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Epidemiological Profile of Dementia in England - Health Information & Health Informatics Assessment Answers

November 12, 2018
Author : Julia Miles

Solution Code: 1EICC

Question:

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Health Information and Health Informatics Assignment 2016 This assignment is designed to demonstrate your knowledge and skills in the field of health information and health informatics.

Tasks (Part A and Part B)

Part A (1) Write an epidemiological profile of dementia in England (approximately 1750 words: 65%

of marks) (If you want to write about another country this may be acceptable but if so please check with Krish Nirantharakumar (K.nirantharan@bham.ac.uk) that sufficient information is available for you to prepare a reasonable assignment. You MUST obtain his agreement to using another country before starting this assignment.) Cite fully all sources used, including giving the URL for web based resources and full references for published sources of data. A standard referencing style such as Vancouver or Harvard should be used. To pass this part of the assignment you need to do the following (not necessarily in this order):

  • Define dementia and report its associated ICD-10 codes* . Explain briefly how the condition is diagnosed* . Give a brief description of its pathology, aetiology, symptoms, and treatment*
  • Provide a brief description of the prevalence of dementia in England*

Compare disease frequency/occurrence in England to that in other countries (developing and developed) Present data from England (e.g. hospital admissions, primary care activity, and general population data) and consider their reliability Compare frequencies/occurrence in different regions of England Describe how frequency/occurrence varies with age, sex, and ethnic and socio-economic groups Describe long term and more recent trends

Finish your report with a bullet point summary (No more than 8 bullet points)

You must use a wide range of sources. For each source of epidemiological data that you use, discuss its strengths and weaknesses and explain precisely what it is describing.

The aim of the exercise is to give a concise picture of this condition. Be clear about the overall story you are trying to tell. Select information, charts and tables to support and illustrate your report.

Part B

(2) You are the public health lead for chronic diseases in your health authority. The local patch you

work in has a high number of dementia-related healthcare costs, which have been rising over the last five years.

You have been asked for your expert views on establishing digital interventions for the local population with the hope of improving care provided to these patients, and assisting their carers. The intervention could be applied in both primary and secondary care, care homes or the community more generally.

Your task is to:

By citing evidence from the literature discuss the potential merits and challenges in establishing such a service (approximately 750 words: 35% of marks) Ensure you identify your evidence sources, cite relevant studies and reviews and briefly comment on their quality, provide specific details of potential benefits and identify challenges with respect to implementation

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Solution:Health Information and Health Informatics

Part A: Epidemiological Profile of Dementia in England

Introduction

Dementia is a clinical syndrome associated with a decline in brain functioning, which is both depressive and chronic (NHS Choices 2017). The International Classification of Diseases (or ICD-10) classifies dementia using the codes F00 to F03. (ICD-10 2007), and any information presented on Dementia should follow the same definition. There are some different types of dementia which include; Vascular Dementia, Lewy Body Dementia, Alzheimer's Disease and Frontotemporal Dementia amongst others. Alzheimer’s disease, as the most common form of Dementia, has its ICD-10 code: G30.

Progression of the disease happens because of changes to the brain cells, either through deterioration of the blood supply to the brain (Vascular Dementia), or plaques and proteins (Lewy Body and Alzheimer’s).

The symptoms of dementia depend on the stages of dementia. Early stage symptoms are common signs such as forgetfulness and repeat questioning. Late stage, patients can become aggressive, unaware of the time and their surroundings, unable to recognize people and need professional personal care support for day-to-day tasks (Kansagara and Freeman 2010; World Health Organization 2016).

How Dementia is Diagnosed and Treated

As dementia is a syndrome (which is to say a set of related conditions that present the same or similar symptoms), there is no single test that can establish a diagnosis. Standardised memory tests are often used (MMSE) but memory loss and cognitive decline are not the only symptoms, and such tests would not identify every case of dementia and may also falsely identify other conditions like dementia. There are other specific symptoms also that should be taken into consideration includingbehavioural change, irritability, the apathy of social skill, and emotional liability. Brain scans and blood tests can also be used to assist in diagnosis or rule out other conditions but it is mandatory to evaluate the history properly to eliminate the differential diagnosis (Iliffe et al., 2005).

There is currently no cure for dementia, but drug treatments can slow progression. Donepezil, rivastigmine, galantamine or Memantine can be prescribed, depending on severity(Alzheimer’s Research UK, 2016; World Health Organization 2016). People who have dementia are usually admitted to the hospital for the management of other associated conditions such as respiratory diseases and injury rather than dementia (Natalwala et al. 2008). These people account for around 3.2 million bed-days annually in a hospital (Boaden 2016).

Dementia in England

In England, Dementia is an underdiagnosed burden. Knowing this, the government started utilizing a method called the Expert Delphi Consensus to create the best estimates of the number of people living in England with dementia in 2007. This was done through a systematic review and an expert panel. This showed that only 42% of people estimated to have dementia were diagnosed between 2010 and 2011 (Parkin and Baker 2016). It is therefore difficult to give a true prevalence figure for dementia because of underdiagnosis.

