Standing at the crossroads: which way will dementia services evolve?

The provision of services for people suffering with dementia in the UK has reached an important crossroads. In reality, no dedicated services exist, with the work being primarily undertaken by old age psychiatrists; with a smaller percentage performed by geriatricians and a minority by neurology. The reason for this distribution was that historically the main requirement was managing Alzheimer’s disease (AD); which before the introduction of cholinesterase inhibitor treatment in 1997 usually presented in the latter stages, predominantly with behavioural symptoms—reinforcing both the psychiatric emphasis and nihilistic attitudes to intervention. Younger patients and rarer dementias were the province of the neurologists, who offered a diagnostic service; while geriatricians managed cognitive impairment in relation to other physical comorbidities.

Since 1997, memory clinics have rapidly evolved, a direction reinforced in the 2001 National Service Framework for Older People (NSF).1 Again, most clinics tend to be in psychiatric services and continue to concentrate on AD. However, it is increasingly recognised that dementia involves more than AD; with particularly, cerebrovascular disease playing an increasing part in the causation and management of many forms of cognitive impairment—lending the memory clinics a more “medical” feel, while at the same time, stroke services begin to look at cognitive as well as physical assessments. Conversely, the fact that Parkinson’s disease (PD) is associated with more severe cholinergic impairments than AD, and that these patients have a high rate of dementia, has led to a traditional medical preserve having to become more “psychiatric”. Now that a cholinesterase inhibitor has been shown to help in PD dementia,2 who will prescribe what and when will hopefully help focus the long awaited clarification of some of these issues.

What is clear is that …