Reinhard Guss is a Consultant Clinical Psychologist, Clinical Neuropsychologist; Dementia Workstream Lead, Member of the Faculty of the Psychology of Older People, BPS and Deputy Chair, Memory Services National Accreditation Programme. He will be speaking at the upcoming BGS Spring Meeting in Nottingham.
Clinical Psychologists have been part of Memory Clinics as long as they have been in existence as a part of service provision in the UK, using neuropsychology skills in the diagnostic process and in the development of coping strategies and employing clinical and psychotherapeutic skills in assisting with adjustment to a dementia diagnosis and in the support of families and carers. An overview of the Psychology position on dementia can be found in the recent paper to the British Psychological Society’s Dementia Advisory Group.
Historically, the diagnosis of dementia was often the domain of Neurologists and Psychiatrist, particularly when this affected younger people, while Geriatricians would have encountered dementia in older people, and may or may not have seen a need to diagnose it in socio-historic context where dementia was seen as untreatable and often a part of ageing that was to be expected.
Twenty years ago the publication of Tom Kitwood’s seminal book “Dementia Reconsidered – the person comes first” laid the foundations of a more psychological model of understanding and treating dementia. A year before, Donepezil, the first of a group of drug treatments for Alzheimer’s disease had been approved in America. While not a curative treatment, the availability of a medical treatment that might maintain functioning for longer led to a surge in interest in diagnosis in the general public as well as in the medical profession, policy makers and health economists began to calculate the benefits of delays in admission to care homes versus the cost of the medication. As these treatments are licensed for some forms of dementia but not others, accurate diagnosis of a sub-type of dementia became important, and due to the initially substantial cost, guidance was introduces as to where in the overall trajectory of a dementia prescribing was seen as most effective. “Memory Clinics”, up until then mainly located in research institutions, specialist centres or universities rapidly developed and became universally accessible across the National Health Service.
While the structure, staffing and services offered in these new clinics varied widely, these were mainly located in “Psychiatry of Old Age” departments, where multidisciplinary teams including nurses, occupational therapist and clinical psychologists were already specialising in the treatment of mental health difficulties in later life, often co-morbid with forms of dementia. Subsequently, some follow-up of dementia in relatively early stages, at least for people with Alzheimer’s disease became more common, in addition to the more traditional services for later stage dementia that had existed in the long stay hospital, in care homes and alongside Social Services provision. While it was recognized that Geriatricians have the skills and knowledge to diagnose dementia and prescribe appropriate medication, their settings lacked the multidisciplinary input, lacked access to Neuropsychology and aftercare, and few attempts were made to establish Geriatrician led “Memory Clinics”.
Earlier diagnosis has developed apace since, with technological developments in neuroimaging and lowering cost of brain scans, and particularly with policy initiatives such as the 2009 National Dementia Strategy for England, followed by the Prime Minister’s Challenge on Dementia and its focus on raising the rate of diagnosis above 66% of all estimated cases across the country. Greater awareness of psychological and psychosocial treatments of dementia and of their benefits particularly in earlier stages has added further to the menu of support and aftercare following a dementia diagnosis. For example, the Faculty of the Psychology of Older People’s consultation with people with dementia resulted in a compendium of psychosocial interventions in early dementia, contributing to the availability of such support to many people in a way that was not envisaged in the early days of memory clinics.
Early diagnosis has also increased opportunities for people affected by dementia to adapt, to adjust, to plan ahead and most importantly to make sense of their often disconcerting, worrying, detached or downright frightening, distressing or depressing experiences. This development has also opened doors to support and interventions at an early time, when they can have an impact that might avoid the terrible states in which health and social care professionals often found people with dementia in the past – and all too often still find today.
The Memory Services National Accreditation Programme (MSNAP), one of the quality assurance programmes hosted by the Royal College of Psychiatrists, sets out standards expected to be met by memory services. Currently these are geared towards services set in secondary care mental health services in the NHS. This, however, is increasingly challenged by alternative models emerging which are located in Primary care and in a variety of co-operations with the voluntary sector. Equally, it would be possible to imagine similar services being established in conjunction with acute hospitals or Geriatrician’s clinics.
I look forward to speaking in more detail about the work of Psychologists in Memory Services, in Dementia assessment, diagnosis and treatment at the BGS Spring Meeting in Nottingham!
See Reinhard Guss’s talk Cognitive reserve and resilience: how clinical psychologists work in dementia assessment and treatment services at the BGS Spring Meeting on Wednesday, 11 April 2018 at 14.00.