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  • I let Ian Greaves know that I had responded to an article in the BMJ which describes, from the vantage of academic service design, that there is need to bring services close to patients to achieve best use of resources and best outcomes. http://www.bmj.com/content/354/bmj.i4536

    My point was that the conclusions from design academia matches well with our experiences in Psychogeriatrics (aka Old Age Psychiatry) with development of social psychiatry teams working out from hospitals and into the community from the 1970s – Tom Arie and others leading the way. Lately the Gnosall model of a memory service within Primary Care has taken the model further, closer to the patient and family, since 2006.

    Ian’s response is to share with me the extraordinary range of new initiatives which are being woven into practice in Gnosall and other places: primary care is where it is all happening.

    Faced with austerity financial constraints and a shortage of trained professionals, necessity is doing what my mother told me it does – generating inventions.

    So Physician Assistants are back on an agenda which Ian (and I) were exploring almost 20 years ago. Nurses and Associate Nurses are being grown through apprenticeship schemes in primary care. People who have entered the workforce as Health Care Assistants or Domestic Workers are enabled to qualify as nurses: A workforce for a community from that community!

    Faced with the collapse of a Practice through retirement of the doctors, the response was to recruit Urgent Care Practitioners (e.g. http://www.careukhealthcare.com/healthcare-jobs/healthcare-professional-jobs/urgent-care-practitioner-paramedic-practitioner-north-east-essex-HC05641).

    In other situations Wellbeing Practitioners are employed to promote health and healthy life-styles http://www.iapt.nhs.uk/silo/files/psychological-wellbeing-practitioners--best-practice-guide.pdf

    Adrian O’Dowd has recently reviewed such initiatives in ‘Home run for integrated primary care?’ BMJ 2016: 353: i2922 doi: 10. 1136/bmj. I2922

    These developments are being explored in 70 centres and will be carefully controlled and evaluated. It is great to learn about new thinking and its application to counter gaps in the care system. It is frustrating that there is a mismatch between what the population needs and what the workforce and service structures prefer to do. New growth which matches and anticipates need is invigorating. Within this movement is a realisation that people are sensible and well educated and are keen to be helped to share responsibility for their own health – in its genesis and in coping when it breaks down in the face of pathology. First recourse for additional help will always be family. But there is a limit to what people can do without expert professional support and treatment.

    The essence of the Gnosall Memory Service is to bring Specialist Psychiatric Expertise into Primary Care – to work with GPs and other healthcare professionals to identify, treat and support people with dementia and related conditions and their families. The Elder Care Facilitator role works well because it is embedded in a competent professional team and the whole is known by and trusted by local people. This is not a question of ‘barefoot doctors’ out on their own and without highly qualified support and direction. It will be important that these new related models cultivate and nurture similar discipline and respect between their component parts.

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    Aducanumab 07 September 2016 | Comments (0)

    ‘Tantilising signs that new Alzheimer’s drug could benefit early stage patients’ says Ian Semple in the Guardian August 31st. Thank goodness for the pointers the Guardian provides, there are so many initiatives to follow and the daily paper offers an easy and reliable filter.

    There had been some inkling of this in conversations with colleagues in recent weeks – the costing of treatment and services for people with dementia have been fairly well mapped out – but there was/is the prospect of something new, different and potentially very expensive on the horizon.

    Well here it is. The paper published in Nature – perhaps the most prestigious of journals – 1st September 2016 (537) 50-56, has 28 authors from institutions in the USA and Switzerland. It describes a study which involved 165 people with a diagnosis of ‘prodromal or mild Alzheimer’s disease with brain A_beta pathology confirmed by molecular PET imaging. They were treated with monthly infusions containing Aducanumab which is a human monoclonal antibody that has been shown to cross the blood-brain barrier. In mice it had been shown to clear away A_beta aggregates (amyloid).

    The trial in these 165 people was designed initially to explore ‘safety, tolerability, pharmacokinetics and pharmacodynamics’ but the results reported here go further than this.

    PET images show impressive clearance of amyloid plaques after one year – the clearance being most emphatic with dosage of 10mgm kgm-1 but evident at 3mgm-1 and 6mgm-1

    Adverse effects appear to be minimal in comparison with placebo.

    But the greatest interest focusses on clinical measures of cognition: MMSE showing falls of 2.81 points for the placebo cohort (32) within the year – people receiving active infusions of Aducanumab had falls which were significantly less at p <0.05

    CDR-SB showed similarly less deterioration of cognition for those receiving active treatment through the year.

