Role of the family physician in dementia care

Dementia is a neurodegenerative condition affecting many areas of life at the same time. It is often associated with medical and social complexities for those living with the condition and is becoming increasingly widespread as the population ages.¹

Dementia care in Canada is characterized by fragmentation of care across sectors,² inadequate numbers of specialists caring for persons with dementia,^3,4 and lack of a national dementia strategy. In part, such challenges lead to delays in diagnosis and active management,³ as well as uncertainty in clinical roles; such uncertainty contributes to the already extensive strain on individuals, families, clinicians, the health care system, and society.

As family physicians are generally patients’ first point of contact with the health system, they are ideally positioned to provide care for individuals living with dementia from early to end stages of the illness. They possess a full and long-term understanding of the medical, social, and psychological situations of these patients and their families. There is a long-standing Canadian consensus that timely detection, diagnosis, and care of those living with dementia are mainly the responsibility of primary health care practitioners, particularly family physicians.^5,6 Family physicians have been involved in developing, leading, and implementing models of care in Canada that meet the needs of frail older adults, including those living with dementia.^7–9

This article, which we developed in conjunction with the College of Family Physicians of Canada’s Health Care of the Elderly Program Committee, describes family physicians’ roles in key aspects of dementia care, from prevention of dementia to its management after diagnosis. In Box 1^7,10,11 we also offer suggestions regarding future directions in dementia care for family physicians.

Box 1. Future directions for dementia care.

Further actions for dementia care by family physicians should include ...

• advocating for a national dementia strategy in alignment with other G7 countries;

• continuing to develop and lead innovative models for the delivery of primary care to individuals living with dementia⁷;

• exploring roles in evolving areas of technology and dementia care, and collaborating with other physicians and service providers;

• having primary care practices intervene in ways that recognize individuals with room for improvement in well-being (higher well-being enables patients to adapt to numerous impairments and diseases^10,11); and

• continuing to lead and participate in professional development initiatives

G7—Group of Seven.

Defining the role

The key aspects of dementia care include prevention, the diagnostic process (including timely diagnosis, dementia staging, and differentiating dementia subtypes), communication of the diagnosis to the patient, and postdiagnosis management, and family physicians should be involved in all of these aspects. People with dementia, as well as their families and caregivers, should expect the following functions from their family physicians.

Contributing to the prevention of dementia.

Family physicians can have an effect on dementia rates by working with patients to reduce risk factors.^12,13 Dementia is not an inevitable consequence of aging. Reducing or stopping smoking and alcohol consumption, managing hypertension, diabetes, obesity, depression, and hearing loss, and maintaining social engagement and increasing exercise are all factors that contribute to the prevention or delay of dementia.^12,13

Providing a timely diagnosis.

Family physicians are optimally positioned to detect changes in thinking and behaviour that might indicate dementia, as reported by the individual or by family members (the term family includes anyone in the supportive network of the person) and other caregivers.¹⁴

A timely diagnosis might reduce uncertainty about what the patient is experiencing and help him or her and the family come to terms with often confusing and stressful changes.¹⁵ It provides time to organize and plan for the future, and might have an effect on reducing institutionalization rates.¹⁶

National recommendations and others advise family physicians not to screen for dementia when there are no symptoms.^17,18

Excluding other conditions that might look like dementia.

Family physicians need to consider and exclude conditions such as depression, thyroid disease, vitamin B12 deficiency, electrolyte disturbances, and glucose level abnormalities. With dementia care, family physicians also need to determine if there are brain problems such as tumours and vascular disease.¹⁹ They must also recognize and evaluate abrupt confusional states (delirium) that are caused by underlying conditions such as infection, uncontrolled chronic diseases, or medication side effects.

Determining the stage of dementia.

Normal age-related memory changes or mild cognitive impairment occurs when there is mild memory loss that does not interfere with usual activities or functions.⁵ Family physicians are well placed to evaluate whether a person has normal age-related memory loss, mild cognitive impairment, or early, middle, or late dementia so that appropriate treatment and planning options can be considered.²⁰

Diagnosing the type of dementia.

Family physicians determine the presence and the type of dementia. They rely on using validated office-based tools to assess memory, performing a physical examination, and asking the affected patient, as well as the family members and caregivers, questions about changes in personality, behaviour, thinking, problem solving, and language abilities. They also evaluate an individual’s ability to perform basic and more complex tasks required for independent living.

