Discussion Session: Chronic Disease and Aging: The Challenge of Alzheimer’s Disease
Speakers: Dr. Bergman, Dr. Ménard, and Dr. Banerjee
Moderator: Paule Lebel, MD, MSc, CSPQ, FRCPC, Director, Centre d’expertise sur la santé des personnes âgées et des aidants (CESPA), Institut universitaire de gériatrie de Montréal; Member, Task Force charged with proposing a Quebec action plan on Alzheimer’s Disease and related disorders.
Dr. Lebel moderated a question period among three physicians tasked with proposing action plans or advising governments and institutions about healthcare decision-making and policy development aimed at better managing increasing numbers of patients with Alzheimer’s disease.
Dr. Lebel echoed Dr. Banerjee’s emphasis on the need for early diagnosis followed by the prompt provision of care and services that promote autonomy as the disease course progresses.
Dr. Bergman responded to a questioner’s concern that the model of care set forth in his presentation failed to account for service and resource disparities between urban and rural settings. Dr. Bergman acknowledged that there is unequal distribution, and that a possible approach could involve setting specific goals about the geographical locations of memory clinics to equalize access. He advocated additional remuneration and financial incentives to encourage professionals to practice in underserved areas. He further suggested that services such as telehealth could play a vital role in helping to cover rural areas with modest access to health personnel and services. Possible solutions to filling such care gaps, and meeting the needs of a heterogeneous population affected by dementing disorders (e.g., with multiple morbidities), could be yielded by pilot programs that seek to close these gaps and through service implementation strategies with 5-year objectives, tasked to meet specific goals in care improvement. Dr. Bergman urged input from practitioners sharing the questioner’s concerns.
Dr. Banerjee responded to a query from a physician concerned that a strategy that trains its resources toward early diagnosis could fail to take action at preventive stages. The questioner wondered how efforts aimed at lifestyle and behaviour modification could inform the national strategies discussed. Dr. Banerjee affirmed that England’s national strategy treats public education as essential to its approach. Communicating vital information about modifiable risk factors for dementia (e.g., the vascular risk factors, the correlation with diabetes and obesity) is part of the strategy. Without this component, Dr. Banerjee agreed, any national strategy on dementia cannot fully succeed.
Dr. Ménard was queried about the role of general practitioners in diagnosing dementia, and whether it is the case in France that the diagnosis may only be provided by a specialist. The questioner noted that there is a strong effort to enable family physicians to diagnose the disease, and to promote such training. Dr. Ménard described the responsibility of diagnosis as shared. Given that tests of 2–3 hours’ duration are performed, this is beyond the family physician’s scope and a geriatrician’s services are needed. However, pragmatic case management must be executed by the GP, he stated, and each family in France is required to designate a GP as this individual will request reimbursement. He emphasized the family physician’s role in initiating the diagnostic process, as the GP is often the one contacted about problems of memory and cognition. The challenge within the current system, Dr. Ménard explained, concerns patient tracking and case management. Physicians may be disinclined to manage cases of patients with dementia as these individuals may form a modest segment of their practice but consume disproportionate resources. He suggested that a useful change would raise the salary cap for case management; ultimately, all GPs would follow some dementia cases at various states of progression.
Dr. Banerjee added that a complication with diagnosing dementia in the primary care setting is that while diagnosing a case of severe dementia is easy, early diagnosis is challenging. Further, he quoted a study that found that over the last decade, physicians have become less confident in their ability to render the diagnosis, reflecting the sense that diagnosing dementia is perceived as complicated and time consuming. Many are anxious about whether they could correctly diagnose the condition. Dr. Banerjee offered that, under a different service and care alignment, wherein memory services would be folded into memory clinics, a wider array of diagnostic and management services could be accessed. Such arrangements are not yet common but are an evolution in healthcare provision he hoped would soon become customary.
Dr. Bergman noted that ever since the 1st Canadian Colloquium on Dementia in 1989, Canadian experts have emphasized the role of primary care in detection, diagnosis, and treatment. He disagreed that a GP could not make a diagnosis of dementia if the proper conditions for making a sound diagnosis were in place. Isolated GPs lacking a wider network to support the diagnosis and management may be hampered in doing so, but a physician situated within a group practice and a support system with trained nurses and appropriate information technologies can, if he or she is trained and works with sound criteria and available referral. He cautioned against general reliance on specialists such as psychiatrists and neurologists, who may not necessarily have the interest or training in detecting dementia. Dr. Bergman hoped to see an end to the practice of patients being “lost” by their general practitioners once they have been referred to secondary care.
Dr. Banerjee added that the situation is apt to change once healthcare systems better incorporate a category such as “GPs with specialist interest.” General practitioners with appropriate training in dementing illness are well situated to render such a diagnosis, but he noted that there are at present too few working within the UK (fewer than 10).
