Dementia describes a range of common and serious degenerative diseases that have huge implications for individuals, families, communities, and economies. Over 800 000 people in the UK have dementia, which affects many millions in Europe and approaching 50 million people worldwide.1
The commonest forms of dementia are Alzheimer’s disease, vascular dementia, and Lewy body dementia. Different types of dementia have different clinical features and run different courses, but all substantially reduce life expectancy, with a mean survival in older people with Alzheimer’s of a little over 4 years.2 The incidence and the health and social consequences of dementia are steadily escalating, creating major problems in both the developed world and in the resource-poor countries of the global South, where the majority of people with dementia are living. An adequate medical and societal response to dementia in the UK has implications for medical training and workforce planning, the support of carers, institutional care, and of course for research into treatments aimed at halting disease progression.
In this issue we look at dementia from a number of primary care angles. In her opening editorial Clare Hilton discusses some of the unintended consequences of well-intentioned schemes to encourage early recognition of dementia, including the opportunistic screening approach suggested by the UK National Screening Committee and the financial incentives provided in the 2014 Dementia Identification Scheme. However, accurate diagnosis is crucial, not least to avoid misdiagnosing other important conditions as dementia, and brief screening assessments are important. In their Research article Creavin et al report the development of a cluster of questions centred around functional rather than cognitive impairment that appear, at least in men, to have similar or better diagnostic value than some more cumbersome instruments. Hilton looks ahead to the establishment of primary care clinics for dementia, where well-trained primary care teams could provide diagnostic and longer-term support for patients and carers, signposting them to specialist services when required.
David Misselbrook approaches the delicate issues surrounding clinical decision making in dementia with great care, negotiating the ethical and practical dilemmas scattered over this clinical minefield, and finds the Debate & Analysis article by Susan Martin on best interest clinical decision making for care home residents, also published in this issue, of considerable value. Perhaps this admirably concise guide, plus the NHS England short guide on dementia diagnosis and management, could be incorporated into practice computer systems to provide an accessible source of guidance and advice.
There are some other gems this month — a positive trial of a brief, practical sleep restriction intervention for the treatment of chronic insomnia from New Zealand, and a persuasive RCT of the treatment of osteoarthritic knee pain from the Netherlands, which shows that paracetamol given in adequate dosage is as good as diclofenac. We also publish a new clinical prediction rule for the diagnosis of meniscal tears in the knee joint and a useful database study on symptoms that warrant investigation in patients who have had cancer in the past. In an exploration of communication in the consultation, Merriel et al found that deeper doctor–patient relationships, measured on a validated scale, are associated with the discussion of more psychological and emotional issues, although health promotion was addressed less often. Finally, French patients, it seems, are divided in their opinions about the potential harms and benefits of pay for performance systems in primary care, with a range of views well captured by Olivier Saint-Lary and colleagues. In Out of Hours we travel to Birmingham to visit those unlikely bedfellows, Andy Warhol and William Morris, to Galilee, to hear tales of country practice and, in Clinical Intelligence, learn about the relentless and troublesome march northwards of the oak processionary moth. Be very afraid.
- © British Journal of General Practice 2015