Memory services: psychological distress, co-morbidity and the need for ﬂexible working – the reality of later life mental health care
It is estimated that the population of older people in the United Kingdom (UK) will grow from 9.6 million in 2005 to 12.7 million in 2021, with rates of dementia and other mental health problems increasing proportionately (Age Concern and the Mental Health Foundation 2006, 2007, Alzheimer’s Society 2007). Over the next 15 years the number of older people with some form of mental health problem is predicted to increase to one in every 15 people. Research into the incidence and prevalence of dementia and other mental health problems shows considerable variation in rates due to different methodologies and measuring instruments utilised. However, a UK Inquiry suggests that approximately 5 percent of older people in the community are likely to have dementia; rising to between 50 percent and 80 percent of those in care homes (Age Concern and the Mental Health Foundation 2006, 2007). The National Dementia Strategy (Department of Health 2009a) estimates that approximately 700,000 people have dementia in the UK, of whom 570,000 live in England. In addition, 10 percent15 percent of older people in the community are likely to have depression, rising to 40 percent in care homes. Both conditions may co-exist. Until relatively recent times, management of dementia has been heavily inﬂuenced
by negative stereotypes and an assumption that the person with dementia should be protected from knowledge of their own condition and its implications. However, over
the last two decades, new pharmacological and psychosocial approaches to treatment have prompted a move toward therapeutic optimism and recognition of the value of early detection and disclosure of the diagnosis of dementia (Pratt and Wilkinson 2001). Wright and Lindesay (1995) charted the early development of memory clinics in the UK. Initially, many were hospital-based assessment and advice services linked to research projects. They were, however, ‘ill-equipped to provide for the ongoing care needs of their patients and most rely on referral to the local health and social services for this’ (Wright and Lindesay 1995: 383). The licensing of new drugs to alleviate some of the symptoms of Alzheimer’s disease
had a signiﬁcant impact on the further development of memory clinics. Donepezil (Aricept) was launched in 1997, Rivastigmine (Exelon) received its licence in 1998 and Galantamine (Reminyl) in 2000; see also the National Institute for Health and Clinical Excellence (NICE) Technology Appraisals (National Institute for Health and Clinical Excellence 2001, 2007) for the evidence base. In many instances clinics were set up speciﬁcally to ensure delivery of treatment with acetylcholinesterase inhibitors (AChEIs). Lindesay et al. (2002) found the number of memory clinics in the UK had doubled by 2000 and that they operated a broader range of service models. During this period there has also been increasing evidence of effective outcomes from
psychosocial interventions for early stages of dementia, e.g. Clare (2003) and MonizCook et al. (2009). These interventions address ways of sharing the diagnosis of dementia, cognitive rehabilitation and stimulation techniques (Clare and Woods 2004, Alzheimer’s Society 2007), and memory groups utilising varied therapeutic strategies (Cheston, Jones and Gilliard 2003), as well as more long-established interventions with carers (Charlesworth et al. 2008). This literature is not reviewed in detail here, but MonizCook and Manthorpe (2009) have edited a wide-ranging, informative and accessible book covering the work of researchers and clinicians in the development and delivery of evidence-based clinical practice in psychosocial interventions for dementia. In this they also draw attention to the importance of tailoring psychosocial interventions for people with dementia to each individual’s circumstances and preferences. Developments arising from research were followed in 2001 by Standard Seven:
Mental Health of the National Service Framework for Older People (Department of Health 2001), which emphasized the importance of achieving early diagnosis for older people with suspected dementia. The combined impacts of the National Service Framework for Older People, NICE Technology Appraisals (National Institute for Health and Clinical Excellence 2001, 2007) and the National Dementia Strategy (Department of Health 2009a) have seen a widespread increase in services. A majority of later life services now offer memory clinics which focus on diagnosis, provision of medication, education and support with adjustment to diagnosis. However, the availability of psychosocial interventions is much more variable. Services are now sufﬁciently widespread that examples of good practice are recog-
nised and have been evaluated (e.g. Croydon Memory Service: Bannerjee et al. 2007 [and see Chapter 8 of this book]; Hull Memory Clinic: Moniz-Cook et al. 2009). Clinical governance issues (Phipps and O’Brien 2002) and quality standards are also being addressed. An accreditation process has evolved from the North West Memory Clinics Network – a joint initiative between Care Services Improvement Partnership (CSIP) North West and the Royal College of Psychiatrists, with contributions from users, carers and other relevant disciplines and agencies. The Memory Services National Accreditation Process is now expanding to provide accreditation for memory clinic services countrywide.
It is hoped that this will continue to evolve and to support standards which enable positive management of the transition to dementia and the delivery of a full range of psychosocial interventions as well as current and future pharmacological treatments.