Brain scans (computed tomography or magnetic resonance imaging) are recommended in some but not all individuals who have dementia, as evaluation can often be done without a scan as per Canadian guidelines.⁵

Communicating a diagnosis of dementia with dignity.

Effective family medicine practice is founded on relationships. Knowing each patient as a whole person allows family physicians to provide a person-centred approach that supports the integrity of the individual. Diagnosing dementia evolves and occurs over time. When physicians are certain about the diagnosis, individualized, honest, and sensitive disclosure should occur.²¹ Communicating a diagnosis of dementia should take place (with permission from the individual) in joint discussion with the person, family members, and other caregivers.²¹

Providing postdiagnosis management and person-centred, integrated care.

Postdiagnosis management of dementia involves various facets of care, such as supporting nonpharmacologic and pharmacologic interventions, ensuring caregiver support, and participating in continuing professional development (Box 1^7,10,11); and practising a person-centred approach is important in delivering these facets of care. Here we present the many facets involved in dementia care and describe family physicians’ roles in supporting them.

Advocacy: Family physicians are strong advocates for their patients within the health care system and elsewhere. They must support strategies of inclusion, contact, respect, and attention to the individual in order to mitigate stigmatization and marginalization.

Treatment with medication: In many cases family physicians will offer treatment of dementia with memory-enhancer medications. These treatments will not change the course of disease, but they might improve symptoms for a period of time.²² Memory enhancers should not be prescribed for persons with mild cognitive impairment because harms outweigh benefits in this situation.²²

Continuity and coordination of care: Family physicians coordinate care across health sectors, community services, and health professionals. They also consider solutions to individuals’ and caregivers’ problems across the stages and transitions of dementia, including advance care planning.^3,6 Family physicians are not expected to provide comprehensive dementia care independently^9,23; caring for persons with dementia requires a collaborative, multiprofessional approach in addition to community and family support.

Management of other conditions: Family physicians are experienced in dealing with multiple co-occurring conditions and providing ongoing evaluation of a person’s status.

Detection and management of behavioural symptoms of dementia: Family physicians are positioned to detect and address early changes in behaviour such as wandering, aggression, and resistance, which can lead to extensive caregiver strain.²⁴

Caregiver burden: Caregiving of persons with dementia has been associated with negative effects on the health of caregivers and early nursing home placement for individuals with dementia.²⁴ Family physicians evaluate strain on caregivers and facilitate a diversity of services to decrease burden, improve quality of life, and enable caregivers to provide at-home care.⁹

Referral to specialists: Family physicians selectively refer individuals for specialty care when an affected person has rapidly progressing dementia, has unusual features of dementia, has more complicated types of dementia (eg, Lewy body disease, frontotemporal dementia), or is younger (age < 65 years).⁵

Referral to community services: Family physicians refer patients and their families and caregivers to community service organizations such as the Alzheimer Society of Canada for information, support, and education about dementia; caregiver support and respite; home assessments for safety; friendly volunteer visitors; and strategies to reduce the risk of unsafe walking (eg, registering for programs such as MedicAlert Safely Home).²³

Driving assessment: Although it might be safe for the person with dementia to drive for some time, family physicians are obliged to consider driving safety in anyone who might have dementia. This might involve referral for an on-road driving test.²⁵ This is one area where referral to an external physician might be relevant to help maintain an ongoing relationship with the patient.

Goals of care: Family physicians have opportunities to initiate conversations with patients’ families to focus on a shared understanding of the values and preferences of those living with dementia. It is important to guide care while patients are still able to communicate their wishes.²⁶

Functional assessment: Family physicians should assess or coordinate assessment for changes in their patients’ ability to perform both basic and instrumental activities of daily living (including decision making regarding finances, driving, health care, and independent living) to make timely interventions to support function and limit disability.^19,27

Pain assessment: Identification and treatment of pain is an important aspect of dementia care within the scope of family practice.²⁸

Conclusion

Family physicians are essential to effective dementia care in Canada. We have described what patients with dementia should expect from their family physicians and have identified their role in key aspects of dementia care. We hope that our clarification of the family physician role in dementia care serves as a guide for clinicians, patients, families, and caregivers, and facilitates understanding of the role and organizing expectations during clinical interactions.