Friday 8 October 2010

Dementia Care

I'm sure everyone's been gripped by the NICE review and preliminary guidance on the NICE Technology Appraisal (TA 111), released yesterday. It goes on, at length, here. Reading the runes, it's likely to be refreshed from preliminary guidance into national NICE guidance in February 2011 which then has significant implications. Implementation and use of Technology Appraisals in clinical care has to be funded and can't be denied solely on cost grounds.

I'm rather relieved, therefore, that in my corner it isn't going to make a significant difference. Does the review of TA 111 matter, than? It was released in September 2007, updated in August 2009, now refreshed in October 2010 for update in February 2011. Does this document have any use or meaning? It will, helpfully, to a lot of other Trusts.

Microsoft Word tells me the preliminary guidance is 21 824 words. There's a lot of it.

I like it.

It's at variance with some folks' wishes who aren't keen on early diagnosis, since the guidance now invites treatment of mild dementia, rather than waiting 'til you're moderately demented before starting medication. This makes sense to me. The medication typically holds a person at their level of cognition for couple of years. Is is better to be held at a level where MMSE is 24/30 or where MMSE is 14/30? There're exceptions (where insight is a curse and distress blessedly diminishes as the ability to forget becomes more intense) but usually it's desirable (and desired by patients/carers) to keep someone at their best, rather than wait for a decline then keep them at that level.

This is what my colleagues and I've done for years. Our local Alzheimer's Society, PCT, Area Prescribing Committee, GPs and Trust Medicines Management Committee uncharacteristiclaly all agreed a care pwathway and funding such that folk with dementia access treatment on diagnosis, irrespective of severity/MMSE. All my patients with mild dementia have been having the drugs for years.

No changes there, then. Speaking with colleagues in other Trusts, it will open up a huge amount of work for them, with literally hundreds of people who've mild dementia who will be entitled to medication and aren't currently on it needing review and discussion and (often) medication initiated, titrated, reviewed then continued under Shared Care.

I don't prescribe a lot of memantine, using it with just a few patients, so the guidance there won't change my world. Opening up memantine so it can be used in the NHS (outside of clinical trials) isn't a change for me, since I am prescribing it already.

Over 20 000 words saying I can practice as I am.

That's the sort of guidance I can stand to receive!


Eileen said...

I'm curious and confused. The original NICE decision that you had to have moderate impairment before you could have treatment always seemed strange to me - I'm a scientist, not a medic. So - were they correct in their ruling? And why have they now changed their minds? Has it anything to do with a change in Government?

As I understood things there was evidence it kept things at a standstill for some time before and that seems a good thing for most cases. Or is there now more overwhelming evidence?

The Shrink said...

Elieen, being fair to them, NICE looked at the evidence in 2007, then 2009 and now in 2010 and have revised their guidance accordingly.

We know people with mild cognitive impairment (MCI) often get better (Ritchie, 2001) and at age 70 only 1 in 200 will go on to develop dementia in the next year (Peterson, 1999).

Treating mild memory problems with dementia drugs wasn't shown to be sensible, when 199 out of 200 would stay the same/get better and not go on to progress to dementia.

You're spot on that the drugs keep things at a standstill (for most folk) for some time (median is a bit over 2 years).

My understanding is that subsequent evidence that drugs worked in mild dementia, and have meaningful benefits, and are cost effective, and improve quality of life, mean that NICE can now validly suggest the use of the medication is extended to patients with mild dementia.

NICE have been correct in their rulings, if you expect them to apply just the evidence base and their economic cost/benefit analysis to what's known at that point in time.

They were criticised for va;uing the evidence base and not bowing to the public opinion, but I find it hard to criticise them for this. The NHS has rationed/finite resources and to allocate these on what's been shown to be effective to address what peoples' health needs are (and not just what is wanted) seems fair.

The crunch now rests with clinicians, who have to sift through memory problems and sort patients into those who have memory problems but don't have dementia, those who have memory problems who need surveillance because they are expected to go on to develop dementia, those who have memory problems and have a dementia that drugs can't help with, those who have memory problems that drugs could help with but aren't safe to use, those who have memory problems who drugs will help with and are on the drugs, those who have memory problems who should be offered medication and aren't on it yet.

It's sadly not so simple as dementia = drug.

hyperCRYPTICal said...

Hello Shrink.

I am one of those people who you refer to who 'aren't keen' on early diagnosis. I have no problem with early diagnosis - but I do have a problem with a doctors insistance that the patient MUST know - whether they want to or not. I would say to you - be guided by the relatives knowledge of the patient and whether knowledge of the diagnosis would be detrimental to the patients well-being.

I live and breathe dementia twenty four hours of every day. It is the main theme of my workplace - which I love and do well - and it is also present in my home life and I love the person I care for.

It is not the first time that dementia has touched my personal life - so I think I can speak with experience.

Please do not dismiss my opinions - purely on the basis that they are opposed to yours! Enter into dialogue with me as I have always believed that is what psychiatrists do well! That is to listen, learn and understand.

Anna :o]

Eileen said...

Thanks - I don't actually have a problem with NICE as long as they stick to drugs and stuff. I agree wholeheartedly about the allocation of finite resources and there are loads of things I feel should not necessarily be part of the NHS remit. I was just curious about what had appeared to change their minds in this case.

I know, for example, that the non-use of a certain cancer drug that is criticised by the patient advocates because "everyone else in Europe uses it" is likely to be joined in with by other countries in the EU - because the drs know that it does not achieve value for money and only use it because they can and so it is expected by the punters. The drs also know that there are dwindling funds everywhere and it is only a matter of time. At least NICE is there to take the flak away from the front line.