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Hurt CS, Burns A, Brown RG, Barrowclough C (2012) Why don't older adults with subjective .... GP: „The group that comes in worried as heck about their memory ...
Preprint version Full article in: Zeitschrift für Gerontologie + Geriatrie, Mar 2017, special issue “110 years after Auguste Deter”, DOI 10.1007/s00391-017-1207-5

Subjective memory impairment in general practice – short overview and design of a mixed methods study Subjektive Gedächtnisbeeinträchtigungen in der Hausarztpraxis – kurzer Überblick und Design einer mixed-methods-Studie

Michael Pentzek, PhD1, Verena Leve, MSc1, Verena Leucht, MSc1

1Institute

of General Practice (ifam), Medical Faculty, Heinrich-Heine University

Düsseldorf, Germany

Correspondence Dr. rer. nat. Michael Pentzek (Dipl.-Psych.) Institute of General Practice (ifam) / Centre for Health and Society (chs) Medical Faculty, Heinrich-Heine University Düsseldorf Werdener Str. 4, 4th floor, 40227 Düsseldorf, Germany phone +49 0211 81 16 818, fax +49 0211 81 18 755 email: [email protected]

Abstract Background: Public awareness for dementia is rising; patients with worries about forgetfulness are not uncommon in general practice. For the general practitioner (GP), subjectively perceived memory impairment (SMI) also offers a chance to broach the issue of cognitive function with the patient. This may support the GP’s patient-centred care in terms of a broader frailty concept.

Objectives: What is SMI (definition, operationalisation, prevalence, burden)? Which conceptions and approaches do GPs have regarding SMI?

Methods: Narrative overview of recent SMI criteria and results; selective utilisation of results from a systematic literature search on GP demetia care; non-systematic search regarding SMI in general practice; deduction of a study design from the overview and development according to international standards.

Results: Studies reveal approx. 60% of GP patients >74 indicating declining memory. Every sixth is worried about that, far less seek medical advice. Worries about SMI are considered a risk factor for future dementia. Specific general practice conceptions about SMI could not be identified in the literature. Using the GRAMMS guideline, the design of an exploratory sequential mixed methods study is presented, which should reveal different attitudes of GPs towards SMI.

Conclusions: SMI is common and troubles a considerable portion of patients. Neuropsychiatric research progresses, but for the transfer of SMI into practice, involvement of GP research is necessary. A new study makes a contribution to this.

Keywords (according to MeSH terminology) dementia; cognition; health services research; attitudes of health personnel; physician-patient relations

Zusammenfassung Hintergrund: Die öffentliche Aufmerksamkeit für Demenz wächst; in der Hausarztpraxis kann sich dies in Sorgen der Patienten/innen um das eigene Geächtnis äußern. Für den Hausarzt/die Hausärztin bieten solche patientenseitig wahrgenommenen Gedächtnisprobleme (SMI, subjective memory impairment) u.a. die Möglichkeit, ins Gespräch über das Gedächtnis zu kommen. Dies kann die hausärztliche Versorgung im Sinne eines erweiterten Frailty-Konzepts unterstützen.

Fragestellung: Was ist SMI (Definition, Operationalisierung, Prävalenz, Bedeutung)? Welche Konzepte von SMI und Umgangsstrategien mit SMI haben Hausärzte/innen?

Methoden: Narrative Übersicht aktueller SMI-Kriterien und -Daten; selektive Nutzung der Ergebnisse einer systematischen Literaturrecherche zur hausärztlichen Demenzversorgung; nicht-systematische Recherche zu SMI in der Hausarztpraxis; Ableitung eines Studiendesigns aus der Literaturübersicht und Entwicklung anhand internationaler Standards.

Ergebnisse: Laut Studienlage geben ca. 60% der Hausarztpatienten/innen >74 ein nachlassendes Gedächtnis an, Sorgen darüber macht sich jeder sechste, weitaus weniger suchen aktiv ärztlichen Rat. Sorgen um SMI gelten als Risikofaktor für eine spätere Demenz. Spezifisch hausärztliche SMI-Konzepte konnten in der Literatur nicht gefunden werden. Anhand der GRAMMS guideline wird das Design einer exploratorischen sequenziellen mixed methods-Studie dargestellt, die über die verschiedenen Einstellungen zu SMI unter Hausärzten/innen Aufschluss geben soll.

