Curiouser and curiouser: the changing numbers in dementia diagnosis

ZPrS_Z4mTom Dening is Professor of Dementia Research at the Institute of Mental Health at the University of Nottingham. He tweets at @TomDening

Dementia is getting more common as the population of the UK and, for that matter, the world gets older. But just how common? How many people are out there? It’s a really important question for us all.

There have been some interesting developments over the last year. Until then, the official figure was 800,000 in the UK. This was based on projections from the MRC Cognitive Functioning and Ageing Study (CFAS), data that were collected during the 1990s, and updated based on the demographic profile of the elderly population since then. So this figure was based on numbers around 20 years old.

Therefore it was important to replicate the study and eventually CFAS II was funded and carried out. The team reported their findings in the Lancet last year. The most important result was that instead of an expected prevalence for dementia of 8.3% in people aged over 65 (giving over 800,000 cases) they found a prevalence rate of 6.5%, which would result in a lower total number of around 670,000. In other words, the total might be as much as 20% less than generally assumed. The most likely reason for this would be a cohort effect – i.e. people born later in the 20th century had enjoyed better health, nutrition, education etc and therefore were living into old age in better general health and with less burden from vascular disease.

The response to this was mixed. To me, it seems like jolly good news if public health has improved and there is less dementia than we expected. Other authorities expressed concern that the CFAS II figures might be overoptimistic, and concerns about having more than one figure being used. It was agreed to establish a Delphi process to review the evidence. The Delphi method is a systematic, interactive forecasting method by which a panel of experts, led by a facilitator, use a series of iterated questions to arrive at a consensus. The advantages of this method are obvious – you can use all the known literature and experts can respond to new findings, hopefully reaching the Truth in the end. From the outside, it may look like a clique.

The results of the process have been published by the Alzheimer’s Society in their Dementia 2014 report http://www.alzheimers.org.uk/dementiauk, though so far only an overview is available.  The crucial figure is now 835,000, or 850,000 in 2015. Slightly surprisingly, this total number has gone up rather than down, despite the CFAS II findings. It represents a prevalence of 7.1% in people aged 65 and over.

At the same time, the Department of Health and NHS England, concerned at apparently low (and variable) rates for diagnosing dementia, have been trying to improve the situation. Most of the effort has been concentrated on GPs, with the aim to have at least two-thirds of people with dementia having a diagnosis. Clearly, the size of the task depends on the denominator: the CFAS II figure suggests that the required number would be about 440,000 and the Dementia 2014 figure would be nearly 600,000.

The third development is that it is widely reported that NHS England has now introduced an incentive payment for GPs based on patients diagnosed with dementia. Payments to GPs are increasingly based around incentives of various kinds but this particular initiative has drawn a lot of criticism (see, for instance, comments on http://www.theguardian.com/society/2014/oct/22/nhs-dementia-diagnoses-gps-patients-criticised) as it has been suggested that this creates financial pressure to push patients into a particular diagnostic category, which can of course have serious implications. Clearly, there is public unease about this, even if some of it is based on a misunderstanding of the complex world of GP payments.  Will £55 push unscrupulous GPs to make fraudulent diagnoses of dementia? Possibly not, but it may subtly alter the threshold at which people are diagnosed as having the condition.

It is a complex and changing situation, but it would be unfortunate if we do too much that causes older people or their families to feel suspicious about the activities or motivations of their doctors. When I explain the NHS to visiting scholars from the planet Zar, they are very interested in the Dementia Challenge. A thoughtful student asked me, “So why is it that the Earthlings are counting more of these cases than actually exist and why are they asking doctors to diagnose a made-up number of cases, and is it good for anyone that they get paid for this?” Good question.

The NHS England Five Year Forward View: A crucial document for our speciality, for the care of older people and for Health and Care Services in England.

David Oliver is President of the BGS, Visiting Fellow at the King’s Fund and Consultant Geriatrician at the Royal Berkshire Hospital, Reading. In part 1 of a 2-part blog, he discusses how the NHS “Five Year Forward View” is important for people involved in the care of older people.

