Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Is that a person, patient or have you already given up on them?
- Devika Khanna (11 January 2008)
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Interpretation of survival of people with dementia
- Murali Vallipuranathan (13 January 2008)
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Need more studies for actual survival rates in dementia rates
- Om Prakash (24 January 2008)
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Measuring survival
- Mary Ganguli (29 January 2008)
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Is Dementia A Lifespan Issue?
- Justin Christian Marley (5 February 2008)
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Personal thoughts from a cricket statistician
- Richard D Lockwood (5 February 2008)
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Caring for the dement patient. Don’t forget his caregiver.
- Isabelle Pitrou (7 February 2008)
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Survival in dementia: is treatment doing well?
- Renato Bertini Malgarini, Giuseppe Pimpinella (7 February 2008)
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The Elephant in the Room?
- Philip M Dainty (14 February 2008)
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Myself
- Hugh Mann (7 May 2008)
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Devika Khanna, Co-chair of Psychiatry StR Committee for East Midlands (North) Nottinghamshire Healthcare NHS Trust, NG3 6AA
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This is a very interesting study, and I agree with Xie et al that focussing on incident cases of dementia can provide clinically more useful information (though of course it has it’s own limitations). As a psychiatry trainee working with the “elderly”, something that has often puzzled me is how every patient beyond a certain age is viewed (not only in psychiatry, but other specialties too) as belonging to this ONE category. Once this is superimposed by the label of “dementia”, these people are confined to an even narrower image and stereotype. It is important to emphasise the heterogeneity of these individual people, not only by realising that they could be of any age spanning at least two generations, but also when applying the results of this study, by realising that although we are provided with useful information in that “survival after the estimated onset of dementia was 4.6 years for women and 4.1 years for men”, in fact “survival varies between 10.7 and 3.8 years between younger old and oldest old”. I agree with the authors that the neuropathology is often mixed in the population, but with the trend for neuropsychological testing and imaging techniques which can provide at least most probable diagnoses, it would have been helpful to have results by subtype of dementia. I would also be interested to know how any psychiatric co-morbidity, in particular depression, affected survival time in these patients. Finally I would like to point out that 4 years or so survival with an illness is a significant period of time, and this emphasises the importance of ensuring optimal management and services for these patient as well as their carers. Competing interests: None declared |
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Murali Vallipuranathan, PhD Student Section of Epidemiology, Institute of Psychiatry, King's College, London SE5 8AF
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Xie et al tried to explore the impact of dementia on life expectancy by measuring median survival rates of people with dementia(1). While life expectancy measures the arithmetic mean of the survival times, the median survival time measures the time at half of the cohort would have died (2). In high risk groups life expectancy is considerably larger than median survival time because of the skewed distribution in the survival times (2). Therefore the impact of dementia on life expectancy can not be directly measured from median survival rates. It needs to be interpreted by comparing with the median survival rates of the same age general population. Secondly though the authors have identified other co-morbid conditions as a characteristic associated with the survival of dementia patients they have not included it in the analysis (1). Instead of that they have resorted to measure self reported health which may be not very valid in a population with possible cognitive impairment. Co-morbid conditions such as diabetes mellitus are associated with dementia and cognitive impairment (3) while affecting their survival independently. Therefore the confounding effect of co-morbid conditions can not be excluded in this study. Thirdly authors have reported that they have found significant trend of decreasing survival with increasing age for men and women. Decreasing survival with increasing age is a natural demographic phenomenon that is observed in life tables and it has no particular significance. Women with dementia having longer survival than men is also not significant because the life tables of England and Wales (4) shows that women in the same age group in general population have longer survival than men. References 1. Xie et al, Survival times in people with dementia:analysis from population based cohort study with 14 year follow up, BMJ, doi:10.1136/bmj.39433.616678.25 (published 10 January 2008) 2. Strauss et al, Life expectancy and median survival time in the permanent vegetative state, Paediatric Neurology, 1999;21:626-631 3. Strachan et al, Diabetes, cognitive impairment and dementia, BMJ 2008;336:6 (5 January), doi:10.1136/bmj.39386.664016.BE 4. Uk Government statistics, http://www.statistics.gov.uk/StatBase/Product.asp?vlnk=14459 Competing interests: None declared |