Diskussion: SMI ist häufig und beunruhigt einen deutlichen Teil der Patienten/innen. Die spezialistische Forschung zu SMI geht voran; für die Umsetzung des Konzepts in die Praxis ist jedoch die Beteiligung allgemeinmedizinischer Forschung unabdingbar. Eine neue Studie soll dazu beitragen.

Schlüsselwörter Demenz; Kognition; Allgemeinmedizin; Einstellungen; Arzt-Patienten-Beziehung

Introduction Memory function attracts increasing attention from media and public in the context of dementia [1,2]. In general practice, this is reflected by patients with dementia fear or worries about their own forgetfulness. For the general practitioner (GP), this subjectively perceived memory impairment (SMI) offers a chance to enter a conversation about cognitive function. In terms of a broader frailty concept [3], incorporation of a patient’s cognitive dimension can enhance the quality of patient care in general practice. It is unknown whether SMI will be a useful and accepted concept in general practice where the bulk of elderly patients is cared for. If SMI is to be considered relevant in general practice, we have to understand how GPs think, feel and respond with regard to SMI. In the first part of this article, we give a short overview of SMI with a focus on the general practice setting. In the second part, we deduce research questions from the overview and present a resultant study design.

Methods Overview: This is a narrative overview [4] based on own expertise and projects in the field of dementia and SMI research, discussion with colleagues, own publications and selection of relevant literature. The part on GPs’ SMI concepts and approaches is supplemented with selective results from a previous project: a systematic literature search of qualitative research regarding GPs’ attitudes toward dementia (metasynthesis; CADIF project [5]). Additionally, a SCOPUS literature search on SMI in general practice was conducted (for search strategies see supplement).Selection criteria for the latter were: direct qualitative or quantitative assessment of GPs, specific focus on SMI or related constructs (not focus on dementia). Study Design: The design was developed in accordance with current guidelines (equator-network.org) and literature on specific topics like GP recruitment, methods integration, pretesting. Experience in multiple research designs and analytic methods from diverse projects with GPs is included in the team. This article does not contain any studies with human or animal subjects. The presented study design has been approved by the Ethics Commission of the Medical Faculty, Heinrich-Heine University Düsseldorf (study no. 4848).

Overview SMI as a construct Subjective memory impairment (SMI) can be described as an individual’s perception of his/her own memory performance being substandard or in decline [6]. SMI has been included as a core criterion of mild cognitive impairment (MCI), but a separation of SMI from MCI has been postulated due to methodological considerations [7]. From a GP perspective, SMI can become manifest in real worries and patient expectations towards the doctor. In consequence, also as a separate symptom, SMI remains “not simply a characteristic of the ‘worried well’ and should be taken seriously” in clinical practice [8, p. 703], because “if people have lingering concerns about their cognitive functioning […], the consequences can be just as real” [9, p. 596 f].

SMI operationalisation SMI is a concept under construction with numerous assessment methods for SMI (ranging from one dichotomous question to scales with multiple items). Rabin et al. [10] report 34 instruments from 19 studies with a total of 380 different memory items, with „Do you feel like your memory has become worse?” or “Do you find you forget people’s names?” among the most frequent. An important differentiation within SMI assessment has to be made regarding intentions associated with SMI: Is SMI only reported on request, is SMI associated with worries, is SMI actively reported to family/GP/etc. (“complainers”)? Burmester et al. [11] found that patients frequently report features of SMI that are not included in questionnaires. The use of structured questionnaires therefore holds the risk of missing individual worries, distress, and fears associated with very specific SMI. The authors suggest open questions for SMI assessment in clinical practice.

