Posted by: Margaret McCartney7 September 2012
Dementia is an unkind illness. It is also politically hot. Paul Burstow, the care services minister, has decided a ‘financial incentive' will be used to encourage English hospitals to screen patients for dementia on admission to hospital for any other condition.
The idea is that it will improve care; the reality is it is likely to cause more problems than it solves. Screening is beloved of politicians looking for a publicity-friendly, active, caring thing to do, and it often pleases healthcare charities, who crave attention for ‘their' illness.
Yet the reality of screening patients admitted with other illness runs contrary to the teaching we all received. An acutely confused or unwell person needs investigation and treatment for the underlying causes. It would be potentially dangerous to diagnose dementia when there is another treatable cause for confusion.
There have been studies done of dementia screening in admitted patients; one flagged up 69% of patients as having ‘possible' dementia, but there was no long-term follow-up so the certainty of diagnosis wasn't validated.1
Indeed, the UK National Screening Committee says screening for Alzheimer's shouldn't be done. It found sensitivity and specificity were too low, meaning large numbers of false positives could be expected, and that there was no evidence screening would reduce mortality or morbidity.2
Yet again, medicine is made to bend to an evidence-free political will. Screening may do harm, but this remains poorly understood by politicians. And so we will have hospitals forced to do testing in order to maintain their funding, and GPs left with tentative or putative diagnoses to sort out in the community. What a mess.
Politics playing healthcare
This is the same Paul Burstow who said last year that antipsychotic drug use in demented people was a ‘silent scandal I am just not prepared to tolerate'. He claimed prescribing of antipsychotic drugs ‘without clear clinical justification', amounted to ‘a deprivation of liberty', adding: ‘Where there is no clinical justification, and that is pretty much the case in two-thirds of prescribing at the moment, what is happening amounts to little more than chemical restraint of people in care homes.'
And certainly, using antipsychotic medication to make people with dementia semi-comatose just to make them easier to manage is neither morally nor ethically justified. Yet Mr Burstow fails to understand the reasons why these drugs are sometimes carefully used. Witnessing carers trying to keep a loved one at home despite physically aggressive behaviour is heartbreaking – and the stigma of using small doses of medication to stop behaviour arising from dementia is unnecessary.
The truth is that sometimes measured and careful use of these drugs is compassionate and good medicine. The end result of the politicisation of dementia will be worse care for patients, and GPs left to sort out the results of ineffective hospital screening. The political drive to stop antipsychotic prescriptions does not tackle the real issue of the poor ratio of qualified staff to patients, and neglects to point out that treatment in these circumstances is difficult and imperfect, and that antipsychotic use may actually be humane.
The political philosophy is to react to bad publicity by doing something new. I'd suggest a better solution might be to staff our wards with good nurses treated as valuable because they are highly skilled in direct frontline care; not to remove our best nurses to management or pseudo-doctor positions.
When politics plays healthcare, the subtleties and dilemmas of medicine are washed away in hyperbole. But screening is not a benign act, and good care for people with dementia is more complex than throwing a few policies at it.
The NHS has been tied up with political whim and soundbite for too long. The sooner the NHS becomes politically independent from government, the better for patients and those who want to serve them best.
Dr Margaret McCartney is a GP in Glasgow
1 Dementia screening in acute medical and geriatric hospital admissions. Psychiatric Bulletin 2009;33:52-4
2 UK National Screening Committee. The UK NSC policy on Alzheimer's disease screening in adults. June 2010. www.screening.nhs.uk/alzheimers