How effective is current care for dementia and how can it be improved further?
Dementia is a syndrome where a group of various medical and behavioural symptoms occur simultaneously. Cognitive functions such as memory, thinking speed, mental agility, language, understanding, judgement and decision making, as well as behavioural symptoms such as depression, aggression, distress and the ability to do daily activities, are in decline. As a result, living independently is difficult and continuing medical and social care is necessary. Alzheimer’s Disease International estimates that there were 46.8 million people worldwide living with dementia in 2015 and predict that this will increase to 131.5 million in 2050 across many countries. Not only is there is a large disparity in diagnosis across developed and developing countries, current medical and social care could be improved further. In most high-income countries, around 50% of people with dementia receive a diagnosis, however, in low and middle income countries, only less than 10% of cases are diagnosed. Care for dementia can be split into social care and medical care. Social care includes support and advice with regards to accommodation such as care homes, nursing homes, modifications to a current residence to suit physical needs, creating and giving access to facilities for social and recreational activities within or outside the care. Medical care refers to health care needs which includes prevention, treatment and medical after-care of a disease.
This project aims to evaluate the current social and medical care for dementia with regards to effectiveness and efficiency. Throughout this essay I will include further improvements to the current model of care that could be made in order to increase diagnosis of dementia and provide seamless, continuing care to dementia patients.
One concern as stated by the World Alzheimer Report of 2016 is that Dementia care is over-specialised which means that a significant portion of overall medical care and treatment is provided by highly qualified professionals. For example, when diagnosing dementia and prescribing medication, a neurologist and/or psychiatrist would be involved. Having to be referred to these specialists after an initial diagnosis by a General Practitioner is a relatively long process that may delay the important treatment required by the patient. There is very little formal recognition of the role of primary care services and few tasks regarding dementia are allocated to this sector. This portrays many potential limitations to the current approach to dementia care because it is unlikely that all medical specialties can work together to provide seamless, continuing care after a patient has received a diagnosis. Many of the specialist services involved in providing care i.e. neurology, psychiatry, General Practice work in isolation. The current specialist model of dementia care does not facilitate effective coordination of care for dementia sufferers with complex conditions involving various medical illnesses. Therefore, current models that mediate care for dementia are unable to provide sufficient treatment in response to the ever increasing numbers of people suffering from dementia. However, the management of complex multimorbidities forms a core function of primary health care.
Therefore, one improvement to the current over-specialised model of dementia care would be to shift more dementia related tasks to Primary care and introduce the strategy of ‘task shifting’ or ‘task-sharing’. This strategy not only allows early diagnosis of dementia but also greater coverage of diagnosis and treatment i.e. allowing more people to be diagnosed in a shorter period of time. This is particularly useful for high-income countries like the UK where dementia services are becoming increasingly stretched as a result of the growing number of dementia sufferers. Diagnosis and medical treatment of dementia could shift from highly qualified professionals such as, psychiatrists and neurologists who have long waiting and referral periods to slightly less-specialised health professionals such as General Practitioners or even Senior Nurses. They would be able to provide the same level of care when they have been given the appropriate training. The World Alzheimer Report 2016 further supports this improvement by stating, ‘When primary care physicians do take responsibility for dementia care, evidence suggests that the care has similar outcomes to that provided by specialists.’
In addition to this, new professional healthcare roles could be created specifically for the diagnosis and treatment of dementia. This would reduce the dependency on highly specialised services that are expensive which delay early diagnosis and vital treatment of dementia as a result of long referral time and chronic underfunding. Their capacity to deal with current increasing levels of need has been reduced. Demand is likely to increase at a more rapid rate than the rate at which highly specialised services develop. When existing healthcare resources are reducing, they do not correspond to the increasing demand of the elderly population. Therefore, these services become less affordable by the NHS, leading to under funding which inevitable leads to less effective care for dementia. Some degree of task-shifting to non-specialist healthcare workers will therefore be an essential component of scaling up services in resource-poor settings. Task shifting models distribute medical treatment of dementia between primary and specialist care and it is hoped that the cost is cheaper but the quality of care is to the same high standard as provided by the current specialised model. There are generally larger numbers of less-specialised, more primary health care professionals. Therefore they may have the capacity to overcome the resource barriers that prevent highly specialist services from diagnosing more cases of dementia.
On the other hand, the authors of a review ‘Health workforce skill mix and task shifting in low income countries: a review of recent evidence’ of the ‘task shifting’ strategy suggest that evidence that supports the strategy is not highly extensive and ‘more rigorous research is required’. A pivotal finding of task-shifted care was that overall quality of care provided began to decrease when the dementia became more complicated. Therefore, this suggests that the quality of training given to non-specialists must be continuous and is critical in order to maintain standards and motivation amongst staff involved in the care of dementia. The main purpose of task shifting is to minimise the time and costs invested in order to improve the health workforce enabling it to deal with increasing numbers of dementia sufferers. This objective comes about because the staff performing the delegated medical tasks require less training over a shorter period of time. The World Alzheimer Report states that, ‘It is quicker and cheaper to train practice nurses to carry out structured diagnostic assessments in primary care, than to train greatly increased numbers of neuropsychologists and neurologists.’ All in all, if more healthcare services were to adopt this task shifting model of care for the elderly with dementia, diagnosis would increase, training and resource costs would decrease which would enable more efficient care for dementia.
