"What is it that one wants to achieve?"
'Traditionally preventive medicine is a combination of medical practices that are designed to avoid disease and illness. It is a proactive approach to patient care with the aim of using evidence-based preventative measures to ensure that any sickness is minimised and detected early so that a patient has the best chance of recovery to optimum health.' This definition is based on a medicalised worldview of preventive medicine. Why can't we use social or political practices to avoid disease and illness? Surely the aim is better population health and is not necessarily about the individual? A healthier population will have a better quality of life, less need for healthcare and in theory should be happier and more content than an unhealthy population.
It is so important because if you believe like I do that dementia is preventable then you have to focus on the so-called modifiable risk factors. It is clear that most of the modifiable risk factors for dementia are strongly associated with deprivation, i.e. low-educational status, sedentary lifestyle, smoking, obesity and hypertension to name a few. So to target these without sound government policy to tackle the root cause is folly.
If this government was serious about their levelling-up agenda and really wanted to tackle inequality they would have dusted off the Black Report into health inequality from 1980 and implemented its recommendations with some modern twists. One modern twist is getting everyone digitally literate with access to the internet. Why didn’t Rishi Sunak mandate that as part of a ‘no child left behind’ policy every school child gets a computer and mandatory access to the internet? Why wasn’t more money allocated to state education to level it up to what is available in the private sector? There has never been a better opportunity, than post-COVID, to transform school education and start to address dementia risk at school.
It is shameful that it is over 40 years since the Black report was published and we still having the same debate. Only this time we have so much better data on the real cost inequality has on society. It doesn’t only affect the lower socioeconomic strata of society, but the upper strata as well. Everyone suffers when there are large inequalities in society.
Every now and then an event or a piece of research has a profound effect on society. It goes viral and it shames us and out politicians into action. This is how protest movements such as #MeToo, #BlackLivesMatter and #TakeBackTheStreets happen. I am hoping this piece of research, which I am so proud of, makes #ThinkSocial, #LevellingUp, #NoChildLeftBehind, #PreventDementia, #ThinkBrainHealth go viral.
I have been criticised for jumping onto the social determinants of health bandwagon now that it is a hot topic. I counter this by stating that it is only a hot topic because COVID-19 exposed the huge and embarrassing inequalities in our country. Another reason has been the current Tory government’s levelling-up agenda to address inequality across the country. The following paper from our Preventive Neurology Unit is another example of how socioeconomic deprivation plays out over a lifetime and is strongly associated with dying from dementia and at a younger age.
Why is this so important?
It is so important because if you believe like I do that dementia is preventable then you have to focus on the so-called modifiable risk factors. It is clear that most of the modifiable risk factors for dementia are strongly associated with deprivation, i.e. low-educational status, sedentary lifestyle, smoking, obesity and hypertension to name a few. So to target these without sound government policy to tackle the root cause is folly.
If this government was serious about their levelling-up agenda and really wanted to tackle inequality they would have dusted off the Black Report into health inequality from 1980 and implemented its recommendations with some modern twists. One modern twist is getting everyone digitally literate with access to the internet. Why didn’t Rishi Sunak mandate that as part of a ‘no child left behind’ policy every school child gets a computer and mandatory access to the internet? Why wasn’t more money allocated to state education to level it up to what is available in the private sector? There has never been a better opportunity, than post-COVID, to transform school education and start to address dementia risk at school.
It is shameful that it is over 40 years since the Black report was published and we still having the same debate. Only this time we have so much better data on the real cost inequality has on society. It doesn’t only affect the lower socioeconomic strata of society, but the upper strata as well. Everyone suffers when there are large inequalities in society.
Every now and then an event or a piece of research has a profound effect on society. It goes viral and it shames us and out politicians into action. This is how protest movements such as #MeToo, #BlackLivesMatter and #TakeBackTheStreets happen. I am hoping this piece of research, which I am so proud of, makes #ThinkSocial, #LevellingUp, #NoChildLeftBehind, #PreventDementia, #ThinkBrainHealth go viral.
Don't we owe it to the next generation to try and prevent them from dying early from dementia? We also need to ask ourselves about what kind of society we want to live in?
Jitlal et al. The influence of socioeconomic deprivation on dementia mortality, age at death and quality of diagnosis: a nationwide death records study in England and Wales 2001-2017. MedRxiv doi: https://doi.org/10.1101/2020.09.28.20203000
Background: Socioeconomic deprivation is postulated to be an important determinant of dementia risk, mortality, and access to diagnostic services. Nevertheless, premature mortality from other causes and under-representation of deprived individuals in research cohorts may lead to this effect being overlooked.
