Key points

Memory clinics provide a valuable service for the assessment and management of people with memory difficulties.

They have also provided a focus for the initiation and monitoring of antidementia drug treatments.

They have grown in number and range of services they provide over the years.

A robust accreditation programme exists to assess the services and service standards.

As the number of people coming forward for investigation of memory problems increases, memory clinics may need realigning more to community and primary care settings.

1 Introduction

The ideas of health in later life that were developed by forward-thinking physicians in the nineteenth century such as Cheyne (1724) and Day (1849), cited by Grimley Evans (1), grew to what we know of today as geriatric medicine. Through pioneering efforts within the UK in the early twentieth century the speciality was nurtured within the ever-evolving structure of the NHS (Chapter 1). Mental health services in the UK of the 1940s and 1950s were based in mental hospitals. With few exceptions, such as Felix Post, a psychiatrist working at the Maudsley Hospital in London, psychiatrists were not interested in older people or the disorders which affected them. However, they complained that mental hospitals were becoming congested and threatened to be overwhelmed by the number of people with ‘senile dementia’ that presented in advanced stages from the growing population who were aged 65 years and above. Thus it was that pioneers of geriatric medicine took on with interest the mental disorders they encountered among their patients in wards and in the community, seeking help from psychiatry only when matters (usually behavioural problems) became extreme. This process of British physicians building on research concepts to deliver health services has been replicated numerous times, notably in the development of service-oriented memory clinics.

The first British memory clinic, inspired by examples from the USA, was established at the Geriatric Research Unit at University College London in 1983 (2). More clinics followed at the Maudsley Hospital (3) and Cardiff (4, 5). These were research ventures involving psychologists, geriatricians, psychiatrists, and sometimes other staff. They began to see patients who had not previously come to specialist services and whose memory problems were usually mild to moderate and potentially responsive to interventions. This experience contrasted with reports that dementia care at the time often consisted of erratic, ad hoc response to individuals and families and other care agencies at times of crisis (6).

There are approximately 800,000 people currently living with dementia in the UK. Over the next 30 years this number has been confidently predicted to double (7). Recent research suggests that improved general health and the reduction of vascular risk factors from middle age onwards, together with the prescription of thrombolytic and lipid-lowering medicines, are reducing the incidence and prevalence of dementia (8). This is good news, but the numbers still remain high. There has been recognition for at least 50 years that dementia is often not identified or diagnosed (9). The Alzheimer’s Society, using national data, concluded that only 46% of people with dementia in the UK had received a formal diagnosis (<www.alzheimers.org.uk/dementiamap>). It seems that the stigma about dementia is having significant negative effects on the diagnosis and management of dementia. The worry is that people are missing out on potentially useful treatments and help. Not having problems recognized and being short-changed by services leads to great frustration and distress; better practices must be identified, resourced, and provided.

2 Development of memory clinics

Memory clinics have been developed with the aim of improving the diagnosis of dementia and thereby improving the care and support that people with dementia and their families receive. When memory clinics were established in the 1980s, they had a number of objectives (Box 6.1) and tended to concentrate expertise within specialist centres, usually within hospitals. Although clearly an area of particular interest to old-age psychiatrists, the development of hospital memory clinics along these lines was almost counter to the genesis of old-age psychiatry, which had had a transformative effect on mental health services for older people and aimed to take services into the community (10). Clinics were, and still are, often associated with university departments and led by physicians or neurologists, though increasingly psychiatrists and psychologists are lead clinicians (11, 12).

Box 6.1 Objectives of the first memory clinics

to forestall deterioration in dementia by early diagnosis and treatment

to identify and treat disorders other than dementia that might be contributing to the patient’s problems

to evaluate new therapeutic agents in the treatment of dementia

to reassure people who are worried that they might be losing their memory, when no morbid deficits are found.

Memory clinics’ original guiding principles are still recognized. The Information Centre definition of 2011 states that memory clinics should ‘aid the early detection and diagnosis of dementia’ and ‘provide early intervention to maximise quality of life and independent functioning and to manage risk and prevent future harm to older people with memory difficulties and their carers’ (13).

Memory services within the NHS have proved popular. A survey in 1993 identified 20 throughout the UK and Ireland (14). This figure rose to 102 in 2002. This rise may partly have been due to the licensing of anticholinesterase drugs for the treatment of dementia (15) and the recommendation by the National Institute of Clinical Excellence (NICE) that cholinesterase inhibitors should be prescribed, by specialists, and only for people with mild to moderate Alzheimer’s disease (16).

Further encouragement came from the Department of Health when, in 2009, Primary Care Trust funding for dementia services was increased. By 2011 there were 337 commissioned memory services in England alone with plans for a further 106 services to be rolled out in the following year (13).

Most of the newer clinics and memory services have been created in districts which are not centres of excellence for research. In the UK (15), most are linked to mental health services, usually within the department for psychiatry in later life, though some clinics are led by physicians or neurologists (10, 12). Scrutiny to determine the best value of memory services (17, 18), together with notes of caution (19) and review of actual practice (20), have begun to refine understanding of their worth.

Approaches to defining and improving standards have begun internationally (21). In the UK, the Royal College of Psychiatrists (Box 6.2) provides an accreditation service that uses criteria agreed in consensus on aspects of structure and function to monitor services and encourage provision of best practice (22). This has allowed the creation of a register of accredited services and this is being used to facilitate audits that inform comparisons between services and rolling programmes for improvement.

Box 6.2 Memory services’ accreditation from the Royal College of Psychiatrists

The Royal College of Psychiatrists sought to address the lack of uniformity by introducing the Memory Services National Accreditation Programme (MSNAP) in 2009.