However, a limitation of this review is that it encompassed evidence from some studies carried out before 2006. As a results, finding may not be generalised to recent times. However, as the studies use extensive evidence, the overall findings may not have been affected negatively by the time scale of the published studies and can therefore still apply to the current situation with regards to care for dementia. Another limitation of this review is that the studies it is reviewing have relatively small sample sizes. This means that it is more difficult to draw credible comparisons between specialised and task-shifting health care systems as the data is not from a large, extensive sample. Therefore, it may not be representative of international or even national healthcare systems. To contradict the limiting effects of this review, data provided from the World Alzheimer Report 2016 is highly extensive as it encompasses findings from various different countries across the world and is therefore internationally representative to a great extent.
Another concern about the effectiveness of current medical treatment for dementia is the overprescription of antipsychotic drugs to address aggressive behavioural and psychological symptoms such as, anxiety, aggression, delusions, hallucinations, apathy and sleep disturbances. Sube Banerjee, Professor of Mental Health and Ageing at The Institute of Psychiatry, King’s College London states that ‘These drugs appear to be used too often in dementia’ and a carer of a dementia patient in a care home states that after giving the patients antipsychotics, “She has slumped sideways and fainted. She cannot move or talk properly and we virtually have to carry her into the car to take her back.’ The prescription of antipsychotics where they may be unnecessary has drastic medical consequences on the health of the patient. Symptoms such as anxiety and aggression could be treated using alternative methods.
In order to combat the unnecessary over-prescription of antipsychotics for certain, relatively less severe symptoms of dementia, an improvement could be to consider non-medical treatments. These alternative therapies include: aromatherapy to help with cognition and anxiety, massage for anxiety, agitation and depression and bright light therapy to alleviate sleep disturbances. Aromatherapy is the use of essential oils from plant extracts for healing and rejuvenating purposes. A study investigating the effect of aromatherapy on patients with Alzheimer's disease found evidence that aromatherapy that certain essential oils such as, rosemary and lemon essential oils in the morning, and lavender and orange in the evening can potentially improve cognition in people with Alzheimer's disease. Results from the study state that all patients showed significant improvement in cognitive function following 28 days of aromatherapy. However, a limitation of this study is that the sample size is relatively small. It consisted of only 28 dementia patients of which 17 had Alzheimer’s disease. Therefore, the results are not generalisable to all dementia patients as they may not be fully representative. Another limitation of this study is that it was conducted in Japan, therefore it is less internally representative as the findings cannot be generalised to all countries. Patients of different ethnicities may not react the same way to aromatherapy treatment. Allergies must also be taken into account as some dementia patients may react adversely to certain essential oils. Hence, a further limitation of this study would be that there is no information on allergic reactions. Nevertheless, the study provides a good starting point for further investigation and clinical trials into aromatherapy as a more appropriate and less severe replacement for anti-psychotics.
Another aspect of dementia treatment that could be reducing the effectiveness of care is the heavy reliance on prescription medication for psychological and behavioural symptoms such as anxiety, agitation and distress. These prescription drugs include the commonly prescribed sedatives: Benzodiazepines. An article by Nick McKeehan from The Alzheimer’s Drug Discovery Foundation uses the results from a data review carried out by Bachhuber MA, Hennessy S, Cunningham CO and Starrels JL in 2015 where it was found that ‘the number of Americans using benzodiazepines increased from 8.1 million in 1996 to 13.5 million in 2013, and the total quantity of benzodiazepine prescriptions filled during that time more than tripled.’ While benzodiazepines are effective at relieving anxiety they should only be used for a short period (up to two weeks) according the Alzheimer’s Society. If the patient continues taking them for longer they can become addictive and may cause unpleasant withdrawal symptoms if the patient stops taking them. The Alzheimer’s Society further state that benzodiazepines ‘are not usually suitable for people with dementia as they can cause excessive sedation (drowsiness), unsteadiness and a tendency to fall, and they may worsen confusion and memory problems.’ However, the problem with current care is that this drug and other similar drugs are still being widely prescribed despite harmful, negative effects.
Therefore, an improvement to this method of treatment could be to once again consider non-medical alternative treatments such as massage, to decrease anxiety and agitation.
Another aspect of current care for dementia is the way in which awareness is raised amongst dementia patients, carers and also the general public. Leaflets are a key method of sharing basic but important information regarding dementia. This could then lead to patients being diagnosed with dementia earlier. However, according to the March 2017 publication of the BMJ, leaflets do not significantly increase dementia diagnoses. A randomised trial investigating the effect of leaflet was conducted. It was found that although sending patients information regarding seeking advice for memory problems increased consultations with GPs, the number of referrals to memory services did not change. Therefore, distributing leaflets did not lead to an earlier diagnosis of dementia. According to the researchers, ‘successful interventions have to target both the public and the practitioners’