Focus on... Dementia
Dementia presents a huge challenge and requires interaction with numerous other areas of care. Here, Professor Steve Iliffe outlines the nuanced approaches CCGs will need in tackling the disease.
The scale of the dementia challenge cannot be underestimated. The number of people with dementia is expected to double over the next 40 years to 1.7 million, and spending could rise from £14.8bn in 2007 to £34.8bn by 2026. In March this year, David Cameron launched the Prime Minister's Challenge on Dementia, describing dementia as ‘one of the biggest challenges we face today'.
For clinical commissioners, the needs of people with dementia are nuanced and require enhanced commissioning skills – tools that are useable for other diseases are not necessarily transferable to dementia.
Population screening for dementia is potentially harmful and does not fit some of the key criteria for a screenable condition – a simple and accurate diagnostic tool, and effective and affordable treatment.
Investigating people with memory loss will identify only 20% of those who will go on to develop a dementia syndrome, but it will send lots of depressed patients to a memory clinic. Case finding, however, is manageable – but requires a high index of suspicion in GPs, and thoughtful use of cognitive function tests and histories to come to tentative conclusions about the likelihood of a dementia syndrome. The article on page 30 shows how nurses, too, have a role to play in case finding.
Much of the focus on dementia has been on early diagnosis, and while this can reduce the distress of a patient and their family, it is pointless if it solves no problem other than the target setter's. Timely diagnosis fits best, in my view, with what family doctors should be doing.
Then there is frailty. The current policy drive around dementia sees frailty as a stand-alone condition. Most people with dementia have serious comorbidities, especially vascular disease and diabetes, many have substantial disabilities, and frailty is common. The policy until now has been defined by narrow specialisms, putting patients with dementia at risk of having one problem addressed and others ignored – old-age psychiatrists running memory services may not be the best people to attend to comorbidity, disability and frailty. Geriatricians may be a better choice, and in their absence GPs will have to stand in. Dr Ian Greaves's case study on page 26 shows how creating care centred around the patients' needs can produce significant savings.
Dementia is usually not a long-term condition. Survival from onset of the first symptoms is about four and a half to five years, and from diagnosis about three and a half years. People under the age of 80 who develop a dementia syndrome tend to survive longer than octogenarians, of whom one in five have the syndrome. Services
need to think of their palliative care role for people with dementia, a task made difficult by the individual's declining ability to communicate their wishes. The pressure on carers throughout the trajectory of dementia cannot be overlooked, and the case study on page 32 shows how simple things can enable carers to enhance their own wellbeing.
And finally, there should be no commissioning of any new service without changing general practice in parallel. GPs will need to establish systematic reviews of patients with dementia and their families, acquire cognitive behavioural therapy techniques like reframing to help patients avoid catastrophising, network with local agencies, respond to challenging psychological and behavioural symptoms, and help manage incontinence. Educational resources are becoming available, but their effective use will probably depend on practice-level educational needs assessments and educational prescriptions.
And an area that requires more thought is the care home sector. This is vital to care for people with dementia, but it is struggling to match the resources it has to the tasks given to it. Commissioners should think seriously about how to reinforce it.
Professor Steve Iliffe is professor of primary care for older people at University College London