Methods: We obtained Office of National Statistics (ONS) mortality data where dementia was recorded as a cause of death in England and Wales from 2001 to 2017, stratified by age, diagnosis code and UK Index of Multiple Deprivation (IMD) decile. We calculated standardised mortality ratios (SMR) for each IMD decile, adjusting for surviving population size in each IMD decile and age stratum. In those who died of dementia, we used ordinal logistic regression to examine the effect of deprivation on the likelihood of being older at death. We used logistic regression to test the effect of deprivation on the likelihood of receiving a diagnosis of unspecified dementia, a proxy for poor access to specialist diagnostic care.
Results: 578,623 deaths due to dementia in people over the age of 65 were identified between 2001-2017. SMRs were similar across the three most deprived deciles (1-3) but progressively declined through deciles 4-10 (Mean SMR [95%CI] in decile 1: 0.528 [0.506 to 0.550], decile 10: 0.369 [0.338 to 0.400]). This effect increased over time with improving ascertainment of dementia. In 2017, 14,837 excess dementia deaths were attributable to deprivation (21.5% of the total dementia deaths that year). There were dose-response effects of deprivation on the likelihood of being older at death with dementia (odds ratio [95%CI] for decile 10 (least deprived): 1.31 [1.28 to 1.33] relative to decile 1), and on the likelihood of receiving a diagnosis of unspecified dementia (odds ratio [95%CI] for decile 10: 0.78 [0.76 to 0.80] relative to decile 1).
Conclusions: Socioeconomic deprivation in England and Wales is associated with increased dementia mortality, younger age at death with dementia, and poorer access to specialist diagnosis. Reducing social inequality may be an important strategy for the prevention of dementia mortality.
Jitlal et al. The influence of socioeconomic deprivation on dementia mortality, age at death and quality of diagnosis: a nationwide death records study in England and Wales 2001-2017. MedRxiv doi: https://doi.org/10.1101/2020.09.28.20203000
Background: Socioeconomic deprivation is postulated to be an important determinant of dementia risk, mortality, and access to diagnostic services. Nevertheless, premature mortality from other causes and under-representation of deprived individuals in research cohorts may lead to this effect being overlooked.
Methods: We obtained Office of National Statistics (ONS) mortality data where dementia was recorded as a cause of death in England and Wales from 2001 to 2017, stratified by age, diagnosis code and UK Index of Multiple Deprivation (IMD) decile. We calculated standardised mortality ratios (SMR) for each IMD decile, adjusting for surviving population size in each IMD decile and age stratum. In those who died of dementia, we used ordinal logistic regression to examine the effect of deprivation on the likelihood of being older at death. We used logistic regression to test the effect of deprivation on the likelihood of receiving a diagnosis of unspecified dementia, a proxy for poor access to specialist diagnostic care.
Results: 578,623 deaths due to dementia in people over the age of 65 were identified between 2001-2017. SMRs were similar across the three most deprived deciles (1-3) but progressively declined through deciles 4-10 (Mean SMR [95%CI] in decile 1: 0.528 [0.506 to 0.550], decile 10: 0.369 [0.338 to 0.400]). This effect increased over time with improving ascertainment of dementia. In 2017, 14,837 excess dementia deaths were attributable to deprivation (21.5% of the total dementia deaths that year). There were dose-response effects of deprivation on the likelihood of being older at death with dementia (odds ratio [95%CI] for decile 10 (least deprived): 1.31 [1.28 to 1.33] relative to decile 1), and on the likelihood of receiving a diagnosis of unspecified dementia (odds ratio [95%CI] for decile 10: 0.78 [0.76 to 0.80] relative to decile 1).
Conclusions: Socioeconomic deprivation in England and Wales is associated with increased dementia mortality, younger age at death with dementia, and poorer access to specialist diagnosis. Reducing social inequality may be an important strategy for the prevention of dementia mortality.
I'm not disagreeing with anything here, but I want to point out- What is it one wants to achieve? I think of my father who succumbed, with very little original comorbidity, after five or ten years (depending on how you count it, and probably longer). He was not poor. Those five or ten years were not happy years. At one point in that time period, he would have told you, that staying alive wasn't worth it; he just at that point was unable to make such a declaration.
ReplyDeleteSo at what point does one want to admit that "life isn't worth it? He had good care which extended his life. There was lots of suffering for him though, towards the last few years (the years that would make a statistical difference when compared to others). Only good part was, for the most part, that it wasn't "him" any more, doing the suffering. Very bad situation no matter how you spin it.
Re: "What is it one wants to achieve?"
DeleteBetter population health. Preventive medicine is about looking after populations and not individuals.