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.
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:
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:
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.
Management of dementia should be multidisciplinary and centred on each patient. Non-pharmacological interventions remain the foundation of care. Primary care physicians should encourage:
Environmental modifications, structured routines, and caregiver education can reduce behavioural symptoms and improve safety.
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:
GPs should review medications regularly to minimise polypharmacy and avoid drugs that worsen cognition, particularly anticholinergic agents and sedative-hypnotics.
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.
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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