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Is this a new era for dementia?

The current national and international focus on dementia has been widely welcomed as a vehicle to raise the profile of, and attract attention to, what has been a hitherto relatively neglected area of scientific interest and clinical practice.

Now, rarely does a week go by without a news story concerning dementia – a research breakthrough, a new technique of care, a human interest story and, unfortunately, an example of where care has fallen below an acceptable standard.

The overarching tale is that this is an illness for which there is no effective treatment. Some drugs are available for Alzheimer’s disease, the commonest cause of dementia, which are of benefit but there is still significant therapeutic nihilism around.

The news a few weeks ago of the putative efficacy of a disease modifying treatment for Alzheimer’s disease has ignited widespread public, professional and political interest and enthusiasm.

Solanezumab (Sola or Solab for short) is a monoclonal antibody directed at the amyloid protein that is regarded by many as being the core pathological abnormality causing cell death, brain shrinkage and ultimately clinical symptoms. Current treatments ameliorate the downstream effects by modulating neurotransmitters and offer symptomatic benefit. Changes to amyloid offer a more fundamental approach in altering the progression of the illness (stabilisation).

The results from a clinical trial were presented at a major international meeting of an open label extension of two double blind placebo controlled trials in patients with mild to moderate Alzheimer’s disease. Although these were negative a further analysis showed that people with mild Alzheimer’s disease had significantly slower progression of their symptoms compared to placebo.

The open label extension publicised gave a total of three and a half years’ worth of observation and showed a reduction of about one third in the expected decline in memory. Another phase three trial in people with mild Alzheimer’s disease is expected to report at the end of 2016 which will give a more definitive answer as to the efficacy of the treatment.

Should we feel the hand of history on our shoulders?

Considering the lack of efficacy of existing treatments for Alzheimer’s disease anything that shows evidence of potential benefit such as this is to be applauded. Testimonials from individuals anxious to be started on treatment are pre-emptive and realistically the availability of the treatment will be some years away.

If further trials prove positive it is likely to benefit a defined group of people with mild Alzheimer’s disease, probably those with evidence of amyloid abnormalities (detected by brain scans or lumbar puncture).

The challenge for the NHS and for professionals involved in the assessment, diagnosis and treatment of people with Alzheimer’s disease is to think ahead by gearing up for a fundamental change in the way the disorder is approached. Solanezumab is given as a monthly infusion, a simple invasive procedure compared to others in neurology but a new venture for many old age psychiatrists. The opportunities and challenges are threefold.

First, it takes the practice of dementia to another level with a potential treatment that could change the way we think of and consider disease. How did it feel when the first drugs to treat cancer were introduced, or the antipsychotics or the first antidepressants?

Second, there is a professional challenge for practitioners involved in dementia to work closely together – specifically psychiatry and neurology – which does not sound a lot to ask in view of the shared interest in brain function of the two disciplines. The relationship should be raised above those personal associations which so often make big changes to practice.

Third, people in the public eye driving interest and awareness of dementia have a responsibility to take a measured approach, this is not to dampen enthusiasm or to curb hope but it will be a long time before a readily available treatment will even halt let alone improve the symptoms of many people who have dementia.

The one simple message is we should be gearing ourselves up for a change – and not before time.

Professor Alistair Burns

Professor Alistair Burns is Professor of Old Age Psychiatry and Vice Dean for the Faculty of Medical and Human Sciences at The University of Manchester. He is an Honorary Consultant Old Age Psychiatrist in the Manchester Mental Health and Social Care Trust (MMHSCT) and is the National Clinical Director for Dementia and Older Peoples’ Mental Health, NHS England.

He graduated in medicine from Glasgow University in 1980 and trained in psychiatry at the Maudsley Hospital and Institute of Psychiatry in London. He became the Foundation Chair of Old Age Psychiatry in The University of Manchester in 1992, where he has been Head of the Division of Psychiatry and a Vice Dean in the Faculty of Medical and Human Sciences, with responsibility for liaison within the NHS. He set up the Memory Clinic in MMHSCT and helped establish the old age liaison psychiatry service in UHSMT. He is a Past President of the International Psychogeriatric Association.

He is Editor of the International Journal of Geriatric Psychiatry and is on the Editorial Boards of the British Journal of Psychiatry and International Psychogeriatrics. His research and clinical interests are in mental health problems of older people, particularly dementia and Alzheimer’s disease. He has published over 300 papers and 25 books.

Professor Martin Rossor

Professor Martin Rossor trained in Neurology at the National Hospital, Queen Square and undertook research into the neurochemistry of degenerative dementia at the MRC Neurochemical Pharmacology Unit, Cambridge.

He is honorary consultant neurologist at the National Hospital for Neurology and Neurosurgery where he established the specialist cognitive disorders clinic which acts as a tertiary referral service for young onset and rare dementias. Clinical research interests are in neurodegenerative disease and particularly in familial disease.

He is the NIHR National Director for Dementia Research, Director of the NIHR Queen Square Dementia Biomedical Research Unit and a NIHR Senior Investigator.

He was Director of the NIHR Dementia and Neurodegenerative Disease Research Network (DeNDRoN) from 2005-2014, Editor of the Journal of Neurology, Neurosurgery and Psychiatry 2004-2009 and President of the Association of British Neurologists 2011-2013.

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