Short summary

Dementia is a condition that affects millions worldwide and is expected to affect even more in the near future as people generally grow older. The management of patients with dementia is important in order to provide the right treatment, counseling and support. In Denmark, general practice serves as the primary contact between the citizen and the health care system. The overall purpose of this project is to improve the management of patients with dementia in general practice, both before and after a dementia diagnosis. 

Rationale

Background

Worldwide dementia affects millions of people and the number is expected to increase rapidly in the next decades because of the trajectory in the number of elderly individuals (1, 2). In 2050, it is estimated that more than 130 million individuals will suffer from dementia (3). Due to the high number and the nature of dementia the cost for the health care system will increase immensely and will be a major concern in all health care systems world-wide (3).  

Diagnostic evaluation of dementia is important in order identify reversible conditions and for people with dementia to receive appropriate treatment, support and counseling (3).

In Denmark and in many health systems, primary care services are the most common first contact for those seeking help for a health problem, and primary care plays an important gate-keeper role, deciding which patients should and should not be referred on for specialist assessment (4). However, diagnosis cognitive impairment in general practice is difficult and several barriers exist e.g. lack of diagnostic tools, time constrains and nihilism (5-10). Further, primary care services struggle to deliver high quality continuing care for people with dementia, even in systems where their role has been made more explicit (3). 

In Denmark, as in many other countries there is not a systematic overview of the quality the management in primary care towards patients with dementia (3). Multimorbidity is frequent in people with dementia (11, 12) and a recent systematic review reported an association between somatic comorbidities and multifaceted late onset AD progression and even suggested that modifying co-morbidity could decrease the speed of deteriation of dementia (13).  Further, polypharmacy defined as concomitant use of more than five drugs is common among elderly patients due to the older, multimorbid population (14). The risk of polypharmacy increase by age and in Denmark and according to a national report from the Danish Pharmacist Association around 1 million Danes fulfill the polypharmacy criteria (15). Polypharmacy is associated with adverse effects like death, hospital admission, interaction and impaired compliance (16, 17). However, even though people with dementia are frail, they have a high risk of excessive polypharmacy (18) and are commonly medicated with antipsychotics (19) even the clinical effectiveness of typical and atypical antipsychotic drugs on neuropsychiatric symptoms in patients with dementia is questionable (20). In contrast, antipsychotic medication has numerous severe adverse (19, 21) and even an increased mortality risk (22). 

People with dementia are more likely to be admitted to general hospital than people of similar age and medical conditions, particularly for falls-related accidents and injuries, urinary tract and respiratory infections, and chronic disease complications that might have been averted with better management in the community (12, 23-25). Additionally, referral rates seem to increase in the last two years of life especially for home dwellers with dementia (23) . 

Traditionally,  Danish epidemiological research has used incident cases of all-cause dementia identified using data from the Danish National Patient Register (26), the Danish Psychiatric Central Register (DPCR) (27) and the Danish National Prescription Registry (28). While the diagnosis of all-cause dementia in either the Danish National Patient Register or the DPCR has a high predictive value of 86% (29), the validity is lower for dementia sub-types as well as among individuals under the age of 65 years (29, 30). Further, functioning like cognition, activity of daily living as well as disease stage has not been available by means of this algorithm. 

In order to manage the increasing number of people suffering from dementia, general practice  is an important health care provider as the current specialist models of dementia care are unlikely to be able to scale up to provide sufficient coverage for the growing number of people affected by dementia (3) However, research into management located within primary care is lacking even though there is some evidence that when primary care physicians take responsibility for dementia care they can attain similar outcomes as specialist. 

Thus, the overall aim of this study is to improve the management of people with dementia in general practice before and after a dementia diagnosis. 

AIMS:

The overall aim is to improve the health care for people with dementia.

Specific aims:

1. To investigate the relationship between dementia and drug use, both before and after a dementia diagnosis.

2. To investigate the link between dementia and health care consumption.

3. To assess the importance of socio-economic position on diagnosis and development of dementia.

Description of the cohort

All consecutive patients referred to diagnostic evaluation of dementia in 2017 and forward to December 1st, 2018

Data and biological material

Data from RKKP database regarding diagnostic evaluation of dementia, national registers.

Collaborating researchers and departments

This project is headed  by professor Frans Boch Waldorff and is initiated by Research Unit of General Practice, Department of Public Health, University of Southern Denmark.