NHS Digital ‘collect and publish data about people with dementia so that the NHS (GPs and commissioners) can make informed choices about how to plan their services around their patient's needs.' (NHS digital 2017). It is based on GP records and probably the most reliable source of data in England and Dementia; it is part of the Quality Outcomes Framework (QoF) as well as government targets to increase the diagnosis rate. The project "Prime Minister's Challenge on Dementia 2020" initiated in 2015 to increase research, care and public awareness about dementia in England increased the diagnosis rate to 67% in March 2016 (Parkin and Baker 2016). Potentially there could still be inaccuracies with recording and coding of illnesses within Primary Care however in the absence of other or more accurate primary data sources this has been utilized to provide recorded prevalence and as the basis for estimates of prevalence including undiagnosed dementia.

Latest data from October 2017 estimated that there are 642,876 people over 65 living with dementia but 440,745with a diagnosis recorded at GP practices. This is a diagnosis rate of 68.6%, which is broadly the same as the figure reported above.

The official England statistics in this report all use people diagnosed, so all of them are likely to be lower than the true number. However, it is the most accurate information available. The difference is shown in the graph which shows estimates compared to diagnosed. As demonstrated over the past 12 months recorded and estimated dementia prevalence is relatively flat. However, year on year this is a different pattern; the number of people with dementia is expected to increase to 850,000 by 2021 (Boaden 2016). It could be argued that this is merely reflective of increased life expectancy and the increase in the prevalence of dementia within older age groups, as examined in more detail later.

Ethnicity

The recorded prevalence information described above also includes ethnicity data which is shown in the following graph below. However, three quarters of people in the data do not have their ethnicity recorded. This is probably due to poor recording of practices. The majority of patients with dementia whose ethnicity we do know are white; followed by Asian, Other and Black. But this might be different if ethnicity was recorded properly. Again this is the best available but should be used carefully.

Age and Sex

Dementia is commonly categorized into two types including early onset dementia (i.e., before 65 years-old) and late-onset dementia (i.e., 65 years-old and over) (Vieira et al. 2013) and late-onset dementia is most common. Early onset dementia is lower in women than in men aged 50–65, while late-onset dementia is marginally less common in men than in women and there is literature that would support this as being plausible (Parkin and Baker 2016).

The graph shows how dementia increases as people get older, for both men and for women. It shows that up to 75 to 79 it is the same for both sexes but after that, there are more cases of dementia in females than males and the gap gets bigger. 21% % of women have a diagnosis by aged 90+ compared to 14% men. The difference is even wider with the estimates.

Regional Differences

The graph below shows that dementia prevalence varies across England. It is highest in the North East and lowest in the South West. The west midlands East, South East and south-west are smaller than England, and the others are higher. The data which is used from Fingertips comes from QoF/NHS digital so should be reliable. The differences could be down to other things than just where the person lives. It might be there are more or less elderly people than other regions or better diagnosing in different areas

Socioeconomic Groups

Data from Fingertips (PHE 2017) shows recorded prevalence of deprivation deciles. This is all of the areas in England in order of how deprived they are divided into ten groups. It shows that Dementia is less common in the least deprived areas and more common in the more deprived areas. This is plausible as deprivation has repeatedly been linked with many adverse health outcomes at a population level.

Prevalence of dementia compared to Other Countries

This syndrome is a global public health issue. As per the report issued by World Health Organization 2016, 47.5 million of individuals have been diagnosed with dementia worldwide with the incidence of 7.7 million new cases per year.

In 2009 Alzheimer Europe undertook a systematic review of peer review articles and reports paper on the dementia prevalence in Europe. They reported that prevalencefluctuates between 5.7% and 21.9% across European countries. The map below is the visualization tool from the Global Burden of Disease Study (IHME 2017) which is considered to be one of the most comprehensive studies available. It shows how dementia varies across the world for Males. (Females is also available and is similar).

It is highest in parts of SouthAmerica and Turkey. It is lowest in sub-Saharan Africa and India. England lies towards the lower end of the scale internationally, as is the case for most developed nations when compared to low to middle-income countries. The Prevalence rate shown on the map is it is age standardized so should account for different age structures.

Comparison of prevalence data of dementia between countries and regions is difficult and less precise due to several issues, and thus, results must be interpreted with caution. This can be due to the difference recording and health systems and in using data to synthesize information.

Summary

Dementia is a global public health problem as 47.5 million people have been diagnosed with dementia and with an annual 7.7 million new cases.

Dementia is underdiagnosed in England according to estimates. It is thought around 67% of cases are diagnosed according to latest data.

Prevalence of dementia increases with age, and there are more very elderly women than men living with dementia.

