Primary care management of dementia

When the decline in memory, cognition, behaviour, and functional ability is progressive and severe enough to interfere with daily life, we are talking about dementia. It is a syndrome that usually affects older individuals. However, as the global population is ageing, primary care doctors find themselves at the forefront of early identification, diagnosis, and long-term management of dementia.

Importance of early recognition and assessment

Early recognition is crucial. So is maintaining a high index of suspicion in older individuals who present with memory complaints, difficulty managing medications or finances, personality changes, or reduced social functioning. Family members can also help, as they often notice symptoms before the patient does.

Brief cognitive screening tools such as the Mini-Cog, Montreal Cognitive Assessment (MoCA), or Mini-Mental State Examination (MMSE) may assist evaluation. Assessment should also include:

• History from caregivers,
• Medication review,
• Depression screening, and
• Evaluation for reversible causes such as hypothyroidism, vitamin B12 deficiency, infection, or adverse drug effects

Diagnosing dementia in primary care

When cognitive impairment is suspected, it is important to establish the subtype of dementia. Alzheimer's disease is the most common form. It is followed by:

• Vascular dementia,
• Lewy body dementia, and
• Frontotemporal dementia

Atypical presentations are also possible. In such cases, neuroimaging and specialist referral may be appropriate. The same goes for rapid progression dementia, early-onset disease, and diagnostic uncertainty.

Non-pharmacological management

Management of dementia should be multidisciplinary and centred on each patient. Non-pharmacological interventions remain the foundation of care. Primary care physicians should encourage:

• Physical activity,
• Cognitive stimulation,
• Social engagement,
• Adequate nutrition, and
• Sleep hygiene

Environmental modifications, structured routines, and caregiver education can reduce behavioural symptoms and improve safety.

Pharmacological treatment

Pharmacologic therapy may offer modest symptomatic benefit in selected patients. Cholinesterase inhibitors such as donepezil, rivastigmine, or galantamine are commonly used in mild to moderate Alzheimer's disease. Memantine may be considered for moderate-to-severe disease.

Physicians should also monitor for adverse effects, including:

• Gastrointestinal symptoms,
• Bradycardia,
• Dizziness, and
• Falls

GPs should review medications regularly to minimise polypharmacy and avoid drugs that worsen cognition, particularly anticholinergic agents and sedative-hypnotics.

How to manage behavioural and psychological symptoms

Behavioural and psychological symptoms of dementia, including agitation, aggression, depression, anxiety, hallucinations, and sleep disturbance, are common and distressing. Therefore, primary care physicians should first identify potential triggers such as pain, infection, constipation, medication changes, or environmental stressors.

Non-pharmacological strategies are preferred. Antipsychotics should be reserved for severe symptoms posing risk to the patient or others, and used cautiously due to increased risks of stroke and mortality in older adults with dementia.

Follow-up and long-term care

Dementia is a progressive illness. Therefore, regular follow-up is necessary to monitor cognitive decline, functional status, driving safety, nutrition, falls risk, and goals of care. Care plans should evolve with disease severity. In advanced stages, palliative care principles, including symptom relief and dignity-focused care, become increasingly important.

The role of GPs is pivotal in coordinating dementia care for the continuum of illness. Early recognition, comprehensive assessment, evidence-based management, and caregiver support at the primary care level can significantly improve outcomes for patients living with dementia and their families.

- Dr Rosmy De Barros

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References

• Browne, B., Kupeli, N., Moore, K. J., Sampson, E. L., & Davies, N. (2021). Defining end of life in dementia: A systematic review. Palliative medicine, 35(10), 1733–1746. https://doi.org/10.1177/02692163211025457
• Siqueira, G. S. A., Hagemann, P. M. S., Coelho, D. S., Santos, F. H. D., & Bertolucci, P. H. F. (2019). Can MoCA and MMSE Be Interchangeable Cognitive Screening Tools? A Systematic Review. The Gerontologist, 59(6), e743–e763. https://doi.org/10.1093/geront/gny126
• Mehta, R. I., & Schneider, J. A. (2023). Neuropathology of the Common Forms of Dementia. Clinics in geriatric medicine, 39(1), 91–107. https://doi.org/10.1016/j.cger.2022.07.005
• Luxton, D., Thorpe, N., Crane, E., Warne, M., Cornwall, O., El-Dalil, D., Matthews, J., & Rajkumar, A. P. (2026). Systematic review of the efficacy of pharmacological and non-pharmacological interventions for improving quality of life of people with dementia. The British journal of psychiatry : the journal of mental science, 228(1), 55–67. https://doi.org/10.1192/bjp.2025.11
• Tampi, R. R., & Jeste, D. V. (2022). Dementia Is More Than Memory Loss: Neuropsychiatric Symptoms of Dementia and Their Nonpharmacological and Pharmacological Management. The American journal of psychiatry, 179(8), 528–543. https://doi.org/10.1176/appi.ajp.20220508
• Schwertner, E., Pereira, J. B., Xu, H., Secnik, J., Winblad, B., Eriksdotter, M., Nägga, K., & Religa, D. (2022). Behavioral and Psychological Symptoms of Dementia in Different Dementia Disorders: A Large-Scale Study of 10,000 Individuals. Journal of Alzheimer's disease : JAD, 87(3), 1307–1318. https://doi.org/10.3233/JAD-215198