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Rapid Responses: Rapid Responses published:
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Dementia Care Strategy
- John .S. Kelly (22 April 2009)
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John .S. Kelly, Consultant Clinical Psychologist North Yorkshire and York NHS PCT HG2 7RY
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Early Diagnosis of Dementia: Is it possible or desirable? The arrival of a National Dementia Strategy is a welcome recognition that the UK like many other economies can no longer ignore the health implications of an expanding older population. Chapter 4 of the strategy specifically addresses the issue of early diagnosis and support and presents the modest potential (predominantly economic) value of early intervention. However, beyond this, there is a paucity of persuasive evidence to show whether early diagnosis of dementia is currently really possible or even desirable. Is the early diagnosis of dementia possible? Firstly, a diagnosis of dementia is (sometimes reassuringly for many) only really ‘possible’ or ‘probable’ until after a post mortem because it is not until after death that the suspected brain pathology can be confirmed and be married with the clinically observed pattern of progressing signs and symptoms seen in life. Secondly, early signs and symptoms heralding a dementia vary and are frequently compounded by issues of ordinary age related cognitive change, psychiatric co-morbidity, and other physical ill health. There are still no pathognomonic markers or diagnostic tests available to indentify the problem or reliably discriminate between the various differentials. Atrophy on CT for example, is frequently of little significance. Typically, the diagnostic pathway leading toward a diagnosis of dementia is a necessarily slower paced affair. After any obvious physical causes are thoroughly investigated and the more common maladies that can cause cognitive impairment are ruled out, serial cognitive reassessments are made so that any deficits can be identified, confirmed and tracked. Eventually, sometimes after many months, either the increasing likelihood of an emerging dementia becomes apparent and a possible diagnosis of dementia begins to be entertained by the patient, their family and their clinician or there is no progression and more benign alternative explanations are considered. Either way, a swift and definitive diagnosis is rarely possible and any organization aspiring to provide such certainty raises the risk of the arguably more distressing scenario of increasing misdiagnoses. Is the early diagnosis of dementia desirable? Unlike the early diagnosis of first episode psychosis or cancer, the early diagnosis of dementia appears to be of little clear benefit to the sufferer. There are currently no effective treatments for the underlying biological pathology and very limited (despite the hype) scope to halt the progression of the disease using pharmacological means. Robust post- diagnostic comprehensive memory services offering memory rehabilitation, counselling and support that might be useful are disappointingly rare. Whilst an earlier diagnosis of dementia may help some patients, their relatives and services prepare in advance, adapt and plan for the inevitable progression of the disease, (and this may be economically advantageous), premature diagnosis giving may also serve to demolish any sense of hope and propagate depression and anxiety. There appears little obvious significant benefit to the patient. Whilst we should heartily welcome the DoH’s dementia care strategy, we should perhaps also exercise caution in the pursuit of a quick or early diagnosis of dementia until we have something better to offer those diagnosed. In the meantime, perhaps we should adhere to a much more collaborative, person centred, and slowly evolving diagnosis process. Dr. John Kelly C.Psychol. AFBPsS
Competing interests: None declared |
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