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Young onset dementia (YOD), defined as dementia diagnosed under the age of 65, presents a particular challenge to services to provide the right care and to clinicians to make an accurate diagnosis. Three leading experts, Alistair Burns, Janet Carter and Jeremy Isaacs provide offer an insight on the latest developments in this area of work.
Current figures suggest that there are 44,000 people with YOD in the UK. The national Dementia Diagnosis Rate counts those over 65, (over 97% of those on the register) with figures about the number of people with YOD available to clinical commissioning groups (CCGs). This way of measuring the number of people with dementia records only current age and does not record people who were diagnosed when aged under 65 and then ‘graduate’ with their illness.
Unlike late onset dementia in which the commonest causes are Alzheimer’s disease, vascular or mixed dementia, YOD is more often due to rare causes, unusual presentations of the common dementias and genetic causes. Indeed, memory problems may not always be the main complaint. People with YOD have a higher likelihood of behavioural problems such that misdiagnosis as a psychiatric condition is not uncommon.
As these rarer causes of dementia are often more difficult to diagnose, there is often a delay to diagnosis – said to be on average twice that of those with late onset disease, and on average, each younger person sees between two and five different consultants before a diagnosis is made.
Understanding the cause of dementia in a younger person is quite rightly relatively intense and more specialist investigations including brain scans and laboratory tests are necessary.
However, it is worth remembering that the majority of younger adults who report memory complaints do not have dementia but are likely experiencing poor concentration and difficulties with attention, often caused by depression and anxiety. It would be inappropriate to subject these individuals to needless and expensive investigations. Therefore, deciding who to investigate and who to reassure can be challenging.
There is good evidence, as with other conditions, that specialism results in a more timely diagnosis, which is particularly important for younger people with dementia. Many traditional memory clinics will be able to provide specialist care for younger people, for example by having a clinician with a particular interest in YOD diagnosis, or by working collaboratively with a specialist cognitive neurology service.
After diagnosis, local services providing age-appropriate aftercare and expertise in managing behavioural problems are essential. People with YOD have distinctive needs due to their age and stage of life. Some of the clinical issues may include the presence of young children, a desire to carry on working, having the option for meaningful social activities and coping with financial commitments when unable to draw a pension and lost earnings. These needs are not currently specifically addressed by mainstream dementia services.
A recent survey of UK memory services showed that, of those who responded, one in three provided no post-diagnostic support services for people with YOD, one in three provided no age-specific occupational or social groups, only 11% identified local short-stay (respite) facilities and only 14% identified local long-term residential care.
While services that are tailored to older people may be able to provide safe and effective care to younger people with dementia, people living with YOD, not surprisingly, often express a preference to have bespoke services.
There are two things that could be done which may help to improve the situation – one clinical and one commissioning.
First, from a clinical perspective, increased awareness of the symptoms of young onset dementia would be helpful. At the very least, thinking about the red flags which alert clinicians to the possibility of dementia in a young person might be helpful, mindful of the adage that if you don’t think about it, you will never diagnose it. The YOD Network at firstname.lastname@example.org has a wealth of information about the condition.
Second, commissioners could consider, as part of their dementia plans, a bespoke piece of work on YOD (we know it is an area of interest and many have done this already). It may be that an STP footprint will be helpful in guiding thoughts. As part of this, a copy of the young onset dementia care pathway can be found here.
The Memory Service National Accreditation Programme (MSNAP) also has new standards for memory services in relation to younger people.
Among examples of those who provide expertise in the field, the Havering Memory Service is a community-based psychiatry-led service that has a clinician with a specialist interest in YOD and provides bespoke post diagnostic support and St George’s Hospital provides a regional cognitive neurology service that has developed bespoke post-diagnosis support for people living with YOD.
We would welcome comments on this topic (email@example.com) and depending on the appetite stimulated can take things forward. In the meantime, to find out more about, or join, the Young Dementia Network visit www.youngdementiauk.org