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BACKGROUND: Information on survival and cause of death in pre-senile dementia is scarce and the organisation of services controversial. AIMS: To study survival, place of death and death certification in pre-senile dementia. METHOD: Patients aged 45-64 were identified from hospital and community sources in the Northern health region (1985-89) and classified as having pre-senile dementia of Alzheimer type (PDAT) or pre-senile vascular dementia (PVD) by applying an algorithm to case notes. Deaths were ascertained from the National Health Service Central Registry (NHSCR) to 31 December 1998. Survival analysis was performed using the SPSS/PC program, and expected survival calculated from life tables. RESULTS: Median survival time from diagnosis was 6.08 years and did not differ significantly in PDAT and PVD, or by age or gender; 19.3% of deaths occurred at home, 24.5% in nursing or residential homes and 56.3% in hospital; 72.4% of the death certificates mentioned dementia or Alzheimer's disease; 15.4% were still alive. CONCLUSIONS: Pre-senile dementia has a variable but usually chronic course, requiring appropriate planning and services.

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Of 117 children attending an aural clinic after screening positive by one or both of two tests for hearing loss at school entry, 43 (36.8%) were either seen again for review or listed for surgery. Clinical findings which were significantly associated with either being reviewed or listed for surgery, as opposed to being discharged, were the presence of conductive or sensory neural hearing loss, pronounced negative pressure, reduced compliance volume or absent stapedial reflexes on impedance testing and the presence of an abnormal tympanic membrane associated with effusion on otoscopy. This population of children were then followed up through their school medical records over 4 y to determine what proportion of those discharged from the clinic had subsequently required some form of surgical intervention due to a hearing problem. Note was also taken of all those actually receiving surgery or long term review for sensory neural hearing loss, these cases being designated as true positives in the aural clinic assessment process. This assessment, albeit of a 'high-risk group', gave rise to a sensitivity of 88.9% and a specificity of 68.0%.

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This study set out to determine the incidence of, and mortality from, oral cancer in the North-East of England between the mid-1970s and the early 1990s; to investigate its relation to material deprivation; and to test the completeness of cancer registry data. The Northern Region Cancer Registry provided details of registrations, deaths and population estimates. For analyses by deprivation, Small Area Statistics were obtained from the 1981 and 1991 censuses. In a selected sample district, 100% completeness and 89% accuracy of cancer registration of these conditions were found. For both tongue and mouth cancer, age- and sex-specific incidence and mortality rates rose with age and there was little change with time. When age-standardised registration and mortality ratios were compared between the Northern Region and England & Wales, only those for mouth cancer in males were significantly different. Crude survival from cancer of the tongue in males improved in the Northern Region from 1971-74 to 1983-86 but there was no improvement in females nor for cancer of the mouth in both sexes. In males for both tongue and mouth cancer, there was a graded increase in the standardised registration and mortality ratios from the most affluent to the most deprived areas but these differences were less marked in females. These differences in mouth cancer incidence found between England & Wales and the Northern Region probably reflect differences in lifestyles. The North ranks worst among the regions of England & Wales on a number of criteria of material deprivation, and long-term unemployment is one of the highest in the country. The analysis by deprivation has shown a clear relation to material deprivation. Whether socio-economic deprivation per se or a different risk factor behaviour associated with deprivation (smoking, alcohol consumption, poor diet) is the cause of these differences is not known. However, it is very likely that different risk factor behaviour plays a major part.

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BACKGROUND: Palliative care services have been criticized for providing specialist care for a privileged few but there is no routinely available information to prove or refute these criticisms. Our survey aimed to identify and describe the patients using specialist palliative care services in a Health District and identify whether any factors distinguished them from other eligible patients who did not use these services. METHODS: Clinical and demographic data were collected retrospectively for all residents of the Health District who died of cancer during 1991. Comparisons were made between those who used specialist palliative care services and those who did not. RESULTS: A total of 521 cases were studied of which 157 (30 per cent) had used the specialist palliative care services. These cases (Group 1) compared with the remainder (Group 2) were statistically significantly (p < 0.05) different in terms of their age at death (mean age for Group 1 was 66.6 years, compared with 73 years for Group 2), survival times from diagnosis (median number of days for Group 1 was 242, compared with 110 days for Group 2) and general practitioner practice. There were no significant differences between the two groups for all other variables, i.e. ward of residence, social class, cancer site and gender. Cases in Group 1 were more likely to die at home (39 per cent compared with 27 per cent in Group 2). CONCLUSIONS: Effectiveness studies in the field of palliative care are essential but difficult. We suggest that there is an important place for local studies of needs and utilization for guiding sensitive contracting.

