Who should be referred for dementia consultation?

As patients with memory complaints in Canada number in the hundreds of thousands, whereas memory specialists are only a few hundred, and as the diseases which give rise to memory complaints are usually associated with aging, it is clear most patients with memory complaints will be cared for by their family physicians. As a result, it is important family physicians recognize typical illness presentations and progression in memory impairment and in dementia. Such knowledge will allow for most patients to be well cared for in that setting. In addition, recognizing what is typical provides a rational basis for the referral of what is atypical. This paper proposes referral of those patients with less common cognitive impairment syndromes, which by virtue of their potential for special treatment, particular harm or public health implications, will require special expertise in diagnosis and management. This approach is rooted in identifying so-called "atypical" features in the history or the physical examination. Importantly, a new but still poorly characterized class of "atypicality" has emerged, which is the atypical treatment response. At this stage of our understanding of what constitutes treated Alzheimer's disease, mechanisms will need to be in place to assist family physicians and others to have an appropriate understanding of treatment expectations and course. The latter is recommended as an important focus for research in the near term.