Wednesday, 31 October 2012

The True Public Health Crisis of the 21st Century

by George Chapman

What will be the largest public health issue facing doctors in the next 10 years? Pose this tricky question to a medic, an aspiring med student at interview, or quite possibly any individual abreast of current affairs, and the response is likely to indicate obesity and/or its associated disease states (Type 2 Diabetes, Heart Disease etc.). Probably somewhat less considered, however, would be the social impact of neurodegeneration in the near future – a loss of physiological structure or function of neurons.  To the average reader, neurodegeneration may seem at first a little random or currently unproblematic; until we consider the UK’s demographic, that is.
Illustrated by the graph to the left, the median age of the male UK population has risen by five years over the past quarter of a century. Consequently, the UK has an ever-ageing population and an ever-rising incidence of illnesses associated with older age. One of these is dementia- the loss of cognitive function (perception, thinking and reasoning- the comprehension and treatment of ideas) usually associated with neurodegeneration of the elderly. With over 1% of the country’s population currently suffering with this terminal condition – a proportion that’s expected to double within three decades[1] – I find it staggering that more has not been done to spread awareness of the illness. To be fair, these statistics haven’t fallen entirely on deaf ears. Alan Johnson MP, former Secretary of State for Health, has himself admitted that ‘Dementia is not an illness we can ignore,’ and more recently David Cameron has pledged to increase funding for dementia research to £66m by 2015. Despite the fact that this is triple what the government set aside for such research in 2010, £66m seems rather insignificant considering dementia currently costs the British taxpayer £17 billion annually. I would imagine that we are all agreed £66m would be a very small price to pay to save annual costs well in excess of this figure, especially considering that this would massively improve our current economic climate in the long run; so why don’t we up the stakes a little, invest even more in research and find a cure sooner?       
Unfortunately, it’s not quite that simple. The bulk of past (and current) research into dementia has been neuroscientific on the cellular and molecular level – to little avail, I’m afraid. After all, how can we expect to find our miracle cure when following stab-in-the-dark lines of inquiry as specific as the role of PGC-1α protein in dementia[2]? To date, neuropharmacological research has only provided clinicians with one subtype of NICE (National Institute for Health and Clinical Excellence) licensed drugs to combat dementia. Dubbed acetylcholinesterase inhibitors (a hardly-snappy, but self-explanatory, name) such drugs seek to prevent further breakdown of acetylcholine – a neurotransmitter essential for the communication between neurons and hence cognitive function. Subsequently, this treatment is exclusively symptomatic and has no effect on reversing neurodegeneration. What’s more, such biomedical research wholly neglects the complex psychiatric dimension of the illness, which pathological changes of neuronal structure cannot necessarily explain.

So far, the limited research yet conducted into non-pharmacological treatment of dementia has been highly fruitful. Cognitive Stimulation Therapy (CST) – a programme comprising fourteen small-group sessions which involve various themed activities – seeks rather to practice perception, memory and other cognitive function than to boost it chemically. Cognitive function may be continually assessed using the thirty-question Mini-Mental State Examination (MMSE) in order to quantify any change in cognitive ability. Interestingly, patients who have completed CST on average answer one more question correctly when compared to their previous score, where the incremental cost effectiveness ratio of CST was £75.32 per additional point[3]. On the contrary, the incremental cost-effectiveness ratio for galantamine – an acetylcholinesterase inhibitor – was £82,000 per QALY[4] (Quality Adjusted Life Year- the addition of an extra year to life expectancy of a patient deemed to be of the same quality as a healthy individual). Furthermore, this increase by one QALY would not guarantee any improvement in cognitive function whatsoever and may therefore have no symptomatic benefit for the patient. Surely this is the main object of an anti-dementia drug? Despite this obvious advantage of CST treatment on paper, an extensive Google search reveals no evidence that the UK government specifically allocates any funding for such therapy. Thus, the discretion to implement CST and the extent to which provision is made for the non-pharmacological treatment lies entirely with the PCT offering geriatric psychiatric treatment.

In my opinion, the failings in UK dementia care do not lie entirely in the treatment patients receive; the social perception of the illness must also be considered. As 50% of the population believes that there is social stigma attached to dementia[5], A National Dementia Strategy concludes that more widespread knowledge and education of the illness is required. Consequently, the annual number of dementia cases left undiagnosed and unreported, due to the inadequate symptomatic knowledge that sufferers’ relatives have and pressure imposed by the social stigma respectively, should begin to fall. Then, limited pharmacological treatments and non-pharmacological resources may be used with greatest efficacy for patients.  That said, I personally haven’t seen a single government-led campaign intended to spread awareness of dementia, and I imagine this is likely to be the case for many of us. Until education of the symptoms and social implications of dementia reaches schoolchildren in the classroom – the learning environment of the next generation in our ever-ageing demographic – we will not be able to tackle and reduce the stigmatised perception of the illness. Unfortunately, until these social perceptions change, which currently accept that dementia is simply old age forgetfulness1, it is unlikely that the British population will prioritise effective research into, and national treatment of, the illness until such time that it has become a much more difficult and expensive public health crisis for us to resolve.

[1] The Department of Health (2009), ‘A National Dementia Strategy’
[3] Martin, K. et al, ‘Cognitive stimulation therapy for people with dementia: cost-effectiveness analysis’, BJP 2006, 188:574-580.
[4] Getsios, D. et al, ‘NICE Cost-Effectiveness Appraisal of Cholinesterase Inhibitors: Was the Right Question Posed? Were the Best Tools Used?’ PharmacoEconomics, Volume 25, Number 12, 2007 , pp. 997-1006(10)
[5] Alzheimer’s Society (2008). Dementia: Out of the shadows. London: Alzheimer’s Society.

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