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February 2005
This time last year I was enthusiastically promoting exercise for mood disorders. I guess we have all had our yearly fling at the gym by now and are settling down resignedly to work towards the financial year end and for GPs the end of QoF. I thought I would focus on something different, therefore, and have been looking up articles and developments in old age psychiatry where it relates to and impacts on general practice.
Dementia in general practice: Common sense suggests that attention to modifiable risk factors might be worth exploring as a means of reducing the impact of vascular dementia, as it has proved so effective for cardiovascular disease and stroke. Alzheimer’s disease has a sense of inevitable and unpreventable about it but it appears to share risk factors with vascular disease and so in time it may become a preventable disease. Other factors such as the use of statins, HRT, NSAIDs and antioxidants all may have some potential in preventing Alzheimer’s disease and encouraging active and sociable lifestyles in late middle age is also seen to be beneficial.(ref1)
It is conceivable that dementia could become a new target for the Quality Outcome Framework (QoF). If so what would the indicators be? First would come diagnostic indicators – referral to a psychogeriatrician might be the gold standard but the numbers involved might break the system and so cognitive screening followed by EEG and MRI scanning to confirm the diagnosis. Expensive, I hear you say? No one said it would be cheap. But do the patients not deserve such a level of accuracy in diagnosis when we are effectively giving them and maybe their relatives what might be a life sentence? Treatment indicators might include the consideration of behavioural and pharmacological interventions and would most probably involve a multidisciplinary review. A subset (as the current QoF mental health area has those on lithium as a subset) might be dementia in those with Parkinson’s Disease.
Given that the European prevalence of dementia of all types is 6.4% (ref2), putting some clinical targets into place is not an altogether silly idea. In our practice of 7100 patients we might expect 450 patients with dementia. It would be valuable to have both preventative and supportive care for them. Ref: 1. Psychiatry - Volume 3 - Issue 12: Old Age Psychiatry 1 Issue 01/12/2004
2. Neurology 2000;54(11 Suppl 5):S4-9
Can we test for Alzheimer’s Disease?
Up until this morning I would have answered “no”, assuming that the diagnosis could not be confirmed until post-mortem. However, a team in America have found a protein in the brain called amyloid-beta-derived diffusible ligand, or ADDL, and on measuring levels in spinal fluid have shown increasing concentrations are related to increased severity of the disease. To date they have only tested 15 patients and 15 controls but the results are promising. If the test can correlate the presence of ADDLs with brain function, it may help in identifying who is at risk for Alzheimer's and evaluate the effectiveness of the new anti-amyloid medicines.
Ref: http://edition.cnn.com/2005/HEALTH/conditions/02/01/alzheimers.test.ap/index.html
To the other extreme:
Boys in care A study has looked at the needs of boys in care and disturbingly but perhaps not surprisingly found high levels of need in this population. 97 boys aged 12-17 who had been admitted to secure care were assessed at admission and again three months later. It was found that 27% had an IQ of less than 70. The need for psychiatric help was high when they were admitted, with the most frequent disorders being depression and anxiety. There were high rates of aggression, substance misuse, self-harm and social, family and educational problems. From this the researchers have developed a youth screening and assessment tool for the Youth Justice System. We don’t see young boys in the surgery very often but are very likely to have dysfunctional consultations with them as young adults. It is difficult to see where we could influence this path into delinquency but maybe an awareness of it might have subtle beneficial effects when dealing with families. Ref: RCP press release. http://www.onmedica.com/content.asp?c=36992&t=1
Eating disorders A friendly medical student posed the question “Are eating disorders more prevalent in Type 1 diabetic females than in other young women?” …. And set about reviewing the literature …. The conclusions are: The prevalence of anorexia nervosa is no higher in women with T1DM than in those without. But: Women with T1DM are more likely to have bulimia nervosa, EDNOS (eating disorder not otherwise specified) or a subthreshold ED (eating disorder) than their non-diabetic counterparts Possible reasons include depression, dietary restraint, difficulties coping with a chronic condition and mother-daughter relationships. EDs in T1DM are associated with insulin misuse and subsequent hyperglycaemia, leading to earlier complications of the condition. Now this rang several alarm bells for our practice since we have several young diabetic patients. And yet when I ran a computer search of all our patients for eating disorders and similar we had none recorded. This suggests we are either poor at recording – unlikely given our current points status in the QoF – or poor at identifying the problems. Sadly I feel the latter is the case and feel we should all be more aware of eating disorders generally. In particular we should identify being a young type 1 diabetic as a potential risk factor for developing eating disorders. Increased awareness and the availability of patient literature is perhaps the first step to dealing with this problem. If anyone has any useful websites relating to eating disorders I would be interested – drop me an email:
KT (with thanks to an industrious med student)
3 February 2005
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