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Om Prakash, Assistant Professor of Psychiatry National Institute of Mental Health And Neurosciences(NIMHANS), Bangalore-29, INDIA
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We must appreciate the study conducted by Xie and his colleagues1 about estimation of survival rates in dementia patients. This study will generate curiosity among researchers throughout world in this neglected area of research. After this study, at least we can give some estimate of survival rate to caregivers of dementia. Nevertheless, more prospective studies needed in other parts of the world in the view of disparity in prevalence rates and other socio- economic factors. Reference: 1. Jing Xie, Carol Brayne, Fiona E Matthews and the Medical Research Council Cognitive Function and Ageing Study collaborators. Survival times in people with dementia: analysis from population based cohort study with 14 year follow-up BMJ 2008; 0: bmj.39433.616678.25v1 Competing interests: None declared |
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Mary Ganguli, Professor Pittsburgh, PA, USA 15213
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Very interesting work and likely to be influential. A point to bear in mind is the manner in which survival /duration of disease is measured. The endpoint is the date of death, but the start date (date of disease onset) is less clear. In the clinical setting it will depend on whether and when the patient/family come to seek services, when the disease is diagnosed, and how observant the family was in detecting the earliest signs. We know that the underlying pathology is present long before the first symptom. In this study, the onset date was estimated as the midpoint between the last evaluation when dementia was not present (i.e. when the individual did not meet operational criteria for dementia) and the first evaluation at which it was present. Quite possibly, subthreshold symptoms could have been present for a while before that date. This could cause a systematic under-estimation of the length of survival. There is no easy solution to this problem in population research, but the point should be born in mind when interpreting such data. Competing interests: None declared |
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Justin Christian Marley, Specialist Registrar in Old Age Psychiatry Rotherham District General Hospital, Moorgate Road, Rotherham, S60 2UD
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Dear Editor, I read with interest the article by Xie et al (1). The authors have identified important predictive findings which hopefully will stimulate further research in this area. I would however draw attention to the possibility that dementia is a lifelong process. If this were the case, then the clearly identifiable onset referred to in the study may be misleading. Both Down's Syndrome and Huntington's Disease may be considered as neurodevelopmental disorders and yet are classically associated with dementia. Within the general population, a number of predictors of dementia have been identified including mild cognitive impairment (2), olfaction (3), duration of diabetes, arterial disease and exercise (4) as well as depression and anxiety symptoms (5). Such predictors hint at a subtle disease process which may occur over many decades. Furthermore clinical dementia may be a marker of underlying confounding medical pathology (e.g. cardiovascular disease)in mortality studies. Measuring such variables in future prospective studies may provide invaluable data for use in predicting mortality. (1) Xie, J et al. Survival times in people with dementia: analysis from population based cohort study with 14 year follow-up. BMJ. 2008. 336. 258-262. (2) Dickerson, B et al. Clinical prediction of Alzheimer disease dementia across the spectrum of mild cognitive impairment. Arch Gen Psychiatry. 2007. 64(12). 144-50. (3) Wang, Q et al. Olfactory identification and apolipoprotein E epsilon 4 allele in mild cognitive impairment. Brain Res. 2002. 951(1). 77-81. (4) Bruce, D.G et al. Predictors of cognitive impairment and dementia in older people with diabetes. Diabetologia. 2008. 51(2). 241-8. (5) Palmer, K et al. Predictors of progression from mild cognitive impairment to Alzheimer disease. Neurology. 2007. 68(19). 1596-602. Competing interests: None declared |
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Richard D Lockwood, Cricket Statistician 23 Dene Hollow, Kings Heath, Birmingham, B13 0EG
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I am not a doctor and this is the first time I have looked at the BMJ. I was alerted to the article by my mother's GP as the possible survival times is an important factor in looking after my mother and calculating the potential benefits and costs of different types of care. I am in the unique position of trying to look after my mother while also working as a cricket statistician so I am able to combine the problems of living with dementia with an ability to analyse the numbers. My mother's GP took the main conclusion of the study and informed me that the average survival rate for a person with dementia was 4 1/2 years, but having read the study that figure has little relevance to my mother. Clinically diagnosed with vascular dementia in 2001 after we had worried about her memory loss for a long period, her latest CT scan has shown signs of Alzheimer's disease, but the psychiatric doctor has not wanted to give any indication of how long she would live... even what had exactly caused the dementia or when it started. According to the average, mum would have died already, but thankfully she was in her 60s when diagnosed so I have gained heart