SMI prevalence The prevalence of SMI strongly depends on the kind of operationalisation, the age group, and the setting [12]. For example, in a group of 70-85-year-old people, 52% reported forgetfulness and 23% reported impairment in everyday functioning due to memory problems [13]. In the age group over 64 years, prevalence rates between 25% and 50% have been reported [14]. SMI prevalence increases with age; Larrabee and Crook found a rise from 43% in the 65-74 age group up to 88% in those above

85 [15]. Figure 1 shows the prevalence of SMI in German general practice from the AgeCoDe cohort [16]. Insert figure 1 here Figure legend: Figure 1: Baseline data from a prospective German cohort study sample of 3.327 GP patients between 75 and 89 years without dementia (AgeCoDe Study [16]). Responses to the item: „Do you feel like your memory is becoming worse?“ (yes/no), in case of response „yes“: „Does this worry you?“ (does not worry me/worries me/worries me a lot)

Begum et al. [17] report a tendency toward rising prevalence of cognitive complaints in different cohorts over time. The reasons for this are unknown. Hypothetical explanations may be growing general health concerns in public or a shift in causal attributions of SMI: Hurt et al. [18] found, that persons who attribute SMI to internal organic reasons (vs. external psychosocial factors such as loneliness) tend to seek help for SMI more frequently.

Factors associated with SMI a) Concurrent: Among sociodemographic variables, older age, female sex, and lower educational level are associated with SMI [16]. SMI also co-occurs with poorer mental and physical health status [19,20]. Hill et al. found robust concurrent relations of SMI with depressive symptoms and anxiety, but the temporal relationship is not clear from longitudinal studies [21]. Among personality factors, SMI is associated with higher neuroticism scores (incl. self-consciousness and anxiety), lower perceived self-efficacy, and rumination as a passive emotion-focussed coping style [19,20]. Meta-analysis confirms that SMI is also slightly associated with worse objective cognitive test performance [22]. People with mild dementia more frequently report SMI than people without dementia (40-50% vs. 17%). However, the diagnostic relevance of SMI for dementia detection is too low for use in general practice, with a sensitivity of 43.0% and a positive predictive value of 18.5% [23].

b) Prospective: There is strong evidence from prospective studies that patients with SMI have an increased risk of future dementia. A meta-analysis found a settingindependent doubling of dementia incidence among people with initial SMI [24].

Jessen et al. [25] specifies, that patients with explicit worries about subjective memory decline have a threefold risk for dementia, a sixfold risk especially for Alzheimer’s dementia. Mendonca et al. [26] und Jessen et al. [27] propose the following features of SMI that are notably associated with progression to dementia: worries about SMI, feeling of decline and of own memory performance being inferior to that of same-aged peers (social comparison), perceived impact of SMI on activities of daily living, memory decline confirmed by an informant. From this perspective, after exclusion of depression and anxiety, SMI assessment could assist the GP in identifying patients who may benefit from regularly monitoring SMI and cognitive function, the patient’s mandate assumed [28].

Burden of SMI A relevant part of older GP patients worries about SMI (see figure 1). In a study by Begum et al. [29], patients with SMI rated SMI burden as being comparable with the burden of several of their other health problems (e.g. hypertension, insomnia, diabetes, impaired vision). About half of the patients with SMI were more concerned about SMI than about their angina, asthma, hypertension, or previous heart attack. SMI is also associated with lower health-related quality of life, which is partly moderated by depressive symptoms [30].

SMI in general practice Within the health care system, persons with SMI will have contact most likely with a GP, far less with a psychiatrist or neurologist. If people worry about memory or intend to speak about dementia with a health professional, studies suggest that GPs are the preferred contact person [31]. But in fact, only a minority of older people with SMI report it to their GPs [12,29]. Patient-sided predictors of help-seeking are more serious concerns, biomedical attribution of SMI, and regular contact with a GP (medical surveillance, check-ups). Barriers include psychosocial attribution of SMI, the availability of alternative help (self-help or relatives), and an impression of GPs being too busy (fear of wasting GPs’ time with SMI) or not helpful in case of SMI (ignorant or powerless) [32]. GPs’ concepts and approaches regarding SMI

