Skip to main content
Log in

Diagnosis and management of dementia in primary care at an early stage: the need for a new concept and an adapted procedure

  • Published:
Theoretical Medicine and Bioethics Aims and scope Submit manuscript

Abstract

Diagnosis of dementia in primary care is both difficult and important. The recommendations by several authors to improve the diagnosis of dementia by general practitioners are important, but insufficient. It is argued that perhaps the disease concept in itself is a cause of confusion for clinicians. Primary care physicians need an adapted procedure, gradually leading to the final diagnosis of dementia. It has to be a stepwise labelling strategy, using global descriptions and non-disease specific labels in the beginning, ending up with well-defined disease criteria. In this process, there is circularity: previous diagnoses have to be kept in mind because symptoms and signs may gradually change during the progression of the disease, leading to reconsideration of previous deleted options. To frame this properly, the primary care physician needs to adopt a broad “frail elderly” geriatric concept. Implementation of this concept not only helps the diagnostic process, but also stimulates the care for dementing patients and their caregivers. Relevant arguments for early diagnostic involvement of primary care physicians can be put forward on condition that a new concept, adapted procedures and adapted instruments are used.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

REFERENCES

  1. Downs M. The role of general practice and the primary care team in dementia diagnosis and management. Int J Ger Psychiat 1996; 11: 937–942.

    Google Scholar 

  2. Iliffe S. Can delays in the recognition of dementia in primary care be avoided? Aging and Mental Health 1997; 1: 7–10.

    Google Scholar 

  3. Pond CC, Mant A, Kehoe L et al. General practitioners' diagnosis of depression and dementia in the elderly: can academic detailing make a difference? Fam Pract 1994; 11: 141–147.

    Google Scholar 

  4. Woolf Sh, Kamerow DB, Lawrence Rs et al. The periodic health examination of older adults: the recommendations of the US Preventive Task Force. J Am Geriatr Soc 1990; 38: 817–823.

    Google Scholar 

  5. Glosser G, Wexlet D, Balmelli M. Physicians' and families' perspectives on the medical management of dementia. J Am Geriatr Soc 1985; 33: 383–391.

    Google Scholar 

  6. American Psychiatric Association. Practice guideline for the treatment of patients with Alzheimer's disease and other dementias of late life. Am J Psychiatry May 1997; 154 suppl.: 1–39.

    Google Scholar 

  7. Dillman RMJ Alzheimer's disease. The Concept of Disease and the Construcion of Medical Knowledge. Amsterdam: Thesis Publishers, Free University Amsterdam, 1990.

    Google Scholar 

  8. Scadding JG. Diagnosis: the clinician and the computer. The Lancet 1967; ii: 977–882.

    Google Scholar 

  9. Cherrier MM, Mendez M, Perryman KM et al. Frontotemporal dementia versus vascular dementia: differential features on mental status examination. JAGS 1997; 45: 579–583.

    Google Scholar 

  10. Liberini P, Valerio A, Memo M, Spano P. Lewy-body dementia and responsiveness to cholinesterase inhibitors: a paradigm for heterogeneity of Alzheimer's disease? Tips 1996; 17: 155–160.

    Google Scholar 

  11. Buschke H, Sliwinski MJ, Kuslansky G, Lipton RB. Diagnosis of early dementia by the Double Memory Test: encoding specificity improves diagnostic sensitivity and specificity. Neurology 1997; 48: 989–997.

    Google Scholar 

  12. De Lepeleire J, Heyrman J, Baro F et al. How do general practitioners diagnose dementia? Fam Pract 1994; 11: 148–152.

    Google Scholar 

  13. De Lepeleire J, Heyrman J, Buntinx F. The early diagnosis of dementia: triggers, early signs and luxating events. Fam Pract 1998; 15: 431–436.

    Google Scholar 

  14. Moons KGM. Diagnostic Research. Theory and Application. Thesis. KUNijmegen, 1996.

  15. O Connor DW, Fertig A, Grande MJ, Hyde BJ, Perry JR, Roland MO et al. Dementia in general practice: the practical consequences of a more positive approach to diagnosis. Br J Gen Practice 1993; 43: 185–188.

    Google Scholar 

  16. Custers EJFM, Regeher G, Norman G. Mental representations of medical diagnostic knowledge: a review. Academic Medicine 1996; 71: S55–S61.

    Google Scholar 

  17. Knottnerus JA, Van der Grinten R. Huisarts en epidemiologie. Utrecht: Bunge, 1994.

    Google Scholar 

  18. Dillman RMJ. Alzheimer ziekte: variatie zonder eenheid. Ned T Geneeskd 1992; 23: 41–47.

    Google Scholar 

  19. Eefsting JA, Boersma F, Van Den Brink W, Van Tilburg W. Differences in prevalence of dementia based on community survey and general practitioner recognition. Psychological Medicine 1996; 26: 1223–1230.

    Google Scholar 

  20. De Lepeleire J, Heyrman J. Diagnose van dementie door huisartsen. Toelichting bij een consensus: deel I. Tijdschrift Geneeskunde 1997; 53: 1461–1467.

