Electronic Letters to:
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eLetters: Electronic letters published:
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Integrated multidisciplinary diagnostic approach for dementia care
- Arun Kumar Jha (9 April 2008)
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Multidisciplinary dementia care: a need for core training in psychiatry and geriatrics still remains
- Judith S.L. Partridge, Laura S. Hill, Specialist Registrar in General Adult and Old Age Psychiatry (17 April 2008)
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Author's reply to A. Kumar Jha: Integrated multidisciplinary diagnostic approach for dementia care
- Frans R.J . Verhey, Claire A.G. Wolfs, Alfons Kessels, Carmen D. Dirksen and Johan L. Severens (25 April 2008)
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Author's reply to J Partridge and L Hill: Multidisciplinary dementia care: a need for core training
- Frans R.J. Verhey, Claire A.G. Wolfs, Alfons Kessels, Carmen D. Dirksen, Johan L. Severens (25 April 2008)
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Integrated multidisciplinary diagnostic approach for dementia care
- Seamus V McNulty, Graham A Jackson; Anthony J Pelosi (22 May 2008)
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Author's reply to S McNulty et al: Integrated multidisciplinary diagnostic approach for dementia
- Frans R. Verhey, Claire A. Wolfs, Alfons Kessels, Carmen D. Dirksen, and Johan L. Severens (11 June 2008)
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Arun Kumar Jha, Consultant Psychiatrist Hertfordshire Partnership NHS Foundation Trust
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arun.jha{at}hertspartsft.nhs.uk Arun Kumar Jha
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To read a randomised control trial (RCT) on dementia care by our Dutch colleagues (Wolfs et al1) was an absolute delight. They deserve a big round of applause for not only conducting a trial in a very complex but essential service but also for demonstrating the fact that an integrated multidisciplinary approach has a positive impact on dementia care. As a consultant old age psychiatrist in the English NHS, would I repeat this study? In the 1970s, we experimented joint working with our colleagues in elderly medical care. At some district general hospitals, joint assessment wards were set up for older patients with complex medical and psychiatric problems. While the idea looked attractive, the key issue for professionals was who provides and who is responsible for care general practitioners, geriatricians or old age psychiatrists. Unfortunately, the arranged marriage between the medical and psychiatric services ended in an amicable separation, if not divorce at most places. This separation has not been helped by the fact that these services are delivered by separate hospital trusts. The situation is getting worse as many more hospitals are being managed by ever growing mega trusts. Psychiatry services for older people are now well established across the UK, based on the principle of multidisciplinary working especially in the community. Dementia care has improved significantly with the introduction of memory assessment services across the UK. To bring physicians and psychiatrists together at the research oriented teaching hospitals may be attractive, but to bring them together for integrated multidisciplinary assessment and diagnostic work does not hold any realistic future. Finally, there are some drawbacks in the Dutch study. Only 65% of patients agreed to take part in the study. The health-related quality of life was the primary outcome of the study. A difference of 10% or more between the intervention group and the control group had been determined as clinically relevant difference, but the study resulted in only 9.6% group difference after 12 months. Moreover, the proportion of patients who improved more than 10% was only 39% compared to over 22% in the control group. Does this modest result justify integration of medical and psychiatric services for dementia care in the UK? The answer, I am afraid, is negative at the moment. The important lesson to learn, however, is to provide a dementia diagnostic service in terms of comprehensive assessment, reaching a diagnosis and communicating that to patients and their carers with a comprehensive care plan. I will be more interested in conducting a RCT to evaluate the clinical effect of a diagnostic approach rather than the traditional assessment approach by the existing community mental health teams for older people. 1 Wolfs CAG, Kessels A, Dirksen D, Severns JL and Verhey RJ. Integrated multidisciplinary diagnostic approach for dementia care: randomised controlled trial. BJPsych 2008; 192: 300-5. Declaration of interest: None Arun Jha, Department of Old Age Psychiatry, Hertfordshire Partnership NHS Foundation Trust, Logandene Carte Unit, Ashley Close, Hemel Hempstead, Herts HP3 8BL. E mail: arun.jha@hertspartsft.nhs.uk |
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Judith S.L. Partridge, SpR Geriatric Medicine St Mary's Hospital, Praed St, London W2 1NY, Laura S. Hill, Specialist Registrar in General Adult and Old Age Psychiatry
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judith.partridge{at}imperial.nhs.uk Judith S.L. Partridge, et al.
