GPs are highly regarded by families of people with dementia because they provide continuity of care, have established relationships of trust, act as advocates and problem-solvers and they open the gates to other sources of help (29). GPs are crucial in the development of care pathways as they are usually the first point of contact for the individual or for family members worried about the signs and symptoms of dementia and are well placed to refer patients and families to suitable supports and services.
However,GPs have identified a lack of knowledge of local health and support organisations as a key learning need in their care of patients with dementia (31). The uncertainty about referral criteria and the insufficient supports and services for those with dementia, greatly affect post-diagnostic care provision. Services offered may be fragmented, poorly coordinated, inflexible and inequitable. This provision of information about available supports is crucial.
A Vision for Change,the report from the expert group on mental health policy, advocates that primary care teams should play a major role in the integrated care of patients with dementia and should work in a coordinated manner with GPs and specialist teams to provide high quality care after diagnosis (32). Key members of the primary care team who may contribute to the care of a patient with dementia are included in Table 7.
Memantine is a non-competitive N-methyl-D-aspartate receptor antagonist (NMDA). Overstimulation of the N-methylD-aspartate (NMDA) receptor by glutamate is implicated in neurodegenerative disorders.
Memantine may be considered as the person’s dementia progresses. It is recommended for the management of moderate Alzheimer’s disease for patients who are intolerant of or have a contraindication to AChEIs and for severe Alzheimer’s disease (18). It may be used alone or in combination with cholinesterase inhibitors (36). It is generally well tolerated although common undesirable effects are dizziness, headache, constipation, somnolence and hypertension (37)
. When prescribing both AChEIs and memantine guidelines advise that treatment should be initiated and supervised by a physician experienced in the diagnosis and treatment of Alzheimer’s disease (18). Needs and management strategies will change as the dementia progresses. The median survival of people with dementia diagnosed at aged 60-69yrs is 6.7 years (interquartile range 3.1-10.8 years),falling to 1.9 years (interquartile range 0.7-3.6 years) for those diagnosed at age 90yrs or over (38). Once the diagnosis is made,the support needs of patients and carers should be carefully assessed. This will need to be repeated over intervals as needs change. The quality of care provided to patients with dementia can be improved by focusing on key areas at this regular review (39). These are listed in Table 6.
Table 6: Areas for Discussion at Regular Review (18) (39) • Medications – including use of antipsychotics • Mental Health – including screen for depression • Social Care • Assessment of Carer’s Needs
Regular physical examination should focus on hearing, vision, nutrition, bowel and bladder function (40).
In the later stages of dementia dental hygiene may be poor, leading to gum disease,tooth decay, infection and difficulty eating. Dental review both early and throughout the illness may help to address these problems (41).
Immunisation guidelines recommend flu vaccine administration for residents of nursing homes and long stay institutions, as well as in persons aged 65 years and over (42).
Along with this regular review, a risk assessment should be performed, in order to detect risk to self or others. This may include assessment of: • Inadvertent self-harm e.g. kitchen accidents, medication mistakes etc. • Deliberate self-harm. • Risks to others e.g. driving, gun ownership, aggression, child-minding when losing ability to do so safely etc. • Elder abuse and vulnerability – Abusive behaviour by family carers towards people with dementia is common, with a third reporting important levels of abuse and half some abusive behavior (43).