Integrated multidisciplinary approach for dementia care

To read the study on dementia care by Wolfs et al ¹ was a delight. They deserve a round of applause for not only conducting a trial in a very complex but essential service but also for demonstrating that an integrated multidisciplinary approach has a positive impact on dementia care. As a consultant old age psychiatrist in the English National Health Service, would I repeat this study?

In the 1970s, we experimented joint working with our colleagues in elderly medical care. At some district general hospitals, joint assessment wards were set up for older patients with complex medical and psychiatric problems. Although the idea looked attractive, the key issue for professionals was who provides and who is responsible for general care practitioners, geriatricians or old age psychiatrists. Unfortunately, the arranged marriage between the medical and psychiatric services ended in an amicable separation, if not divorce, at most places. This separation has not been helped by the fact that these services are delivered by separate hospital trusts. The situation is getting worse as many more hospitals are being managed by ever-growing-mega trusts.

Psychiatry services for older people are now well established across the UK, based on the principle of multidisciplinary working especially in the community. Dementia care has improved significantly with the introduction of memory assessment services across the UK. To bring physicians and psychiatrists together at the research-oriented teaching hospitals may be attractive, but to bring them together for integrated multidisciplinary assessment and diagnostic work does not hold any realistic future.

There are drawbacks in the Dutch study. Only 65% of patients agreed to participate. Health-related quality of life was the primary outcome. A difference of 10% or more between the intervention group and the control group had been determined as a clinically relevant difference, but the study resulted in only 9.6% group difference after 12 months. Moreover, the proportion of patients who improved more than 10% was only 39% compared with over 22% in the control group. Does this modest result justify integration of medical and psychiatric services for dementia care in the UK? The answer, I am afraid, is negative at the moment. The important lesson to learn, however, is to provide a dementia diagnostic service in terms of comprehensive assessment, reaching a diagnosis and communicating that to patients and their carers with a comprehensive care plan. I would be more interested in conducting a randomised controlled trial to evaluate the clinical effect of a diagnostic approach rather than the traditional assessment approach by the existing community mental health teams for older people.