    Google Scholar 

  21. De Lepeleire J, Heyrman J. Diagnose van dementie door huisartsen. Toelichting bij een consensus: deel II. Tijdschrift Geneeskunde 1997; 53: 1524–1530.

    Google Scholar 

  22. Corey-Bloom J, Thal LJ, Galasko D et al. Diagnosis and evaluation of dementia. Neurology 1995; 45: 211–218.

    Google Scholar 

  23. American Psychiatric Association DSM-IV Primary Care, International Edition. Washington: American Psychiatric Press, Inc, 1994.

    Google Scholar 

  24. Campbell Aj, Buchner DM. Unstable disability and the fluctuations of frailty. Age and Ageing 1997; 26: 315–318.

    Google Scholar 

  25. Hadley EC. The Science of the Art of Geriatric Medicine. JAMA 1997; 273: 1381–1382.

    Google Scholar 

  26. Eulderink F, Heeren TJ, Knook DL, Ligthart Gj eds. Inleiding gerontologie en geriatrie Houten/zaventem. Bohn Stafleu Van loghum, 1993, p. 66.

  27. Sipsma DH. Modellen en paradigma's in de geriatrie. Medisch Contact 1993; 48: 1229–1231.

    Google Scholar 

  28. Spreeuwenberg C. Verpleeghuisarts of geriater? Medisch Contact 1995; 50: 507.

    Google Scholar 

  29. World Health Organisation. The Public Health Aspects of the Ageing of the Population. Kopenhagen, 1959.

  30. Becker PM, Cohen HJ The functional approach to the care of the elderly: a conceptual framework. J Am Geriatr Soc 1984; 32: 923–929.

    Google Scholar 

  31. Mold WM, Blake GH, Becker LA. Goal oriented medical care. Fam Med 1991; 23: 46–51.

    Google Scholar 

  32. Hertogh CMPM. Het “geriatrische” van verpleeghuisgeneeskunde, voorbij cure en care. Tijdschr Gerontol Geriatr 1997; 28: 3–4.

    Google Scholar 

  33. Skurla E, Rogers JC, Sunderland T. Direct assessment of activities of daily living in Alzheimer's disease. J Am Geriatr Soc 1988; 26: 196–197.

    Google Scholar 

  34. Haley WE, Pardo KM. Relationship of severity of dementia to caregiving stressors. Psychol Aging 1989; 4: 389–392.

    Google Scholar 

  35. Butler RN, Finkel SI, Lewis M et al. Aging and mental health: diagnosis of dementia and depression. Geriatrics 1992; 6: 49–57.

    Google Scholar 

  36. Greer M. Dementia: a major disease of aging. Geriatrics 1982; 37: 101–103.

    Google Scholar 

  37. Robinson P, Bush T, Von Korff M et al. Primary care physicians' use of cognitive behavioral techniques with depressed patients. J Fam Pract 1995; 40: 352–357.

    Google Scholar 

  38. Wonca Classification Committee. Functional Status Measurement in Primary Care. New York: Springer Verlag, 1990.

    Google Scholar 

  39. Hutchingson A, Bentzen N, König-Zahn C eds. Cross Cultural Outcome Assessment: A Users' Guide. European Research Group on Health Outcomes (ERGHO), 1997.

  40. Ritchie K. The screening of cognitive impairment in the elderly: a critical review of current methods. J Clin Epidemiol 1988; 41: 635–643.

    Google Scholar 

  41. Bowers J, Jorm AF, Henderson S et al. General practitioners' detection of depression and dementia in elderly patients. Med J Australia 1990; 153: 192–196.

    Google Scholar 

  42. Henderson HS, Huppert FA. The problem of mild dementia. Psychological Medicine 1984; 14: 5–11.

    Google Scholar 

  43. Cooper B, Bickel H. Population screening and the early detection of dementing disorders in old age: a review. Psychol Med 1984; 14: 81–95.

    Google Scholar 

  44. Almind G. The General Practitioner and the dementia patient. Dan Med Bull 1985; 32 (suppl 1): 65–68.

    Google Scholar 

  45. Van de Cammen TJM. Diagnostic Approaches and Management Aspects of Dementia. Delft: Eburon Publishers, 1991.

    Google Scholar 

  46. Wilson DB, Guyatt GH, Streiner DL. The diagnosis of dementia. Can Med Assoc J 1987; 137: 625–629.

    Google Scholar 

  47. O Connor DW, Pollitt PA, Hyde JB, Brook CPB, Reiss BB, Roth M. Do general practitioners miss dementia in elderly patients? Br Med J 1988; 297: 1107–1110.

    Google Scholar 

  48. Ormell J, Tiemens B. Recognition and treatment of mental illness in primary care. Gen Hosp Psychiatry 1995; 17: 160–164.

    Google Scholar 

  49. Boise L, Camicioli R, Morgan D, Rose J, Congleton L. Diagnosing Dementia: Perspectives of Primary Care Physicians. Paper presented ad the 50th annual Scientific Meeting of the Gerontological Society of America, November 1997, Ohio, USA.