The SCOPUS search for studies on GPs’ views on SMI revealed 140 hits; title/abstract review left four full text articles (all quantitative), two of which proved to be out of scope. The remaining two studies offer only little insight into GPs’ concepts and approaches regarding SMI: Croisile and Rothoft [33] report data from a French questionnaire study on GPs’ SMI handling, apparently having been subject to considerable sampling bias, making it hard to interpret: Questionnaires were handed out personally to GPs by representatives of a pharmaceutical company (response rate 97%), the setting is not reported. An unclear SMI definition was given at the questionnaire outset, and figures are unusually high (43% of GPs with recent memory/dementia training, GP-reported average of 12 SMI-related consultations per week, 72% react to SMI with cognitive tests, 59% with laboratory tests, 91% prescribe nootropics). In the second relevant study [34] 29 GPs were asked about 549 of their non-demented patients, how they rated their patients’ cognitive status. The GPs used a questionnaire for each patient: SMI as a source for rating a patient’s cognitive status was used for 66% of patients, direct observation of cognitive problems for 89%, general knowledge of a patient for 56%, informant reports for 37%, risk factors for 15% and tests for 1.5%. For GPs, SMI seems to be one relevant clue to a patient’s objective cognitive status. The systematic search from the CADIF study revealed some studies with information on GPs’ responses and attitudes toward SMI (see table 1). Insert table 1 here

Study Design The design of the project “SMI-GP – Subjective memory impairment in elderly primary care patients: conceptions and approaches of general practitioners” is presented according to the guideline for Good Reporting of A Mixed Methods Study (GRAMMS [39]). The methods of each study part are further specified with items from reporting standards for qualitative [40] and survey research [41]. Figure 2 illustrates the design. Insert figure 2 here Figure legend: Figure 2: Exploratory sequential design of the SMI-GP study

GRAMMS (1) justification for a mixed methods approach: The presented overview indicates the urgent need for further research with a focus on SMI in general practice. There are no studies adding to a theoretical framework of SMI from a GP perspective. Table 2 outlines the two proposed rationales for SMI research: Insert table 2 here

The clinical relevance of GP research is evident: First, SMI prevalence is assumed to rise and to become more and more part of the patients’ agenda [17,18]. Patient-centeredness demands appreciation of such patient needs. Second, the diagnostic and prognostic value of SMI for the identification/prediction of depression and dementia will increase as ongoing research will reveal a more sophisticated differentiation of SMI [26,27]. Third, worries about SMI offer a chance for the GP to pick up the issue of cognition with the patient, in order to incorporate the cognitive dimension into a broader frailty concept of patient care. Implementation of new strategies for SMI assessment and management presupposes knowledge on barriers like misconceptions and impedimental attitudes of GPs. A scientific construct with no equivalent in routine clinical practice has no chance to be applied in real health care settings. Research questions: Which conceptions do GPs have regarding subjective memory impairment? What do GPs think and feel about SMI as a construct, its clinical relevance, and its diagnostic properties? Which strategies do GPs apply when dealing with SMI? Are assessment methods used (e.g. interview/questionnaire, which questions)? How do GPs respond to patients’ memory complaints? Which heuristics and ideas have evolved from general practice for SMI management? How do GPs value and integrate SMI within their clinical decision making?

GRAMMS (2) purpose, priority and sequence of methods: One way of conducting mixed-methods studies is to apply qualitative techniques with the subsequent use of questionnaires to quantify the results in a bigger sample: qualitative study parts guide questionnaire construction, whereas questionnaire