October 23rd 2014 is memorable to me, as it’s my 23rd wedding anniversary. It’s also now of significance to the rest of us, as the date that NHS England’s “Five Year Forward View” plan was published. I realise not many of you will have had the time or necessarily inclination to read it, though at only 39 pages it’s an easy canter.

I also know it hasn’t attracted much Twitter activity from fellow BGS members. But it’s a document which I suspect will have far reaching influence and implications for the services we all work in. These implications seem largely positive. Let me explain why.

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 Will volunteer success deliver the elusive Holy Grail of PPI?

Liz Charalambous is a qualified nurse on a female, acute medical HCOP (Health Care for Older People) ward at Queen’s Medical Centre, Nottingham University Hospital Trust.

Having nursed in different areas for over 30 years, she currently balances her time between clinical work, research into the prevention of delirium and studying for a MSc. in Advanced Nursing at the University of Nottingham.

Here she discusses whether PPI (Patient and Public Involvement) can contribute to person-centred care. Liz tweets from @lizcharalambou

Recent media coverage highlights loneliness in the elderly population and how some organisations are taking steps to combat this, such as the ‘Be a friend’ campaign launched recently by Friends of the Elderly http://www.beafriendtoday.org.uk/ . Patients and relatives must breathe a sigh of relief that when their loved one is admitted into hospital, at least they will be surrounded by others and therefore not at risk of loneliness.

Unfortunately, this is not always the case. Despite NICE guidelines for Delirium (2010) https://www.nice.org.uk/guidance/cg103 and Dementia (2006) http://www.nice.org.uk/guidance/cg042 calling for the involvement of families, as well as the much-vaunted Holy Grail of PPI (Patient and Public Involvement) post Francis, many older people remain at risk of confusion and developing delirium purely by virtue of the fact they are over 65 years of age and clinically unwell. Staff are very often tied up with the clinical side, and rightly so. A blocked airway, arrhythmias, acute kidney injury and clinical deterioration remain a priority over holding someone’s hand. Continue reading

Writing, music and geriatric medicine

The Secret Life of a Geriatrician

 This new BGS blog series shows how passion for a career and extra-curricular activities can share fascinating qualities.

Desmond (Des) O’Neill is a geriatrician and cultural gerontologist in Dublin. He is also the local lead for the IAGG-ER Congress in 2015

 

Last week was even more fun than usual. In addition to my current day job in the Acute Medical Unit, I was involved with a concert of works by our composer-in-residence; my first time speaking at a book festival; a talk to emergency physicians on traffic medicine at IAEM 2014; sitting in on a cracking competition in geriatric medicine between Irish medical schools, the Jack Flanagan Prize; and attending a study day on architecture, design and medicine.

 

Working as a geriatrician is fun in general: it remains one of life’s mysteries to me that this seems counter-intuitive not only to the general public but also to some (albeit increasingly fewer) of our medical colleagues, especially since entry to training in geriatric medicine has become so highly competitive in Ireland.

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Seeing The Whole Picture

The Secret Life of a Geriatrician

This new BGS blog series shows how passion for a career and hobby can share fascinating qualities.

Philip Braude is an ST6 in Geriatric Medicine, specialising in perioperative medicine

There is a flash of knowing and relief as I click the shutter capturing a distinctive moment of the natural world. I take a moment to flick on the camera’s display screen to reassure me that everything has gone to plan, or not, and I make corrections for the next picture. Creating a cohesive image from the complex order and behaviour of wildlife takes planning, patience and perseverance.

My passion for nature photography grew from a need to relax away from long general medical on-calls. Many twilight evenings I would use my camera as an excuse to roam London’s outer green spaces. However, my understanding of this art form has developed alongside my medical career.

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Many older adults still homebound after 2011 Great East Japan Earthquake

A new study, published online in the journal Age and Ageing today, shows that the homebound status of adults over the age of 65 in the aftermath of the 2011 Great East Japan Earthquake is still a serious public health concern. Of 2,327 older adults surveyed, approximately 20% were found to be homebound.

