Review: Preventing Dementia by 2020

The article reviewed here is an editorial ‘Prevent Alzheimer’s Disease by 2020: A national strategic goal’ by Khachaturian and Khachaturian and freely available here.

Firstly this is an American article and so this is about a strategy to prevent dementia which factors in resources that are available in the USA (see review of the UK National Dementia Strategy here). The proposed strategy does however includes a proposal to set up a global network which would be indispensable to overcoming the significant challenges set out in the article.

The authors reference articles on the two Leon Thal Symposiums (see review of one here) as well as a webinar event on dementia prevention held in conjunction with the Alzforum. These conferences/events have facilitated the development of a strategy

It is Rocket Science!

The authors liken the prevention of Alzheimer’s Disease by 2020 to the Apollo space mission. Thus they write that

‘The national strategic goal to prevent AD within a decade is no more difficult, ambitious, or premature than the 1960s Apollo space program. The vision of preventing AD by 2020 is an attainable scientific objective‘

After the introduction, the authors focus on the governance of any necessary programs and the need to be able to rapidly respond to emerging scientific findings and opportunities. Later in the editorial they focus on the need for prevention trials and the establishment of a national registry of at-risk subjects who are willing to undergo clinical trials. They carry across the rationale from treatment to prevention trials showing that there are many similarities. They also give a broad costing for these trials. Towards the end of the article they write that

‘The goal of the proposed National Strategic Plan is to create a new paradigm for planning and supporting the organization of worldwide cooperative research networks to develop new technologies for the early detection and treatment of various forms of memory impairments‘

I thought this was an upbeat editorial with ambitious goals. But I think that is just what is needed. As they note earlier in the editorial there will be a very substantial increase in the number of cases of dementia in coming decades which as well as affecting the lives of the people with dementia and their families will have wider repurcussions on economies. This pattern is expected not just in countries such as the USA and the UK but in countries across the world. In the second quote above they use the term ‘memory impairment’ which is useful given the emerging disease entities such as mild cognitive impairment which are currently being further clarified and which are closely (although not invariably) related to dementia. This is also a tacit recognition that dementia strategies need to be sufficiently broad to capture the multiple pathways that lead to dementia.

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Review: Transfers to Psychiatry Through the Consultation-Liaison Psychiatry Service

The paper reviewed here is ‘Transfers to Psychiatry through the Consultation-Liaison Psychiatry Service: 11 Years of Experience’ by Christodolou and colleagues and freely available here. The authors aimed to characterise patients that were seen by Consultation-Liaison Psychiatry services and transferred to the inpatient environment. In the abstract they write that

‘Medical diagnoses do not seem to play a major role in the transfer to the psychiatric ward. From the psychiatric diagnosis, depressive and dysthymic disorders are the most common in the transferred population, whilst the transfer is influenced by social factors regarding the patient, the patient’s behaviour, the conditions in the ward she/he is treated in and any recent occurrence(s) that increase the anxiety of the staff‘

The study was undertaken in a district general hospital in Athens with 650 general hospital beds and 18 beds on the psychiatric unit. The data was sampled from a 10-year period ending just prior to a change in law (March 1989- December 1999) which influenced admission of detained patients to psychiatric units. A control sample consisted of patients that were not transferred to the psychiatric ward during a single year of the study period. The control group were corrected for age and sex. Demographic and other details were recorded and these are identified in the methods section.

In the results section, 294 patients were transferred over the 10 year period and 225 patients were identified for the control group. The researcher provide a number of different results. Some of the results I found particularly interesting. Thus 5.2% of the referrals to the consultation-liaison (C-L) service were eventually transferred to the psychiatric unit while 9.9% of the admissions to the psychiatric unit were from the C-L service. The majority of the control group and the transfers were medical referrals. The differences between the transfer and control group in terms of marital status were particularly interesting with married status being significantly more likely in the control group. In the transferred group 75.8% had a past psychiatric history whereas in the control group this figure was significantly lower at 63.1% (p<0.01 – Fisher’s exact test). In terms of diagnostic labels, the transfer group were significantly more likely than the control group to have a personality or mood disorder while the reverse was true for acute adjustment disorders and no diagnosis. A number of other results are presented and the authors discuss the implications.

The authors note in their discussion that this was a retrospective study and suggestive a prospective design as a basis for subsequent studies. I would argue also that this is an exploratory study in that the data is being used to characterise the different populations i.e. transfers and non-transfers. Thus it is likely that some of the correlations will produce false positives but the positive findings in this study can serve as testable hypotheses in subsequent studies. The other question to ask is to what extent are these results unique to a district general hospital in Greece. The researchers note that legislation following the study period changed the nature of transfers and the psychiatry service set-up and so it is reasonable to suppose that differing legislations in other countries might impact on the relationships identified. A finding I thought significant was that marital status was significantly different in both groups and again to what extent does culture interact with this relationship?

In summary I thought this retrospective study used a large dataset to generate testable quantitative hypotheses (e.g transfers are significantly more likely to be married than non-transfers) that would lend themselves to a prospective study or replication studies. The researchers have also generated a number of testable qualitative hypotheses (e.g the hypothesis involving the relationship between impulsive/disruptive behaviour, somatic illness and transfer) which can be supported both through strengthening of the quantitative findings on which they were based as well as qualitative approaches to either replication of confirmation through other paradigms.

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