Dementia Centred

By Prof. Emma Reynish

December 6th, 2016

Reflection and action on outcomes of dementia

In England and Wales more people now die of Alzheimer's disease and other dementias than anything else. A similar picture is most likely to exist for the rest of the UK. For healthcare professionals who are involved in the management of people with dementia, this news offers an opportunity for reflection and action. What does this mean for us and our approach to the older population? 

Three factors are noted as contributing to this statistic:

  • People are living longer than ever before, and with increasing age being the most significant risk factor for dementia it follows that mortality due to dementia is reflecting this trend.
  • Improvements in detection and diagnosis of dementia are leading to more people being identified as having dementia, leading to an increased reporting on death certificates. Department of Health initiatives starting with the Prime Minister's Challenge, and the introduction of the dementia Commissioning for Quality and Innovation (CQUIN) in acute hospitals have probably had an influence here. Methodological changes in the coding of dementia have also played their part.
  • Finally, mortality rates for the other diseases with high mortality rates - coronary heart disease, cerebrovascular disease (such as stroke), chronic lower respiratory disease (such as emphysema and chronic bronchitis), and lung cancer - have declined continually since analysis began in 2001. These changes are attributed to improved treatment and prevention. This fact in itself feeds into the first point mentioned and has resulted in people living longer.

In the news coverage of this Office of National Statistics (ONS) finding, little has been mentioned about this final point and yet the success of improved treatment and prevention for conditions such as coronary heart disease and cerebrovascular disease should perhaps both be celebrated and used as a template for advancing the management of dementia. The urgent need for a “cure” that is the battle cry from many dementia charities should be put into the context of the enormous progress that has been made in the fields of coronary heart disease and cerebrovascular disease in the last 40 years. Neither of these conditions have a known “cure” and yet with meticulous research that has exposed risk factors, increased basic pathophysiological and clinical understanding, fine-tuned diagnosis and allowed the stepwise development of interventions, however big or small, people are now dying less frequently than before from these conditions. 

The prevention story for both of these conditions is strong. It has been developed from the basis of epidemiological research on risk factors but has metamorphosed to a double-pronged approach with both primary (before disease onset) and secondary (from the point of disease onset) prevention being important aspects of clinical management. 

For many medical practitioners the changes in life expectancy of the population have been visible within the context of our own clinical practice. During my house officer posts in the early 1990s people in their 80s were the regular population of geriatric medicine wards, and 90-year-olds were rare. Today ward rounds predominantly visit people in their 90s and people in their second century of life are not unremarkable. Unfortunately, these are now the people who are at risk of dying and more often than not a dementia diagnosis is part of their multi-morbidity. In the ONS report the leading cause of death in both males and females over the age of 80 was dementia. This is a new population for clinical medicine but also a new and fascinating population for epidemiological study. 

Epidemiological studies form the backbone of the prevention story and allow hypotheses to be generated and tested. Applying this to the field of dementia (whether primary or secondary prevention) opens many avenues to the improvement of dementia management and subsequent outcome without even straying into the domain of a “cure”.

Dementia research and understanding lags the field of coronary heart disease and cerebrovascular disease but even now mid-life risk factors are known to be predictors of later life dementia onset and clinical research is starting to examine prevention strategies. The prevention framework also gives us the option of secondary prevention. What does or could this look like in the field of dementia? Clinical management that focuses on the prevention of further decline springs to mind, with a maintenance of physical, cognitive and social activity, and active prevention of delirium and falls, to name but a few possible strands to the intervention. 

For healthcare professionals who are involved in the management of people with dementia, this ONS report offers ideas for the future. The opportunities to continue to build our understanding, generate and test hypotheses and deliver increasingly precise clinical care to the subgroups of this population who have the greatest potential for benefit (personalised clinical management) are vast. We should be heartened by the results of reduced mortality that have been reported for other conditions, and by learning from their progress start to realise that the opportunity to improve the outcomes of our patients with dementia is within sight.