Niche In-Brief Spring 2018 - Flipbook - Page 4
New diagnostic criteria has been published which is no
longer based on the presence of a dementia syndrome.
Specifically, the Alzheimer's Disease classification
(National Institute on Aging-Alzheimer's Association
International Workgroup; McKhann et al. 2011) is now
based on the presence of biomarkers, which include
cerebrospinal fluid findings from lumbar punctures,
amyloid scans, and MRI hippocampal findings. Forty
percent of those with positive biomarkers will progress to
mild Alzheimer's Disease within two years, suggesting
there is a strong case for clear identification and
intervention for this group.
Finally, even in the absence of a new disease modifying
treatments the evidence that at a significant proportion of
dementias might be preventable through lifestyle factors
is mounting. The recently published Lancet Commission
report on ‘Dementia prevention, intervention, and care’
(Livingston et al., 2017) makes the point that while ageing
is the single most important risk factor for developing
dementia, it is not an inevitable consequence.
Using a life-course model of risk, based on the calculation
of ‘population attributable factors’, the report described
how over a third of new cases of dementia could
theoretically be eliminated, or significantly delayed, if
certain lifestyle factors were removed before the onset of
dementia. These include increasing childhood education
and exercise, maintaining social engagements, reducing
or stopping smoking, and the management of hearing
loss, depression, diabetes, hypertension, and obesity.
The need for reconfiguration of Memory Assessment
Services:
The current status of Memory Assessment Clinics does
not emphasise the ‘prevention’ model in Alzheimer's
Disease. If patients are assessed in clinic prior to the
onset of dementia, most often, they are discharged back
to primary care to wait until they progress.
At the point at which patients present with the syndrome
of dementia in the ‘mild to moderate stage’, they may be
referred back for symptomatic treatment, provided the
underlying cause of their dementia is Alzheimer's Disease
or dementia due to Parkinson’s Disease or Lewy Body
Dementia. For most other dementias, no medication or
other intervention is available.
Prior to the dementia stage, while still in the mild cognitive
impairment stage, in general, no intervention is offered. In
some cases, those referred back to primary care in this
stage may never find their way back to the Memory
Assessment Service for treatment, or, families have to
struggle to get a re-referral when an individual’s condition
declines.
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There is a clear need to consider new approaches to
how very early cognitive decline should be managed.
This would ideally be done in the context of a ‘Healthy
Brains’ Clinic’, with a focus on: identifying which
patients in the early stage of mild cognitive impairment
will progress to dementia compared to those whose
condition will remain static or even improve; prevention
and slowing the rate of conversion to dementia through
medication (when available); health-related behavioural
change, or; other non-pharmacological interventions
(i.e. cognitive training/stimulation, reduction of social
isolation etc.). The model of a Healthy Brains’ Clinic is
distinct from current Memory Assessment Service
models, which focus on people with established
dementia who need support in managing their
symptoms.
Pilot Healthy Brains Clinic in Manchester:
At Greater Manchester Mental Health Foundation
Trust, a pilot Healthy Brains Clinic has now been
established alongside the existing Memory Assessment
Service. Through a reconfiguration of the service and
of staff roles, all individuals referred to the service who
do not meet the criteria for a clinical diagnosis of
‘dementia’, but clearly have cognitive impairment, will
be directed to the Healthy Brains’ Clinic for more
detailed cognitive testing and determination of
biomarkers. From there, those found to be at risk of
progression will be offered regular clinical follow-up,
cognitive stimulation/brain training, and a bespoke
healthy lifestyle programme, with the aim of delaying
the onset of dementia, or, failing that, identifying the
conversion to dementia at the earliest possible point,
thereby ensuring that treatment is not delayed.
Summary:
The clinical approach to dementia in the UK now needs
to move beyond just diagnosing and supporting people
with existing dementia and urgently needs to focus on
prevention, delay of onset of dementia, and very early
identification of individuals at risk of progressing from
MCI to dementia. This can best be done in the setting
of a Healthy Brain Clinic. As pointed out by the 2017
Lancet Commission by Livingston et al., ‘acting now on
dementia prevention, intervention, and care will vastly
improve living and dying for individuals with dementia
and their families, and in doing so, will transform the
future for society’.
Iracema Leroi and Francine Jury
Greater Manchester Dementia Research Centre
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