findings yield a representative picture of qualitative results (exploratory sequential mixed methods design) [42]. In the first qualitative project part, the research subject (SMI in general practice) will be opened up by means of narrative interviews and focus group discussions. This is done in areas where little or no previous research exists and validated quantitative instruments (i.e. a measure of GPs’ conceptions and approaches to SMI) are not available. Qualitative research on members of the target population for the later questionnaire will provide first insights into possible constructs, linguistic usage, and wording of items for the quantitative instrument. The qualitative data (together with theoretical considerations) build the basis for the content validity of item construction “that is grounded in the views of participants“ [42, p. 11]. The quantitative project part will capture many resources for pretesting and achieving an adequate response rate. GRAMMS (3) Methods – sampling, data collection, analysis: a) Qualitative methods: 12 narrative interviews and 4 focus groups (4-12 participants) will be conducted. Purposive heterogeneous sampling is applied to include male and female, rural and urban, more and less experienced GPs. In-depth narrative interviews [43] focus on individual cases and generate ad-hoc narratives. They are capable of generating a deeper and more “internally valid” understanding of the reasons why GPs feel, think and act in a particular way [44]. Focus groups discussions produce data that are specific to the dynamics of interaction found in a group setting (“chaining”, “cascading”). Listening to others’ experiences stimulates own experiences and ideas in participants, suitable to encompass problem solving strategies, collective attitudes and non-public beliefs [45]. Qualitative analysis: Interviews and focus groups will be audiotaped and verbatim transcribed, then coded line-by-line using software. Directed content analysis [46] in a multi-professional team will be performed by iterative phases of deductive and inductive coding and a revision of the category system after coding of 25% of data [47]. b) Quantitative methods: Sampling will be done using data from the German National Association of Statutory Health Insurance Physicians (KBV, German physician registry). The questionnaire will be applied to a random sample of 1.000 German GPs with an envisaged response rate of 40%. The resultant sample size (n=400) is based on the 1:20 item-to-subject ratio for factor analysis by Hair et al. [48], thus the questionnaire will be limited to 20 relevant items. A continuous and personnel-

intensive recruitment and follow-up procedure will be applied on the basis of own and international experience with GP recruitment [49] (e.g. two reminder actions, telephone pre-contact, upfront incentives, personalized envelopes, invitations and questionnaires). The analysis of questionnaire data will be adapted to the definitive questionnaire and data quality. Objectives: descriptive results on item level, combination of data reduction on item level (e.g. principal component analysis) with subsequent typification on GP level (cluster analysis) [50], group comparisons and/or multivariate regression analyses to identify associations with GP conceptions. Response rate calculation and estimation of non-response bias are done in accordance with international standards [51].

GRAMMS (4) integration of qualitative and quantitative project parts: The mode of methods integration is building a quantitative instrument on the basis of qualitative results [52]. As a theoretical framework, the Theory of Planned Behaviour [53] (figure 3) will additionally guide questionnaire construction. Insert figure 3 here Figure legend: Figure 3: Sketch of Theory of Planned Behaviour applied to the SMI-GP study

The methodological basis for item construction will be in accordance with standards of question wording and questionnaire design [54]. The building procedure follows various stages. Among the most important is cognitive pretesting of items [55]. Five GPs will be presented the questionnaire face to face by a researcher with the instruction to think aloud. Specific probing questions will be applied to reveal comprehension problems with instructions, specific terms and scaling (comprehension probing, category selection probing). The cognitive interviews will be audio-recorded, notes and memos will be prepared. The results of the pretests will be integrated into a revision of the questionnaire. In a quantitative pretest, a preselection of items will be answered by a convenient sample of 100 GPs for item analysis, i.e. psychometric properties like floor and ceiling effects, item selection index (discriminability and difficulty), internal consistency.

Outlook Subjective memory impairment (SMI) is common among older patients in general practice and calls for the physicians’ attention. Whereas neuropsychiatric research advances, complementary activities on a clinical side would help improving the understanding of SMI in clinical settings. The presented SMI-GP project is one first step in this direction in terms of basic research on GPs’ conceptions and approaches regarding SMI. The qualitative data collection is under way. The results may be useful for the development of SMI strategies, interventions and educational programs. Considering the GP perspective, SMI may become an important and noninvasive part of stepwise recognition of cognitive decline or depression in a lowprevalence setting.

Funding The SMI-GP study is funded by the Research Committee of the Medical Faculty, Heinrich-Heine University Düsseldorf (grant no. 43/2015).

