SIGN dementia guideline recommends that GPs manage the condition more proactively, says Dr Honor Merriman
Forgetfulness and a declining ability to carry out everyday tasks are often considered a normal part of ageing; however, the SIGN guideline on management of patients with dementia shows GPs how they can be more proactive so that patients and their carers receive more help at an early stage.1
The new dementia indicators in QOF2 encourage GPs to set up a register of patients with dementia, and this will stimulate GPs to seek out such patients.2
Memory loss is a common early sign, especially if it lasts more than 6 months. The patient's family and friends may report memory loss to the GP before the patient is aware that there is a problem.
The simplest assessment tool is the Mini Mental State Examination (MMSE).3 A score of more than 12 is an indication for specialist referral.4 It is also useful to find out from family and carers how much the mental impairment affects day to day living. The simplest questionnaire for this is the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE).5 Both of these documents are at the end of the SIGN guideline.1
Common causes of mental impairment are anxiety and depression.The advice in the depression indicators in QOF2 is to use questionnaires to assess patients so that the diagnosis can be confirmed and the severity assessed.2 Treatment for these conditions is usually effective even if there is co-existing dementia.
It is worth screening patients with dementia for hypothyroidism, and B12 and folate deficiency. Treatment of these conditions, which may co-exist with dementia, can improve mental functioning and quality of life. It is also useful to carry out a full physical and medication review as many older patients are on several medications and may have co-morbidities that contribute to their poor functional state.
Early referral to a specialist ensures that the most appropriate cholinesterase inhibitor is used.4 Specialist services are responsible for starting and monitoring medication. The three medications that have proved to be effective are donepezil, rivastigmine and galantamine.
Behavioural problems are common in patients with dementia and can make life difficult for carers. Newer antipsychotics (olanzapine or risperidone) are preferred as older medication (chlorpromazine or haloperidol) can cause sedation and confusion.It is conjectured that the newer anti-psychotics may increase the risk of stroke, so their use should be restricted to situations where patients cannot receive proper care due to behavioural problems.1
Carers of dementia patients need to know as much as possible about the condition and its management. They should be informed who else can help with care.The Alzheimer's Society is a good source of information.6
Towards the end of a patient's life, coordinated community team care using the Gold Standards Framework is beneficial.7
The SIGN guideline provides clear advice to clinicians – so much can now be offered to patients that early assessment is essential. It lists the few herbal remedies and non-pharmacological interventions that have been proven to be helpful.The quick reference guide makes a good addition to any set of practice protocols.8
- Scottish Intercollegiate Guidelines Network (SIGN 86). Management of patients with dementia. Edinburgh: SIGN, 2006.
- British Medical Association. Revisions to the GMS contract 2006/07. Delivering investment in general practice. London: BMA, 2006.
- Folstein M, Folstein S, McHugh P. "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12 (3): 189–198.
- National Institute for Clinical Excellence. Technology Appraisal Guidance No.19. Guidance on the use of Donepezil, Rivastigmine and Galantamine for the treatment of Alzheimer's disease. London: NICE, 2001.
- Jorm A. A short form of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE): development and cross-validation. Psychol Med 1994; 24 (1): 145–153.
- Scottish Intercollegiate Guidelines Network (SIGN 86). Management of patients with dementia. Quick Reference Guide. Edinburgh: SIGN, 2006.