The task | Objectives within the task | How to achieve the objectives |
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Pattern recognition (interpreting the meaning of accumulating symptoms) | Growing personal awareness/knowledge of members of the public as well as professional experience amongst practitioners | - Personal experiences offer a lot of lessons. The professional who is also a carer/relative/friend can ‘see the other side’.- Produce a video for professionals about the life of people with dementia at home. |
 | Understanding the difficulties of the diagnostic process | - Recognition of complexity/uncertainty.- Listening to carers and family members. |
 | A raised profile for dementia in the GP’s work environment (increasing receptiveness) | - The professional and organisational culture of the practice is important: create a learning environment.- Include reminders and templates in electronic medical records.- Seek greater understanding of cognitive symptoms and their effects on patients.- Education should be tailored to individual practice team’s needs. |
 | Practice team awareness of the issues | - Partners need to allow and encourage nurses and receptionists to attend training. Doctors also need to be prepared to learn from non-medical professionals.- Non-clinical staff need to be empowered to alert clinicians to changes in individuals’ behaviour (for example, repeated requests for regular medication, repeated defaults from consultations).- Involve the whole team in clinical meetings. |
 | Practice systems for intelligence gathering, collation of information and knowledge of individual’s family circumstances and social networks, and responsibility for acting on that gathered knowledge | - ‘Key worker’ roles in bigger practices.- Having ‘at risk’ registers. - In smaller practices, all team members meet with the patient and carer at some point of time.- Named family or carer main contact important, especially for those living alone.- Establishing relationships with patient’s neighbours/milkman and so on. |
 | Continuity of care for individuals, which deepens knowledge, allows observation over time, and permits trust to develop | - Systems for maintaining continuity of care need to be discussed explicitly, especially in large group practices.- Dementia needs active management by the practice. |
 | Managing expectations of patients and carers by primary care team | - Promote their role in early diagnosis by explain their roles in a simple language.- Promote a message for those attending for a first consultation that they will be taken seriously and their needs listened to.- Promote understanding that presenting for this initial consultation may be a hard decision for individuals/families and that ‘we’ are there to promote the interests and care to all parties caught up in this process. |
Assessing the degree of impairment | Getting all sides of the story: patient, carer, others (including own team and local Social Services in case known to them) | - Experience matters here, so exchanging experience may be a mechanism.- If known to allied health professionals, they can provide useful insights.- Role of key worker is important as it may be difficult to collate information from many people.-Visit at home and seeing patients in typical environment with typical others. |
 | Assess the risks and challenges | - Think about the level of concern of patients/carers and others.- What is patient like when out of ‘normal’ environment, for example, on holiday, in hospital – provides insight into level of impairment. |
 | Consider other long-term conditions and their relationship to the symptoms of dementia, and other functional abilities (hearing or visual impairments, mobility problems) | - Information and explanation crucial but, with many people, having an information cascade is useful. |
 | Using locally preferred (standardised) assessment tools; knowing their limits | - There is guidance on the usefulness of the different tools[38]- Agreement between psychiatrists about what they use and then pass information to GPs. |
 | Using tacit knowledge (instincts, hunches, acquired experience) | - Acknowledge that tacit knowledge is useful. |
 | Self-awareness of changes in thinking abilities (planning, calculating), and recognition of compensatory adaptations by other people (for example, someone else takes over the bill-paying) | - Ask about the methods they are using to cope with their disabilities. |
Discussing possible diagnoses | Disclosure – who, when and to whom? (This is no different from breaking bad news for any other condition) | - Attention to context when giving diagnosis: where it should be done, who is present, how will they get home/be spending the rest of the day. Involving/initiating their support network can greatly help future management. Examples:(1) A support package should be given with names and addresses of the various bodies that may be able to provide help.(2) A follow-up visit should be arranged with a support nurse in a week or two to enable questions to be asked when patients and their families have had time to think things through.- Consider patient’s confidentiality. Think about when you should regard the patient as being a dependant, as in the case of a dependent child.- A process for communications between specialists is required to take the responsibility of follow-up after disclosure. |
 | Negotiate disclosure of the diagnosis with patient/carer | - This could be tied up with end of care and advance care planning - breaking bad news and discussing options for the future. |
Responding | Maintain a positive attitude about dementia: ‘something can be done’ - based on awareness of local resources | - Wider understanding about differential diagnosis (Alzheimer’s disease/vascular dementia/Lewy body dementia) and its implications for treatment and management.- Awareness of range of possible interventions other than medical treatment. For example: training packages for improving communication and use of activities such as Sonas).- Forming closer links between GP surgeries and local dementia specialist support services. |
 | Getting support and involvement of secondary care | - Specialist services offer assessment and diagnostic services. Having a responsive local specialist service makes a difference to GP behaviour.- May be useful if special services could provide a summary of how their cognitive symptoms translate into activities of daily living and some strategies of dealing with them.- Lack of accessibility and approachability of the resources could lead GPs to feel unsupported and frustrated. Training of psycho-geriatricians and improved communication could help. |
 | Phase in responses involving resources/services | - Professional requires clear understanding of what is available.- Requires an assessment of that person’s needs, and those of their family or other supporters. |
 | Locate services and assess if they make a difference | - Think in terms of advanced support systems, care packages, alarm systems, simple behavioural strategies for carers.- Map local and national services, including voluntary organisations. |
 | Medication for dementia and ‘shared care’ systems | -T ake cultural factors of the practice and local specialist services into consideration. |
 | Support for carers (practical, information, psychological support ) means understanding how and why family members respond differently to dementia | - Liaise with local carers’ group.For example, names and addresses of other patients at a similar stage of the illness made available (if there is consent) for perhaps a ‘buddy’ system.- Be aware that stigma applies to services as well as dementia itself. This may influence your source of advice.- Assess capacity and effect of the new Act/importance of discussing power of attorney early on while the patient still has capacity.- Record patient’s views early on in the disease process so that can use this as a guide later. |