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BACKGROUND: Screening for hearing loss in English children at entry to school (age 5-6 years) is usually by pure tone audiometry sweep undertaken by school nurses. This study aimed to compare the validity and screening rates of pure tone audiometry with impedance screening in these children. METHODS: Two stage pure tone audiometry and impedance methods of screening were compared in 610 school entry children from 19 infant schools in north east England. Both procedures were completed by school nurses. The results of screening were validated against subsequent clinical assessment, including otological examination and actions taken by an independent assessor. RESULTS: Both methods produced broadly similar validation indices after two stages of screening: sensitivity was 74.4% for both methods; specificity was 92.1% and 90.0%; and predicted values of a positive test 43.2% and 37.6% respectively for pure tone audiometry and impedance methods. Single stage screening in both methods produced higher sensitivity but lower specificity and predictive values of a positive test than two stage screening. Screening rates were appreciably higher with impedance methods than with pure tone audiometry. CONCLUSIONS: In choosing the method to be used, it must be borne in mind that the impedance method is technically more efficient but takes longer than pure tone audiometry screening. However, the latter method allows opportunity for other health inquiries in these children.

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STUDY OBJECTIVE: To investigate the relationship between presenile dementia of the Alzheimer type (PDAT) and family history, medical history, cigarette smoking, and exposure to aluminum. DESIGN: A case-control study in which 109 cases of clinically diagnosed PDAT and 109 controls matched for age and sex were compared for exposure to the risk factors. Odds ratios (ORs) were calculated using McNemar's test. SETTING: The northern health region of England. PATIENTS: Cases comprised those under 65 years diagnosed as having dementia by specialist services, who met clinical algorithm criteria for Alzheimer's disease (AD). Cases were confirmed at interview. MAIN RESULTS: Comparing cases with controls, (ORs) significantly greater than unity were obtained when there was a first degree relative with dementia (OR 2.5, 95% confidence interval 1.05, 6.56), any relative with dementia (OR 2.1, 95% CI 1.01, 4.55), and any relative aged less than 65 with dementia (OR 8.0, 95% CI 1.07, 348). Exposure to moderate levels of cigarette smoking (cumulative) was not significant; nor was exposure to aluminum in drinking water, diet, and medicinal sources. CONCLUSION: In this study of modest statistical power, a family history of dementia was confirmed as a risk factor in PDAT. No significant relationship between exposure to aluminium in water supplies, tea, and antacids was found. What is important, however, is the bioavailability of all dietary aluminium, determined by the concentrations of dissolved silicon in water: this requires further investigation.

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BACKGROUND: In a study of patients with presenile dementia of Alzheimer type (PDAT), we aimed to investigate functional dependency in relation to the time since diagnosis and place of residence. Use of community and support services and the time between diagnosis and entry to permanent residential care were also studied. METHOD: Interviews with 109 cases of PDAT (diagnosed before age 65) and their carers. RESULTS: The need for assistance in activities of daily living (ADL) was progressive with time from diagnosis. Five years after diagnosis, 57% of patients remained at home, 20% of whom required some assistance in each of six areas of ADL. The need for assistance in each ADL category was significantly greater for cases in permanent residential care than for those at home. There were no significant differences between the Mini-Mental State Examination (MMSE) scores of patients at home and those of patients in permanent care. Incontinence and the relationship of the carer to the patient were the strongest predictors of permanent residential care. Respite care had been offered in 63% of cases; 71% of these offers had been accepted. CONCLUSIONS: Patients with PDAT who have a living relative are cared for at home for a considerable period of time despite severe cognitive impairment and loss of independence measured by ADL. The reports of carers suggest there is scope for improvement in supportive services to meet this community need.

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The current round of mergers between Health Authorities and Family Health Service Authorities (FHSAs), when set in the competitive context of markets, has profound implications for training in Public Health Medicine. This paper considers the phases in the management of change and the costs, benefits and principles for trainers, trainees and organisations as mergers take place. Particular emphasis is placed on understanding the motives of and learning from the change that is taking place.

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BACKGROUND: Presenile dementia of alzheimer type is a rare condition, and a report drawn from a large population may be useful to general practitioners. AIM: A study was undertaken in the Northern Regional Health Authority area to investigate general practitioner referral practice, hospital investigations and diagnosis in cases of presenile alzheimers disease. METHOD: Reviews of 186 sets of case notes of patients diagnosed between 1985 and 1989, and follow-up interviews with the principal carer in a subsample of 73 surviving patients were undertaken. RESULTS: In 63% of cases, formal diagnosis of presenile alzheimers disease was made by a neurologist, in 27% of cases by a psychiatrist and in 9% by a physician. Symptoms of depression had been noted in 45 patients (24%) and 21 had been prescribed antidepressant drugs prior to specialist referral. Computerized tomography scans were requested significantly more frequently by neurologists than other specialists and lumbar puncture was virtually only done by neurologists, but there were no significant differences between specialists regarding other clinical investigations. Domiciliary care or day centre attendance were more likely to be arranged at hospital discharge by psychiatrists than other specialists, but at follow-up interview no differences in community care provision were found according to initial specialty. Interviews with relatives of surviving patients revealed that at initial contact with general practitioners 48% of patients were unaware that they had any problem. Only 13 relatives (18%) felt they had been given sufficient information at diagnosis concerning the chronic and progressive nature of the disease, and at follow up 26% remained unaware of the existence of the Alzheimer's Disease Society. CONCLUSION: These results reinforce the importance of the role of general practitioners in arranging and coordinating appropriate support for patients and their relatives, in providing continuity of care and in advising the families of the existence of voluntary organizations.

