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Home > Comment > BMJ
2009;338:b931, doi: 10.1136/bmj.b931 (Published 10 March 2009)

Published 10 March 2009, doi:10.1136/bmj.b931
Cite
this as: BMJ 2009;338:b931

Editorials

The National Dementia strategy in England

A "smorgasbord" of evidence, economics, and obligation

Public awareness of dementia is currently high, thanks to touching
personal accounts of the illness through individual experience,
such as that of the writer Sir Terry Pratchett.1 In
the United Kingdom, dementia affects about 700 000 people at an
estimated cost of £17bn (19bn; $24bn) a year.2 The
National Dementia strategy for England—the product of extensive
consultation with an estimated funding of £150m—was launched
in February 2009.3 The
main outputs are 17 recommendations coalesced around three
areas—raising awareness, diagnosing the disease early on, and
improving quality of care. The mantra of "a memory clinic in every
town" was one of the publicity sound bites,4
but it raised legitimate questions about the evidence behind
the strategy. How many of the 17 recommendations are evidence
based? How many can be? The answer to both questions is—some of
them.

The recommendations include a mix of long awaited priority setting
and reaffirmation of existing legislation. Some are obvious—for
example, good quality information for people with dementia and
their carers and improved community support and implementation
of the Carers’ strategy—aspirations that simply provide a
stimulus for local initiatives. The benefits of early diagnosis and
intervention are highlighted—for economic reasons and for individual
wellbeing. The need to improve the quality of care for people with
dementia in general hospitals and in institutional care is stressed.
The research base needs to be expanded, with coordination between the
Dementia and Neurodegenerative Diseases Network, charities, and the
research councils. The cited justification for the recommendations
includes economic necessity, empirical research, and patients’
preferences (and sometimes all three). The strategy does not suggest
the introduction of screening but that awareness needs to be
raised. Memory clinics are not buildings but pathways to
coordinated multidisciplinary care.

The management of dementia is supported by a substantial body of
evidence in several key areas. The clinical efficacy of drugs for
dementia is accepted, although their cost effectiveness in the early
stages of the illness has not been proved to the satisfaction of the
National Institute for Health and Clinical Excellence.5
Effective interventions to relieve stress on carers are available,
with effect sizes comparable to drug treatments.6
Early intervention and home support delay entry into institutional
care.7
Drug treatments for behavioural problems can treat symptoms but
concerns exist about their safety, particularly in the long
term.8
Standards in nursing and residential homes can be measured and
improved with specific attention.9
Detection of dementia in primary care can be improved.2 New
treatments are emerging and preventive strategies may soon become a
reality.10
Memory assessment services can lead to improved quality of care.
What is lacking is the longer term outcome studies of particular
types of service and the benefits of a holistic approach
(combinations of health and social care, dementia care mapping, and
integrated drug and psychosocial approaches).

Similar plans are being developed for UK devolved nations, and
countries across Europe are beginning to prepare for the emerging
health and social care challenges presented by dementia. Many
have specific dementia plans (Norway, Ireland, and Germany in
particular), and the French dementia plan has received high
level political backing from President Sarkosy, together with
1.6bn over
five years. This plan is characterised by transparency and unitary
governance, although it spans the education, health, research, and
social ministries. Its main objectives are to improve knowledge about
dementia, reduce stigma, provide better education and training for
professionals, ensure that people with dementia are properly
diagnosed, and develop a range of services for people with dementia
and their carers.11
The three measures that have similarities to the English plan are
that specific units for people with behavioural problems will be
created; the plan will be underpinned by an increase in research
aimed at providing a better evidence base; and information from
all the memory consultations will be captured by an electronic
database.

The intermingling of research evidence with current best practice
is a logical way forward, and the strategy should be in the
context of other initiatives such as the Carer’s strategy, the
Care Quality Commission, and Putting People First.12
The National Dementia strategy is a reminder of the importance
of dementia, the imperative to raise awareness about the needs
of carers, and the potential of drug and non-drug interventions.
It is not about drugs, screening, or buildings. It is about
people and their carers. Like every other strategy, its worth
will be shown by how it is used locally. Improvements in dementia
care will come from interweaving awareness, evidence, and
implementation.

Cite this as: BMJ 2009;338:b931

Alistair Burns, professor of old age
psychiatry1, Philippe Robert,
professor of psychiatry2

1 University of Manchester Psychiatry Research Group, Manchester
M13 9PL, 2 Centre Mémoire de Ressources et de Recherche, CHU de Nice,
Hôpital de Cimiez, 06000, Nice, France

Alistair.Burns{at}manchester.ac.uk

Competing interests: AB is editor in chief of the
International Journal of Geriatric Psychiatry, co-chairs the
research advisory panel of the UK Alzheimer’s Society, and was a
member of the raising awareness workgroup of the National
Dementia strategy consultation. He receives research funding and
consultancy fees from drug companies that manufacture and market
drugs for Alzheimer’s disease including Eisai, Pfizer, Shire,
Novartis, Janssen Cilag, Wyeth, and Lundbeck. PR co-chairs the
behavioural and psychological subgroup of the European
Alzheimer’s Disease Consortium (EADC) and was a member of the French
report committee devoted to the report of the French National
Alzheimer’s Disease National Plan. He receives research funding and
consultancy fees from drug companies that manufacture and market
drugs for Alzheimer’s disease including Eisai, Pfizer, Novartis,
Janssen Cilag, Wyeth, and Lundbeck.

Provenance and peer review: Commissioned; not
externally peer reviewed.

References

Terry Pratchett. http://www.terrypratchett.co.uk/.

Burns A, Iliffe S. Alzheimer’s disease. BMJ
2009;338:b158.[Free Full Text]

Department of Health. Living well with dementia: a
National Dementia strategy. 2009. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_094058.

Santry C. Dementia plans: high hopes but who will pay?
Health Serv J 19 Feb 2009.

National Institute for Health and Clinical Excellence.
Alzheimer’s disease—donepezil, galantamine, rivastigmine (review) and
memantine: guidance. 2007. www.nice.org.uk/guidance/index.jsp?action=download&o=36558.

Brodaty H, Green A, Koschera A. Meta-analysis of
psychosocial interventions for caregivers of people with dementia. J Am
Geriatr Soc 2003;51:657-64.[CrossRef][ISI][Medline]

Gaugler JE, Kane RL, Kane RA, Newcomer R. Early
community-based service utilization and its effects on institutionalization in
dementia caregiving. Gerontologist 2005;45:177-85.[Medline]

O’Brien J. Antipsychotics for people with dementia.
BMJ 2008;337:a602.[Free Full Text]

Proctor R, Burns A, Stratton Powell H, Tarrier N,
Faragher B, Richardson G, et al. Behavioural management in nursing and
residential homes: a randomised controlled trial. Lancet 1999;354:26-9.[CrossRef][ISI][Medline]

Burns A. Alzheimer’s disease: on the verges of
treatment and prevention. Lancet Neurol 2009;8:4-5.[CrossRef][ISI][Medline]

French National plan for Alzheimer and related
diseases 2008-2012. L’engagement de tous. www.plan-alzheimer.gouv.fr/

Department of Health. Putting people first: a shared
vision and commitment to the transformation of adult social care. 2007. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndguidance/DH_081118.

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