Editorials depletion,7 but delusions are linked to relative preservation of the parahippocampal gyrus,8 while aggressive behaviour is related to abnormalities of serotonergic function.9 As these phenomena are disparate, they may respond to different agents or different doses of the same agents. In practice many patients with dementia have more than one type of behavioural or psychiatric symptom, but it should be possible to undertake separate studies focusing on common disturbances such as aggression or psychosis when they are clinically important and represent the most problematic behavioural or psychological symptom for that individual patient. Most intervention trials for behavioural or psychological signs in dementia have a duration of less than three months. In this time frame low doses of neuroleptic drugs are well tolerated, but the issues of longer term efficacy and safety are not addressed. For example, one prospective study following a research cohort of patients with dementia has suggested that neuroleptic agents might hasten cognitive decline,2 while another found no differences in the persistence of psychotic symptoms over one year in patients taking or not taking antipsychotic medication.10 Furthermore, the high placebo response rates5 and the spontaneous resolution of psychotic symptoms within three months10 among many sufferers indicates that a substantial proportion of patients may not require pharmacological treatment. Clinical trials, mainly with an open design, have also been undertaken with a wide range of nonneuroleptic treatments including anticonvulsants and trazadone, as well as non-pharmacological treatments such as carer training or sensory inputs.11 Again these trials have generally been small and have clustered together different behavioural and psychological signs. In the few preliminary studies which have been conducted carbamazepine and trazadone appear to be as effective as neuroleptics,11 although the main areas of improvement are agitation, aggression, and restlessness, rather than psychosis. Encouraging data are starting to emerge from the secondary analysis of trials involving cholinesterase inhibitors, suggesting that 50% or more of patients with psychotic symptoms experience improvement.11 Placebo response rates are, however, high, and the patients were recruited because of cognitive impairment not because of psychotic symptoms. Although this does not constitute evidence of efficacy, it indicates the need for specific intervention trials.
Dementia is a common condition, and sufferers have a particularly high risk of adverse treatment responses, so it is important to have clear evidence that treatments are both effective and safe. There is an urgent need for double blind trials focusing on specific behavioural or psychological signs in dementia, with designs that allow for the high rates of spontaneous remission, especially studies using cholinesterase inhibitors and non-pharmacological intervention strategies. Given current knowledge, unless symptoms are extremely distressing it would seem appropriate to monitor the disturbances for at least one month before starting pharmacological treatments. The monitoring period allows time for spontaneous resolution, while psychosocial interventions may facilitate better practical management or evoke key elements from the very pronounced “placebo” response. Better evidence is required before individual pharmacological agents are licensed specifically for managing behavioural or psychological signs in dementia. Clive Ballard MRC clinical scientist-senior lecturer in old age psychiatry John O’Brien Senior lecturer in old age psychiatry Newcastle General Hospital, Newcastle upon Tyne NE4 6BE (
[email protected])
JOB has received a research grant from Pfizer while JOB and CB have jointly received a research grant from Eli Lilly. CB acted as principal investigator for a recent trial of quetiapine for Zeneca and acted as a member of an advisory committee for Janssen.
1
Ballard C, Oyebode F. Psychotic symptoms in patients with dementia. Int J Geriatr 1995;142:202-11. 2 McShane R, Keene J, Gedling K, Fairburn C, Jacoby R, Hope T. Do neuroleptic drugs hasten cognitive decline in dementia? Prospective study with neuropsy follow up. BMJ 1997;314:266-70. 3 McKeith IG, Fairbairn A, Perry R, Thompson P, Perry E. Neuroleptic sensitivity in patients with senile dementia of Lewy body type. BMJ 1992;305:673-8. 4 Current problems in pharmacology. CSM Update 1994;May: 20-6. 5 Schneider LS, Pollock VE, Lyness SA. A metaanalysis of controlled trials of neuroleptic treatment in dementia. J Am Geriatr Soc 1990;38:553-63. 6 Burns A, Craig S. Neuroleptics in the treatment of Alzheimer’s disease. Neurobiol Ageing 1998;19 (suppl 4):450. 7 Perry EK, Marshall E, Kerwin J, Smith DJ, Jabeen S, Cheng AV, et al. Evidence of monoaminergic; cholinergic imbalance related to visual hallucinations in Lewy body dementia. J Neurochem 1990;55:1454-6. 8 Förstl H, Burns A, Levy R, Cairns N. Neuropathological correlates of psychotic phenomena in confirmed Alzheimer’s disease. Br J Psychiatry 1994;165:53-9. 9 Palmer AM, Francis PT, Benton JS. Pre-synaptic serotonergic dysfunction in patients with Alzheimer’s disease. J Neurochem 1987;48:8-15. 10 Ballard CG, O’Brien J, Coope B, Fairbairn A, Abid F, Wilcock G. A prospective study of psychotic symptoms in dementia sufferers: psychosis in dementia. Int Psychogeriatrics 1997;9:57-64. 11 Ballard CG, Gray A, Ayre G. Psychotic symptoms and behavioural disturbances in dementia: a review. Revue Neurologique (in press).
