Family physicians are in a unique position to identify those at risk of dementia, and craft individualised management plans to reduce the rate of cognitive decline. SingHealth Duke-NUS Memory & Cognitive Disorder Centre shares more.
With a soaring number of dementia cases on the horizon, primary care doctors should be well-equipped to manage the condition in collaboration with specialists in the field. With their intimate knowledge of their patients, family physicians are in a unique position to identify those at risk, and craft individualised management plans to reduce the rate of cognitive decline.
INTRODUCTION TO DEMENTIA
Dementia, now also known by the term major neurocognitive disorder, is a decline in cognition that is severe enough to affect the function of an individual. The prevalence of dementia in Singapore was found to be 10% among the elderly above 60 years of age, from a Well-being of the Singapore Elderly (WiSE) study conducted in 2013.
With our ageing population, these numbers are expected to soar. Dementia will be a condition seen often enough to warrant a label of chronic disease similar to that of hypertension or diabetes in the near future. As such, through collaboration with experts in the field, primary care doctors should be equipped to manage these patients in the primary care setting.
THE LINK BETWEEN CARDIOVASCULAR RISK FACTORS AND DEMENTIA
Multiple cardiovascular risk factors have been studied with varying outcomes on their link to dementia. Some of these factors have been shown to increase the risk of cognitive decline and have been linked to the development of both Alzheimer’s and vascular dementia.
Evidence suggests that patients with diabetes are at greater risk of cognitive decline and both vascular and Alzheimer’s dementia. A study found this to be consistent in our local population in that diabetes at all stages in life increases the risk of progression to cognitive impairment by at least two-fold.
As for hypertension, a definite link between hypertension in mid-life and the development of dementia exists, but this association is much stronger and more established with vascular dementia than Alzheimer’s.
Hypertension in late-life has not been shown to have this similar association. In fact, some studies demonstrate it may actually be protective against the development of dementia. There is also evidence that good control of these conditions can reduce the progression of cognitive impairment.
Studies are equivocal about hyperlipidaemia and its association with cognitive decline. There is insufficient evidence to demonstrate a benefit in the consumption of statins in the risk reduction of cognitive decline.
In addition, there is some evidence, although inconsistent, that mid-life obesity increases the risk of the development of dementia. A decline in weight from mid-to-late life has also been shown to increase this risk.
IMPORTANCE OF EARLY DETECTION
Dementia should not be mistaken for age-related memory loss. Patients who complain of any degree of memory impairment should be evaluated to determine the extent of memory loss and cognitive decline, together with the presence of other associated features before coming to a diagnosis.
Early detection empowers a person with dementia to be able to:
- Prepare themselves and family members emotionally, creating a support system with feelings of empowerment and readiness, rather than anger, shock and denial.
- Have a comprehensive memory assessment, functional assessment, and a look into their behaviour and mood issues. These other aspects of patient care can unravel other issues that occur frequently in elderly such as falls, anxiety and
depression. A look into care arrangements may find other concerns such as caregiver stress.
- Be given a decision as to whether or not to start medication for dementia. There is some evidence to suggest that anticholinesterase inhibitors may be beneficial in mild dementia as well, although they are more frequently used in moderate to severe dementia.
- Make decisions about their future while they still have mental capacity – creating a Lasting Power of Attorney (LPA), writing a will, or giving information about their care preferences in an advanced care plan.
- Anticipate future care requirements so that families can make arrangements.
Mr TBH, a 75-year-old retired sales manager with a medical history of diabetes, hypertension and hyperlipidaemia was brought in to SingHealth Polyclinics (SHP) by his daughter for concerns of gradual and progressive short-term memory loss
over the last few years.
He had misplaced his personal items (house keys, wallet) on multiple occasions and had forgotten to attend a few medical appointments. His family noticed he had become repetitive with questioning in the last few months and was unable to recall what activities he had done in the past week.
On one night the week prior, he returned home past midnight to a worried and frantic family as he had lost his way home. Mr TBH admitted that this happened, saying it was a “one-off” and that it would not happen again. He denied all other problems related to poor memory and function.
