Head To Head

Would doctors routinely asking older patients about their memory improve dementia outcomes? No

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f1745 (Published 26 March 2013) Cite this as: BMJ 2013;346:f1745
  1. Margaret McCartney, general practitioner
  1. 1Glasgow, UK
  1. margaret{at}margaretmccartney.com

The UK government is planning to introduce incentives for general practitioners to check for dementia in all patients aged 75 and older. Jill Rasmussen (doi:10.1136/bmj.f1780) says that it will allow earlier support for patients with dementia, but Margaret McCartney says that industry has more to gain than patients

We are already screening for dementia. Never mind the evidence based conclusion from the UK National Screening Committee that “screening should not be offered,”1 our hospitals now receive financial incentives to do exactly that.

In early 2012 the Department of Health’s new Commissioning for Quality and Innovation (CQUIN) payments aimed to increase the rate of diagnosis of Alzheimer’s disease by asking everybody admitted to hospital over the age of 75 whether they have been more forgetful in the past 12 months to the extent that it has significantly affected their daily life.2 The question has to be asked within 72 hours of admission, and hospitals must achieve 90% compliance over three consecutive months before payment. Patients answering “yes” must have a “diagnostic assessment.”

The CQUIN document says that this is “awareness raising rather than formal screening.” But what is screening if it is not looking for a condition that the patient did not complain of or demonstrate symptoms of? And importantly, evidence of benefit is lacking. We do not have clear data on the positive predictive value of the question in real life or knowledge of the amount of harm that will be caused through overinvestigation and the lack of consent for the process.

The same document claims that anxiety will be raised unnecessarily, “only if the process is done badly,” and justifies it by claiming that “doing nothing is not an option.” Nevertheless, it admits that, “There will never be enough old age psychiatry liaison teams to assess, diagnose, and manage people with dementia in the general hospital,” and that, “Help from organisations such as the Alzheimer’s Society will be important.” So there is resource to pay for non-evidence based screening, yet a seeming acceptance that the NHS cannot offer adequate specialist care, and that people will be directed to the third sector instead.

This is a disservice to people with life impairing dementia, but it is also disease mongering in people with mild or occasional memory problems who live well. Patients in the community are also to be screened—the Department of Health has said that the general practitioner contract will “reward practices” that screen patients at supposedly high risk of dementia.3 We know the harms of screening have been insufficiently studied.4 We know that it will often detect mild cognitive impairment and that this does not necessarily progress to dementia.5

Industry influence

So who will benefit from possible “pre-disease” being diagnosed? The obvious answer is the pharmaceutical industry, which could see its market grow from increasing numbers of people being diagnosed with mild cognitive impairment.

Industry has taken a position at many high tables. The Alzheimer’s Society has a policy of accepting drug company funding to a maximum of 5% of its total,6 and Andrew Chidgey, its director of external affairs, said on Twitter on 14 December 2012 that he meets “on and off” with the industry, including “looking round Eli Lilly to get an update on their research.” Jeremy Hunt, health secretary, tweeted on 20 December, “Feeling optimistic about progress in dementia research. Thanks @Lillypad for great visit.”

Eli Lilly recently published press notices about phase III clinical trials of solanezumab, a monoclonal antibody that it says shows “slowing of cognitive decline in patients with mild Alzheimer’s disease.” However, there was no significant change in the cognitive and functional outcomes used as primary endpoints, and only a prespecified secondary analysis showed benefit; to date neither the data nor any information about whether the benefit was clinically useful have been published.7

In December the Social Market Foundation published a report on dementia diagnosis, A Future State of Mind, sponsored by Lilly, which railed against GPs, saying, “Early diagnosis is obstructed principally by problems in primary care associated with the capability of GPs, time constraints and physician perceptions of the benefits of diagnosis.”8 The document makes proposals to “improve early diagnosis,” but does not include assessments of the harms of screening or overdiagnosis.

Other industries also stand to benefit from more “early” diagnosis. Adverts on bmj.com have included those for a nutritional product “designed specifically for people living with early Alzheimer’s disease.”9 The claims of effectiveness are based on trials over six months that showed only small overall differences and used memory test outcomes rather than functional performance.10

Cambridge Cognition, a technology company, recently announced government support for trials of its high tech early dementia assessment service that could “reduce time to diagnosis from 18 months to 3 months.” The service uses a diagnostic tool on a tablet computer that it claims, “in less than 10 minutes, differentiates between patients with normal and abnormal memory.”11 However, the company cites a specificity of 92%, which will result in many false positive diagnoses.12

Direct resources where most needed

The rush to “early” diagnosis has missed crucial dialogue. Earlier than what? Why? We should aim for timely, consensual diagnoses as part of a dialogue, not a test foisted on a patient who seeks healthcare with other priorities and lacks the choice and chance to consent, or not. A negative dementia screening result does not mean people do not have to plan for their future. This political drive will overdiagnose and overtreat many people with minor memory changes, who cannot benefit from screening and may only be harmed by it. Instead of shiny gadgets and incentives for hospital doctors to fill out admission questionnaires, we should turn our attention to the low tech, hard graft of supporting people with severe symptoms and their families with the front line care they need—and whose voices are scarcely heard.

Notes

Cite this as: BMJ 2013;346:f1745

Footnotes

  • Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare I am GP whose income is potentially affected by the GP contract requirements.

  • Read Jill Rasmussen’s side of the debate, doi:10.1136/bmj.f1780

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References