dementia Scale23), confidence (eg, Confidence in Dementia Scale23), or attitudes and beliefs (eg, Approaches to Dementia Questionnaire24) on working with people with dementia.
This review will consider qualitative studies that explore physiotherapists’ or physiotherapy students’ experience with providing physiotherapy care to people with dementia as they relate to knowledge, confidence, attitudes, and beliefs. For the purpose of this review, any type of dementia (eg, Alzheimer's Disease, vascular dementia) will be included. Studies investigating physiotherapist or physiotherapy student knowledge, confidence, attitudes, and beliefs on working with a general aging population (ie, not dementia specific) will be excluded from this review.
This review will consider studies that include physiotherapists and physiotherapy students who have worked or had a clinical placement in any setting where people with dementia might access physiotherapy care (eg, hospital, private clinic, community, or nursing home). Studies from all countries will be considered.
Types of studies
This review will include quantitative, qualitative, and mixed-methods studies where qualitative and/or quantitative data relevant to the topic can be isolated and extracted. Quantitative studies may include observational studies (eg, cohort studies, case-control studies, or cross-sectional studies). Interventional studies (eg, randomized controlled trials, quasi-experimental studies) that are investigating the effect of an action or intervention on our phenomena of interest will not be considered for inclusion as it is outside the scope of the review; however, if intervention studies report baseline (pre-intervention) data that can be extracted for analysis, they will be included. Qualitative studies may include any qualitative methodologies (eg, phenomenology, grounded theory, ethnography, action research, or qualitative descriptive) that explore physiotherapists’ or physiotherapy students’ experience with providing physiotherapy care to people with dementia.
Only full-text studies published in peer-reviewed journals in English will be considered for inclusion in this review. Published abstracts and gray literature will not be included in this review. However, we will search gray literature to identify papers relevant to this topic and ascertain whether they have been published elsewhere.
The proposed systematic review has been registered with PROSPERO (CRD42020181845) and will be conducted in accordance with the JBI methodology for mixed methods systematic reviews.25
An initial limited search of MEDLINE and CINAHL was undertaken to identify articles on the topic. Search terms fell into the categories of population (ie, physiotherapist, physical therapist) or phenomena of interest (ie, knowledge, confidence, attitudes, and beliefs towards dementia care). The text words contained in the title and abstract of relevant articles, and the index terms used to describe the articles were used to develop a full search strategy for MEDLINE (see Appendix I). The search strategy, including all identified keywords and index terms, will be adapted for each information source. The reference lists of all studies selected for critical appraisal will be screened for additional studies. Citation tracking of included articles will also be performed using Google Scholar.
The databases to be searched include MEDLINE (Ovid), CINAHL (EBSCO), Embase (Ovid), Emcare, PsycINFO (Ovid), Scopus, Web of Science, Informit, ProQuest Dissertations, ERIC (ProQuest), and Google Scholar.
Following the search, all identified citations will be loaded into EndNote v.X9 (Clarivate Analytics, PA, USA) and duplicates removed. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review using Covidence (Veritas Health Innovation, Melbourne, Australia). Potentially relevant studies will be retrieved in full and their citation details imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia).25 The full text of selected citations will be assessed in detail against the inclusion criteria by two independent reviewers. Reasons for exclusion of full-text studies that do not meet the inclusion criteria will be recorded and reported in the systematic review. Any disagreements that arise between the reviewers at each stage of the study selection process will be resolved through discussion or with a third reviewer. The results of the search will be reported in full in the final review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram.26
Assessment of methodological quality
Two reviewers will independently appraise the methodological quality and risk of bias of the included studies using the JBI checklist for analytical cross-sectional studies, the JBI critical appraisal checklist for cohort studies, and the JBI critical appraisal checklist for qualitative research from JBI SUMARI.25 Where a study recorded a “yes” for the majority of questions considered, this will be reported as a low risk of bias. Any disagreements between reviewers will be resolved through discussion. If consensus cannot be reached, a third reviewer will be consulted. The results of critical appraisal will be reported in narrative form and in a table.22
Where data pertaining to methodological quality (ie, study methods) cannot be obtained from an included paper, we will request data from authors via email. If we are unable to obtain the data, we will mark the relevant criteria “unclear.” All studies, regardless of the results of their methodological quality, will undergo data extraction and synthesis (where possible). The overall methodological quality will be considered in the synthesis of the data.