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Potential cases of presenile dementia of the Alzheimer type (PDAT) in the Northern Health Region (estimated population aged 45-64, 655,800) were ascertained for the years 1979-86 from in-patient ICD-9 codes and other sources. An algorithm was applied to the casenote information to distinguish between Alzheimer-type and other forms of dementia. A search of the NHS central register was made to establish date and place of death. Estimates were made for patients with missing case records. The point prevalence rate for PDAT was estimated as 34.6 per 100,000 with an annual incidence of 7.2 per 100,000 in the 45-64 age range. These rates are compared with those reported in other studies. Five-year survival following diagnosis for incident cases of PDAT was 64% with a longevity quotient (LQ), the percentage of expected time actually survived, of 69%. There was no evidence of a more malignant course in PDAT when compared with survival in older patients with dementia of the Alzheimer type (DAT) in other studies. Sixty-six per cent of deaths occurred in hospital, 19% at home and 15% in residential homes.

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STUDY OBJECTIVES: To assess the value of death certification for the epidemiological study of dementia, the frequency with which the condition was recorded on death certificates of patients diagnosed with some form of dementia before the age of 65 years was studied. A further objective was to identify variables associated with failure to record dementia on the certificate. DESIGN: A cohort of patients with presenile dementia, differentiated by a clinical algorithm applied to hospital case records, was traced through the National Health Service Central Registry and details of certified causes of death were obtained. SETTING: The Northern Regional Health Authority in England. SUBJECTS: Prevalent cases of presenile dementia resident in the northern health region during 1986 traced up to April 1992. MEASUREMENTS AND MAIN RESULTS: The underlying cause of death was recorded as dementia or as Alzheimer's disease in 53% of cases of clinically diagnosed presenile Alzheimer's disease, 33% of cases of presenile vascular dementia, and 10% of cases of presenile dementia secondary to another neurological condition. Dementia or Alzheimer's disease was recorded in any part of the certificate in 75% of cases of Alzheimer's disease, 52% of vascular dementia, 33% of other dementias, and in 65% of cases overall. Dementia or a cerebral condition of a kind that can result in dementia was recorded in 80% of all cases. Failure to mention dementia was related to the clinical type of dementia, shorter duration of illness, and earlier period of study. CONCLUSIONS: The underlying cause of death seriously understates the frequency of dementia, but when the recording of other brain disease is taken into account the presence of potentially dementing brain disease is recorded much more frequently. It is suggested that coding chronic conditions present at death, such as dementia, in addition to those causing or contributing to death would improve the value of death certificates for epidemiological purposes.

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The 1990 contract for general practitioners made annual health checks for people aged 75 and over compulsory. We review the costs and effects of different approaches to the health check, focusing on the method advised in the 1990 contract. This involves an annual home-based functional assessment by a member of the primary health care team, known as a blanket assessment. Our review of published randomized controlled trials shows such assessments have few consistent benefits. Data on the costs of assessment are usually reported in summary form, with little or no information on which costs are included. In studies where average costs are given for assessments, because of salary and travel expenses, the costs are high. Several promising methods for reducing costs in assessment, and a method with potential to improve effectiveness, are currently outside the terms of the 1990 contract. These methods are described. Revision of the 1990 contract should incorporate the flexibility to encourage more cost-effective approaches to assessing the elderly such as a two-stage assessment or using volunteers. A monitoring group is needed to establish how health checks are being implemented. This group could co-ordinate and advise on standardized criteria for methods of costing and assessing effectiveness in assessment programmes.

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The principles of and experience with a family study and survey undertaken by first-year medical students are reported. The family study is based on the observations made by pairs of students on a selected family, which includes a pregnant mother, in the Newcastle upon Tyne area. These observations include the family context, the pregnancy, the early development of the new-born baby, and the use of health and other services. The family survey records and analyses relevant data on the collective group of selected families. The family study acts as a preparation for clinical understanding by emphasizing the individual or family view. In addition, students learn that the collective epidemiological approach provided by the survey can guide the clinical impression gained from the observational study, yet each individual and family remains unique. An early opportunity is therefore provided for students to explore and integrate these two approaches.

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