In this edition of International Psychogeriatrics, Pertrazzuoli et al. (Reference Petrazzuoli2017) address attitudes to dementia by primary care physicians (PCPs) across a range of European countries. The article focusses on diagnosis, screening instruments and drug treatment, and finds a wide range of approaches to the PCPs’ role in referral for diagnosis and medication prescription. The findings include that PCPs who are allowed to prescribe dementia drugs, engage in higher levels of diagnostic work up, despite all the barriers to identification ably summarized in the paper. Perhaps, this heterogeneity is not random: it may be that roles and responsibilities for PCPs in relation to dementia are in transition.
There is no doubt that the prevalence of dementia is increasing, with worldwide numbers doubling every 20 years (Prince et al., Reference Prince, Brycea, Albanesea, Wimo, Ribeiroa and Ferri2013). This poses a major workforce challenge for health and community services. Around the world, health systems need to identify the most appropriate response to this, including role redefinition for specialist doctor, primary care doctor, and other parts of the system, particularly in primary care. New roles or expanded roles in case management and health and community service navigation should be considered (Goeman et al., Reference Goeman, Renehan and Koch2016). This challenge needs to be addressed urgently.
What is the role of PCPs in the health system in relation to dementia? Should they make the diagnosis? Or should they just identify a cognitive problem? What is the benefit of an early diagnosis? Should PCPs be allowed to prescribe anti-dementia drugs? Are there other roles for PCPs in dementia care – both early and later in the course of the disease? Under what circumstances should they refer to specialist care and what assistance can that provide? And what approach to dementia should be taken by about other parts of primary care – nurse practitioners, nurses, pharmacists, and allied health practitioners among others?
Answers to these questions in part have been explored by the World Organization of Family Doctors, WONCA. WONCA identifies the unique features of primary care as “first contact, longitudinality (continuity), comprehensiveness, and coordination” (WONCA 2013, p4). The scope of practice of family doctors includes to “ensure access to comprehensive primary and secondary services; manage . . . chronic disease; ..and coordinate individual clinical, community and public health services” (WONCA op cit. p5). These features and roles undoubtedly have a part to play in dementia identification and ongoing management, from first contact identification of a cognitive problem, through diagnostic work up (including identification and management of the common differential diagnoses/comorbidities – depression, delirium, and medication side effects) and to continuing and comprehensive management of the person living with dementia, often for many years.
Management does not just include prescribing of dementia medication, which in isolation is more an appropriate response to acute disease than to a chronic illness like dementia. A chronic disease management approach must be adopted, with inter alia regular review and potentially a checklist of issues to be addressed, some on a regular basis. Such issues would include the following:
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1. The PCP must pay full attention to the effects of cognitive impairment on the management of other health problems: A person with cognitive impairment loses the ability to self-manage their chronic diseases, including: Identifying problems, making decisions, utilizing appropriate resources, attending appointments, understanding information, and negotiating shared goals of care (Ibrahim et al., Reference Ibrahim, Anderson, MacPhail, Lovell, Davis and Winbolt2017). Support must be provided by the PCP, perhaps in collaboration with a carer, in all these areas. They will need additional help with their insulin injections, puffers, and other treatments. This may need to be managed by the PCP in collaboration with the pharmacist (Lalic et al., Reference Lalic2016).
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2. Primary and secondary prevention: Diet, exercise, and other preventive activities will need to be structured around the person's cognitive abilities, their ability to cook, their balance as affected by dementia and other issues, and will need additional support.
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3. Hospital stays are extended for people living with dementia and are also likely to be punctuated by delirium, falls, and other problems (Alzheimer's Australia, 2014). The PCP could assist with the transition to hospital by documenting the cognitive problem and warning the staff of the need for additional attention.
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4. People living with dementia also lose their ability to perform activities of daily living and will need increasing support from family and services. The PCP and indeed the whole primary care team have a role to play in identification of what is needed (this not simple and requires a structured approach), coordination of services, and collaboration with others in enabling the person to be as independent as possible.
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5. A feature of primary care is intersectoral collaboration (World Health Organisation (1978), Declaration of Alma Ata VII, 4), and for patients with dementia, the PCP may need to work with sectors outside health, such as housing, financial services, and legal services (e.g. Advance Care Planning).
