Guidelines for preventive activities in general practice

Mental health and substance use

Dementia

      1. Dementia

Mental health and substance use | Dementia 

Case finding age bar

09 1014 1519 2024 2529 3034 3539 4044 4549 5054 5559 6064 6569 7074 7579 ≥80
It is estimated that over 400,000 people in Australia are living with dementia. Dementia is the leading cause of death in women and a leading cause of burden of disease overall.1,2 Dementia is the fourth-highest cause of disease burden in women, responsible for 6.8 disability-adjusted life years (DALYs) per 1000 population. Dementia is the sixth-highest contributor to disease burden in men responsible for 5.8 DALY per 1000 population.3 The prevalence of dementia is increasing as the population ages.4

Although dementia is usually regarded as a disease of older age, younger-onset dementia is becoming increasingly recognised. In 2019, more than 27,000 people were thought to be living with younger-onset dementia in Australia.5
 

Screening

Recommendation Grade How often References
General population screening for dementia is not recommended. Not recommended (strong) NA 6

Case finding

GPs should be alert to the symptoms and signs of dementia, which include not just memory difficulties, but also changes in personality, behaviour and executive function. These may be detected opportunistically and assessed using questions addressed to the person and/or their carer, including formal cognitive function tests and carer scales. Symptoms such as apathy and low mood may lead the GP to consider depression. Depression and dementia may co-exist, and both may need diagnosis and management. Conditionally recommended Opportunistically 6
Be alert for dementia in those with increasing age. For other risk factors known to be associated with dementia, see Box 1. Conditionally recommended Opportunistically 7,8,9,10,11,12,13,14,15,16,17,18,19,20,21
For people with any of the findings listed below*, over several consultations obtain a history from the person and their family, and perform a comprehensive physical examination. Consider administering of one of the following cognitive screening tests: *Symptoms such as memory loss or behaviour change, concerned family members, history of repeated head trauma, Down syndrome, elevated cardiovascular risk, depression or a history of depression. Practice point N/A 22,23
For people who are showing signs of dementia, concerns or symptoms should be explored when first raised, noted or reported by the person, carer(s) or family and should not be dismissed as ‘part of ageing’. Practice point N/A 6

Preventive activities and advice

Recommendation Grade How often References
Provide preventive advice in relation to the following associations with dementia. See Box 2.
 
Practice point N/A 24

Dementia is a strong source of burden for carers and for the health system overall. It is vitally important that GPs move to prevent as much dementia as possible through attention to the risk factors, and then recognise and assist the person to manage their life if they develop dementia.

The best time to identify risk factors is earlier in life. GPs’ work in identifying and modifying cardiovascular and other risk factors in midlife also reduces the risk factors for dementia. Dementia risk scores may help.25 It may be helpful for GPs to mention the risk score to patients as a motivating factor for behaviour change. The health assessments funded for midlife and the care plans for chronic disease management may help with this.

GPs need to recognise and respond to the barriers to the identification of dementia. These include:

  • system-related factors (eg short consultation lengths)
  • GP factors (eg difficulties of diagnosis and management)
  • patient factors around stigma and a consequent reluctance to discuss dementia, or around difficulties in understanding the concept26
  • patients being investigated for dementia (eg in the case finding paradigm outlined above, patients need to be aware of the reasons for the questionnaire investigations and follow-up blood tests and referrals)

A preference not to be told the diagnosis should be respected. However, it is important that the person and/or their carer understands that there is a problem with cognition that will need management. The concept of secondary prevention (ie slowing the progression of the disease using the strategies outlined above) can then be introduced (eg smoking cessation, correction of hearing impairment, optimal management of other cardiac risk factors, diet and exercise).

Box 1. Risk factors associated with dementia (other than increasing age, which doubles the risk for every five-year increase)

  • A family history of Alzheimer’s disease and genetic factors6
  • A history of repeated head trauma27
  • Down syndrome
  • Elevated cardiovascular risk6,27,28
  • Depression or a history of depression6,27
  • Low education levels28
  • Smoking 14,27,
  • Physical inactivity27,29
  • Aboriginal and Torres Strait Islander status
  • Low social contact27
  • Hearing loss27

