Taking dementia seriously

Reply to BMJ 2012; 344:e2347: Published 27 March 2012: Challenge to end “national crisis” of poor dementia care 

'National crisis'

Published as a letter in the BMJ on 18 April 2012. Written by Dr Peter J. Gordon:

Taking dementia seriously
It is indeed welcome that our government is taking dementia seriously and I support the three pronged approach that our Prime Minister has set out.[1] However, yet again, we find that the language used by those in high authority is the language of fear. This ‘national crisis’, we should make clear, is due to the increasing ageing of our population and not to any change in the disease entity itself. It is then unwise to talk in war-like terms of ‘fighting back.’[2] Dementia is not the same as cancer or HIV and if such parallels are used they should be carefully explained.

In the BMJ there has been much debate about screening tests for other conditions but I am not aware of the evidence for screening for signs of early dementia, in the age group set out here. Furthermore, we do not know what impact such screening for early signs might have both for the individual and society at large.[3]

In England incentivised care is being planned for screening and Dr Hilton considers “the financially incentivised cognitive screening of older people admitted to hospital is also overdue and very welcome.” Incentivised care for depression and the use of the PHQ-9 screening test to establish severity has already been shown to have had unforeseen consequences.[4]

Some have suggested the routine use of the 4-item Abbreviated Mental Test score (AMT-4) in our Accident and Emergency departments.[5]  It is a very crude measure, which does not differentiate between delirium and dementia. Given that in such circumstances our elderly are especially vulnerable and may also be physically unwell, we must consider carefully whether this is the right time and place for such screening. Medicine has a long track record of relying upon holistic skilled medical assessments and we should only depart from such with caution.

Our acetyl-cholinesterase inhibitors are not disease modifying. If I had Alzheimer’s disease I would want to be given the opportunity to try them for the potential of mild symptomatic relief but I would also want the truth of any medication to be discussed with me in a balanced and accurate manner. There is evidence that this is not happening.[6]

Simplified approaches bring about simplified answers. It is likely that the heavy-handed prescribing of anti-psychotics[7] for our vulnerable elderly will not be helped by such polemics of fear.  David Cameron talks as if dementia were a simple entity and as if science had its measure. We agree with the Prime Minister that we want to improve dementia assessment, care and understanding but we must remember that we are facing a condition which is complex and which deserves a more considered response than some of these headline measures.

[1] BMJ2012;344:e2347 Cameron launches challenge to end “national crisis” of poor dementia care.  Published 27 March 2012

[2] Williamson T. Defusing the Dementia ‘time bomb’ Mental Health foundation 16 Feb 2012

[3] Gordon, P and Gordon, S. Issues around early diagnosis of Alzheimer’s disease, BMJ 2011;343:d6613

[4] Mitchell, C, Dwyer, R, Hagan T & Mathers, N. Impact of the QOF and the NICE guideline in the diagnosis and management of depression. British Journal of General Practice. Volume 61, Number 586, May 2011

[5] Schofield I et al. Validity of the 4-item Abbreviated Mental Test in Accident & Emergency. Chief Scientists Office, Scottish Government

[6] BMJ2012;344:e1086 How the FDA forgot the evidence: the case of donepezil 23 mg. Published 22 March 2012

[7] Banerjee, S. The use of antipsychotic medication for people with dementia: Time for action. A report for the Minister of State for Care Services by Professor Sube Banerjee. Nov 2009

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