Dementia diagnosis in primary care: Thinking outside the educational box

Dementia syndromes are common, increasing in prevalence and are the largest cause of disability in industrialized societies. The costs of care for people with dementia in the UK are greater than the annual expenditure on heart disease, stroke and cancer, combined. Delayed recognition of dementia is common in community settings, but its causes are poorly understood. Specialists tend to identify lack of diagnostic skills amongst primary care physicians as the main cause, and attempt to remedy these limitations with training and the use of brief instruments for assessing cognition. This approach appears to have had little impact over the last decade. There are fundamental misunderstandings regarding how the diagnostic characteristics of dementia syndromes diverge from the cognitive changes of normal aging, and how dementia emerges through the personality of the individual. This paper discusses the factors/ processes involved in these changes in cognitive function, behavior and personality and why recognition of dementia in primary care is problematic, especially at an early stage. The important and tractable factors impeding earlier recognition of dementia in primary care include deficits in management (rather than diagnostic) skills amongst primary care practitioners and lack of adequate specialist support (including psychology and social work expertise) over the long term. Nevertheless, we believe that the diagnosis and early clinical management of dementia can be achieved in the setting of primary care. The pattern of interweaving psychological, social and economic factors relevant to the needs of individual patients and their carers can be taken into account and met in the community, providing sufficient expert resources are available and systematically organized. This paper explores the different dimensions of relevant management skills and systems and makes proposals regarding changes in primary and secondary care that will increase earlier diagnosis in the community. © 2009 Future Medicine Ltd.