  50. Mc Whinney IR. Textbook of Family Medicine. New York: Oxford Univeristy Press, 1989, pp. 12–20.

    Google Scholar 

  51. Knottnerus JA, Metsemakers J, Höppener P, Limonard C. Chronic Illness in the community and the concept of “social prevalence”. Fam Practice 1992; 9: 15–21.

    Google Scholar 

  52. Buntinx F, Knottnerus JA, Jolles J et al. Dementia in General Practice: incidence, prevalence and social prevalence and co-morbidity. Arch Public Health 1994; 52: 475–487.

    Google Scholar 

  53. Vernooij-Dassen M. Huisarts en dementie: de begeleiding van patiënt en centrale verzorger. Huisarts en Wetenschap 1996; 39: 504–507.

    Google Scholar 

  54. Haley W. The family caregiver's role in Alzheimer's disease. Neurology 1997; 48: S25–S29.

    Google Scholar 

  55. Donaldson C, Tarrier N, Burns A. The impact of the symptoms of dementia on caregivers. Br J Psychiatry 1997; 170: 62–68.

    Google Scholar 

  56. Bannister C, Ballard C, Lana M, Fairburn A, Wilcock G. Placement of dementia sufferers in residential and nursing home care. Age and Ageing 1998; 27: 189–193.

    Google Scholar 

  57. Resnik D. To test or not to test: a clinical dilemma. Theoretical Medicine 1995; 16: 141–152.

    Google Scholar 

  58. Bayer AJ, Pathy MSJ, Twining C. The memory clinic: a new approach to the detection of early dementia. Drugs 1987; suppl. 2: 84–89.

    Google Scholar 

  59. Mc Lean S. Assessing dementia. Part I: difficulties, definitions and differential diagnosis. Austr New Zeal J Psychiat 1987; 21: 142–174.

    Google Scholar 

  60. Maguire CP, Kirby M, Coen R et al. Family members' attitudes towards telling the patient with Alzheimer's disease their diagnosis. BMJ 1996; 313: 529–530.

    Google Scholar 

  61. Aisen PS, Davis KL. The search for disease-modifying treatment for Alzheimer's disease. Neurology 1997; 48 (suppl 6): S35–S41.

    Google Scholar 

  62. Verhey FRJ, Heeren TJ, Scheltens PH, Van Gool WA. Cholinesteraseremmers bij de ziekte van Alzheimer: voorlopige aanbevelingen voor de praktijk. Ned T Geneeskd 1998; 142: 3091–2096.

    Google Scholar 

  63. Eccles M, Clarke J, Livingstone M, Freemantle N, Mason J. North of England evidence based guidelines development project: guideline for the primary care management of dementia. BMJ 1998; 317: 802–808.

    Google Scholar 

  64. Clarfield AM. The reversible dementias: do they reverse? Ann Intern Med 1988; 109: 476–486.

    Google Scholar 

  65. Walstra GJM, Teunisse S, Van Gool WA, Van Crevel H. Reversibele dementie bij bejaarden verwezen naar een polikliniek voor geheugenstoornissen. Ned Tijdschr Geneeskd 1997; 141: 376–380.

    Google Scholar 

  66. Weything MD, Bossuyt PMM, Van Crevel H. Reversible dementia: more than 10% or less than 1%? A quantitative review. J Neurol 1996; 242: 466–471.

    Google Scholar 

  67. Larson EB, Reifler BV, Summi SM, Canfield CG, Chinn NM. Diagnostic evaluation of 200 elderly outpatients with suspected dementia. J Gerontol 1985; 40: 536–543.

    Google Scholar 

  68. Van Oyen H, Dom H, Baro F, Wostyn P, Roelands M. Cognitive impairment and mortality. Acta Psych Belg 1997; 97: 166–180.

    Google Scholar 

  69. Mittelman MS, Ferris SH, Shulman E et al. A family intervention to delay nursing home placement of patients with Alzheimer's disease. A randomised controlled trial. JAMA 1996; 276: 1725–1731.

    Google Scholar 

  70. Sackett DL, Haynes RB, Tugwell P. Clinical Epidemiology: A Basic Science for Clinical Medicine. Boston: Little Brown and Company, 1985.

    Google Scholar 

  71. Mowry BJ, Burvill PW. A study of mild dementia in the community using a wide range of diangostic criteria. Br J Psychiatry 1988; 153: 328–334.

    Google Scholar 

  72. Pellegrino ED. An academic base for family practice. Ohio Gen Practitioner 1965; xx: 8.

    Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Rights and permissions

Reprints and permissions

About this article

Cite this article

De Lepeleire, J., Heyrman, J. Diagnosis and management of dementia in primary care at an early stage: the need for a new concept and an adapted procedure. Theor Med Bioeth 20, 213–226 (1999). https://doi.org/10.1023/A:1005488328563

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1023/A:1005488328563

Navigation