A team of researchers led by Naoki Kondo of the University of Tokyo’s School of Public Health studied data from the city of Rikuzentakata, an area that was seriously damaged by the disaster. Of its total population of 23,302 before the events of 2011, 1,773 people died or are still missing. Of 7,730 houses, 3,368 (43.6%) were affected with 3,159 “completely destroyed”. Much of the population had been concentrated in flat coastal areas, and since the community infrastructure was totally shattered, many people who lost their houses insisted on moving to areas in the mountains. Continue reading

What I do is who I am – the importance of activity in care homes

Lorraine Bridges is the Senior Communications Manager at the College of Occupational Therapists. She tweets at @L_BridgesLivingWellThroughAcitivityinCareHomesToolkit

Occupational therapists help people to carry out essential occupations – the activities that make up our daily lives – from washing and dressing, the weekly shop, visiting friends and all the things we enjoy in life.  For older people occupations are vital for health, social inclusion, and mental wellbeing, but become more difficult due to increasing frailty. Geriatricians will be all too familiar with the serious risks of immobility.

The College of Occupational Therapists, like the British Geriatrics Society, firmly believes in equal access to health and social care and developed the Living Well Through Activity in Care Homes Toolkit to ensure that people living in care homes have the same access to occupational therapy as those living in their own home.  The resource is part of the College’s wider aim to champion dignity, choice, respect and control for older people, recognising occupational therapists’ unique skills in enabling occupation and understanding how dementia, co-morbidities, and other factors such as poor vision, impact on activity participation. Continue reading

Good Vibrations: whole body vibration treatment

Falls are common in older people and are the direct cause of many osteoporotic fractures. There are limited treatments available to help frail older people who are at risk of falls. A study funded by the National Osteoporosis Society and the British Geriatrics Society on the potential benefits of whole body vibration for frail older people has now been published in Age and Ageing.shutterstock_83367871

The collaborative work between the University of Loughborough and Nottingham University Hospitals NHS Trust showed that older people attending a falls prevention programme are able to tolerate whole body vibration.

Patients were recruited at The Nottingham University Hospitals Rehabilitation Unit and all of them took part in the NICE recommended falls prevention programme, which includes exercise. They were split at random into three groups. One group used a vibration platform that moved vertically up and down; one used a vibration platform with a “see-saw” action and one group stood upon a stationary platform whilst a buzzing noise was played so that they thought they were receiving vibration (sham vibration). The vibration training involved visiting the unit three times per week over 12 weeks, and standing on the plate during several short bouts of vibration, for a maximum of 6 minutes in total. Continue reading

Empowering Allied Health Professionals – opportunity to attend valuable conference

Empowering allied health professionals to transform health and care services

 

THIS OPPORTUNITY HAS NOW CLOSED – a successful applicant has been chosen.

Thanks to everyone for getting in touch!

See here for this conference, which is of interest to all AHPs

 

The British Geriatrics Society is offering a free place at the above conference for an allied health professional, as an opportunity for personal development and to help share the learning from this important meeting. Continue reading

Improving bone health and reducing fractures in Parkinson’s Disease

Celia Gregson (@CeliaGregson) is an academic at University of Bristol who combines bone research with clinical work as a consultant in the Hip Fracture Unit at the Royal United Hospital Bath (@RUHBath). She and her colleague Veronica Lyell, who has also a special interest in Parkinson’s disease, have written a review article on bone health in Parkinson’s disease, and here they describe the work as recently published in Age and Ageing journal.parkinsonsFracture

A collaboration between the Royal United Hospital Bath NHS Trust and the University of Bristol has recently published the first suggested guideline regarding the assessment and management of bone health and fracture risk in patients with movement disorders for whom to date no specific guidelines exist. The full paper can be seen here and below we outline the key points.

Parkinson’s Disease (PD), affecting almost 127,000 UK adults, is the second most common neurodegenerative condition after Alzheimer’s disease. Prevalence is increasing within our ageing population, affecting an estimated 1% aged >60 years. PD is primarily a neurological disorder; causing tremor, slowness of movement and muscle rigidity. However, it is less commonly recognised that people with PD have substantially higher fracture risk. Continue reading