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6. The PCP and the primary care team will need in this work to pay attention to the availability of services in their particular context, while potentially advocating for more services in areas of need (Sherbino et al., Reference Sherbino, Frank, Snell and Sherbino2015). The specific scope of their work may be defined in part by the accessibility of other services: in remote rural areas with little access to services, the PCP will do more, although telehealth and other technological solutions may assist. But indeed workforce constraints are already dictating that they should do more, in all the areas mentioned above.
These roles and responsibilities of the PCP and primary care team in relation to dementia are yet to be fully explored and documented, let alone taught at undergraduate or postgraduate level. This has to change. Petrazzuoli has shown that PCPs who are allowed to prescribe are more active in diagnostic workup. In a similar way, surely PCPs who are aware of the possibility of a structured approach to dementia management, using a chronic disease framework, will become more proficient at the identification of dementia as well, as their role will be more clearly defined. They may then safely move on to diagnosis and prescription of dementia drugs. This would not obviate the need for specialist care, which will always remain important for the many difficult diagnostic and management conundrums. These too need to be defined.
To quote from World Health Organisation (2016):
Transformative advances alongside a more effective use of existing health workers are both needed and possible through: the adoption of inclusive models of care encompassing promotive, preventive, curative, rehabilitative and palliative services; by reorienting health systems towards a collaborative primary care approach built on team-based care; and by fully harnessing the potential of technological innovation. (p. 8)
As health professionals, we need to promote ongoing discussion and agreement between all the players about a health system response to dementia. While the players must include health professionals at all levels including nursing and allied health, there is a need to engage policy-makers; communities; health managers; and academic institutions (Boelen Reference Boelen2000, figure 20) about a way forward. Ideally, this could result in a mapped process of change to bring primary care into focus not just in dementia identification but in evidence based management. We should not lose sight of the ultimate aim: to enable people living with dementia to build on their existing strengths, while supporting their carers both paid and unpaid.
Conflict of interest
None.
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In this edition of International Psychogeriatrics, Pertrazzuoli et al. (Reference Petrazzuoli2017) address attitudes to dementia by primary care physicians (PCPs) across a range of European countries. The article focusses on diagnosis, screening instruments and drug treatment, and finds a wide range of approaches to the PCPs’ role in referral for diagnosis and medication prescription. The findings include that PCPs who are allowed to prescribe dementia drugs, engage in higher levels of diagnostic work up, despite all the barriers to identification ably summarized in the paper. Perhaps, this heterogeneity is not random: it may be that roles and responsibilities for PCPs in relation to dementia are in transition.
There is no doubt that the prevalence of dementia is increasing, with worldwide numbers doubling every 20 years (Prince et al., Reference Prince, Brycea, Albanesea, Wimo, Ribeiroa and Ferri2013). This poses a major workforce challenge for health and community services. Around the world, health systems need to identify the most appropriate response to this, including role redefinition for specialist doctor, primary care doctor, and other parts of the system, particularly in primary care. New roles or expanded roles in case management and health and community service navigation should be considered (Goeman et al., Reference Goeman, Renehan and Koch2016). This challenge needs to be addressed urgently.
What is the role of PCPs in the health system in relation to dementia? Should they make the diagnosis? Or should they just identify a cognitive problem? What is the benefit of an early diagnosis? Should PCPs be allowed to prescribe anti-dementia drugs? Are there other roles for PCPs in dementia care – both early and later in the course of the disease? Under what circumstances should they refer to specialist care and what assistance can that provide? And what approach to dementia should be taken by about other parts of primary care – nurse practitioners, nurses, pharmacists, and allied health practitioners among others?
Answers to these questions in part have been explored by the World Organization of Family Doctors, WONCA. WONCA identifies the unique features of primary care as “first contact, longitudinality (continuity), comprehensiveness, and coordination” (WONCA 2013, p4). The scope of practice of family doctors includes to “ensure access to comprehensive primary and secondary services; manage . . . chronic disease; ..and coordinate individual clinical, community and public health services” (WONCA op cit. p5). These features and roles undoubtedly have a part to play in dementia identification and ongoing management, from first contact identification of a cognitive problem, through diagnostic work up (including identification and management of the common differential diagnoses/comorbidities – depression, delirium, and medication side effects) and to continuing and comprehensive management of the person living with dementia, often for many years.