Saving lives or sustaining the public’s health? The English white paper is stronger on disease than it is on health
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ngland’s long awaited public health white paper, Saving Lives: Our Healthier Nation,1 has finally appeared over a year after publication of the green paper.2 The British prime minister has written the foreword and 12 ministers have signed the preface—symbols of the relative importance of the health strategy and the importance attached to cross 17 JULY 1999
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government working. But the title, Saving Lives, the headline target to prevent 300 000 deaths, and the proposal to introduce defibrillators in public places seem to emphasise narrow, disease based health care over wider public health concerns. The four priority areas remain the same as in the green paper: coronary heart disease and stroke; 139
Editorials cancer; mental health; and accidents. More challenging targets have been set in some areas, such as suicide and undetermined injury, and there is a greater emphasis on health in later life. Some major new public health initiatives are proposed to improve the quality of the public health function. The Health Education Authority will be replaced with a Health Development Agency that will act as a public health equivalent of the National Institute for Clinical Excellence, the body charged with ensuring evidence based practice within the NHS. In addition, there will be a public health development fund and regional public health observatories to monitor progress on reducing health inequalities. The specialty of public health will be opened up to those without medical training, and there will be a national development plan for public health staff such as health visitors, midwives, and school nurses. Strengthening the public health function will be the subject of a separate paper. There is much in the white paper to welcome. Some of the views expressed during the consultation period have been taken on board—for example, a stronger position on fluoridation has been adopted— and account has been taken of the findings of two studies commissioned to review the previous English health strategy, the Health of the Nation.3 In particular, the proposals to strengthen research and development in public health are an important advance— the new Health Development Agency will provide a much needed evidence base for the new strategy by producing guidelines for health programmes and evaluating and disseminating research on public health. Although expected, the absence of a target to reduce health inequalities is nevertheless disappointing. One of the aims of the strategy is to “reduce the health gap,” but the government argues that “many of the underlying causes will take a generation or more to work through.” The difficulties in converting a desire to reduce inequalities into an achievable target have been acknowledged,4 but the task is not impossible. For example, target 2 of the World Health Organisation’s European region’s Health 21 strategy (to which the United Kingdom is a signatory) states, “By the year 2020, the health gap between socioeconomic groups within countries should be reduced by at least one quarter in all member states, by substantially improving the level of health of disadvantaged groups.”5 This has symbolic importance rather than practical application, but targets act as an important marker of a government’s priorities and provide motivation.6 Furthermore, a range of principles for setting targets on inequalities has been proposed elsewhere and other countries have set equity targets.7 The government has published a separate report,8 accompanying the white paper, setting out how it aims to reduce inequalities in response to the Acheson inquiry on health inequalities.9 The response describes in detail government policies which address each of Acheson’s 39 wide ranging recommendations. While the breadth of the response is laudable, some will argue that current and planned policies do not go far enough. Most important, it remains to be seen whether this cross government action, to which the government is committed at all levels, will reduce health inequalities. 140
The proposed new targets in the white paper have taken into account the calls for more emphasis on health in later life. For example, targets to reduce coronary heart disease, stroke, and cancer now include those aged 65-74 as well as those aged under 65 years. But the priority areas and targets remain primarily disease based. Our review of the Health of the Nation found that the predominance of the medical model underlying the strategy was a major barrier to its ownership by agencies outside the health sector, notably local government and voluntary agencies.3 However, the new post of specialist in public health, equivalent to a consultant and open to a range of disciplines, rightly recognises the multidisciplinary nature of public health. There is an argument that local government rather than health authorities should lead in the local implementation of a national public health strategy. But the government wishes to retain a lead role for the NHS, with for instance, responsibility for health improvement programmes remaining with health authorities. Implementation of Saving Lives will therefore be monitored through separate performance assessment arrangements for the NHS and local government. Though such monitoring is welcome, it leaves open the question of how joint action is to be monitored. The lack of effective monitoring of the implementation of the Health of the Nation strategy was one of its main weaknesses.3 If the new strategy is to succeed central government must provide a clear lead across the whole range of policies which affect health. In this respect, the development of health impact assessments at national and local level is particularly welcome. Most important, the strategy needs to be communicated imaginatively to a wide range of agencies—both governmental and non-governmental—and the public to ensure broad ownership among those who must contribute to improvement of the population’s health. Naomi Fulop senior lecturer in health services delivery and organisation London School of Hygiene and Tropical Medicine, London WC1E 7HT (
[email protected]).
David J Hunter professor of health policy and management Nuffield Institute for Health, University of Leeds, Leeds LS2 9PL (
[email protected]).
1 2 3 4 5 6 7 8 9
Department of Health. Saving lives: our healthier nation. London: Stationery Office, 1999 (Cm 4386). Department of Health. Our healthier nation: a contract for health. A consultation paper. London: Stationery Office, 1998. Department of Health. The health of the nation: a policy assessed. London: Stationery Office, 1998. Association of Public Health, the Health Education Authority, and the King’s Fund. Our healthier nation: a response to the public health green paper. London: King’s Fund, 1998. World Health Organisation Europe. Health 21—health for all in the 21st century. Copenhagen: WHO Regional Office for Europe, 1999. Nutbeam D, Wise M. Planning for health for all: international experience in setting health goals and targets. Health Promotion Internat 1996; 1:219-26. Whitehead M, Scott-Samuel A, Dahlgren G. Setting targets to address inequalities in health. Lancet 1998; 351: 1279-1282. Department of Health. Reducing health inequalities: an action report. London: Department of Health, 1999. Acheson D. Independent inquiry into inequalities in health report. London: Stationery Office, 1998.
We ask all editorial writers to sign a declaration of competing interests (www.bmj.com/guides/confli.shtml#aut). We print the interests only when there are some. When none are shown, the authors have ticked the ‘‘None declared’’ box. BMJ VOLUME 319
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