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A Brief Guide to the Diagnosis and Treatment of Dementing Disorders for Primary Care Physicians

The diagnosis of Alzheimer's disease and related dementias is often cited by primary care physicians as an area of medical practice that they would like to know more of. In one study, almost half the persons with dementing disorders in a primary care practice were undiagnosed and as a result, untreated. One of the primary explanations for the failure to diagnose Alzheimer's disease and related dementias is our failure to screen for cognitive impairment in medical practice. Many patients in early stages of the disease are capable of carrying on cogent conversations, and as a result, the early signs of dementia are missed during routine clinical exams. This guide was developed for primary care physicians and provides information about diagnostic protocols, an introduction to cognitive screening tools, resources for the patient and family, a list of current literature and links to educational opportunities about the diagnosis and management of dementing disorders.

 

Please note: The WAI does not endorse any particular diagnostic or screening tool or treatment for the management of dementing disorders. If you have comments or questions about the information included below, please do not hesitate to contact Suzanne Bottum-Jones at 608-829-3302 or bottumjones@wisc.edu.

 

 

Background: The Need for Continuing Education

In 2003, the Office of Continuing Medical Education (CME) and the Wisconsin Alzheimer’s Institute at the University of Wisconsin School of Medicine and Public Health completed a statewide needs assessment. The goal of the needs assessment was to:

  1. Identify the critical gaps facing health professionals in translating science and evidence into best care practices for patients with Alzheimer’s disease.
  2. Identify the learning and practice needs of primary care physicians, specialists and allied health professionals in this therapeutic area.

This research was designed to identify current practice in the care of persons with dementia and then to determine best practices throughout the State. There were multiple methods of data collection including surveys, telephone interviews with opinion leaders and focus group meetings occurring in 4 sites throughout Wisconsin. The results of the statewide needs assessment were as follows:

 

Knowledge Deficiencies: The participants in the needs assessment identified very specific gaps in current knowledge that served as barriers to the diagnosis and treatment of dementia. These included:

  • Inability to identify persons needing evaluation (the absence of routine screening).
  • Absence of readily available and easily interpretable diagnostic tools.
  • Inability to monitor the effectiveness of current therapies.
  • Lack of information about the benefits of current treatments.
  • Lack of knowledge about available resources for patients and families.

Practice Obstacles: Barriers to diagnosis and treatment of persons with dementia were accentuated by obstacles identified in medical practice. Practice obstacles included:

  • 15-minute appointments.
  • Inadequate reimbursement for the time required to make a diagnosis.
  • Reliance on families to bring symptoms of cognitive impairment to the attention of the physician (the absence of screening and diagnostic tools).
  • Administrative pressure to "produce".
  • Absence of a social worker and/or supportive staff to assist families and patients with dementia.

The knowledge and practice obstacles identified by the focus groups led to uncertainties about the clinician’s ability to diagnose dementing disorders, manage complications of dementia and deal with the multiple needs of patients and families. One important comment was that making the diagnosis of dementia was like opening "a can of worms," creating an added burden on an already busy primary care physician. As a result, "dementia is not a priority."

 

Based on the outcomes of the needs assessment described above, physician education was included in the Memory Screening Initiatives that were implemented in 11 Wisconsin counties from 2005-2008. These initiatives were designed to break down the barriers that physicians encounter with the lack of screening tools for identifying early memory loss symptoms, the time to perform the screen, the lack of knowledge about the treatment of dementing disorders and the lack of knowledge about community services that can support patients and families.

 

 

Diagnostic Protocols

 

 

Screening Tools (feel free to print and use these)

 

 

Resources for the Patients and Family

 

 

Current Literature

  • Alzheimer's Disease (2006). The Lancet, 368:387-403.
  • Guidelines for Alzheimer's Disease Management prepared by the California Workgroup for Alzheimer's Disease Management (2008). 9-10.
  • Effectiveness of Cholinesterase Inhibitors and Memantine for Treating Dementia: Evidence Review for a Clinical Practice Guideline (2008). Annals of Internal Medicine, 148(5):379-397.
  • Atri A, Shaughnessy LW, Locascio JJ, Growdon JH (2008). Long-term course and effectiveness of combination therapy in Alzheimer disease. Alzheimer Dis Assoc Disord, 22(3):209-221.
  • Josephs, KA (2007). Frontotemporal Lobar Degeneration. Neurol Clinic, 25:683-696.

 

 

Educational Programs

Educational opportunities for physicians, nurse practitioners, physician assistants, psychologists, etc. to learn about the diagnosis and management of dementing disorders.

 

From the Wisconsin Alzheimer's Institute:

From the Medical College of Wisconsin:

 

From the Alzheimer's Association:

 

 

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