Text adapted from "The patient with dementia" in Psychiatry in primary care by Kenneth Le Clair, Dallas Seitz and Julia Kirkham. (CAMH, 2019).
Dementia and Comorbid Disorders
Not only are older adults more likely to develop dementia, but they also 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. Many of these patients also have functional changes and disabilities associated with their multiple chronic illnesses.
Patients in primary care with possible dementia require a systematic, feasible approach that:
- defines the risks (e.g., roaming, driving; see page 232)
- provides a means of understanding and identifying the multiple causes of dementia
- sets out a care plan that will address dementia and comorbid complexity
- enables the primary care practitioner to work effectively with the patient, family and health care team.
Using the P.I.E.C.E.S. Three-Question Template
(For more on using the P.I.E.C.E.S. checklist, please refer to the page on Diagnosis.)
The P.I.E.C.E.S. framework includes a three-question template for assessing a patient who has dementia and comorbid conditions. The 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)
What has Changed?
Asking what has changed gives you insight into the diagnosis. Knowing what patients were able to do throughout their lives that required cognitive abilities, and looking for changes in these abilities, will flag possible dementia. This approach is much more sensitive than asking patients if they have a certain ability because it is the changes that are red flags. This 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 changes also helps with the differential diagnosis. When a change occurs acutely, you need to think about delirium. An intermediate change that is predated by mood symptoms may point to depression. Progressive, vague-onset change suggests Alzheimer’s dementia.
What are the Risks and Causes?
Determining immediate and potential future risks is critical for patients with dementia. Use the mnemonic RISKS to explore the various common risks in people with cognitive impairment:
- Roaming: people with dementia are prone to wandering; critical to identify degree to which wandering may put patient at risk of harm
- Imminent physical danger: particularly related to falls, fires and kitchen hazards (e.g., leaving the stove on, being around knives and other sharp objects)
- Kinship risks: includes risks to others, as well as possible elder abuse
- Substance misuse, including safe use of prescription medication, and safe driving
The P.I.E.C.E.S. approach allows you to consider the range of factors that may contribute to, cause or influence cognitive impairment in your patient. It looks at the following factors.
- Physical: diseases, drugs, discomfort
- Intellectual: dementia, mild cognitive impairment
- Emotional: depression, psychosis
- Capabilities: activities of daily living
- Environment: over/understimulation, relocation, change in routine
- Social: care.
What is the Action?
Think about the 3 Is:
- What are the Investigations I need to do?
- What are the Interventions I need to think about, both immediately and in the long term? This focuses particularly on medical interventions.
- What are the Interactions I need to consider? 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?
- The Primary Care Practitioner Role
- Screening & Assessment
- Resources & References