Dementia Screening

Welcome!While you’re finding your seats, please

consider the following question:

What are the needs of patients with dementia, their families and carers?

Dementia Screening

Annual symposium ofRCGP Thames Valley Faculty

30 April 2013

John Cosgrove

Dementia Screening•Background•Patient needs•Other benefits of screening•Risks•Who benefits?•How to implement the DES and LES•What might we do instead?

Background

Prime Minister’s Dementia Challenge

•Marketing Plan to raise awareness•Case finding DES (CVD, Down’s, LD, PD)•NHS Health Checks: awareness & signposting

What are the needs of patients with dementia, their families and carers?

•Support• personal care• emotional support• carer support• financial (benefits)•Signposting

What are the needs of patients with dementia, their families and carers?

•Advance planning•Lasting power of attorney

•Equipment•Memory aids

What are the needs of patients with dementia, their families and carers?

•Treat reversible causes•Effective treatment•Manage comorbidities

•Reduce stigma

What other benefits might a dementia screening programme have?

•Prevalence (determine & increase)•Establish need for resources•Raise priority for research

What are the risks of a dementia screening programme?

•Medicalise ageing•Disengagement of informal carers•Opportunity costs• those with health care needs but different or

no diagnosis• diversion of resources from those in greatest

need

What are the risks of a dementia screening programme?

•GP time for referrals•Anxiety (itself causing cognitive impairment)• during testing• uncertain prognosis of MCI• poor prognosis of dementia•False hope•Unrealistic expectations

What are the risks of a dementia screening programme?

•Insurance•Misperception of capacity• family disharmony• financial abuse

Who benefits from dementia screening?

•Some patients/carers•Primary care (£3000 for DES; LES)•Secondary care•Pharmaceutical industry•Politicians•Research

How to implement the DES

Which cognitive test?•Quick•High specificity•Good sensitivity

Mini-COG•2-4 min•89% specificity•76% sensitivity

How to implement the LES

What might we do instead?(aka alternative DES)

•Collaboration between GP, SS, psych, families•Outreach clinics•Shared/patient-held record•GP multimorbidity clinic•Advance planning support

•GP diagnosis

What else might help?

Reading

GrassrootsGP.org/dementia-screening

Mendeley list• John@DrCosgrove.net

Reading•Angermeyer MC, Holzinger A, Carta MG, et al. Biogenetic explanations and public acceptance of mental illness: systematic review of population studies. The British Journal of Psychiatry 2011;199:367–72.•Armstrong R. General Medical Services – Contractual Changes 2013/2014. Letter to the Chairman of the General Practitioner’s Committee. 2012.https://www.wp.dh.gov.uk/publications/files/2012/12/GMS-Contract-letter.pdf (accessed 16 Dec2012).•Banerjee S, Willis R, Matthews D, et al. Improving the quality of care for mild to moderate dementia: an evaluation of the Croydon Memory Service Model. International journal of geriatric psychiatry 2007;22:782–8.•Brayne C. The elephant in the room - healthy brains in later life, epidemiology and public health. Nature Reviews Neuroscience 2007;8:233–9.•Brayne C, Davis D. Making Alzheimer’s and dementia research fit for populations. The Lancet 2012;380:1441–3.•Brayne C, Fox C, Boustani M. Dementia screening in primary care: is it time. Journal of the American Medical Association 2007;298:2409–11.•Brunet MD, McCartney M, Heath I, et al. There is no evidence base for proposed dementia screening. BMJ 2012;345:e8588–e8588.•Brunet MD, McCartney M, Heath I, et al. Re: Open Letter to The Prime Minister and the Chief Medical Officer Regarding Proposals to Introduce Screening for Dementia. British Medical Journal (Rapid Response). 2012.http://www.bmj.com/content/344/bmj.e2347/rr/621214 (accessed 7 Jan2013).