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Wolfs et al (1) describe an integrated multidisciplinary approach to dementia care showing benefits in health-related quality of life. We agree with the authors that no single medical speciality has the expertise to fully deal with the complex range of physical, psychological and social issues affecting those with dementia and thus a multi-speciality approach seems preferable. However we propose that trainees in old age psychiatry and geriatric medicine currently receive insufficient formal training in physical and mental health issues respectively. Whilst a multidisciplinary approach to care clearly demonstrates benefits, both old age psychiatrists and geriatricians need certain common skills in order to function autonomously in situations independent from the multidisciplinary team. This requirement for generic cross-speciality skills is heightened by the current delivery of psychiatric and medical services by different trusts in different geographical locations. Our experience from working in four deaneries is of an arbitrary system of cross-speciality training between old age psychiatry and geriatric medicine, where trainees seek additional experience as they feel necessary. Inevitably this leads to huge variation in exposure and inadequate training for many, which is likely to impact on the quality of care given to older patients. This is particularly evident in end of life care provision, an area faced by trainees in both disciplines. A more structured approach to teaching palliative medicine for frail, older patients with dementia would enrich clinical training in old age psychiatry and geriatric medicine. As the physical and mental health needs of the older population are inextricably linked, both specialities will encounter issues from outside their sphere of expertise during community and inpatient work. Difficult decision making regarding feeding, withdrawal of care, Do Not Attempt Resuscitation Orders and terminal care planning is frequently encountered by psychiatrists looking after patients with dementia and yet current training neglects these areas. Conversely issues regarding capacity, challenging behaviour and psychosis may be problematic for geriatricians without additional support. Whilst we appreciate that frequent inter- speciality referral is an essential element to quality care we suggest that formal exchange placements throughout registrar training would improve confidence with approaching the diagnosis and initial management of simple problems. 1 Wolfs CAG, Kessels A, Dirksen CD, Severens JL, Verhey FRJ. Integrated multidisciplinary diagnostic approach for dementia care: randomised controlled trial. Br J Psychiatry 2008; 192: 300-305. Declaration of interest: None Judith SL Partridge, Specialist Registrar in Geriatric Medicine, St Mary’s Hospital, Praed Street, London W2 1NY. Email: Judith.Partridge@imperial.nhs.uk Laura S Hill, Specialist Registrar in General Adult & Old Age Psychiatry, Devon Partnership Trust, Wonford House Hospital, Exeter EX2 5AF. |
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Frans R.J . Verhey, Old Age Psychiatrist PhD, MD, Claire A.G. Wolfs, Alfons Kessels, Carmen D. Dirksen and Johan L. Severens
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f.verhey{at}np.unimaas.nl Frans R.J . Verhey, et al.
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Kumar Jha feels that our study is flawed by an inclusion of only 65% of patients willing to participate. A participation rate of 65% is common in this type of studies. We anticipated before the start of the study that the rate of non-participants may amount to 40%, and therefore the actual inclusion rate was higher than expected. More importantly, the two groups did not differ regarding relevant characteristics affecting the prognosis, such as age, diagnosis, sex, and baseline cognition. Moreover, Kumar Jha found the results of our study quite modest. We do not entirely agree with this: a difference of 9,6 percent between groups regarding health related quality of life is higher than found in any pharmacological study in dementia so far. We furthermore emphasize that usual care in our region is provided by an active university medical centre and a community mental health service that have collaborated in the past on several projects. We therefore expect that the effects of our study may be underestimated, and would be higher when DOC-PG was situated in another region. Indeed, a marriage between different disciplines involved in the care for people with dementia sometimes involves conflict and is dependent on the willingness to invest in the relationship. So far, a lot of work has already been performed and although the marriage still isn’t perfect (which marriage is?), we think that it does have a realistic and happy future. Declaration of interest: none |
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Frans R.J. Verhey, Old Age Psychiatrist PhD, MD, Claire A.G. Wolfs, Alfons Kessels, Carmen D. Dirksen, Johan L. Severens
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f.verhey{at}np.unimaas.nl Frans R.J. Verhey, et al.
