1. Core business for general practice: recognition of and response to dementia Ngaire Kerse Professor, General Practice and Primary Health Care, University of Auckland Steve Iliffe Professor of Primary Care for Older People University College London Practice Based Commissioner, Brent PCT www.evidem.org.uk

2. What is dementia? A complex multi-factorial syndrome. Querfurth H, Laferla M Alzheimer’s Disease N. Engl J Med 2010;362:329-44 Memory loss plus one other impaired cognitive domain Not rocket science

3. How do you know you are normal? HEALTHY MemoryOccasional lapses OrientationFull in time, space & person Judgement & problem-solvingSolves everyday problems Outside homeIndependent functioning At homeActivities & interests maintained Personal careFully capable Based on the Clinical Dementia Rating scale (CDR) Hughes CP et al A New Clinical Scale for the staging of Dementia Br J Psychiatry 1982;140:566-572

4. Global assessment ~ early dementia MemoryLoss of memory for recent events OrientationVariable disorientation in time & place Judgement & problem- solving Some difficulty with complex problems Outside homeEngaged in some activities but not independently: may appear ‘normal’ At homeMore difficult tasks & hobbies abandoned Personal careNeeds some prompting

5. Time Global cognitive functioning Normal ageing Linguistic skill and general intelligence decline over decades A B C D Dementia trajectory E Symptomatic but pre-diagnostic phase with brain compensation occurring, over several years Symptomatic & post-diagnosis phase, with progressive decline over years D1 D2 Cognitive impairment & dementia

6. Cognitive assessment Mini-Mental State Examination (MMSE) 6CIT GPCog MOCA Verbal fluency Clock drawing Diagnosis Informant history Cognitive function tests Blood screen (FBC, thyroid function) Scanning NICE 2006

7. Psychosocial support Regular doctor-initiated contact –Catastrophic thinking, beliefs attitudes fears Review global assessment –Focus on ‘still do’, reframe as a disability Manage co-morbidities Review support needed Carer’s health Robinson L et al for the DENDRON Primary Care Clinical Studies Group Primary care & dementia: 2 Case management, carer support & the management of behavioural and psychological symptoms IJGP 2009; Nov 27 [Epub ahead of print]

8. Core business in general practice Continuity of contact Population reach Pattern recognition Problem solving not protocol driven Systematised care Mary 75 yrs, widowed 2 yrs, Hx breast cancer age 50 Complains of losing her keys, forgetting appointments, even left her best dress at the drycleaners for 2 months

9. Now MMSE 26 Depressive symptoms Offer treatment –Talking, exercise and drugs Improves 2 years time Brought by daughter Noticed definite change (you have too) Disheveled MMSE 22 diagnosis ?Alzheimers type Bloods, request imaging