36-37 - DISEASE: Mind over matter

If the pandemic has taught us anything, it is that careful planning ahead makes an enormous difference to health outcomes for millions of people. It was true of COVID-19 and it is especially true in terms of dementia.

With new treatments for Alzheimer’s Disease (AD) now feeling more a near-term reality rather than a distant hope, we need to urgently reconsider the dementia management landscape. This was starkly emphasised by recent news highlighting that some dementia patients can be waiting up to a year for diagnosis. Inevitably, such a delay may worsen the condition as it prevents actioning earlier interventions which could make a difference.

The most promising and advanced of the new generation of potential treatments are already undergoing phase 3 clinical trials. Whilst many continue to pursue the well-known amyloid plaques target, others are focusing on breaking down the toxic tangles of tau protein in the brain that are understood to be a major driver of the disease.

This means a disease-modifying medication could soon become available: treatments which not only slow the rate of commonly seen cognitive and functional decline in AD, but that also fundamentally slow the progression of the disease.

The prospect of innovative products to treat AD, and other associated diseases, is hugely encouraging. It offers the hope of transforming the lives of millions of people with the condition, and the millions more who love and care for them.

The impact of any new drug, however, risks being greatly undermined without an improved clinical pathway in place for patients. A fit-for-purpose pathway is vital to optimise the patient experience; ensuring rapid and accurate diagnosis resulting in a referral to discuss the diagnosis and treatment options, then access to treatment through prescription, and post-diagnostic support and follow-up care.

Dementia is currently a specialists’ domain with consultants often taking the lead in diagnosis, prescription and management. But that approach is unlikely to be sustainable when new treatments become available, given that there are currently 850,000 people living with dementia in the UK.

With the number of people with dementia forecast to almost double to 1.6 million by 2040, the scale and the need to prevent, diagnose, treat, support, and live well with dementia will only become greater.

But it is vital to ensure that the people who are on the frontline of delivering that primary care have the expertise, the support from multidisciplinary teams and the resources to give quality care, rather than creating a lottery of ad hoc and variable care.

A particular challenge will be in managing the early stages of the disease when people are concerned, but are not certain, that they may have AD or another form of dementia. Improving the skills and knowledge of GPs is therefore paramount as more people come forward.

Developing such an effective primary care pathway, that will genuinely meet the needs of patients with dementia, must involve the service users themselves – both people with dementia and their families and carers.

The urgency around putting a pathway in place has also been accelerated by other positive developments in the field of AD diagnostics. Scientists are on the cusp of major advances in developing a new generation of tests. These will be based on blood-based biomarkers, digital health technology and psychometric analysis, which could see the diagnosis of AD become as straightforward as the current universal tests for pregnancy, common cancer screening, diabetes or COVID-19.

In developing tests that are simple to administer and cheaper to process, researchers are opening the door to enable diagnosis at a much earlier stage in the disease’s progress, establishing grounds for earlier interventions and effective treatment.

New smart psychometric testing is also poised to transform the speed, ease and accuracy of diagnosis and treatment monitoring. That, in turn, will allow patients to get involved in carrying out the tests from the comfort of their homes or in the waiting room before they see their GP. This will enable GPs to dedicate their limited time resource to focus on direct patient management.

The fact that GPs have an existing relationship of trust with patients can help them to explore the patients’ thoughts and concerns about symptoms in a familiar setting that reduces stress and anxiety.

Armed with new diagnostic tools, they will eventually be confident enough to prescribe new medications to many of the patients they see, yet still have the option to refer patients with unusual symptoms or elevated risk to secondary care and specialist treatment.

This collaborative approach has huge advantages and GPs are already expressing strong interest in playing a key role. Indeed, one enterprising medical practice in Bristol has already set up its own fully managed and resourced in-house service along the lines of a GP-based memory clinic. This enables individuals to undergo a series of tests to support a diagnosis of dementia.

Creating such a coordinated care pathway that defines the roles of the multidisciplinary care team – GPs, specialists, carers, patients and their relatives – will help to ensure timely, efficient and effective diagnosis and treatment that will make an enormous difference to millions of people.

Ultimately, a joined-up approach means that when therapeutic treatments become available, people affected by dementia will have a smooth and efficient pathway that they can navigate with ease. It is in everyone’s interests to have a process that is as good as the products.