Head To Head

Would doctors routinely asking older patients about their memory improve dementia outcomes? Yes

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f1780 (Published 26 March 2013) Cite this as: BMJ 2013;346:f1780
  1. Jill Rasmussen, general practitioner with special interest in mental health and learning disability
  1. 1East Surrey, Clinical Commissioning Group, Caterham CR3 5QX, UK
  1. jill.Rasmussen{at}virgin.net

The UK government is planning to introduce incentives for general practitioners to check for dementia in all patients aged 75 and older. Jill Rasmussen says that it will allow earlier support for patients with dementia, but Margaret McCartney (doi:10.1136/bmj.f1745) says that industry has more to gain than patients

Earlier identification of dementia gives patients and their families and carers more opportunity to consider the implications of the diagnosis and to make decisions while the patient can actively participate. Although no preventive or curative treatments are available, we have pharmacological interventions such as cholinesterase inhibitors that can optimise a patient’s capabilities during early dementia, enabling them to play more active roles in society, spend quality time with “near and dear”; and enjoy a better quality of life.1

Many people attribute memory problems to old age. Unfortunately, many healthcare professionals are guilty of the same presumption when confronted with an older patient or concerned relative with memory complaints. Timely diagnosis in dementia gives the opportunity to maximise the benefits of current interventions.

Need for better care

The Appraisal of Screening for Alzheimer’s Disease 2009 concluded that “an evidence based routine screening programme for Alzheimer’s disease that will reduce mortality and morbidity is not yet a possibility.” The appraisal also highlights that the UK is in the bottom third of European performance for diagnosis and treatment of dementia, and that services and support for patients, families, and carers are inadequate.2

The challenges faced by those affected by dementia go beyond health and social care. An Alzheimer’s Society survey of people with early dementia in 2012 found that as many as 67% of the 306 respondents felt isolated from society and that communities fail to appreciate their problems or make reasonable adjustments to meet their needs.3

Since 2009 there have been important policy initiatives in the UK to increase awareness of dementia and to establish effective services for early diagnosis and intervention; ensure adequate support after diagnosis; and make our communities more dementia friendly.4

Guidelines from the National Institute for Health and Clinical Excellence in 2011 endorsed the use of cholinesterase inhibitors in mild to moderate Alzheimer’s disease.5 Models of memory services have shown that diagnosis should be embedded more in the community, with general practitioners taking ownership and closer liaison with secondary services.6 GPs’ concerns about cognitive assessment tools have been addressed in a toolkit published by the Alzheimer’s Society.7 We have made considerable progress since 2009 in ameliorating the effect of dementia.

Opportunity to ask about memory problems

The 2012 report of the All Party Parliamentary Group on Dementia finds no justification for population screening but recommends opportunistic questioning about memory problems.8 Advanced age is the predominant risk factor for dementia, and many people over the age of 65 will have at least one long term health problem. These patients usually attend primary care regularly for reviews or annual flu jabs. Such interactions give cost efficient opportunities to inquire about health concerns, including memory problems. Taking advantage of these contacts could improve early detection and might help overcome the impression that primary care has been a barrier to diagnosis rather than a portal to advice and services.

In this environment of routine visits, general queries about health, including memory problems, can be raised without causing undue anxiety. It therefore seems sensible to explore possible memory and cognitive deficits in these patients. Equally, heath professionals must be alert to other groups at higher risk of dementia—for example, those with Parkinson’s disease or learning disability, especially Down’s syndrome.

Cost of failure to identify dementia

Evidence shows that failure to recognise dementia results in greater financial and personal costs and crisis in management. This results in inappropriate hospital admissions, earlier need for nursing home placement, and poorer quality of life for patients and their near and dear.8 Dementia is the greatest health concern among people over 55.9 Physical, psychiatric, and psychological clinical outcomes are better for everyone when crisis care is avoided and care follows a preventive model.

Failure to identify dementia deprives everyone involved—especially patients—of valuable time when the short and long term future can be discussed before events become critical. Early identification of disease, including dementia, improves treatment options and allows everyone to be better prepared to face the future. Important medicolegal issues should be discussed, such as lasting power of attorney, and personal decisions should be made while the patient can participate.

Some healthcare professionals see no value in diagnosing dementia because there is no cure. But most patients with dementia will live with the disease for years, and there is much that can be done to help them along the journey. Evidence is increasing that improvements in lifestyle (exercise, diet), combating obesity, and optimising control of comorbidities (hypertension, diabetes, cerebrovascular disease) can delay the onset and slow the progression of dementia.10 When impairment results from causes other than dementia, it is imperative to identify and treat these and to reassure patients.

Some patients will not want to pursue investigation of any memory problems, and their decision must be respected. We currently have no cure for dementia, but there is agreement that early detection benefits patients.11 12

We have interventions, such as cognitive stimulation,13 that can help preserve competence for as long as possible. There is increasing provision of services within health, social care, and the voluntary sectors to support people with dementia, their families, and carers. We must ensure that such services and support are available to everyone with dementia.

Earlier diagnosis will not alter the ultimate outcome, but the better informed and prepared we all are, the better equipped we will be to tackle the challenges that dementia presents.

Notes

Cite this as: BMJ 2013;346:f1780

Footnotes

  • Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare I am the clinical lead for mental health, learning disability and dementia for East Surrey CCG; co-developer of MoodHive (Depression Anxiety Pathway); chair of the Learning Disability Special Interest Group and Clinical Champion for Dementia at the Royal College of General Practitioners; as a director of Psi-napse, an independent consultancy I have advised pharmaceutical companies, venture capital banks, and organisations such as the Wellcome Trust about new therapeutics for psychiatric and neurological disorders.

  • Read Margaret McCartney’s side of the debate, doi:10.1136/bmj.f1745

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

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