Dementia: issues in early recognition and intervention in primary care

Changes in health policy in the UK are creating an experiment in dementia care which will be of importance to other societies and healthcare systems. A report from the Audit Commission, Forget Me Not 2002,1 concludes that general practices should make greater efforts to diagnose dementia in its early stages. Likewise the National Service Framework (NSF) for Older People2 emphasizes the need for early detection, with an enhanced role for primary care. A major challenge to implementation, however, is the observation that a substantial minority of general practitioners (GPs) are unconvinced of the benefits of early diagnosis. In the Audit Commision's survey of 8051 GPs in 73 areas of England, only 60% agreed that an early diagnosis of dementia was important—no change from the proportion in pilot data from 12 areas, collected in 1999.3 Probably, however, GP opinion has become more favourable since the publication of National Institute for Clinical Excellence (NICE) guidance on use of acetyl-cholinesterase (AChE) inhibitors for the treatment of Alzheimer's disease4—advice that may have come too late to have much impact on the full survey. A common argument is that, in the absence of effective treatment, there is nothing to be gained from early diagnosis. Forget Me Not 2002 notes that GPs who reported having received sufficient training in diagnosis and management were the ones most likely to favour early diagnosis; most GPs did not feel that they had received sufficient training. These findings may in part explain why nearly 75% of patients with moderate to severe dementia are unrecognized by primary care clinicians as having cognitive impairment.5 The Audit Commission1 points out that, if the condition is not recognized early, the patient and family commonly experience a crisis, with specialist services called in too late to establish supportive care. More positively, the NSF suggests that early diagnosis provides access to treatment, allows planning of future care and helps individuals and their families come to terms with the prognosis.