Reading•Brunet MD, McCartney M, Tomlinson J, et al. Open Letter to The Prime Minister and the Chief Medical Officer Regarding Proposals to Introduce Screening for Dementia. British Medical Journal (Rapid Response). 2012.http://www.bmj.com/content/344/bmj.e2347/rr/619428 (accessed 7 Jan2013).•Bunn F, Goodman C, Sworn K, et al. Psychosocial Factors That Shape Patient and Carer Experiences of Dementia Diagnosis and Treatment: A Systematic Review of Qualitative Studies. PLoS Medicine 2012;9:e1001331.•Burns A, Iliffe S. Dementia. BMJ 2009;338:b75–b75.•Courtney C, Farrell D, Gray R, et al. Long-term donepezil treatment in 565 patients with Alzheimer’s disease (AD2000): randomised double-blind trial. Lancet 2004;363:2105–15.•Department of Health. The mandate—a mandate from the government to the NHS Commissioning Board: April 2013 to March 2015. 2012. •George DR, Qualls SH, Camp CJ, et al. Renovating Alzheimer’s: “Constructive” Reflections on the New Clinical and Research Diagnostic Guidelines. The Gerontologist Published Online First: 2012. doi:10.1093/geront/gns096•George DR, Whitehouse PJ, D’Alton S, et al. The art of medicine: Through the amyloid gateway. Lancet 2012;380:1986–7.•Gordon PJ. Window tax. Mental Health and Social Inclusion 2012;16:181–7.

Reading•J B. Cholinesterase inhibitors (ChEIs), donepezil, galantamine and rivastigmine are efficacious for mild to moderate Alzheimer’s disease. 2012. doi:10.1002/14651858.CD005593•Knapp M, Prince M, Albanese E, et al. Dementia UK: A report into the prevalence and cost of dementia prepared by the Personal Social Services Research Unity (PSSRU) at the London School of Economics and the Institute of Psychiatry at King’s College London, for the Alzheimer's Society. London: 2007. •Koekkoek PS, Janssen J, Kappelle LJ, et al. Early detection of dementia: not only doom and gloom. BMJ Rapid Responses. 2013.http://www.bmj.com/content/345/bmj.e8588/rr/629558 (accessed 11 Feb2013).•Manthorpe J, Samsi K, Campbell S, et al. From forgetfulness to dementia: clinical and commissioning implications of diagnostic experiences. British Journal of General Practice 2013;63:69–75.•Moorhouse P. Screening for Dementia in Primary Care. The Canadian Review of Alzheimer’s Disease and Other Dementias 2009.•Okura T, Heisler M, Langa KM. Association between cognitive function and social support with glycemic control in adults with diabetes mellitus. Journal of the American Geriatrics Society 2009;57:1816–24.•Palmer K, Bäckman L, Winblad B, et al. Mild cognitive impairment in the general population: occurrence and progression to Alzheimer disease. The American Journal of Geriatric Psychiatry 2008;16:603–11.

Reading•Rasmussen J, Greaves I, Cartmell N, et al. Re: Open Letter to The Prime Minister and the Chief Medical Officer Regarding Proposals to Introduce Screening for Dementia. British Medical Journal (Rapid Response). 2012.http://www.bmj.com/content/344/bmj.e2347/rr/620234 (accessed 7 Jan2013).•Richards M, Brayne C. What do we mean by Alzheimer’s disease? BMJ 2010;341:c4670–c4670.•Satcher D. Mental health: A report of the Surgeon General. 1999. •Sontag S. Illness as Metaphor. New York: : Farrar, Straus and Giroux 1978. •Stephan BCM, Savva GM, Brayne C, et al. Optimizing mild cognitive impairment for discriminating dementia risk in the general older population. The American Journal of Geriatric Psychiatry 2010;18:662–73.•Summerfield D. Depression: epidemic or pseudo-epidemic? Journal of the Royal Society of Medicine 2006;99:161–2.•TC R, JR M. Anti-dementia drugs for people with memory problems but without dementia. 2012.•UK National Screening Committee. The UK NSC policy on Alzheimer’s disease screening in adults. 2010. •Wilson JMG, Jungner G. Principles and practice of screening for disease. Public health papers 1968;34.•Brodaty H, Low L-F, Gibson L, et al. What is the best dementia screening instrument for general practitioners to use? The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry 2006;14:391–400.