CLINICAL EVALUATION AND DIAGNOSIS
He was referred to the SHP Geriatric Service (GRACE): Memory and Cognition clinic and seen by a Family Physician. Cognitive assessments performed using the Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) Test revealed problems with working memory and recall. Laboratory tests were arranged, and he was sent for a computed tomography (CT) brain scan in one of the tertiary hospitals.
The results of the investigations were reviewed in the memory clinic. He was subsequently diagnosed with Alzheimer’s dementia and started on donepezil. He was referred to a dementia day care centre and encouraged to continue with mental stimulation activities.
OPTIMISING DEMENTIA MANAGEMENT IN PRIMARY CARE
Given the strong link between cardiovascular risk factors and the development of dementia, more emphasis should be placed in its prevention. Good and adequate control of cardiovascular risk factors will reduce the incidence of stroke and heart disease, which in turn could have a role in preventing dementia.
Primary care physicians are well-placed in the community to manage these cardiovascular risk factors, prevent comorbidities associated with these conditions, and hopefully work towards reducing the rate of cognitive decline.
Primary care physicians have an intimate knowledge of their patients through longitudinal follow-up and walking them through all vicissitudes of life. They have the benefit of understanding their pre-morbid cognitive function, personality, functional status and social circumstance in addition to the medical issues these patients may have. This puts them in a
unique position to identify the patients at risk, notice cognitive changes early, and then craft individualised management plans for persons with dementia.
SingHealth Polyclinics runs the SHP Geriatric Service (GRACE): Memory and Cognition clinic with the support of partner specialists within the tertiary hospitals, enabling our family physicians to diagnose, evaluate and manage persons with
dementia, whilst keeping these patients engaged in community activities as far as possible.
THE SINGHEALTH DUKE−NUS MEMORY & COGNITIVE DISORDER CENTRE
The SingHealth Duke−NUS Memory & Cognitive Disorder Centre was officially launched in September 2020 to provide integrated multidisciplinary clinical practice for cognitively-impaired patients, promote health services, advance innovative research and introduce educational programmes for medical professionals and the public.
The virtual Centre brings together the strengths and expertise of healthcare professionals from neurology, psychiatry, geriatric medicine, internal medicine, primary care and community care from across SingHealth institutions, so patients can receive the right care, at the right time and place.
- Subramaniam M, Chong SA, Vaingankar JA, et al. Prevalence of Dementia in People Aged 60 Years and Above: Results from the WiSE Study. J Alzheimers Dis. 2015;45(4):1127-1138. doi:10.3233/ JAD-142769
- Alzheimer’s Disease International. World Alzheimer Report2014: Dementia and Risk Reduction: An Analysis of
Protective and Modifiable Factors. http://www.alz.co.uk/research/ world-report-2014.
- Ng TP, Feng L, Nyunt MSZ, et al. Metabolic Syndrome and the Risk of Mild Cognitive Impairment and Progression to Dementia: Followup of the Singapore Longitudinal Ageing Study Cohort. JAMA Neurol. 2016;73(4):456–63. doi:10.1001/jamaneurol.2015.4899
- Baumgart M, Snyder HM, Carrillo MC, Fazio S, Kim H, Johns H. Summary of the evidence on modifiable risk factors for cognitive decline and dementia: A population-based perspective. Alzheimers Dement. 2015;11(6):718-726. doi:10.1016/j.jalz.2015.05.016
Dr Farah Safdar Husain is a Family Physician and the Deputy Clinical Lead of the Geriatric Workgroup with SingHealth Polyclinics (SHP). She is the Programme Director for the SHP Geriatric Service (GRACE): Memory and Cognition clinics and the Service Chief representing SHP for the SingHealth Duke-NUS Memory & Cognitive Disorder Centre. She is also actively involved in education as Core Faculty Member for the Family Medicine Residency Programme and Clinical Faculty for Yong Loo Lin School of Medicine, National University of Singapore.
GPs who would like more information about managing dementia in primary care, please contact Dr Farah at firstname.lastname@example.org.
GPs can call the SingHealth Duke-NUS Memory & Cognitive Disorder Centre for
appointments at the following hotlines:
Singapore General Hospital: 6326 6060
Changi General Hospital: 6788 3003
Sengkang General Hospital: 6930 6000
National Neuroscience Institute: 6330 6363