from the likely 10 year survival rate. My point is that the overall average is rather meaningless, the age of the patient being the most important factor, together with the sex of the patient, so in fact the general range of between 8 to 12 years I was given by one specialist is still a valid basis for a woman of my mother's age. Her score on the mental test has been declining so this is also useful in working out the speed the dementia is progressing I'm glad to have read the article but I am lucky to have the ability to understand the figures and to realise the average is not the whole story. Are there any statistics available for the different types of dementia - even between the general categories of Vascular, Alzheimer's and Mixed Dementias, although from personal experience the diagnosis is particularly difficult - mum could be placed in any of the 3 categories at various stages. One of my roles as a cricket statistician was to help in the development of the first cricket rating system to take more factors into account than simple batting and bowling averages.... now the same skills have come in useful in interpreting this data. Other patients, families or even doctors will not have this ability and may be rather distressed by the 'average' results! Competing interests: None declared |
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Isabelle Pitrou, Public health resident (MSc) Département d’Epidémiologie, Biostatistique et Recherche Clinique, Hôpital Bichat, Paris, France
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I read with interest the article by J. Xie et al.1 measuring survival times of people with dementia. Results found by the authors (median survival of 4.5 years) can effectively be used for prognosis and planning for patients, carers, service providers and policy makers. One growing concern with dementia is the organisation of the healthcare system: development of specialized care centers and institutions for dementia are still needed. Also, more than 50% dement patients remain home being helped in their daily tasks by a formal (i.e, licensed caregiver) or informal (e.g, family member) caregiver. Previous studies showed that caregiver often face difficulties (e.g; loneliness, anxiety) and can suffer from psychological distress leading to caregiver burn-out 2 3 4. Efforts should be made to promote psychological support for caregivers and increase communication between caregivers and physicians. As life expectancy is increasing and population is ageing, dementia will become more prevalent and caregiver burden may consequently increase. 1. Xie J, Brayne C, Matthews FE. Survival times in people with dementia: analysis from population based cohort study with 14 year follow- up. Bmj 2008;336(7638):258-62. 2. Pitrou I, Drouet M, Ladner J, Moynot Y, Czernichow P. [Alzheimer's disease, profile and needs for professional caregivers]. Soins Gerontol 2006(59):19-24. 3. Zhang B, Mitchell SL, Bambauer KZ, Jones R, Prigerson HG. Depressive Symptom Trajectories and Associated Risks Among Bereaved Alzheimer Disease Caregivers. Am J Geriatr Psychiatry 2008;16(2):145-155. 4. Alzheimer’s disease. Help for caregivers. OMS en collaboration avec Alzheimer’s Disease International; 1999. http://www.alz.co.uk/adi/pdf/helpforcaregivers.pdf Competing interests: None declared |
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Renato Bertini Malgarini, Pharmacovigilance Unit Italian Medicines Agency (AIFA), Giuseppe Pimpinella
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The Article of Xie et al. (1) is very interesting, but we deem that the multivariate analysis is incomplete. In fact, the possible influence of pharmacological treatment of dementia has not been taken into account. Recent studies have reported an increase in mortality in patients with dementia treated with antipsychotics (2) and adjustment with respect to the use of antipsychotic medications should have been considered. References 1. Xie J, Brayne C, Matthews FE and the Medical Research Council Cognitive Function and Ageing Study collaborators. Survival times in people with dementia: analysis from population based cohort study with 14 year follow-up BMJ 2008; 336:258-262. 2. Wang PS, Schneeweiss S, Avorn J et al. Risk of death in elderly users of conventional vs. atypical antipsychotic medications. N Engl J Med 2005; 353(22):2235-41 Competing interests: None declared |
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Philip M Dainty, Specialist Registrar Staffordshire General Hospital
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Sir, Xie et al (1) provide us with welcome data allowing us to more adequately inform patients with dementia (and their carers). As a professional caring for such patients (and their relatives)it seems that the main failing of care is the lack of clear information given to patients, and subsequent advanced planning. At present we are reactive rather than proactive, and thus forfeit opportunities to intervene early. With increasing numbers of those with dementia, a proactive approach is paramount. Both primary and secondary care must aim to identifying in advance the wishes and needs of people, and providing information regarding issues such as preferred place of care, enteral tube feeding and prognosis. Failure to do this, along with poor engagement of community care homes, will lead to us all being trampled underfoot by the medical elephant in the room. Competing interests: None declared |
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Hugh Mann, Physician Eagle Rock, MO 65641 USA
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I'm trying to remember Competing interests: None declared |
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