Conflict of interest M. Pentzek, V. Leve and V. Leucht declare that there are no conflicts of interest.

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Table 1: Findings related to SMI from qualitative studies with GPs on dementia Theme

Example citation

SMI of minor relevance

“memory complaints tended to arouse the GPs’ suspicion to a lower degree.” [35, p. 222]

SMI = depression

“[SMI was seen by GPs as] usually being a sign of depression rather than dementia, in which the concern about memory loss comes more from family members.” [36, p. 78]

SMI = worried well

GP: „The group that comes in worried as heck about their memory, you test them and you can't find any problem. The group that is brought in by relatives, there's usually a problem.” [37, p. 460]

Reassuring patients with SMI; attribution to aging

GP: „I told her, ‘being forgetful certainly is a matter of age‘. I said, ‘look at me, I am 25 years younger, and I forget a lot of things, too.“ [38]

Table 2: Conceptions of SMI from a psychiatric and a GP perspective

Prevailing concept

Consequenc e

Operationali sation

Research focus

Psychiatric research rationale SMI = dementia risk factor

Inclusion as criterion for MCI or assessment as a separate risk factor for dementia Questionnaires (multipleitem scales)

SMI differentiation with the aim of predicting dementia

Hypothetical general practice rationale (aims of SMI-GP study) Cognition in general of minor relevance, possibly included in an advanced frailty concept; if at all, SMI only relevant as explicit complaint? not known; individual heuristics and rules of thumb

not known; as complaints are presented verbally in the patient-doctor communication, GPs may prefer interview measures, not questionnaires no focus identified; several papers on SMI prevalence, some on help-seeking in general practice

SMI with serious worries; 3,8%

SMI with worries; 13,5%

no SMI; 41,3%

SMI without worries; 41,4%

Qualitative data collection and analysis (SRQR reporting standards)

Integration / building

Quantitative data collection and analysis (SURGE reporting standards)

Phase I.a) focus groups: 4 group discussions with GPs; aim: peer group interaction  profession-specific attitudes, meaning and linguistic usage

Phase I.b) narrative interviews: 12 interviews with GPs; aim: ad-hoc narratives on individual cases  “internally valid” understanding of GPs emotional involvement, cognitive beliefs and intentions

Phase II. data analysis: verbatim transcription; content analysis with inductive and deductive line-by-line coding; aim: categories of SMI concepts and approaches Phase III. integration of theory and qualitative data with standards of item construction and question wording: multiprofessional sessions with methodologists and GPs; aim: first draft of questionnaire Phase IV.a) qualitative pretests: cognitive interviews with 5 GPs incl. general/ comprehension/category selection probing; aim: insight into cognitive processes of reading and responding to items  item modification

Phase IV.b) quantitative pretests: psychometric item analysis (difficulty, discriminability, selectivity) with questionnaires from 100 GPs  modification and selection of definite items

Phase V. questionnaire: recruitment, pre-contact, dispatch of questionnaires, reminder procedures, non-responder contact

Phase VI. data analysis: data entry, plausibility checks, monitoring; data reduction: principal component analysis; typification based on factors: cluster analysis

G R A M M S r e p o r t i n g

s t a n d a r d s

Attitudes (cognitive, affective; instrumental & experiential) Example aspect: What do GPs feel when patients report memory complaints? (e.g. helplessness, time pressure etc.)

Subjective norm (perceived expectations from patients, relatives, society, system, colleagues; injunctive & descriptive) Example aspect: What do GPs think their patients expect from them in case of memory complaints?

Behaviour control (self-efficacy & controllability) Example aspect: What do GPs think of their ability to assess SMI in an adequate way?

Intentions

Behaviour

Example aspect: Would GPs use tools for detailed SMI assessment?

Example aspect: How do GPs respond to SMI? (e.g. reassurance, follow-up etc.)