Box 2. Risk reduction interventions for cognitive decline and dementia24

Physical activity interventions
  • Physical activity should be recommended to adults with normal cognition to reduce the risk of cognitive decline
  • Physical activity may be recommended to adults with mild cognitive impairment to reduce the risk of cognitive decline
Tobacco cessation interventions
  • Interventions for tobacco cessation should be offered to adults who use tobacco because they may reduce the risk of cognitive decline and dementia in addition to having other health benefits
Nutritional interventions
  • A Mediterranean-like diet may be recommended to adults with normal cognition and mild cognitive impairment to reduce the risk of cognitive decline and/or dementia
  • A healthy, balanced diet should be recommended to all adults
  • Vitamins B and E, polyunsaturated fatty acids and multicomplex supplementation should not be recommended to reduce the risk of cognitive decline and/or dementia
Interventions for alcohol use disorders
  • Interventions aimed at reducing or ceasing hazardous and harmful drinking should be offered to adults with normal cognition and mild cognitive impairment to reduce the risk of cognitive decline and/or dementia in addition to other health benefits
Cognitive interventions
  • Cognitive training may be offered to older adults with normal cognition and with mild cognitive impairment to reduce the risk of cognitive decline and/or dementia
Social activity
  • There is insufficient evidence for social activity reducing the risk of cognitive decline/dementia
  • Social participation and social support are strongly connected to good health and wellbeing throughout life, and social inclusion should be supported over the life course
Weight management
  • Interventions for midlife overweight and/or obesity may be offered to reduce the risk of cognitive decline and/or dementia
Management of hypertension
  • Management of hypertension should be offered to adults with hypertension
  • Management of hypertension may be offered to adults with hypertension to reduce the risk of cognitive decline and/or dementia
Management of diabetes
  • Management of diabetes in the form of medications and/or lifestyle interventions should be offered to adults with diabetes
  • Management of diabetes may be offered to adults with diabetes to reduce the risk of cognitive decline and/or dementia
Management of dyslipidaemia
  • Management of dyslipidaemia at midlife may be offered to reduce the risk of cognitive decline and dementia
Management of depression
  • There is currently insufficient evidence to recommend the use of antidepressant medicines to reduce the risk of cognitive decline and/or dementia
  • Management of depression in the form of antidepressants and/or psychological interventions should be provided to adults with depression
Management of hearing loss
  • There is insufficient evidence to recommend the use of hearing aids to reduce the risk of cognitive decline and/or dementia
  • Screening followed by provision of hearing aids should be offered to older people for timely identification and management of hearing loss

GPs should be aware of the increased risk for dementia for Aboriginal and Torres Strait Islander people. This particularly applies to those who have suffered trauma, for example the Stolen Generations.6 For specific recommendations and advice, refer to the Dementia section in the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people and the Best-practice guide to cognitive impairment and dementia care for Aboriginal and Torres Strait Islander people attending primary care.

GPs should be aware that culturally and linguistically diverse (CALD) populations may have culturally specific understandings of and attitudes towards dementia and how it should be managed.7 Ethno-specific workers may be able to assist GPs who are concerned about undertaking primary or secondary prevention in this context.

