Early identification and management of dementia in general practice

The number of Australians experiencing dementia is on the rise, with researchers projecting there will be almost one million patients living with the condition by 2050. These numbers underline the importance of GPs being able to recognise the signs of dementia, and help patients and their families come to terms with and manage its effects.
 
The Federal Government has created a Dementia and Aged Care Services Fund to help meet this challenge. One of the program’s fruits, a new training program in Tasmania to help GPs and practice nurses provide earlier diagnoses of dementia, was announced earlier this week by the Minister for Aged Care Ken Wyatt, with hopes that it may be nationally applicable.
 
‘Training our GPs and practice nurses is of vital importance to dementia care in Australia,’ Minister Wyatt said. ‘Securing early diagnosis provides important opportunities for treatment to improve symptoms, to get patients’ affairs in order and smooth the path for the future, and to access community services and supports.’
 
Professor Dimity Pond, a GP and professor of general practice at the School of Medicine and Public Health in Newcastle, was an advisor to the Tasmanian training module. She agrees with Minister Wyatt that identifying dementia early can be helpful; although it is important to note that not every patient is ready or willing to receive the diagnosis, Professor Pond has found it is often of great assistance to the patient’s family.
 
‘A few years ago we did telephone interviews with about 80 family members of people with dementia. There wasn’t a single family that wasn’t struggling, even though only half the patients we recruited had been formally diagnosed,’ she told newsGP.
 
‘So [helping the family is] a big reason for making the diagnosis earlier rather than later. But then we need to be respectful of the patient’s ability to cope with that, as well.
 
‘It’s very challenging.’
 
GPs can look out for certain flags that may indicate dementia in some patients, such as regularly forgetting appointments or experiencing particular changes in their domestic lives.
 
‘For example, one of my patients told me, “My husband’s started cooking. We’ve been married for 40 years and he never cooked before, but now he says I take so long and make such a mess that he’s going to do it”,’ Professor Pond said. ‘That speaks to me of someone who can no longer sequence tasks.
 
‘With stories like that, you need to pay attention and think, “Something’s going on here”.’
 
However, it is vital to first ensure the issues are not being caused by something else, such as depression, high blood sugars or a brain tumour. Even some medications, such as certain incontinence drugs, can produce dementia-like symptoms over time.
 
Once a GP has good reason to believe a dementia diagnosis is definite or likely, the next step is disclosure to the patient and/or their family. Discussions about dementia can be difficult, as GPs are conscious of maintaining a good doctor–patient relationship for providing care after the diagnosis has been made.
 
‘GPs keep seeing the patient,’ Professor Pond said. ‘Specialists might see them once a year, but they don’t have the same ongoing role.’
 
It may occasionally be best to refer a patient to a memory assessment specialist for certainty in diagnosis, but also to keep the doctor­–patient relationship separate from that diagnosis. Regardless, this option can still require a delicate discussion.
 
‘If you are sending a patient to a specialist, you have to raise the possibility of memory problems, even if you don’t mention the words “dementia” or “Alzheimer’s”,’ Professor Pond said.
 
But because dementia can be a terminal illness – it is currently the second leading cause of death in Australia – discussing it with patients and their families is often essential, despite its difficulty.
 
‘A big advantage of talking about dementia early on is getting the family and the patient on the same page about what the future holds, and if the patient wants to go to hospital in the event the condition affects their basic body functioning, or whether it might be better to remain in the home,’ Professor Pond said.
 
‘I broach that topic very early on, if I’ve made a timely diagnosis that’s early; I’ll talk to the patient and their family about advance care planning.’

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