    This is all amazing. The amyloid hypothesis has been with us for many years and massive investments have been made world-wide seeking therapies based on this. My understanding has been that other projects have shown it is possible to clear away amyloid but this has not been associated with improved outcomes of cognition. It has seemed that all that investment had been misdirected. Here is a careful study from respected sources which breathes new life into the hypothesis and gives new hope for people who develop Alzheimer’s disease.

    The implications for modes of clinical investigation and treatment costs and ethics are hard to cope with.

    For people living with dementia now and for their families, this paper will arouse agonies of wondering that they were born too soon.

    For people anxious that their memory , or the memory and behaviour of a loved one, is deteriorating it will raise concerns even further and is likely to escalate demands for additional investigations, earlier and costlier. Findings from such investigations will not proceed to treatment beyond those already licensed because this one-off small study, reported beyond its original design ambitions, is at odds with previous investigations based on the same hypothesis and the findings need to be replicated in much bigger studies.

    Something else for us to think about.

    Today I am reading about nanoparticles in the brain – air pollution and its consequences.

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    30th August 2016 | By David Jolley

    After the days of clinging heat and sun it was wonderful to walk with the dogs along the path between trees which goes down to the golf course. After 5pm on a Friday and not much action on the course. The pebbled path is home to puddles after the rain and droplets from an earlier shower cool and freshen the air and add to the feeling of descending a tamed mountain stream.

    Time and freedom in our parks and green spaces are joys and balm for those living in towns and cities.

    We had heard earlier in the week that the body of a man had been found, murdered, near Speakers’ Corner in Hyde Park, in the early hours of Friday morning. The body proved to be that of Jairo Medina who had been recognised for his excellent work as a carer of Joe Behrens http://alzheimersshow.co.uk/blog/2014/05/06/joe-behrens-is-93-years-old-dementia-doesnt-restrict-my-life/ with the Margaret Butterworth award 2015. A young Egyptian man of no fixed abode – does that mean ‘homeless’? – has been arrested and accused of his killing.

    Jairo Medina

    So the freedom and therapy of the park is transformed to a scene of devastation: one splendid person can continue his work no more. Another person is under scrutiny – thrown into public light from anonymity by such a desperate occurrence. No doubt we will learn quite how they came together on that night and maybe motives will become apparent. We take our deepest thoughts and feelings to quiet places of nature. There is danger in depths and passions.

    The need for care arising from dementia is confirmed. The skilled and dedicated work of unsung people is given a little bit of sunlight. The example which Margaret Butterworth gave is appreciated. Unexpected dangers are seen.

    My personal struggles this week have included an exchange with Professor David Oliver on the matter of NHS Continuing Health Care www.bmj.com/content/354/bmj.i4214/rapid-responses.

    It is a matter where we reveal our defining values and is one where I think Professor Oliver and I would wish to agree – but somehow this is not how it has seemed.

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    15th August 2016 | By David Jolley

    ‘Golden’ is Black Country for anything which is wonderful, as in ‘He was Golden’ – from a widow remembering a much loved husband.

    Friday took us to Warburton Street in Didsbury – tucked away and still with its cobbles, but much tidier and to a degree more limited than it was in the 1970s. Then Eric Morten was still publishing his books on local history. The book shop no longer straggles the two sides of the street and the pavement display of second hand books is constrained to one table instead four of five. But it is still a special place and Number 4 is just right for lunch with special friends from the 1970s.

    B is now a Dame and D a retired Professor – both still active in responsible roles, as are their spouses. It is just good to know that these lovely honest human beings are still so much themselves – as are we, we trust – interests in families, other friends, the health of the locality as well as the nation.

    Is that why I am digging this morning? – ridding beds, which might be home to flowers, cut into the grassed area which is the Manchester Road Corner across from The George and Dragon and The Wheatsheaf, of the weeds which have taken hold following a tentative bid to plant them by another voluntary group who have found the task beyond them.

    These challenges and our responses to them are what defines us, what defined us in the 1970s and still runs true. Defined Rob Jones who worked with B before both came to spend time with us – marvellous fusion of spirits in causes which have remained related if not identical.

    The key has to be to put your hands on, risk getting them dirty, and use the received wisdom and restrictive rules of the time with a pinch of salt. That is how I see our Dementia Conversations initiative, and that’s the point of the spade in my hand this morning.

    A lady stopped to say thank you. ‘I am retiring next week. I shall come and join you’. A taxi driver drew up and came over. He had words of advice and pointed us to a similar initiative he’s seen in another part of the town.

    It is catching .....

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