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Dementia

My Lords, this has been a singularly well informed and at times extremely moving debate. Only those who have witnessed and experienced the progressive deterioration in intellect and personality of a family member can recognise how immensely distressing, even agonising, that experience can be. Alongside obesity and type 2 diabetes, dementia stands now as one of the greatest public health challenges of the age. As Members of your Lordships' House have said today, it is likely that by 2025 the number of people with dementia in the United Kingdom will almost have doubled. As the Alzheimer’s Society has made clear in its excellent briefing, the cost of dementia will rise from £15 billion today to more than £23 billion by 2018. One of the problems is early diagnosis, to which many noble Lords have today referred. I propose to spend a little time on that, because it is crucial. My noble friend Lady Murphy said in her excellent introduction that there are about 150 causes of dementia, many of them exceptionally rare. More than 80 per cent of patients with dementia are suffering from Alzheimer’s disease, but there are other, not uncommon causes—as the noble Baroness, Lady Gardner of Parkes, said, multi-infarct dementia resulting from repeated minor or major strokes is an important one. So, too, is Lewy body dementia. It is less common, occurring in association with, but not invariably so, Parkinson’s disease, because of the deposition of Lewy bodies throughout the cortex of the brain. Fronto-temporal dementia is also quite different. It is crucial to get the diagnosis right because research is progressing in many parts of the world which is bringing within sight the prospect of a more effective treatment for the various dementias, particularly for Alzheimer’s disease, which may be a crucial development alongside the improvement in the standards of care to which many noble Lords have referred. Unfortunately, there is no precise diagnostic test for Alzheimer’s disease. CT scanning and magnetic resonance imaging may help to show shrinkage of the brain. There are other tests, such as those for memory. More recently, a precisely defined test-your-memory test has proved to be extremely valid. It has been designed to minimise operator time and to be suitable for non-specialists to use. However, as a recent editorial in the British Medical Journal stated: ""Diagnosis requires consideration of the person’s education, culture, and circumstances; dementia presents when a person’s cognitive abilities are no longer adequate for them to cope with their environment. A high flying executive may experience problems early in the … process, whereas a resident of a care home may have no difficulty with his or her routine until pronounced changes have occurred"." Many years ago, when I held a chair of neurology in Newcastle-upon-Tyne, I was involved with Professor Roth, Doctor Blessed and Professor Tomlinson in studying the changes in the brain occurring in patients with Alzheimer’s disease. We all recognise, as several people have referred to today, that, as we get older—I am approaching my 87th birthday—we often find problems with the memory, particularly memory for proper names. It is extremely embarrassing when you encounter somebody whom you know extremely well and suddenly find that their name has gone—you can call that selective nominal aphasia, benign cognitive impairment or benign senescent forgetfulness. In a way, Alzheimer’s disease is a rapidly progressing, advanced form of that kind of impairment, as the work of Blessed, Roth and Tomlinson showed, because, even with normal ageing, there is an increase in the number of senile plaques in the brain cortex. That number is vastly increased in patients with Alzheimer’s disease. What about research? The Newcastle scientists, helped by the biochemists, the Perrys—husband and wife—found a serious reduction in the concentration of acetylcholine in the brain cortex. Acetylcholine is a neurotransmitter which carries messages from one nerve to another. That finding led to the introduction of drugs which inhibited the enzyme which degrades acetylcholine. Those are the drugs called donepezil, and many of its other derivatives, which have proved to be helpful in delaying to some extent the progression of the disease. However, that is symptomatic treatment; it does not strike at the root cause of the disease. In these senile plaques, which are so characteristic, and the neurofibrillary tangles which appear throughout the brain cortex, chemical substances have been identified, not least beta-amyloid and its precursor, but also a substance called phosphorylated tau, which appear to be markers of the process occurring in the cortex in these conditions. Work is now in progress in a number of centres in the UK and abroad where individuals are attempting to introduce techniques to reduce the level of those substances within the brain cortex. A few years ago, an attempt was made to produce a vaccine and the vaccine against beta-amyloid was shown to be, in some ways, effective. Unfortunately, in clinical trials, it also produced unacceptable degrees of brain inflammation and the trials had to be discontinued, but other methods are now being explored. Although, as a number of noble Lords have said, the amount of money being spent on dementia research in the UK is much less than in other countries, we do have centres of excellence—I was talking yesterday to Professor Martin Rossor, who is a leader in this field at the National Hospital for Neurology and Neurosurgery, Queen Square. He commends, incidentally, as do I, the National Dementia Strategy, though he feels—and I ask the Minister to comment upon this—that though the dementia strategy is excellent in what it plans and proposes for the elderly patient with dementia, he feels it is less suitable for those who develop dementia at a relatively early age, in their 40s and 50s. The Minister may wish to comment on that point, but it is an excellent document. These centres of excellence are in London, in Oxford and at the outstanding Centre for Brain Ageing and Vitality, led by Professor Tom Kirkwood, in Newcastle-upon-Tyne, funded by the Medical Research Council and the Wellcome Trust, where some outstanding work is going on. I stress these points because I genuinely believe that, within the next 10 years, we will see mechanisms introduced whereby forms of treatment for Alzheimer’s disease will become much more effective than those available now. That kind of treatment must stand alongside the crucial improvements in care and the other objectives so clearly set out in this dementia strategy. I think we have considerable optimism for the future.