  1. Grossberg GT, Christensen DD, Griffith PA, Kerwin DR, Hunt G, Hall EJ. The art of sharing the diagnosis and management of Alzheimer’s disease with patients and caregivers: Recommendations of an expert consensus panel. Prim Care Companion J Clin Psychiatry 2010;12(1):cs00833. doi: 10.4088/PCC.09cs00833oli.
  2. Robinson L, Gemski A, Abley C, et al. The transition to dementia – individual and family experiences of receiving a diagnosis: A review. Int Psychogeriatr 2011;23(7):1026–43. doi: 10.1017/S1041610210002437.
  3. Australian Institute of Health and Welfare. Australian burden of disease study. Australian Government, 2023 [Accessed 5 March 2024].
  4. Australian Institute of Health and Welfare. Dementia in Australia. Australian Government, 2023 [Accessed 5 March 2024].
  5. Dementia Australia. About younger-onset dementia. Dementia Australia, n.d [Accessed 17 May 2023].
  6. Cognitive Decline Partnership Centre, The University of Sydney. Clinical practice guidelines and principles of care for people with dementia. The University of Sydney, 2016 [Accessed 5 March 2024].
  7. Boustani M, Peterson B, Hanson L, et al. Screening for dementia in primary care: A summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2003;138(11):927–37. doi: 10.7326/0003-4819-138-11-200306030-00015.
  8. National Collaborating Centre for Mental Health. Dementia: A NICE-SCIE guideline on supporting people with dementia and their carers in health and social care. National Institute for Health and Care Excellence, 2006.
  9. Gao S, Hendrie HC, Hall KS, Hui S. The relationships between age, sex, and the incidence of dementia and Alzheimer disease: A meta-analysis. Arch Gen Psychiatry 1998;55(9):809–15. doi: 10.1001/archpsyc.55.9.809.
  10. Lautenschlager NT, Cupples LA, Rao VS, et al. Risk of dementia among relatives of Alzheimer’s disease patients in the MIRAGE study: What is in store for the oldest old? Neurology 1996;46(3):641–50. doi: 10.1212/WNL.46.3.641.
  11. Lenoir H, Dufouil C, Auriacombe S, et al. Depression history, depressive symptoms, and incident dementia: The 3C study. J Alzheimers Dis 2011;26(1):27–38. doi: 10.3233/JAD-2011-101614.
  12. Fleminger S, Oliver DL, Lovestone S, Rabe-Hesketh S, Giora A. Head injury as a risk factor for Alzheimer’s disease: The evidence 10 years on; a partial replication. J Neurol Neurosurg Psychiatry 2003;74(7):857–62. doi: 10.1136/jnnp.74.7.857.
  13. Anstey KJ, Eramudugolla R, Hosking DE, Lautenschlager NT, Dixon RA. Bridging the translation gap: From dementia risk assessment to advice on risk reduction. J Prev Alzheimers Dis 2015;2(3):189–98. doi: 10.14283/jpad.2015.75.
  14. Anstey KJ, von Sanden C, Salim A, O’Kearney R. Smoking as a risk factor for dementia and cognitive decline: A meta-analysis of prospective studies. Am J Epidemiol 2007;166(4):367–78. doi: 10.1093/aje/kwm116.
  15. Alzheimer’s Disease International (ADI). World Alzheimer report 2014. Dementia and risk reduction. An analysis of protective and modifiable risk factors. ADI, 2014 [Accessed 6 March 2024].
  16. Beydoun MA, Beydoun HA, Gamaldo AA, Teel A, Zonderman AB, Wang Y. Epidemiologic studies of modifiable factors associated with cognition and dementia: Systematic review and meta-analysis. BMC Public Health 2014;14(1):643. doi: 10.1186/1471-2458-14-643.
  17. Flicker L, Holdsworth K. Aboriginal and Torres Strait Islander people and dementia: A review of the research. A report for Alzheimer’s Australia. Alzheimer’s Australia, 2014.
  18. Broe T, Wall S. The Koori dementia care project (KDCP): Final report. Dementia Collaborative Research Centres, 2013 [Accessed 5 March 2024].
  19. Smith K, Flicker L, Lautenschlager NT, et al. High prevalence of dementia and cognitive impairment in Indigenous Australians. Neurology 2008;71(19):1470–73. doi: 10.1212/01.wnl.0000320508.11013.4f.
  20. Australian Health Ministers’ Advisory Council’s (AHMAC) National Aboriginal and Torres Strait Islander Health Standing Committee. Cultural respect framework 2016–2026 for Aboriginal and Torres Strait Islander health. AHMAC, 2016 [Accessed 14 March 2024].
  21. Smith K, Flicker L, Shadforth G, et al. ‘Gotta be sit down and worked out together’: Views of Aboriginal caregivers and service providers on ways to improve dementia care for Aboriginal Australians. Rural Remote Health 2011;11(2):1650. doi: 10.22605/RRH1650.
  22. Bradley K, Smith R, Hughson JA, et al. Let’s CHAT (Community Health Approaches To) dementia in Aboriginal and Torres Strait Islander communities: Protocol for a stepped wedge cluster randomised controlled trial. BMC Health Serv Res 2020;20(1):208. doi: 10.1186/s12913-020-4985-1.
  23. Haralambous B, Dow B, Tinney J, et al. Help seeking in older Asian people with dementia in Melbourne: Using the cultural exchange model to explore barriers and enablers. J Cross Cult Gerontol 2014;29(1):69–86. doi: 10.1007/s10823-014-9222-0.
  24. World Health Organization (WHO). Risk reduction of cognitive decline and dementia: WHO guidelines. WHO, 2019 [Accessed 5 March 2024].
  25. Anstey KJ, Zheng L, Peters R, et al. Dementia risk scores and their role in the implementation of risk reduction guidelines. Front Neurol 2022;12:765454. doi: 10.3389/fneur.2021.765454.
  26. Magin P, Juratowitch L, Dunbabin J, et al. Attitudes to Alzheimer’s disease testing of Australian general practice patients: A cross-sectional questionnaire-based study. Int J Geriatr Psychiatry 2016;31(4):361–66. doi: 10.1002/gps.4335.
  27. Livingston G, Huntley J, Sommerlad A, et al. Dementia prevention, intervention, and care: 2020 report of the Lancet Commission. Lancet 2020;396(10248):413–46. doi: 10.1016/S0140-6736(20)30367-6.
  28. Anstey KJ, Lipnicki DM, Low LF. Cholesterol as a risk factor for dementia and cognitive decline: A systematic review of prospective studies with meta-analysis. Am J Geriatr Psychiatry 2008;16(5):343–54. doi: 10.1097/01
  29. Barnes DE, Yaffe K. The projected effect of risk factor reduction on Alzheimer’s disease prevalence. Lancet Neurol 2011;10(9):819–28. doi: 10.1016/S1474-4422(11)70072-2.
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