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This pathway is for the initial assessment and primary care diagnosis of people presenting with cognitive problems suggestive of possible dementia.
People with mild dementia (MMSE greater than 20/30, GP-COG 9-11/15 or normal cognitive test but also with functional impairments) or people presenting below the age of 65 should generally be referred to the Memory Clinic for detailed assessment.
People with moderate or advanced dementia (MMSE less than 20/30, GP-COG less than 9/15) may be diagnosed in primary care by their GP without referral to specialist services.
The following patient groups are more at risk of developing dementia and may be specifically targeted for assessment by primary care services:
Normal cognitive test and no functional impairments or evidence of alternative diagnosis.
The Alzheimer's Disease Risk Index may be useful for patients who are worried about their risk of developing dementia (for example if they have a family history of dementia) but who currently have no objective evidence of cognitive decline. It is free to use and involves completion of a 10-15 minute lifestyle questionnaire online before a personalised risk score is produced. Information is provided to help interpret the risk score and highlight modifiable lifestyle risk factors.
A detailed history is very helpful in making a diagnosis of dementia and which type of dementia is most likely. Timing of first awareness of symptoms, how the decline is progressing and which cognitive tasks are most challenging is crucial. Additional features to check for include: history of stroke or head injury, presence of visual hallucinations, whether word-finding or short term memory is more of a problem, emotional liability or inappropriate behaviour.
Any suggestion of focal neurological deficits should be explored by examination as they may support a diagnosis of vascular dementia or point to an alternative diagnosis than dementia.
The presence of a coarse resting tremor might support the possibility of Dementia with Lewy Bodies or Parkinson's disease dementia.
It is strongly advised that the patient's GP raises the possibility of dementia with the person presenting (and their carer/family member present).
Tests in primary care are now a QOF requirement (must be undertaken within 6 months before or after first coding a diagnosis of dementia on the person's record):
A cognitive test:
MMSE (The mini-mental state examination was originally distributed free, but the current copyright holders will not grant permission to include or reproduce an entire test or scale in any publication.)
Dementia is more likely if:
It is important to ensure that the person diagnosed is suitably read coded in their Primary Care computer record. The Dementia Support Service can be contacted on 0300 123 2029.
It is recommended that all patients diagnosed with dementia are referred to the Devon Dementia Support Worker Service for information, advice and signposting when necessary.
Identification of the carer for a person with dementia is crucial. It provides opportunities for:
An annual Dementia review in primary care is a Quality and Outcomes Framework requirement. Although QOF is not specific about what should be done during the review, the following should be considered:
For advice on the management of severe behavioural or psychological problems displayed by people with dementia please see the following very useful Pharmacological Management of Severe Behavioural & Psychological Symptoms of Dementia (BPSD)
See Joint Formulary: 4.11 Dementia
When deciding to refer to the Memory Clinic the GP should provide the patient with written information on what to expect.
Please include the following information in the referral proforma:
For those patients whose learning disability precludes them from completing the tasks required in the ACE III, please refer straight to the local learning disability service (now known as IATT: the Intensive Assessment and Treatment Team for Adults with a Learning Disability) for an adapted dementia assessment.
This guideline has been signed off by the Devon Partnership Trust.
Publication date: March 2018