Pentzek/Leve/Leucht: SMI in general practice

Supplement: Search strategies 1) Example search strategy from the CADIF metasynthesis Example Database: Ovid MEDLINE(R) 1 exp Dementia/ 2 exp Cognition/ 3 exp Cognition disorders/ 4 exp Memory/ 5 exp Memory disorders/ 6 (dementia* or cognit* or memory).tw,ot. 7 Alzheimer*.tw,ot. 8 or/1-7 9 10 11 12 13 14 15 16

exp Family Practice/ or exp General Practice/ exp general practitioners/ or exp physicians, family/ or exp physicians, primary care/ exp Primary Health Care/ ((family or general*) adj3 practi*).tw,ot. ((family or general* or primary care) adj3 (physician* or doctor* or med* or intern*)).tw,ot. (primary adj6 health care).tw,ot. PCPs.tw,ot. or/9-15

17 18 19 20 21 22 23 24 25 26 27

exp Interview/ exp Interviews as topic/ exp Observation/ exp Qualitative research/ exp Videotapes/ exp Videotape Recording/ (interview* or observation*).tw,ot. focus group*.tw,ot. ((video or videotape) adj6 recording).tw,ot. (qualit* adj3 research*).tw,ot. ((constant comparison or content or conversation* or discourse or semiotic or thematic) adj1 analys*).tw,ot. 28 (ethnograph* or field observation* or grounded theory).tw,ot. 29 (hermeneutic or narrative or naturalistic inquiry or phenomenolog* or theoretical sampl*).tw,ot. 30 or/17-29 31

8 and 16 and 30

2) SCOPUS search strategy: studies on SMI in general practice ( TITLE-ABS ( "subjective memory impairment" OR "subjective cognitive impairment" OR "subjective memory decline" OR "subjective cognitive decline" OR "memory complaint" OR "cognitive complaint" OR "memory concerns" OR "cognitive concerns" OR "memory complaints" OR "cognitive complaints" OR "memory concern" OR "cognitive concern" OR "worries about memory" OR "worries about cognition" OR "worries about cognitive" OR "worry about memory" OR "worry about cognition" OR "worry about cognitive" OR "subjective memory loss" OR "subjective cognitive loss" OR "subjective memory problems" OR "subjective cognitive problems" OR "subjective memory deficits" OR "subjective cognitive deficits" OR "subjective memory complications" OR "subjective cognitive complications" OR "subjective memory difficulties" OR

"subjective cognitive difficulties" OR "subjective memory problem" OR "subjective cognitive problem" OR "subjective memory deficit" OR "subjective cognitive deficit" OR "subjective memory complication" OR "subjective cognitive complication" OR "subjective memory difficulty" OR "subjective cognitive difficulty" OR "concerns about memory" OR "concerns about cognition" OR "concerns about cognitive" OR "complaints about memory" OR "complaints about cognition" OR "complaints about cognitive" OR "concern about memory" OR "concern about cognition" OR "concern about cognitive" OR "complaint about memory" OR "complaint about cognition" OR "complaint about cognitive" OR "Memory Failure" OR "memory failures" OR "memory worries" OR "memory worry" OR "memory concerns" OR "memory concern" OR "Dementia concerns" OR "Concerns about dementia" OR "Dementia concern" OR "Concern about dementia" OR "worry about dementia" OR "worries about dementia" OR "dementia worry" OR "dementia worries" OR "dementia fear" OR "fear of dementia" OR "perceived memory impairment" OR "perceived cognitive impairment" OR "perceived memory decline" OR "perceived cognitive decline" OR "perceived memory loss" OR "perceived cognitive loss" OR "perceived memory problems" OR "perceived cognitive problems" OR "perceived memory deficits" OR "perceived cognitive deficits" OR "perceived memory complications" OR "perceived cognitive complications" OR "perceived memory difficulties" OR "perceived cognitive difficulties" OR "perceived memory difficulty" OR "perceived cognitive difficulty" OR "subjective forgetfulness" OR "perceived forgetfulness" ) ) AND ( TITLE-ABS ( "family practice" OR "family medicine" OR "family physician" OR "family doctor" OR "general practice" OR "general practitioner" OR "primary care" OR "primary health care" OR "health professional" OR "health care professional" ) )