Promoting function-oriented, primary care approaches to improve the management of cognitive impairment and dementia

Primary care is currently at the forefront of a profound reorienting of healthcare systems worldwide, aimed at enhancing the health and well-being of older persons for various compelling reasons. Due to population aging, primary care, including community-based healthcare, will serve as the initial point of contact for an increasing number of older adults facing common age-related conditions and declines in capacity. The current supply of many specialists and healthcare professionals, especially those with geriatric competencies, is inadequate to address the rising demand and health needs of large and rapidly growing aging populations [1]. Additionally, primary care is increasingly recognized as the ideal setting to implement risk reduction strategies, including lifestyle changes, to mitigate modifiable risk factors for highly prevalent chronic diseases [2].

In this context, a perspective paper published in the Journal of Internal Medicine by a group of experts on Alzheimer's disease and related dementias (ADRD) in the United States outlines the opportunities, challenges, and potential solutions related to the early detection of cognitive impairment within primary care settings [3]. ADRD is among the foremost causes of mortality, disability, and dependency globally, posing a serious threat to the sustainability of social and healthcare systems, especially in low-resource settings. Cognitive impairment frequently goes underdiagnosed or is identified only after significant delays. This situation limits access to preventive, therapeutic, and rehabilitative interventions, intensifies the burden on caregivers, and potentially increases the risk of adverse outcomes. In light of these considerations, the paper emphasizes the critical role of primary care in conducting early cognitive evaluations, promoting brain health, facilitating lifestyle modifications, addressing reversible factors contributing to cognitive decline, and enhancing health and safety outcomes for both at-risk individuals and those already affected [3]. Practical solutions are also proposed to overcome existing barriers to detecting ADRD in primary care [3].

The paper by Fowler et al. reaffirms the centrality of primary care in the management of ADRD [3]. However, primary care approaches to ADRD should ideally be nested within broader care models aimed at improving the overall health, functioning, and well-being of older adults. There is growing recognition that disease-oriented frameworks may fail to capture critical health aspects relevant to older persons and their carers [4]. A primary focus on specific nosological conditions may result in healthcare systems that are poorly responsive to the multifaceted needs and priorities of older people and may inadvertently lead to misclassification, mistreatment, malpractice, and inequalities [4, 5]. Furthermore, disease-centric approaches may contribute to fragmentation rather than integration of care. For example, many of the measures identified as pivotal for enhancing the detection and management of dementia in primary care—including the adoption of brief screening and assessment tools, the use of biomarkers, and the implementation of health promotion and prevention strategies—are also applicable to a range of chronic, age-related diseases, such as diabetes, cardiovascular diseases, and cancer. This redundancy can create overlapping, vertical care pathways, complicating the allocation of already limited healthcare resources and placing additional strain on primary care professionals.

In contrast, horizontal, function-oriented primary care models are better aligned with the core principles of quality care for the older person. These principles emphasize a comprehensive and coordinated approach that focuses on both medical and nonmedical health determinants, establishes person-centered goals, ensures the implementation of meaningful and acceptable interventions, and provides the basis for monitoring and reevaluation over time [1, 5]. Building on these foundations, the World Health Organization (WHO) published the Integrated Care for Older People (ICOPE) handbook to sustain the capacity building of health and care workers in primary care for the delivery of ICOPE [6]. The ICOPE approach aims to optimize intrinsic capacity (i.e., the composite of all the physical and mental capacities of the individual) and functional ability (i.e., the attributes that enable all people to be and do what they have reason to value) close to where the person lives [7]. Central to the ICOPE approach is the holistic assessment and monitoring of six interconnected intrinsic capacity domains, namely, locomotion, cognition, psychological capacity, vitality, vision, and hearing, as well as the social and physical environment an individual engages with. Losses in these capacities can be prevented and managed through a range of tailored, evidence-based, multimodal interventions and social support [6].

Strengthening primary care is also critical to enhance the management of ADRD, resulting in substantial clinical benefits and positive public health outcomes. However, as outlined in the ICOPE handbook, implementing a brief, comprehensive assessment, ideally including cross-cultural tools, may identify potential impairments in cognitive functioning while also providing an opportunity to explore other health domains that are similarly relevant to the well-being of the older person [6]. Assessing declines in intrinsic capacity domains may support the early identification of factors and conditions that may have a detrimental role on cognition, such as hearing loss, vision impairment, depressive symptoms, and undernutrition, the in-depth assessment of diseases and risk factors associated with impaired cognition, the detection of reversible causes of cognitive decline, and the evaluation and management of social and physical environments. Finally, ICOPE provides an opportunity for health (including brain health) promotion and prevention. Cognitive preservation and dementia prevention can be enhanced through “ground-state” preventive approaches that include personalized interventions, lifestyle recommendations, and public health policies [8]. Overall, adopting such a function-oriented primary care approach does not overlook the unique aspects of dementia. Instead, it integrates the prevention, detection, and management of dementia within the broader clinical complexities of older adults, considering the various physiological, clinical, and socio-environmental factors that affect aging-related conditions.

Nevertheless, such a reorientation of healthcare cannot be limited to the clinical (micro) level. Achieving integrated health and social care for older people, including those at risk for and living with ADRD, requires substantial transformations also at the service (meso) and system (macro) levels. This is crucial to ensure the sustainability and scalability of the approach, as well as to optimize the allocation of healthcare resources. In this regard, the WHO ICOPE implementation framework outlines a range of actions aimed at various stakeholders, including policymakers, funders, and decision-makers, providing guidance on how to implement ICOPE and integrate it with local health and social care services [9]. The ultimate goal of reorienting care from a reactive to a proactive and preventive model is to ensure a continuum of integrated care, allowing older persons to benefit from timely interventions according to their evolving needs [10]. This implies (1) a clear understanding of older persons’ needs and priorities, (2) mapping of available resources, and (3) their reallocation to build a multidisciplinary and integrated care model. In other words, to build a more inclusive and sustainable future for our care systems, it is necessary to bridge sectors and competencies, looking beyond the standalone disease paradigm to more pragmatically embrace the clinical and social complexity of older persons.

The author has no conflicts of interest to disclose.