It appears that prevalence has an association with deprivation as dementia is less common among the least deprived.

Ethnicity is poorly recorded with lots of missing data. However, it seems to show that dementia is more common in white people than other ethnic groups.

Dementia prevalence varies across England. This could be due to some factors including the age of the different populations.

It is difficult to compare rates in different countries due to different recording and healthcare systems.

Part B

Dementia is a global health problem affecting a large number of populations and creating a high monetary burden on the society. It is speculated that the £19 billion is spent annually on the services related to the care of the dementia patients (Parkin and Baker 2016). This amount is higher than the treatment cost of cancer, stroke and heart disease. The prevalence and financial implications are that small effects on cognitive decline, or on the incidence of clinical dementia, may have a significant impact on healthcare costs and the overall burden of dementia to society and individuals with the disease (Gates et al., 2016). A person who has dementia loses the ability to live autonomously as their worsening condition forces them to depart from active participation in workplace, society, and home. Eventually, they required assistance from family members, carer, and physician. After considering the treatment modality, recently digital health interventions (DHIs) are utilized to relieve the healthcare burden of medical institutions by enhancing individualized care through positive behavior change theory (Pagoto and Bennett 2013). A literature review of the topic on general effect of DHIs focusing on web-based strategies is conducted based on the search of Cochrane Library. Broad search as performed with the keyword "digital intervention." Peer-reviewed papers were subsequently found manually to identify documents focusing on web-based strategies. The search was then repeated by using both two critical words including digital intervention and dementia to examine the specific effect of DHIs on dementia.

It is reported that the DHIs can be used in any setting including primary and secondary care, care home, and the general community can help in improving care for patients with dementia and assisting their caregivers in England. Several initiatives have been conducted to evaluate the effect of this on the cure of mental disease worldwide (Digital Dog 2015, Center for Digital Health Interventions 2017). DHIs, include monitor devices, mobile phones, email, web-based strategies, and telemedicine for early diagnosis with accuracy (Widmer et al. 2015). The advantage of remote monitoring is that people with dementia can live independently and can stay at home independently. This monitoring device gives the accurate information about the patients' physical activity and sleep pattern; the information is reliable too. Through DHIs it is now possible to tailor the treatment modalities for good quality of living. The system can be used as to monitor the daily activities of the patient, to ensure the safety of the patient. The audio and video sensors can be set near the bed and around the patients to measure anxiety and stress levels. DHIs can easily monitor by the carer and clinicians (Digital Single Market, 2015). In 2005, Murray et al. opine that the Interactive Health Communication Applications has the positive impact on the users as compared to the non-users. The users have had an essential knowledge, feel better socially supported and improve behavioral and clinical outcomes. In detail, IHCAs had a positive effect on knowledge (standardised mean differences (SMD) 0.46; 95%CI 0.22 to 0.69), social support (SMD 0.35; 95% CI 0.18 to 0.52) and clinical outcomes (SMD 0.18; 95% CI 0.01 to 0.35). IHCAs also have a positive effect on self-efficacy (SMD 0.24; 95% CI 0.00 to 0.48) and continuous behavioural outcomes (SMD 0.20; 95% CI 0.01 to 0.40).

Devi et al., in 2015 conducted a systematic review to evaluate the effect of internet-based supported programmes for people with the heart disease. The authors concluded that the there is no as such positive impact on the health condition of the patient. There is no evidence of the decrease rate of mortality associated with the heart patient. The study was based on the small number of the studies i.s six studies. The cost of the intervention and setup cost was not discussed by the author (Devi et al. 2015). No useful information can be gathered from this article as limited and low-quality evidence was selected by the author.Similarly in (Fleming, R. and Sum, S., 2014.), a total of 232 papers were identified as potentially relevant, and 41 of those met the criteria, the findings highlighted studies in the area are usually limited by very small samples, high drop –out rates, very basic statistical analyses and lack of adjustment for multiple comparisons and poor performance of the technology itself. Further in (Nicole Coates et al., 2015), again findings show that several systematic reviews have indicated the computerised cognitive training (CCT) could be effective in people with mild cognitive impairment (MCI) and dementia, but reviews have reached inconclusive and mixed results, and have refrained from pooling data into a meta-analysis, so an appetite in the specified area maybe that further studies are conducted which may show something more conclusive. (Powell etal., 2008), again highlighted that outcomes were inconsistent but suggested that the interventions had moderate effects.The DHIs can be the efficient method for the mild case of dementia, as the digital monitor system can help in early diagnosis. For the severe cases, it cannot be as such efficient as the patient requires the assistance and care of others. DHIs can give reliable information about the condition of the patient to the carer as well as the physician too. Although studies on dementia have been found these are cleary inconclusive, a pilot study will provide more information on the specific effect of IHCAs on people with dementia and their carers as well as the cost-effectiveness of the programs.

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