Differences in care between younger and older patients in the 2019 English national memory service audit, 2021, Cook et al

Abstract

Aims and method
This paper analyses how practice varied between patients aged <65 and ≥65 years in the 2019 UK national memory service audit.

Results
Data on 3959 patients were analysed. Those aged <65 (7% of the sample) were less likely than those aged ≥65 to be diagnosed with dementia (23 v. 67%) and more likely to receive a functional, psychiatric or no diagnosis. Younger patients were more likely to have magnetic resonance imaging; use of dementia biomarkers was low in both groups. Frontotemporal dementia and functional cognitive disorder were diagnosed infrequently. Use of dementia navigators/advisors and carer psychoeducation was similar between groups; younger patients were less likely to be offered but more likely to accept cognitive stimulation therapy.

Clinical implications
Memory services seeing younger people need expertise in functional cognitive disorder, alongside clinical skills and technologies to diagnose rarer forms of dementia. Further work is needed to understand why cognitive stimulation therapy is less frequently offered to younger people.

Open access, https://www.cambridge.org/core/jour...ervice-audit/44E239FDA0BA5EC3882F403554B7C499

 

Some interesting reflections by UK psychiatry about younger people reporting cognitive problems but clinicians admitting there is a lack of a body of knowledge and evidence into what may be causing this, especially advanced imaging etc to investigate the causes of their cognitive problems.

“Although it is important not to pathologise people who present with mild symptoms not meeting thresholds for psychiatric diagnosis, giving meaning to people's symptoms usually requires healthcare professionals to give those symptoms a label or to provide an explanatory formulation”

As long as it explained in the formulation read by other clinicians and to the patient and family, the lack of scientific investigation into this area.

 

@trish.

The pathway into a Memory Clinic in the UK (to my understanding, we don’t have them here in NZ) would be a person complains of cognitive difficulties to GP and they are likely to have a history taken of say head injury, alcohol etc. and do basic cognitive testing and if any neurological symptoms, a limited neurological exam, they would order bloods looking for causation. If there are neurological signs and symptoms, they are likely to be first seen by a neurologist who can do more detailed examination of the entire neuro system and perhaps do some imaging. If nothing is found, this would be passed back to GP. If person continues to experience difficulties, GP is likely to do a MMSE (Mini Mental Status Exam) a test that takes about 10 mins and covers many cognitive domains and is the global standard for testing for neurocognitive and degenerative disorders, this is usually the minimal requirement to get into a Memory Clinic or to see a Psychologist or Psychiatrist in NZ. There is a cut off score for referral but in some cases when the distress or work/social/educational dysfunction is causing problems, they will be accepted for assessment. A neuropsychological assessment and examination (psychologist) can take up to 8 hours over 1-6 sessions. It is comprehensive coverage of all cognition and will involve history and impact of any mental health disorders that have been identified on screening. If person has no identifiable problems on this testing or unspecific and not suggestive of any known neurocog disorder, they are likely to get a Functional Cognitive Disorder diagnosis (but usually after more bloods are done and some imaging like MRI or SPECT/PET depending on resources available). People who have some impairment on testing but no known cause are likely to get a non-specified diagnosis or instructions to GP to repeat cognitive testing say every 6 months or a year.

A brief summary from 2015 on FCD is here: https://pn.bmj.com/content/15/6/436

I am not au fait with ICD-10 classification of psychiatric disorders except for physical codes. NZ moved away from UK models and classification around mental disorder throughout the 80’s and I was not taught it (but understand the concepts and criteria, very stigmatising as it also presumes aetiology especially stress induced in ME and other yet unexplained illnesses. We use DSM 5 (USA) which is criteria based and has multiple axis coding of health domains.

In addition: there are known neuropsychological deficits for ME.