Professor Sube Banerjee, Professor of Dementia, Brighton and Sussex Medical School
Sube Banerjee is Professor of Dementia at Brighton and Sussex Medical School. He was the joint lead for the first National Dementia Strategy (2009-2014). In September 2014, this strategy was "refreshed and updated" with the publication of a Dementia Toolkit, aimed at helping GPs make more timely diagnosis and offering them advice on how to provide post-diagnostic support. The strategy has also prompted the development of dementia-friendly communities. This viewpoint is based on a recent Sube Banerjee’s article – 'Multimorbidity - older adults need health care that can count past one' (The Lancet, Vol 385 (9968); DOI: http://dx.doi.org/10.1016/S0140-6736(14)61596-8)
The challenges faced by health systems across the world force us to see what can be improved and to make choices about how greatest health gain can be achieved.
There is increasing evidence that the group where there is the greatest need for improvement and for positive change is older people with multimorbidity. The extent to which their healthcare needs are met well or badly is an indication of the successes and failures of healthcare systems across the world in the 21stCentury. The increase in longevity in developed and less developed economies alike is a testament to the success of 20thCentury medicine as well as economic and social development. Research, policy and action has transformed our ability to prevent infant mortality, prevent and treat infectious diseases, and more recently to prevent and treat the great killers in mid-life such as heart disease and cancer. This is a fantastic success. But with increasing longevity comes multimorbidity (people with two or more long-term conditions), and with multimorbidity comes complexity. While multimorbidity is not just a problem of older adults, its prevalence is much higher in older age groups with 65% of those aged 65-84 and 82% of those aged 85 or more so affected. [1]
It is however much more difficult to picture multimorbidity than it is a single illness. The dominant paradigms we developed in the 20th Century to understand ill health find it difficult to count to more than one. [2] We need a prism that enables us to see what complexity and multimorbidity mean for individuals and systems. Dementia provides us with such an instrument to understand and interrogate our knowledge, beliefs and actions. Dementia is a concrete example of a disorder that illustrates all the complexities of the challenges of multimorbidity and the implications of not addressing them in a systematic fashion. The numbers of people with dementia worldwide will triple from 34 now to 115 million in 2050 [3]. People with dementia have the highest level of multimorbidity; only 5.3% of people with dementia have no other long term condition and that they have on average 4.6 of these conditions. [4]
Multimorbidity in dementia predicts poor outcomes and poor quality service response. But why? A large part of the answer is because health systems are providing 20thCentury medicine to a 21stCentury patient population. General hospitals are increasingly filled with older people with multimorbidity admitted as an emergency. People over 65 make up over 60% of admissions, 70% of occupied bed days, 85% of delayed transfers, and 65% of emergency readmissions. Those over 65 make up 17% of the UK population but account for 68% of hospital emergency bed days. [5] These 20thCentury hospital services are generally designed for people, often young or in middle age, with one thing wrong with them. Research, policy and health systems have evolved in past 50 years to generate increasing specialisation to deliver increasingly technical treatments for individual conditions. This paradigm of uni-disciplinary technical super-specialism has become dominant. It casts a dense shadow, acting to devalue and impair the growth of the generalism and integrative focus of much of primary care and geriatric medicine. These siloed services in hospitals often fail the frail elderly populations with multimorbidity. Conditions other than that of the specialty, with dementia a good example, are often seen as a complication, ignored or managed by multiple specialist referral which may be both inefficient and ineffective.
Clinical guidelines for chronic illnesses almost always focus on single disorders even though most with those disorders will have multimorbidity. [4] Therapeutic and adverse effects may differ in those with multimorbidity. Dementia provides good examples in this regard. In those with depression and dementia at the same time, antidepressants that work well in those without dementia appear to have no effect.[6,7] In terms of serious adverse effects, the use of antipsychotic medication in those with dementia has been shown to have a greater mortality than in those without dementia. [8] What works in a single disorder, does not necessarily work in multimorbidity; what is safe in a single disorder is not necessarily safe in multimorbidity.
We need to develop a 21stCentury healthcare that works for those with multimorbidity as well as those with one thing wrong with them. It would be multidisciplinary and integrative, valuing generalist skills as well as the technical. It would be patient-centred, focussed in what works for the patient not what works the service or clinicians want to do. Any solution to this complex set of problems is likely to be complex itself; it will require us to combine the technical innovation and high science of the 20thCentury medicine with new ways of organising and delivering services. This requires political imagination, courage and will to re-engineer cherished current systems and services. The clinical and financial pressures imposed by our current system should however be the impetus to moving decisively on this. We need to develop our services to meet the actual needs of our patients now, not just those of the last century. This means a system that works for multimorbidity and this means a system that works for those with dementia.
[1] Barnett, K., Mercer, S. W., Norbury, M., Watt, G., Wyke, S., & Guthrie, B. (2012). Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. The Lancet, 380(9836), 37-43.
[2] Banerjee, S (2015). Multimorbidity in older adults – the need for a 21stcentury healthcare that can count past one. Lancet.
[3] Alzheimer's Disease International. (2009). World Alzheimer Report 2009. Available at: http://www. alz. co. uk/research/files/WorldAlzheimerReport.pdf.
[4] Guthrie, B., Payne, K., Alderson, P., McMurdo, M. E., & Mercer, S. W. (2012). Adapting clinical guidelines to take account of multimorbidity. British Medical Journal, 345(oct04), e6341-e6341.
[5] Imison C, Poteliakhoff E, Thompson J (2012) Older people and emergency bed use - Exploring variation. London: King’s Fund.
[6] Rosenberg, P. B., Martin, B. K., Frangakis, C., Mintzer, J. E., Weintraub, D., Porsteinsson, A. P., ... & Drye, L. T. (2010). Sertraline for the treatment of depression in Alzheimer disease. The American Journal of Geriatric Psychiatry, 18(2), 136-145.
[7] Banerjee, S., Hellier, J., Dewey, M., Romeo, R., Ballard, C., Baldwin, R., ... & Burns, A. (2011). Sertraline or mirtazapine for depression in dementia (HTA-SADD): a randomised, multicentre, double-blind, placebo-controlled trial. The Lancet, 378(9789), 403-411.
[8] Banerjee, S. (2009). The use of antipsychotic medication for people with dementia: Time for action. London: Department of Health.