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At the heart of general practice since 1960

Diagnosing early dementia – cornerstone for change

Case

history

Mrs Jones has become a bit of a regular. You have seen her several times and she has also consulted all the partners and practice nurse. Although she does have well-controlled ischaemic heart disease, her requests are usually trivial – such as for items from her repeat prescription list. Today she wants to discuss her arthritis, but tells you that paracetamol actually controls her pain very well. This is a virtual replica of a discussion you shared two weeks ago! Dr Melanie Wynne-Jones discusses.

Why do some patients consult unusually frequently?

Some patients are just unlucky, with more than their fair share of disease. Some have multiple or complex chronic illnesses for which frequent consultations are appropriate. But most people experience a number of symptoms each week, yet do not all visit their GP. Factors that affect the threshold for consulting include:

•Fear of what a symptom may represent

•A wish to relieve discomfort/ inconvenience, ranging from severe pain to 'not being ill over Christmas'

•Pressure from relatives or work

•Ignorance about the natural course of minor self-limiting conditions

•A belief that all symptoms justify medical input rather than self-care

•Temporary or permanent 'acopia', such as during a severe illness, after bereavement or as a result of learning disability or psychiatric illness

•Loneliness1

•Dependent personality or relationship with the doctor

•Medically unexplained symptoms2

•Access to, and availability of, appointments/telephone advice3,4.

Some patients consult repeatedly because their ideas, concerns or expectations have not been satisfied, either because they are unrealistic, or because the doctor has failed to elicit or address them5.

Why do consulting rates matter?

Resources, including GP time, are finite; overload can compromise other patients' care or lead to practice team stress and burnout.

Advanced access3, changes in skill mix6 and the new GMS2 contract7 encourage 'episodes of consulting' rather than continuity of care, making it harder to spot or address inappropriate consulting. Without an established doctor-patient relationship, the individual doctor may not feel on sure ground about previous episodes and may get it wrong; the patient may be more defensive or even complain.

GPs increasingly face these challenges in an NHS where the customer is king yet must attempt to limit patient demand where it is not congruent with medical need.

How to ensure appropriate consulting

One strategy is routine monitoring of consulting rates and skill mix; this is easily done with modern computer systems. It is harder to evaluate whether better clinical outcomes and/or patient satisfaction have resulted from time spent in consultation, and justify the use of resources such as prescribing and referral.

The new contract is a step in this direction; private companies such as Kaiser Permanente, are better at it and are waiting in the wings.

GPs are now expected to reflect on the content and outcome of their consultations for personal development and appraisal, as well as for business purposes.

Personal and practice audits, and significant event analyses, will help; the quality and outcome framework also includes a requirement to carry out and reflect on patient satisfaction surveys7,8.

What is Mrs Jones's problem?

Her vague requests, single-problem consulting, pleasant manner, and apparent satisfaction with consultation outcomes suggest you are too available (or too nice!) or have failed to spot her hidden agenda. But it is quite possible that she is in the early stages of dementia.

People who realise their memory or mental function is not what it was often compensate in the early stages by being excessively careful – writing notes, double-checking, or seeking advice from family, friends and authority figures including doctors.

They can seem quite competent during a short consultation, or appear to have a mildly eccentric or obsessional personality.

The busy or unfamiliar GP may not realise there is a problem until something blatant happens or a concerned third party draws attention to their behaviour.

How should you approach this?

Many older people readily admit their memory is not what it was and are willing to respond to tactful questions about their global function and participate in a mini mental state examination. If this raises concerns, Mrs Jones can be referred for more formal assessment and possibly treatment (despite recent concerns over its effectiveness9).

She may have early Alzheimer's or cerebrovascular dementia as she also has ischaemic heart disease. But she may be offended by your questions and deny any problem. Her present situation does not justify anything more than attention to risk factors, and a wait-and-see policy.

Attempts to contain her consulting, for example by patient-education, or agreed follow-up at intervals, should be tried, but will probably be unsuccessful; encouraging her to consult by telephone may open the

floodgates!

References

1 Someone to talk to? The role of loneliness as a factor in the frequency of GP consultations. Ellaway A et al. British Journal of General Practice vol 49 no. 442 p363-7

2 Beyond somatisation: a review of the understanding and treatment of medically unexplained physical symptoms , Burton C, British Journal of General Practice vol 53 no. 488 pp231-9

3 Advanced Access The NHS

Plan 2001 www.dh.gov.uk/assetRoot/

04/08/27/00/04082700.pdf

4 Setting standards based on patients' views on access and continuity: secondary analysis of data from the general practice assessment survey. Bower P et al. BMJ 2003;326:258 , doi:10.1136/bmj.326.7383.258

5 Importance of patient pressure and perceived pressure and perceived medical need for investigations, referral, and prescribing in primary care: nested observational study. Little S et al BMJ 2004;328:444, doi:10.1136/bmj.38013.644086.7C

6 Agenda for Change, New Ways to Work, the Changing Workforce Programme. NHS Modernisation Agency www.modern.nhs.uk

7 nGMS www.bma.org.uk

8 General Practice Assessment Questionnaire www.gpaq.info

9 Long-term donepezil treatment in 565 patients with Alzheimer's disease (AD2000): randomised double-blind trial AD2000 Collaborative Group.

Lancet 2004; 363: 2105-??????

Melanie Wynne-Jones is a GP in Marple, Cheshire

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