Dementia and comorbid chronic illness
People in later age are most vulnerable for dementia. The prevalence of dementia increases significantly among those over 65 years of age. The older the person, the higher the prevalence of dementia and comorbid disorders.
Patients who are older often have multiple chronic illnesses. Among people over age 65 in primary care, 80 per cent have at least one chronic illness and over 45 per cent have two or more. Also, many patients over age 65 have functional changes and disabilities associated with their multiple chronic disorders.
Patients in primary care with a possible dementia require a systematic, feasible approach that will:
- define the risks (e.g., roaming, driving)
- provide a means of understanding and identifying the multiple causes
- set out a care plan that addresses dementia and comorbid complexity
- enable the primary care provider to work effectively with the person, family and health care team
A systematic but feasible approach has been developed in the P.I.E.C.E.S. program. The clinical foundation framework used in this program is the three-question template (3-Q template), which is an excellent framework for assessing an individual with dementia with comorbid conditions.
The three-question template
The three-question (3-Q) template is based on the following questions:
- What has changed? Think P.I.E.C.E.S. (physical, intellectual, emotional, capabilities, environment, social).
- What are the risks and causes? (think P.I.E.C.E.S.)
- What is the action? (intervention, interaction and information)
1. What has changed?
Asking "What has changed?" gives the primary care provider insight into the diagnosis.
Defining what the person was able to do through his or her life that required cognitive abilities, and looking for changes in these abilities, will flag a
This approach is much more sensitive than asking if a person does or does not possess an ability. This is because it is the "changes" that are critical red flags to possible cognitive impairment. The approach is also more effective than defining the chief complaint because the chief complaint may only be what has been there for some time.
Identifying the changes also helps with the differential diagnosis. When a change occurs acutely, the clinician needs to think about delirium. An intermediate change that is predated by mood symptoms may point to depression. Progressive, vague-onset change suggests a dementia of the Alzheimer's type.
2. What are the "RISKS" and causes?
In patients with dementia it is critical to determine immediate risks and potential future risks. The acronym RISKS can guide the primary care provider in exploring the breadth of common risks in people with cognitive impairment. These risks include:
Roaming: identifying the degree to which wandering may put the person at risk for harm
Imminent physical danger: particularly related to falls and fire
Kinship risks: includes risks to others as well as elder abuse
Substance misuse and safe driving
Using the P.I.E.C.E.S. approach allows the primary care provider to consider the range of factors that may contribute to the cognitive impairment.
The P.I.E.C.E.S. approach looks at the following factors:
Physical: diseases, drugs, discomfort
Intellectual: dementia, mild cognivite impairment
Emotional: depression, psychosis
Capabilities: activities of daily living
Environment: over/understimulation, relocation, change in routine
3. What is the action?
Primary care providers should think about "the three Is":
- What are the Investigations I need to do?
- What are the Interventions that I need to think about, both immediately and in the long term? This focuses particularly on medical interventions.
- What are the Interactions that need to be considered? That is, what kind of psychosocial caregiver support do I need to think about and what do I need to discuss with the patient, family and colleagues? What information will enable effective response to treatment and flag critical factors for review and follow-up?
Psychiatric interviewing series
David Goldbloom and Nancy McNaughton demonstrate clinical interviewing situations.
Psychiatry in primary care toolkit
The Psychiatry in Primary Care App has been decommissioned.
The revised print version of Psychiatry in Primary Care is avaible through the CAMH store.
We have posted a number of revised chapters from the book in Treating Conditions and Disorders in the new Professionals section of camh.ca.
Fourth Canadian Consensus Conference on the Diagnosis and Treatment of Dementia Recommendations for family physicians (2014)
Caregiving strategies for older adults with delirium, dementia and depression (RNAO, 2004, 2010)
Recommendations on screening for cognitive impairment in older adults (Canadian Task Force on Preventative Health, 2015)
Dementia, disability and frailty in later life – mid-life approaches to delay or prevent onset (NICE guideline NG16, 2015)