Quantitative and qualitative data will be extracted from studies included in the review by two independent reviewers using the JBI mixed methods data extraction form in JBI SUMARI.25 The data extracted will include specific details about the populations, study methods, phenomena of interest, context, and outcomes of relevance to the review questions. Specifically, quantitative data will comprise data-based outcomes of descriptive and/or inferential statistical tests. Data extraction of qualitative studies will involve extracting all the results of the studies verbatim. This may include extracting results from the abstract, results, and appendices sections of the article. In addition, qualitative data will comprise themes or subthemes with corresponding illustrations and will be assigned a level of credibility. Where data pertaining to populations, study methods, phenomena of interest, context, or outcomes cannot be obtained from an included paper, we will request data from authors via email.
Two researchers will independently complete a pilot data extraction of at least two qualitative and two quantitative studies (if available). Following this process, the two researchers will discuss whether any additional information is required during the extraction. If any additional information is required, the wider team will be consulted before any amendments are made. Any additions will also be reported in the final manuscript.
Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Authors of papers will be contacted to request missing or additional data, where required.
The quantitative data will be converted into qualitized data. This will involve transforming the quantitative results into textual descriptions or narrative interpretation to respond directly to the review question.27 Data will be transformed using thematic analysis, which involves identifying patterns through the process of coding quantitative data.28 Quantitative data will be coded using one or more of the five methods described by Tashakkori and Teddlie29: modal, average, comparative, normative, and holistic. Data will be coded to describe a relevant phenomenon or association.
Data synthesis and integration
This review will follow a convergent integrated approach according to JBI methodology for mixed methods systematic reviews using JBI SUMARI.25 We will use a thematic synthesis method that involves coding qualitized and qualitative data, and grouping these codes based on similarity in meaning to produce specific (descriptive) themes in tabular form.30 If possible, these descriptive themes will then be used to develop analytical themes and a conceptual framework. Where codes cannot be grouped to make a specific (descriptive) theme, they will be reported as a narrative. The results will be displayed in a summary of results table, as well as in narrative form.
Appendix I: Search strategy
Date searched: September 9, 2020
1. World Health Organization. Global action plan on the public health response to dementia 2017–2025. Geneva: World Health Organization; 2017.
2. WHO Thematic Briefing, Prince M, Guerchet M, Prina MA. The epidemiology and impact of dementia: current state and future trends. 2015.
3. Australian Institute of Health and Welfare. Hospital care for people with dementia 2016–17 [internet]. 2019 [cited 2020 Apr 8]; AIHW Cat. no. AGE 94. Available from: https://www.aihw.gov.au/reports/dementia/hospital-care-for-people-with-dementia-2016-17/contents/table-of-contents
4. Dementia Australia. Economic cost of dementia in Australia: 2016-2056 [internet]. 2017 [cited 2020 Apr 8]. Available from https://www.dementia.org.au/sites/default/files/NATIONAL/documents/The-economic-cost-of-dementia-in-Australia-2016-to-2056.pdf
5. Dementia Australia. Diagnosing dementia [internet]. 2020 [cited 2020 Apr 9]. Available from: https://www.dementia.org.au/information/diagnosing-dementia
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8. Law C-K, Lam FM, Chung RC, Pang MY. Physical exercise attenuates cognitive decline and reduces behavioural problems in people with mild cognitive impairment and dementia: a systematic review. J Physiother 2019;66 (1):9–18.
9. Brett L, Traynor V, Stapley P. Effects of physical exercise on health and well-being of individuals living with a dementia in nursing homes: a systematic review. J Am Med Dir Assoc 2016;17 (2):104–116.
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12. Queensland Health. Dementia Enablement guide [internet]. 2015 [cited 2020 Apr 9]. Available from: https://www.health.qld.gov.au/__data/assets/pdf_file/0017/621710/dementia-enablement-guide.pdf
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