Are memory clinics effective? The odds are in favour of their benefit, but conclusive evidence is not yet available
Authors: RJF Melis, EJ Meeuwsen, SG Parker, MGM Olde Rikkert
Journal: Journal of the Royal Society of Medicine (2009)

Following other European nations, England has recently announced an ambitious national strategy to improve the healthcare of people suffering from dementia.1,2 Despite the general applause that the strategy received, an issue has been raised about one of the strategy's three key aims: to improve early diagnosis and treatment through the establishment of a nationwide network of multidisciplinary memory clinics. The criticism of this strategy focuses on the effectiveness of the follow-up that can be provided through memory clinics after a diagnosis is made.3

Those who are sceptical about the benefits might be accused of therapeutic nihilism. However, the critical question is: what is the proven effectiveness of memory clinics? We argue that, although the odds are strongly in favour of the benefit of comprehensive multidisciplinary memory clinics in the diagnosis and treatment of dementia, evidence from direct randomized comparisons with usual care is as yet largely unavailable. This does not necessarily mean that we must wait until the evidence becomes available, but it does suggest that careful observation of the introduction of memory clinics on a larger scale would be worthwhile.

At present, there are no cures for dementia, but there are lots of things that can be done to improve the lives of patients and carers.4,5 It has also been shown that already modest net gains can be value for money: Banerjee and Wittenberg suggest that memory services need only achieve a modest increase in average quality of life of people with dementia, plus a 10% diversion of people with dementia from residential care, to be cost-effective based on the Croydon Memory Service Model.6

This evidence leads us to suggest that there is a good chance that a state-of-the-art multidisciplinary memory clinic will be an effective and cost-effective healthcare service for providing dementia diagnostics and guidance. However, the specific question about whether memory clinic services as a whole have been shown to be (cost-) effective in a direct comparison with usual care has a negative answer.

When reviewing the available literature on direct comparisons of memory clinics with alternatives it is important to separate studies evaluating the memory clinic as a diagnostic setting from studies evaluating memory clinics as a therapeutic setting for dementia treatment and guidance. We know of two direct randomized comparisons of the memory clinic as a diagnostic setting. The study of Wolfs et al. showed that in comparison with usual care an integrated multidisciplinary approach to dementia diagnosis in a memory clinic setting increases health-related quality of life of the dementia patients, adds very useful information and is affordable.7 The pilot study of Logiudice et al. showed some beneficial effects of dementia diagnosis at a memory clinic (as opposed to not being offered this service) on the health-related quality of life of dementia caregivers.8 We do not know of studies directly comparing dementia guidance and treatment by memory clinics to usual care other than the AD-Euro Study that we are currently performing in a number of multidisciplinary memory clinics in the Netherlands and the PLASA study conducted in 49 hospitals in France.9,10 The AD-Euro Study is a randomized controlled trial that studies the effectiveness and efficiency of post-diagnosis treatment and care coordination of dementia patients and their caregivers as provided by memory clinics compared to dementia guidance provided by general practitioners (ClinicalTrials.gov Identifier {type:clinical-trial,attrs:{text:NCT00554047,term_id:NCT00554047}}NCT00554047). The PLASA study compares structured memory clinic treatment and guidance to usual memory clinic care.

We conclude that there is enough evidence on the effectiveness of the individual elements of memory clinics, but hardly any evidence is available through direct randomized comparisons of memory clinics as a whole. Because dementia is such an important societal issue, this good quality evidence is ultimately needed. However, the problems related to dementia are too urgent to refrain from action until the time this evidence is finally available. Instead, we suggest using the momentum that has been created to define and implement state-of-the-art multidisciplinary memory clinics based on the available best evidence and consensus trajectories, but to do it sensibly: in close collaboration with all parties involved and accompanied by rigorous evaluation. If the evaluations show memory clinics to be as valuable as expected, no adjustments will be necessary. If not, current policy would have to be reconsidered.