Dr Simon Wright is Consultant Psychiatrist for Older People at Rotherham Doncaster and South Humber NHS Foundation Trust and mamber of the BGS Dementia and related disorders special interest group
The issue of the early diagnosis of dementia, although not new, has recently been highlighted by the National dementia CQUIN for the screening for cognitive disorders in patients admitted to acute care, which commenced in 2012.
Other initiatives including a new NHS Call to Action, “The Right Care” has highlighted the need for acute hospital to be more “dementia aware and friendly”, given the problems associated for caring for somebody with dementia in an acute setting. including delayed discharge and increased re-admission rates. A similar CQUIN programme is to be started in primary care from April 2013.
Previous government strategies and various reports have highlighted the need for early diagnosis, including the National Service Framework for Older People in 2001. This document established the need for a protocol within primary care for the detection of cognitive impairment after a patient presents with cognitive problems. The National Dementia Strategy in 2009 highlighted the need for early diagnosis, as did its follow up, Living Well with Dementia and the subsequent Dementia Commissioning Packs to be used by CCG’s to commission services for dementia in 2011. Further initiatives to promote early diagnosis have included the Prime Minister’s Challenge on dementia in 2012 and other reports such as Unlocking the Diagnosis by the All Party Parliamentary Group on Dementia and the Alzheimer’s Disease International report entitled, World Alzheimer’s Report 2011: the benefits of early diagnosis and intervention.
More recently, the Alzheimer’s Society and the NHS atlas of variation have highlighted the large discrepancy in diagnosis rates for dementia across the country. These vary from around 32 per cent to 75 per cent in certain areas of England, with generally a much higher percent of people being diagnosed in Scotland and Northern Ireland compared to England and Wales. The Secretary of State, Jeremy Hunt, has now said that, “it is time for the worst performing areas to wake up to the dementia time bomb we are facing”. He also states that, “we have also asked local areas to set ambitious targets to improve dementia diagnosis over the next two years and I hope those with the worst performance can learn from the best and help make England one of the best places in Europe for dementia care”.
Much debate has taken place recently about the effectiveness of population based screening in terms of increasing diagnostic rates, as well as perhaps causing psychological distress to those who are identified. The aim of the CQUIN, both in the acute and primary care, has been said by its advocates to be “case finding” rather than screening. This is because patients or their carers are first asked the question whether or not memory impairment has been present in the last twelve months to a degree that has affected functional ability. Only if this is reported as positive, is a cognitive screening test undertaken.
Another consideration is the oft held belief that nothing can be done for people with dementia and therefore diagnosis is not so important. However, since 1997, drugs which have symptomatic benefit for patients both for cognition, behaviour and function in Alzheimer’s disease and Parkinson’s disease, have been available; i.e. Donepezil, Galantamine, Rivastigmine and Memantine. These drugs are now all off patent and their prices are falling, so a month’s supply of Donepezil can cost as little as £2.00. There is some evidence that treatment with Acetylcholinesterase inhibitor and Memantine can, for example, delay progression to nursing home care as well as providing symptomatic relief. Given the lessening cost pressures for prescribing these drugs, careful consideration needs to be taken in identifying and appropriately prescribing all the drugs for dementia to patients with an appropriate dementia. Currently there is a fifty fold variation in prescribing prevalence across England, as evidence by the NHS atlas variation and the recent anti-psychotic audit in dementia by the NHS institute shows that the use of drugs for dementia remains depressingly low in England at around 10 per cent of those that are potentially eligible. Given their symptomatic benefit and the cost compared to, for instance, nursing home placement costing more than £25,000 per year, this may well provide a powerful argument to support current strategies for improving diagnostic rates for dementia, Alzheimer’s disease and Parkinson’s disease dementia in particular, who may respond to a drug for dementia and other useful psycho-social interventions.