There is increasing public awareness of dementia, and growing policy support for developing services for people with dementia and their carers.
Early diagnosis of dementia within primary care is important because this allows those with dementia and their family care networks to engage with support services and plan for the future.
There is, however, evidence that dementia remains under-detected and sub-optimally managed in general practice. Up to 60% of patients with dementia syndromes are not diagnosed by their primary care physicians.
Dementia ES requirements
The enhanced service (ES) for dementia, 'facilitating timely diagnosis and support for people with dementia' to give it its full title, has been designed to reward GP practices in England for undertaking a proactive approach to the timely assessment of patients who may be at risk of dementia.
The ES suggests that this is done opportunistically in the patient’s annual review. During the review an enquiry should be made of the patient and their carer, if present, whether they have concern about their memory.
If they do have concern and if they are in agreement, the General Practitioner Assessment of Cognition (GPCOG) is then used to assess their memory.
As the payments are linked to ‘assessment for dementia’ code they do not rely on diagnosis and the capacity of the memory services in your locality.
In our practice we have included two questions to the computer prompts in the annual reviews for at risk groups, including patients with diabetes, CHD and stroke.
- When speaking does the patient have more difficulty in finding the right work or tend to use the wrong worse more than they used to?
- Is the patient having trouble concentrating and/or remembering things that have happened recently.
It should be possible for your locality to develop a template to embed the GPCOG tool into your clinical system and encompass the necessary clinical information and codes required as evidence for delivery of the ES.
Dementia prevalence rises with age and it might be worth a telephone call to the nursing and residential homes in your practice area. They should be able to help identify those they think might have dementia and these are 'low hanging fruit' for you to prioritise.
This is a lot of work for little reward and is compounded by the QOF requirement for ongoing annual reviews of those diagnosed with dementia. The carer examination is good practice, but it can double or triple your workload.
There are a lot of GPs who consider the diagnosis of dementia disabling and prefer to label only those with a serious loss of function.
Our practice uses the code 'memory problem – symptom' for those without a formal diagnosis. About a fifth of these patients were found to have other causes for their problems other than dementia. These were mainly depression, B12 deficiencies and other physical health problems that meant that they had become frail.
Dr Greaves is a GP in Stafford, West Midlands