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Partridge and Hill raise the important point that professionals in old age psychiatry and geriatric medicine must have sufficient training in physical and mental health issues, respectively, and we fully agree with them. However, although substantial overlap between specialties may exist, we also feel it is important that the responsibilities of each is clearly delineated. In several countries, including the UK and the Netherlands, statements of agreement between the disciplines regarding the policies and practices have been drafted Declaration of interest: None |
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Seamus V McNulty, Consultant Psychiatrist NHS Ayrshire and Arran, Graham A Jackson; Anthony J Pelosi
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seamus.mcnulty{at}aapct.scot.nhs.uk Seamus V McNulty, et al.
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Wolfs and her colleagues have described a cluster randomised controlled trial in The Netherlands in which patients with suspected dementia received integrated multidisciplinary assessment or usual care.1 Input to the intervention group aimed to combine the hospital-based approach of a memory clinic with the care orientated approach of a community mental health team. This intervention led to some modest improvements in outcome. Usual care during the trial was provided by the general practitioner or involved referral to a regional memory clinic, or a department of geriatric medicine or an elderly mental health service. The integrated approach only lasted for about two weeks after which detailed diagnostic and therapeutic advice was given to general practitioners. Given that dementia is a progressive neurodegenerative disorder with constantly changing medical and social care needs we would be surprised if this intervention could sustain superiority over ongoing care from any community mental health service for elderly people - no matter how rudimentary. Further details on treatment as usual would have been useful, as would a reanalysis of the results taking into account the different types of service received by the control patients. We agree with Wolf et al that memory clinics need to integrate with multidisciplinary community services. We have argued previously that the subspecialist memory clinics in the United Kingdom have not been useful in the overall management of dementia since they have distorted care priorities and have focussed on the prescribing and monitoring of medication.2 Wolf and colleagues’ controlled trial has provided support for integration of services for the diagnosis and care for dementia. This has to be organised not only in the initial diagnostic stages but also on an ongoing basis, with close liaison between multidisciplinary health services, local social work departments and primary care throughout the course of patients’ progressive illness. 1. Wolfs CAG, Kessels A, Dirksen CD, Severens JL, Verhey FR. Integrated multidisciplinary diagnostic approach for dementia care: randomised controlled trial. Br J Psychiatry 2008; 192: 300-5. 2. Pelosi AJ, McNulty S, Jackson G. Role of cholinesterase inhibitors in dementia needs rethinking. BMJ 2006; 333: 491-3. Seamus V McNulty North West Kilmarnock Area Centre Western Road Kilmarnock KA3 1NQ Email: seamus.mculty@aapct.scot.nhs.uk Graham A Jackson Leverndale Hospital Glasgow G52 7TU Anthony J Pelosi Hairmyres Hospital East Kilbride G75 8RG |
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Frans R. Verhey, Old Age Psychiatrist PhD, MD, Claire A. Wolfs, Alfons Kessels, Carmen D. Dirksen, and Johan L. Severens
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f.verhey{at}np.unimaas.nl Frans R. Verhey, et al.
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Organizational models designed to create connectivity, alignment and collaboration within and between the cure and care sectors are needed, and our study provides the evidence to support this approach. Our diagnostic intervention indeed lasted only a few weeks, but in our view, dementia care is a chain of services, starting with a short but comprehensive diagnostic phase resulting in a treatment plan that lasts throughout the course of the illness. Our intervention was merely the beginning of that chain, and we acknowledge that this is an ongoing process. In contrast to McNulty et al, who found the results of our study modest, we value a difference of almost 10 percent between groups regarding health related quality of life as substantial and clinically relevant, and anyway higher than found in any pharmacological study in dementia so far. The suggestion of McNulty et al to compare different types of services would be interesting, but the design of our study was not appropriate for such a reanalysis, as it would be subject to confounding by indication. Nevertheless, McNulty et al raise the important point that dementia care needs an integrated approach on an ongoing basis, and we agree wholeheartedly. Declaration of interest: none |
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