Effectiveness of dementia follow-up care by memory clinics or general practitioners: randomised controlled trial

BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e3086 (Published 15 May 2012)
Cite this as: BMJ 2012;344:e3086

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Meeuwsen et al investigated a very important topic which has not been investigated in the past, but there are a few points we would like to address here. The results of this study conclude that no evidence was found regarding memory clinics being more effective than general practitioners. However, in this study researchers should collect symptoms of dementia and measure if there are significant improvements in memory clinics as compared to general practitioners rather than measuring the same instruments as outcomes (individuals may vary in symptoms).

The primary outcome should be the improvement of symptoms rather than overall quality of life and other measurements in the study since improvement of symptoms can measure the contribution of memory clinics directly. Overall quality of life could be influenced by many other factors such as environment, financial status, marital status, functional status and others. Sleeping disturbance is a common symptom in dementia but it was not measured in this study. Adequate nutrition is another important factor associated with dementia and it can be improved through consultation. Furthermore, the research measures the severity of dementia at baseline; however, this indicator was not measured at follow up.

Competing interests: None declared

Heng-Hsin Tung, Associate Professor

Daniel L. Clinciu PhD, Liang-Kung Chen MD, PhD, Che-Wei Lin, MD, MPH, Kuan-Chia Lin, PhD

National Taipei University of Nursing and Health Sciences, 365 Ming Te Road PeiTou , Taipei 112 , Taiwan, R.O.C.

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Thanks to Dr Meeuwsen and colleagues for their important additions to understanding the dynamics of care for people with dementia and their family carers (1). Their finding that the usual care provided within Dutch General Practice is at least as effective as that provided by secondary care Memory Clinics is encouraging, adding to the accumulating evidence that Primary Care does quite well for its patients and families. The situation they have explored takes people away from Primary Care for assessment, investigation and diagnosis. Not everyone is willing to cross that divide. The Gnosall model, to which they refer with generosity (2), takes specialist skills which are usually tied into a secondary care clinic out to the front line. They have become part of the Primary Care Team www.gnosallsurgery.co.uk/clinics-and-services.aspx?t=5 . This means that there is no divide for patients or families: people are seen within the Practice for their memory problems just as they are for other symptoms and complications. There is a full (seamless) spectrum of care from identification through assessment, investigation, diagnosis, treatment and on-going support. All components benefit from the local and expert knowledge of the Practice with the added potential of specialist skills and advice. The service has been available for six years. We have outlined a three tier model wherein 90% of all patients might be managed entirely within augmented Primary Care (3). Our experience is that this can be done in the short term and sustained in the long term. Take up rates are high (our register includes more people than would be predicted by extrapolation from published epidemiology). Satisfaction rates with care are the highest in the county administrative area. The costs associated with the use of other healthcare as reported by the Primary Care Trust (PCT) are extraordinarily low (cost savings by the Practice calculated by the PCT are in excess of £1m on a budget less than £8m). Integrated work with local Social Services and voluntary and informal support is an essential natural ingredient. Thus we agree with Dr Meeuwsen and colleagues that Primary Care can and does do well for people with dementia. That is not to deny the potential and contribution of specialists and secondary care services, or the scope for improvements. It would be a tragic misreading of matters if their work or that of others, including ourselves, were to be seen to dismiss specialists as only relevant in pursuit of diagnosis. This is not a question of ‘either/or’ but of togetherness What we are seeing is appreciation of the strengths of all components of dementia care. We believe their best use will be achieved by closer integration and availability of knowledge and expertise across the time-course of the condition. This includes approaches to reducing risk before the clinical syndrome emerges, living with the condition, dying with the condition and readjustment for families in the ever-after. Integration of care has once again been given high profile on the political agenda in England. A historical reflection on the twists and turns of integration shows the traps of a debate on (re)organising care focused on professional and provider boundaries, rather than on the interests and needs of the public and service users/patients (4). With the developing insights in dementia care about the powerful place of primary care, we have an opportunity to take a better path to deliver integrated care. References: (1) Meeuwsen E J et al. Effectiveness of dementia follow-up by memory clinics or general practitioners: randomized controlled trial. BMJ 2012; 344:e3086 doi: 10.1136/bmj.e3086 (2) Greening L et al. Positive thinking on dementia in primary care: Gnosall Memory Clinic. Community Practitioner 2009; 82(5) 20-23 (3) Jolley D, Greaves I, Greaves N and Greening L Three tiers for a comprehensive regional memory service. Journal of Dementia Care 2010; 18 (1) 26-29 (4) Wistow G "Still a fine mess? Local government and the NHS 1962 to 2012", Journal of Integrated Care, 2012; 20(2) 101 – 114

Competing interests: None declared

David Jolley, Psychiatrist

Ian Greaves, Michael Clark

PSSRU The University of Manchester, Dover Street Building, Dover Street, Manchester M13 9PL

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