What shapes GPs decisions to pursue a diagnosis of dementia? A qualitative study

Problem

Dementia primarily affects older adults, and all forms of it are characterised by cognitive impairment and functional ability decline. In the UK, estimates suggest that over 800,000 people above the age of 60 currently live with dementia. With an aging population, prevalence will continue to rise to 2 million by 2050.Dementia is primarily identified by general practitioners, who refer suspected cases to specialist services for a formal diagnosis. Early diagnosis of dementia has proven benefits to patients and carers. Access to additional treatment and support services can increase health outcomes and quality of life. It also enables patients and their families to come to terms with diagnosis, and to plan effectively for the future whilst still having capacity. Yet, current research suggests that almost 50% of patients living with dementia do not have a diagnosis in their health record. This study investigated the specific barriers and facilitators faced by GPs when presented with cases of suspected dementia.

Approach

A national UK wide qualitative interview study of GPs was conducted. Semi-structured interviews were conducted face to face, either in person or via Skype. All interviews were transcribed verbatim and analysed thematically.

Findings

12 interviews were conducted.Themes related to clinical uncertainty, barriers, and facilitators to pursuing a diagnosis were identified.Features contributing to diagnostic uncertainty included patient personality differences, intelligence levels, and atypical presentations of dementia. The presence of multi-morbidity and polypharmacy had implications on both presenting features and the threshold of confidence GPs had in the pursuit of diagnosis. Limitations of the various screening tools was a sub-theme, as determining dementia or providing baseline evidence for specialist services was not always possible.Specific barriers and facilitators included; the potential effectiveness of pharmacological treatment, access to additional care that a diagnostic label may provide, perceived stigmatisation, patient readiness, the involvement of family members, the mobility and frailty of patients, and the extent to which dementia was a clinical priority. Time was a significant challenge for all participants. GPs were typically concerned with the additional access to care that a dementia diagnostic label may provide. Where GPs perceived this to be minimal, diagnosis was less likely to be pursued.

Consequences

Dementia can be a challenging disorder to accurately diagnose early. This study provides new insights into specific barriers and facilitators that influence the diagnostic process. As there is no gold standard test, successful diagnosis relies on time from third parties to make observations, and agreement between GPs, patients, and families. Targeted interventions highlighting the specific benefits and additional care accessed as a result of a formal diagnosis would be highly beneficial in increasing diagnostic rates of dementia.