Neurodegenerative Disease Alzheimer’s Disease


In the majority of countries, only specialist physicians (neurologists, psychiatrists, geriatricians and physicians with a qualification in geriatrics) may write the initial prescription.33 Currently, in many European countries the general practitioner can renew or interrupt symptomatic treatment and it is his or her duty to monitor its tolerance and efficacy. The therapeutic objectives should be explained to the patient and his or her care-giver by the PCP,34


diagnosis.16,32 who


The role of the PCP in therapeutic management exceeds the framework of pharmacological treatment. Indeed, with regard to non-pharmacological treatment, the role of the PCP is above all to set up support services and, of course, to ensure follow-up.


First of all, management of a patient’s co-morbid conditions is one of the major roles of the PCP.36


The general objectives of the follow-up


plan of AD patients are the detection, prevention and treatment, when possible, of complications (falls, malnutrition, BPSD), based on a global assessment.1,2,37


The care and assistance plan will be truly


effective only if the PCP facilitates its application with the aim of detecting, preventing and treating complications as soon as they appear in order to reduce their impact on the patient and his or her relatives.37


The follow-up plan may be tailored to the individual case in conjunction with a specialist evaluation every six months in order to provide the PCP with all the information necessary for follow-up; a frequency of every one to three months depending on the stability of the symptoms, the severity of the disease and co-morbidities is proposed in many European guidelines. The members of the European Alzheimer’s Disease Consortium have put forward propositions concerning patient follow-up based on the French PLASA study, a randomised controlled interventional study of 1,120 patients with AD.38


should also explain the benefits expected from the pharmacological treatment.35


movement and walking easier and to reduce the risk of falls. The physical and emotional health status of the care-giver may also be appraised to prevent care-giver exhaustion.46


The PCP needs to estimate the need for


The PCP must be able to


recognise distress in care-givers and to evaluate their physical state. The scientific literature supports creating a close relationship with care-givers of AD patients.17,47


Moreover, support services are generally underused by PCPs, especially in the early stages of the disease, with large variations between countries, notably in Europe.33


However, many


authors have underlined that the PCP should be familiar with support services, in particular the respite facilities available (day care centres, adult care centres, temporary stay in a nursing home, respite care at home) and also home support services (personal assistance, home help supports). Finally, in all cases collaboration with specialist physicians (neurologists, geriatricians or psychiatrists) is needed; furthermore, a recent work has shown that PCPs are seeking a more cohesive form of interdisciplinary dementia care.48


Considering these issues, studies have focused on how to improve the management of AD in primary care practice.49,50


The need for


better education and training programmes for PCPs has been demonstrated in both the early diagnosis and management of AD.6,51 Indeed, sufficient knowledge is one of the prerequisites for adequate dementia management. Training programmes have been developed in most European countries, and relevant educational projects now exist for PCPs.6,52


in improving detection rates in dementia.53


Prevention of crisis situations such as admission to an institution and ‘emergency’ hospitalisation is one of the major goals of any follow-up plan. The management of AD patients in crisis situations is a dynamic and time-consuming three-sided relationship between the family care-giver, the demented patient and the family physician.


The PCP must first ensure that the diagnosis has been disclosed and basic education on AD provided. Then, at each visit, the physician needs to evaluate cognitive, functional and nutritional status. It is also essential to evaluate behavioural changes, gait and balance disorder, co-morbid diseases and the tolerance/efficacy of drugs.38,39


In the event of BPSD and after initiating non-pharmacological measures – in particular environmental measures – the PCP may be led to prescribe psychotropic treatments. It should be noted that antipsychotic drugs must be reserved for specific situations and used in short courses at a low dose, with frequent reassessment of the risk–benefit ratio.40


If the patient has weight loss >2kg over the previous three months, or more than 4% in one year, the PCP should look for a somatic cause and, if none is found, they should advise an enriched diet.42


Weight loss is often accompanied by complications such as sarcopenia and falls, which are associated with a higher risk of institutionalisation and mortality.43,44


In the event of falls, after a


physical or iatrogenic cause has been sought, the patient should be encouraged to walk for 30 minutes every day or three times a week, preferably with the care-giver or, if this is not possible, with the help of a physiotherapist.45


The patient’s home should be adapted to make 22


Monitoring of the patient’s nutritional status is also an important part of follow-up.41


Many of these educational approaches are effective Indeed, it is essential to


train PCPs because their intervention is complex at all levels: they are expected to detect the early onset of dementia, disclose the diagnosis, co-ordinate home care, follow through treatment issues, provide basic education to the care-giver and stay involved in the care process. PCPs have a duty to keep their professional practices and skills up to date, by various means. They must have optimal initial knowledge about the disease and then undergo continuous training in order to progress their professional skills. Considering the likely future prevalence of AD, PCPs will be increasingly confronted with the problems raised by the disease. Dementia in general and AD in particular will have a large impact on the health and healthcare needs of northern countries. For these reasons, it is essential to clearly define the role of primary care providers and to improve their knowledge about the disease and related guidelines.20


In conclusion, PCPs must follow the general objectives of identifying dementia and allowing early diagnosis, disclosing diagnosis to both the patient and his or her family, preventing and treating, if possible, the complications of AD (falls, malnutrition, BPSD) and implementing a follow-up plan.1,2,37


It is also important for PCPs to develop interactions with specialist physicians and all community professionals who intervene in the management of AD patients. The key role of PCPs is consolidated by the confidence of family care-givers in their skills. Nevertheless, clear and validated guidelines covering all aspects of AD care, from early diagnosis to adequate referrals, should improve the ability of PCPs to support many time- and energy-consuming home care situations. Intervention studies addressing the gaps in the skills of PCPs in dementia management could be helpful in supporting the family care-giver.3


Currently, further work, especially the creation of evidence-based practice guidelines, is needed to establish quality indicators for primary dementia care. n


EUROPEAN NEUROLOGICAL REVIEW


home support or respite care (day care centres, temporary stay in a nursing home). PCPs often report a lack of information on support services.48


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