Thursday, 23 October 2014

A demented government plan

As you will have noted in previous posts, I intend to write without fear or favour about mental prowess, and in that spirit can only describe as stupid a government plan to pay General Practitioners £55 for the next 6 months for every diagnosis of dementia they make.  First and foremost, getting a diagnosis of dementia can damage the life chances of elderly patients.  Second, dementia is not currently a treatable condition. Third, doctors cannot diagnose the condition accurately. Fourth, a proper assessment of dementia requires a base rate psychological assessment and then a re-test 6 months or more later. Fifth, a GP ought to be allowed to exercise some professional judgment without being suborned to meet the Flavour of the Month Five Year Plan.

So, to what do we owe this stupidity? The reasons given are that the Powers That Be have determined that dementia is under-diagnosed, and therefore family doctors need an incentive to label people properly, rather like pouring concrete walls to make rivers run in tidy straight lines. One of the things this silly policy intends is that doctors should “visit care homes to assess very elderly people who have not previously been checked for dementia”. What fools. How will this pointless paper exercise assist the brain function of the elderly? In the better homes they are already being given tasks and experiences to keep them mentally active (more in hope than because of established efficacy) and in the poorer homes they would do those exercises if they could afford to hire the staff.

Prof Sir Simon Wessely, who can always be counted on to make sensible remarks despite being President of the Royal College of Psychiatrists and a Knight of the Realm said “"at the moment the evidence favours either improving social care, or investing in research to find new treatments that actually modify the course of the disease. Until that happens I can see little point in this initiative.” By rights, that ought to stop the nonsense in its tracks, but here is a little further explanation.

When you try to diagnose dementia, you come up against g (general intelligence). It is simply inescapable. To get advance warning of memory problems you have to test memory. Because all mental abilities are correlated in a positive manifold, a bright person with memory problems will often still have a better memory than a duller person without memory problems. If you want any accuracy you have to do a full intelligence test and a full set of memory tests. By looking at both types of performance you can hazard a guess as to whether current memory abilities are worse than would be expected, given the estimated lifetime intelligence level of the person concerned. To improve on that initial opinion, you treat it only as a baseline, and test the person again after at least another 6 months, when practice effects should have faded, and the condition may have progressed. You draw the line of slope, and make some predictions about the rate of decline, distinguishing between the age related norm and the faster decline that may be part of dementia.

Of course, all this takes time, so standard NHS policy is often restricted to doing a one time screening test, coupled sometimes with a brain scan. The latter is pretty to look at, but of surprisingly little diagnostic help. Most of the observable changes are those seen in people of that age, and the correlation between the scan and real life capability is weak.  Nonetheless, a doctor then signs a form and bingo, your chances of getting into a pleasant nursing home are reduced to almost zero.

An elderly friend, of high ability and inquisitive mind, with failing physical health, selected a nearby nursing home, not far from his flat, which would keep him in touch with his friends and his old haunts. He had previously mentioned to his hospital doctors that he was worried about his memory, and so was given a screening test. On this slender basis he was diagnosed with dementia. The nursing home turned him down, on the basis that they would have taken him, given his presentation at interview, but that they could not take on someone with a dementia diagnosis. They were implacable when, late in the process, I found out what had happened, studied the psychological report, and pointed out that this conclusion was premature, to say the least. After some discussion he is now in his flat, with staff visiting daily, and the arrangement seems to be working for the time being. His memory is still good, his physical state rather frail. Should things get worse, he will not be able to go to his preferred nursing home.

Even if dementia could be diagnosed with a high level of accuracy (perhaps using annual symbol-digit subtest scores) diagnosis without an effective treatment is a baleful gift. Expectations are reduced, friends drift away, and normal decline becomes abnormal disease.

Of course, it is very likely that every single person associated with this stupid policy is probably well intentioned and perfectly capable of solving difficult intellectual problems in other contexts, and also kind to children and animals. However, some collective process seems to have drained the intellect out of them. Come to think of it, perhaps the policy was formulated in a moment of abstraction brought about by poor concentration and failing memory. Perhaps they all drifted into the conference room at the Dept of Health, forgot why they had come into that particular room, signed a document they found there because it seemed the sort of thing they had always done, and then tried to make their way down the maze of corridors to the room they half-recognised as their own office. I hope they will be treated kindly, kept warm and well fed,  and that absolutely no-one will stoop to denouncing them for £55 a head.


  1. In European countries, most men have taken some kind of IQ test when up for conscription around age 19. It would seem like it would be feasible for those IQ scores to be used in diagnoses of mental decline if permission is given. There would be various ways that privacy could be protected.

  2. Dear Steve, Good idea. It would provide hard evidence of pre-morbid ability, and one could even repeat the test, as Ian Deary did with the Scottish 11 Plus test with the older people. Getting the data might provide a problem, because I do not know where the records would be kept, but it is worth the search. It will be a diminishing resource, because no-one born after October 1939 had to do National Service.