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Kieran Walsh: Dementia—new approaches to care and cure

Dementia is a growing public health challenge around the world. It is already a major problem in developed countries, but incidence and prevalence are set to increase rapidly in developing countries in the next 20 years. So dementia is truly a global phenomenon and, as a result, the World Innovation Summit for Health (WISH) Oxford Series decided to make it one of the main sessions at their UK meeting in 2019.

The session was called Innovative Approaches to Dementia Care and Cure: The Search for Better Outcomes: it looked at advances in policy and practice in the diagnosis and management of dementia.

The session started with the issue of care. The number of people predicted to develop dementia in the next 20 years means that new approaches to care are urgently required. The first step in enabling the provision of care is making a diagnosis—but even that is not straightforward. A diagnosis of dementia still carries stigma in many countries and so lots of patients and their families will not go to their doctor and say that they have a problem in the first place. A great deal of public health education is necessary.

The education of healthcare professionals is also needed. In many countries, there has been investment in the education of specialists with expertise in neurodegenerative conditions. These specialists are essential but just as important are the large numbers of GPs and nurses working in primary care who are on the frontline and who need to know when to suspect and how to diagnose this condition. Guidelines for the diagnosis of dementia are important—but just as important are policies to enable the implementation of these guidelines. This will not happen without a primary care workforce that has been educated and empowered to look after patients with dementia. A team based approach is also needed, and so education and support must be provided for therapists, pharmacists, and all other members of the multi-professional team. A core part of the team is the patient and their carers—they should be at the centre of any care plan. 

New approaches to cure are needed as well. Unfortunately, progress in developing new drug treatments for dementia has been painfully slow. As a result, some pharmaceutical companies are pulling out of this field as it has been so difficult to bring new drugs to market. Trials are expensive—it can take several billion pounds to develop a new drug and prove its effectiveness. Development times are also long. Alzheimer’s disease progresses slowly and so it can take a long time to demonstrate the effectiveness of a drug.

Another problem is that drugs will only work for a specific diagnosis, and dementia itself is not a diagnosis. The most common cause of dementia is Alzheimer’s disease, but this is a difficult diagnosis to make. So it is not surprising that drug development is difficult when the diagnosis that the drug is supposed to be treating is not completely clear. Most people with dementia are old, and many have comorbid conditions—both of which present a challenge to the pharmaceutical sector, which is used to dealing with younger patients with single conditions. There is no easy fix for any of these problems, but the pharmaceutical industry, regulatory agencies, and governments are exploring solutions. It may be that more public monies will be required to fund research in this important area of population health need. In the future, research should also help us to diagnose patients with precise forms or subsets of dementia and who will be more likely to respond to specific treatments.

At present there is no cure for Alzheimer’s disease or other forms of dementia, and this can lead some to look at this area with a degree of diagnostic and therapeutic nihilism. But an important component of the treatment of any condition is hope, and there are lots of innovations that give ground for hope in this condition. Many of these relate as much to care as to cure. Just one is the attractively named Dementia Adventures—this project aims to help people with dementia to get outdoors and reconnect with nature and get back a sense of adventure in their lives. It also gives them something to look forward to and to keep hope alive.

Kieran Walsh is clinical director of BMJ Learning and BMJ Best Practice. He is responsible for the editorial quality of both products. He has worked in the past as a hospital doctor—specialising in care of the elderly medicine and neurology. 

Competing interests: Kieran Walsh works for BMJ Best Practice, which produces a range of clinical decision support resources in neurodegenerative conditions.