Having the conversation – identifying cognitive impairment and providing appropriate chronic disease management care planning in primary care.

Abstract

General Practitioners (GP) and Practice Nurses (PN) must be alert to the presence of a dementia as it impacts on all chronic disease management (CDM). Effective dementia care requires collaboration between GPs and PNs and other members of the primary care team, however the PN is well-positioned to take a central role in identifying cognitive impairment and providing appropriate chronic disease management care planning in primary care. Nurses are the most trusted health professional with the PN often having a relationship that extends over many years with the patient and is usually responsible for the development of CDM plans. By increasing confidence to talk about cognition and the knowledge and skills to identify CI and its impact on an individual’s health self-management, the PN can play a vital role in improving dementia care in primary care. The PN can potentially increase identification of CI in the patient group with existing chronic disease, normalise the conversation about cognition and develop individualised chronic disease management in the context of the individual’s cognitive status supporting self-management. The Dementia Pathways Tool, an online resource, has been developed to help GPs and PNs to deliver best-practice dementia care and cognitively aware chronic disease management.