This chapter examines the role of the primary care team in the management of patients with dementia. Traditional interventions such as medication play a limited role. Instead, management focuses on enabling the patient with dementia to live to the maximum of his or her potential. To achieve this, the primary care team must play its role as part of a wide network of individuals and organisations, all working towards this aim.

Primary care is well placed for this task. The general practitioner (GP) may already have an established relationship with the patient and other members of the family and will have a good understanding of the current health status and previous history. The patient’s journey, from diagnosis to end of life, will often be shared with the GP.

The percentage of people with dementia who have received a diagnosis in the UK increased from 43.3% in 2011 to 46% in 2012. This illustrates what is referred to as the ‘dementia gap’, that is, the differential between expected and recorded diagnoses of the condition. This percentage varies considerably from area to area.

Local prevalence will be affected by demographic features, including the cultural and ethnic make-up of each practice population. Incidence and prevalence will continue to increase because of the increasing proportion of older adults in the population. Primary care will be required to play a key role in managing these increasing numbers.

The above-mentioned figures suggest that less than half of the people with dementia in the UK have been given a diagnosis of dementia. The estimated prevalence figure has a large margin of error, being based on census figures rather than diagnostic criteria, but there is widespread acceptance that a large cohort of undiagnosed individuals exists in the UK.

Although there may be some benefit in earlier pharmacological treatment to treat symptoms arising from dementia, the main advantages in an earlier diagnosis lie in enabling the patient with dementia, together with family and carers, to come to terms with the condition and to plan for the future, while the patient still has the capacity to do so. This opportunity can be formalised by engaging in the process known as advance decision planning. For further information, see Chapter 12.

Some authorities support formal screening for dementia. An example of this approach would be testing the cognitive function of individuals at a younger age than the expected onset of dementia. This would aim to pick up early signs of cognitive decline. However, screening for dementia does not fulfil standard criteria. Having identified an individual at an earlier stage of the disease process, a positive intervention which will alter the course of the disease needs to be identified, and such an intervention is yet to be demonstrated.

Case finding may be a more appropriate approach. This involves searching for patients with clinical features of dementia who have not been identified and diagnosed with the condition. Possible groups of patients to focus on when conducting such a search are included in Box 10.1.

It would seem logical and good practice to plan interventions as early as possible in the course of dementia, in order to prevent or delay the onset of the condition. This area is currently generating a great deal of interest. As yet, however, there is no definite evidence that any specific preventative intervention will modify the course of the illness.

Within the heterogeneous group of conditions represented by the term dementia, the strongest case for intervention would appear to hold for vascular dementia. Vascular dementia itself is thought to involve a range of different processes, but modifying cardiovascular risk factors may delay the onset and reduce the severity of cerebrovascular disease, in turn reducing the risk of developing vascular dementia.

GPs may be questioned by their patients as to whether other strategies can prevent or delay the onset of dementia. These may include ‘exercising the mind’ (such as learning a second language or musical instrument or perhaps completing the daily crossword), supplements, diets and relaxation strategies, such as yoga and meditation. The best response would be to first ascertain that no harm will be caused by the activity, if indeed such an assessment is possible, and then to offer realistic but positive encouragement. Once again, however, there is no evidence of any of these strategies having a positive impact on the disease process.

Current National Institute for Health and Care Excellence (NICE) guidance states that a diagnosis of dementia should be made by a specialist, but there may be times when it is better for this to be carried out in primary care. One reason would be patient choice, but other reasons would include the severity of the dementia and the mobility of the patient.

The assessment of a patient with cognitive impairment in primary care can take longer than the standard 10-minute general practice consultation. History taking can be time consuming. It is a process that may span several consultations, as supporting histories from family and carers are often required.

Before making an assessment, it is important to consider the issue of consent. Consultations regarding possible dementia are unusual in that the patient is often brought by a relative or carer and may not be aware of the reason for the consultation. Consent for assessment must first be obtained if a patient has the capacity. If not, any further medical intervention must be in that person’s best interests. This can make an already challenging consultation more difficult. Initial assessment is summarised in Box 10.2.