Impact of the National Dementia Strategy in a neurology-led memory clinic

The National Dementia Strategy (NDS) was officially launched on 3 February 2009. It proposed three key themes to address the problem of dementia: improved awareness of the condition, early diagnosis and intervention, and higher quality of care. A pathway for NDS implementation, anticipated to roll-out over a five-year period, was proposed.¹ One year on, the National Audit Office (NAO) published a report into progress on NDS delivery, but frontline services were omitted since they were not anticipated to have changed, as local implementation plans are still being developed. Old age psychiatrists and general practitioners (GPs) were surveyed as part of the audit, but neurologists and geriatricians with specialist interests in dementia and cognitive disorders did not feature.²

The possible impact of NDS in a neurology-led memory service was examined by comparing referral numbers, sources and diagnoses in the 12-month periods immediately before (February 2008–February 2009) and after (February 2009–February 2010) the NDS launch (Table 1).

These data showed a 12% increase in new referrals seen in the second time period, with a marked increase in the percentage of referrals coming from primary care (70.2% ν 58.2%). The null hypothesis that the proportion of new referrals from primary care was the same in the cohorts referred before and after NDS launch (equivalence hypothesis) was rejected (χ²=6.18, df=1, p<0.01).

A decrease in the percentage of patients receiving a diagnosis of dementia (DSM-IV-TR criteria) was noted in the patient cohort from the second time period (29.8% ν 32.9%). The null hypothesis that the proportion of new referrals receiving a diagnosis of dementia was the same in the two cohorts was not rejected (χ²=0.63, df=1, p>0.1).

These findings may indicate that the NDS has increased the total number of referrals to neurology-led memory clinics, perhaps by raising awareness of dementia, although the increase is not as marked as that seen following the publication of guidelines on identification, treatment and care of people with dementia under the joint auspices of the National Institute for Health and Clinical Excellence and the Social Care Institute for Excellence (NICE/SCIE) in November 2006.^3,4 The post-NDS increase in referrals has come mostly from primary care, supporting the NAO finding that GPs are becoming more positive about diagnosing dementia early,¹ but with no accompanying increase in the number of new diagnoses of dementia, hence no evidence for closure of the dementia ‘diagnosis gap’ (too few people being diagnosed with dementia or diagnosed early enough). The impression is that more ‘worried well’ individuals are being referred, rather than those with previously undiagnosed dementia. This is of concern since, as remarked in another context, ‘Health services struggle when they are overwhelmed by people who don't need to be there' (T Stephenson, Observer, 26 July 2009). GPs may need more guidance in identifying possible dementia cases requiring onward referral to secondary care. A previous study noted only 20% of GP referrals to this clinic had undergone any assessment with a recognised cognitive test.⁵

• © 2010 Royal College of Physicians