Management does not just include prescribing of dementia medication, which in isolation is more an appropriate response to acute disease than to a chronic illness like dementia. A chronic disease management approach must be adopted, with inter alia regular review and potentially a checklist of issues to be addressed, some on a regular basis. Such issues would include the following:
1. The PCP must pay full attention to the effects of cognitive impairment on the management of other health problems: A person with cognitive impairment loses the ability to self-manage their chronic diseases, including: Identifying problems, making decisions, utilizing appropriate resources, attending appointments, understanding information, and negotiating shared goals of care (Ibrahim et al., Reference Ibrahim, Anderson, MacPhail, Lovell, Davis and Winbolt2017). Support must be provided by the PCP, perhaps in collaboration with a carer, in all these areas. They will need additional help with their insulin injections, puffers, and other treatments. This may need to be managed by the PCP in collaboration with the pharmacist (Lalic et al., Reference Lalic2016).
2. Primary and secondary prevention: Diet, exercise, and other preventive activities will need to be structured around the person's cognitive abilities, their ability to cook, their balance as affected by dementia and other issues, and will need additional support.
3. Hospital stays are extended for people living with dementia and are also likely to be punctuated by delirium, falls, and other problems (Alzheimer's Australia, 2014). The PCP could assist with the transition to hospital by documenting the cognitive problem and warning the staff of the need for additional attention.
4. People living with dementia also lose their ability to perform activities of daily living and will need increasing support from family and services. The PCP and indeed the whole primary care team have a role to play in identification of what is needed (this not simple and requires a structured approach), coordination of services, and collaboration with others in enabling the person to be as independent as possible.
5. A feature of primary care is intersectoral collaboration (World Health Organisation (1978), Declaration of Alma Ata VII, 4), and for patients with dementia, the PCP may need to work with sectors outside health, such as housing, financial services, and legal services (e.g. Advance Care Planning).
6. The PCP and the primary care team will need in this work to pay attention to the availability of services in their particular context, while potentially advocating for more services in areas of need (Sherbino et al., Reference Sherbino, Frank, Snell and Sherbino2015). The specific scope of their work may be defined in part by the accessibility of other services: in remote rural areas with little access to services, the PCP will do more, although telehealth and other technological solutions may assist. But indeed workforce constraints are already dictating that they should do more, in all the areas mentioned above.
These roles and responsibilities of the PCP and primary care team in relation to dementia are yet to be fully explored and documented, let alone taught at undergraduate or postgraduate level. This has to change. Petrazzuoli has shown that PCPs who are allowed to prescribe are more active in diagnostic workup. In a similar way, surely PCPs who are aware of the possibility of a structured approach to dementia management, using a chronic disease framework, will become more proficient at the identification of dementia as well, as their role will be more clearly defined. They may then safely move on to diagnosis and prescription of dementia drugs. This would not obviate the need for specialist care, which will always remain important for the many difficult diagnostic and management conundrums. These too need to be defined.
To quote from World Health Organisation (2016):
Transformative advances alongside a more effective use of existing health workers are both needed and possible through: the adoption of inclusive models of care encompassing promotive, preventive, curative, rehabilitative and palliative services; by reorienting health systems towards a collaborative primary care approach built on team-based care; and by fully harnessing the potential of technological innovation. (p. 8)
As health professionals, we need to promote ongoing discussion and agreement between all the players about a health system response to dementia. While the players must include health professionals at all levels including nursing and allied health, there is a need to engage policy-makers; communities; health managers; and academic institutions (Boelen Reference Boelen2000, figure 20) about a way forward. Ideally, this could result in a mapped process of change to bring primary care into focus not just in dementia identification but in evidence based management. We should not lose sight of the ultimate aim: to enable people living with dementia to build on their existing strengths, while supporting their carers both paid and unpaid.
Conflict of interest
None.