General practitioners approach to diagnosis, disclosure and management of dementia in the Maltese islands

Abstract

National Dementia Strategies abroad suggest that early detection of Alzheimer's disease (AD) and other dementias in the community depends on an improved knowledge of the condition among general practitioners (GPs). There is no data on clinical diagnosis and management of dementia in the community in the Maltese islands. The aim of the study was to assess if further training is required for local GPs to approach better diagnosis and management of dementia, with particular interest on AD. A total of 346 questionnaires were mailed to members of the Malta College of Family Doctors (MCFD), of which 131 were valid. Questions were sectioned in four main data groups: demographic, diagnosis, disclosure and treatment. The majority of GPs (76.0%) called for a national protocol for diagnosis of dementia and AD and felt they need more training (56%). Loss of memory (90%) and behavioral symptoms (77%) were the symptoms which made GPs most likely to suspect dementia. On suspicion of cognitive impairment, a general physical examination and interview with the family were the first two actions taken in the majority of cases. One in ten GPs adopted a wait and observe approach, with close follow-up every two to four months and referral to specialist was overall considered late. The majority of GPs (89%) agreed that early diagnosis of AD may postpone or preclude costly institutionalization. Psychometric tests were considered to be useful for assessing the severity of dementia (55%) with few (27%) commenting that they are not readily available in community practice. Most GPs preferred to exclude a number of other conditions which may cause cognitive impairment in their work-up although only 39% correctly excluded all other possible differentials listed. Moreover, local GPs took a cautious approach towards disclosure and communicated diagnosis only if sure of it. Those who were routinely disclosing amounted to just below a third with only a fifth believing this was of any benefit. The results also showed that disclosure consultation generally focused onto medical issues like prognosis and progression of the condition (86%) but also included caregivers' health issues. On pharmacotherapeutic management, half of the GPs would consider acetylcholinesterase inhibitors (AChEIs) in mild cognitive impairment. Psychotropic drug use was found to be low. Aims of treatment were delay In

institutionalization (67%) and maintenance of functional ability (60%). Only a third believed that AChEIe; should be prescribed only by relevant specialists and 65% had a tendency to prescribe them in the community. Follow-up is close to every two to four months (69%) with the rest opting for a six to eight monthly period. Domiciliary home help (85%) and Telecare services (81 %) were mostly recommended by GPs to aid their patients and caregivers even though these are of no particular benefit for disease management. Non-pharmacological approaches to managing people with AD were met by the highest rate of absenteeism. Of these, multisensory stimulation was the one which was mostly recommended (53%). The data from this study indicated that there is not enough knowledge on the diagnosis, disclosure, management and treatment of dementia, particularly AD, among the Maltese and Gozitan GPs. Furthermore, such data would be of benefit in the development of an on-going educational training programme on dementia involving GPs that would invariably lead to an enhancement of high quality dementia care within the community.

Key words: Alzheimer's disease, dementia, general practitioner, diagnosis, disclosure, management, Malta