Editorial - February 2003
Dementia Rising Tide or Crest of the Wave?
"A golden old age is within the reach of us all" So recent research from Imperial College London reassures us, provided we have health, freedom to choose retirement date and a degree of autonomy in where we live.
Dementia, on the other hand, is no respecter of persons striking one in five over 80 in the UK (and apparently one in two over 85 in the USA dont move there!) Precise aetiology still unknown, risk factors for some subtypes do relate to lifestyle, with smoking and other contributors to vascular risk obvious areas for individual modification.
Once youve got it, its all too late or is it? In fact, those working in the field would argue that there has never been a more exciting time to be doing so, with increased recognition that something can be done for sufferers and carers alike.
Diagnosis alone is a most important first step towards challenging the myths prevalent still even amongst medical circles that Dementia is an inevitable life sentence without remission. It can be, but not necessarily so. Much can be done to alleviate suffering through recognition of what is behind behavioural changes, and through offering appropriate "bespoke" packages of care. Equally, recognizing that people with Dementia do badly in the alien environs of acute medical hospitals, and can deteriorate as a consequence of iatrogenic illness, in particular adverse reactions to medication, can allow for the development of services sensitive to these issues.
There has been groundbreaking progress in the development of drugs which have the potential to treat the symptoms of Dementia. Choline esterase inhibitors have been licensed in the UK for several years, and are showing encouraging promise not only for some sufferers of Alzheimers Disease for which they have the current seal of approval of NICE, but also for Lewy Body Dementia and Dementia associated with Parkinsons Disease, and most recently, research has suggested for Vascular Dementia too. A variety of other drugs are in development, with the Holy Grail being the discovery of drugs which would prevent an illness which is probably decades in the making in any individual.
Despite proven benefit, the Health Community has been slow to acknowledge and fund these new treatments. Something about the unprotesting nature of our current cohort of seventy and eighty year olds? Survivors of the last world war, they tend to be grateful for whatever little the Health Service hands down to them. Still slower has been the recognition that Acute Hospitals are dangerous places for people with Dementia. Unable to recognize their own symptom sources, let alone understand the procedures and practices of a high tech environment, consequent behaviors tend to get responded to with potent medication, starting a spiral of progressive decline.
Here too, hope is on hand! The Department of Health has commissioned a group from the USA to assist in a process of piloting alternative ways of assessing and managing illness in a pre-identified group of vulnerable elderly people with Dementia. Ten PCTs from around the country, including two from Bristol and one from South Glos, were invited to send delegates from the Health and Social Communities to Minnesota, headquarters of United Health Care, last November. A return posse from the States has just completed a review in situ. All concerned are positive about the potential for transferring the principles of assertively managed care to the NHS. The Avon Community is keen to be at the forefront of what is felt to be an enlightened approach to caring for older people, notwithstanding the inevitable detractors who will rail against any change in established practice.
Most concur that it would not be difficult to improve on the current systems in Bristol which result in elderly people with Dementia being regarded by many as a bed-blocking nuisance. There are major problems in the whole system of determining where people are treated and cared for. Care Homes have been closing because of inadequate fee levels, and people who do need Nursing Home care have frequently found it impossible to obtain. The old story of "Wrong kind of beds, wrong people in them" once again.
A revolution is required in tilting the statutory service response towards proactive intervention identifying vulnerable people, creating bespoke care plans for and with them and their carers, and then ensuring that the right range of rehabilitative services and long term care opportunities are available. Roll on the revolution!
Dr Niall Moore
Consultant Psychiatrist
Co-Editor Bristol Med-Chi Editorial Panel