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Denmark

2012: National Dementia Strategies (diagnosis, treatment and research)

Background information about the National Dementia Strategy

Status and historical development of the National Dementia Strategy

In 2009, work was started under the auspices of the Ministry for Social Security and the Ministry for Health and Internal Affairs with the aim of establishing how people with dementia were treated both medically and socially.

A working group was set up by the Ministries and there was participation from “Danish Regions” (which are responsible for the hospital sector and GPs), and “Danish municipalities (KL)” which are responsible for social care. The Finance Ministry also participated in this group.

Several meetings were held in smaller groups to describe the field as thoroughly as possible and to find out what the obstacles are for the future development in this field.

This work resulted in 14 recommendations, which were put forward to the Danish Parliament in December 2010 and agreed on as focus points for the following years.

Duration of the National Dementia Strategy

The National Dementia Strategy runs from 2011 to 2014.

How the National Dementia Strategy is funded

A total of approximately Euro 4.1 million was allocated to the National Dementia Strategy.

Provisions or procedure for implementing the Strategy

The Plan has recommendations in many fields as indicated by the participation of three different ministries and other stakeholders. Each is responsible for the implementation of different parts of the strategy.

Procedure for monitoring progress made in achieving the goals set

There is no formal procedure to monitor the progress of the plan in achieving the goals set.

Involvement of the Alzheimer association (and/or people with dementia)

The Danish Alzheimer Association was involved in the drafting of the 14 recommendations mentioned above. However, in 2010 there was a conference on creativity in awareness raising campaigns which was inspiring but the Danish association was not invited to take part in the drafting of such campaigns.  This was not part of the National Dementia Strategy as it took place before the Strategy. A new campaign is being organised as part of the Strategy but it has not yet been implemented.

Alzheimer association’s overall assessment of the National Dementia Strategy

The Alzheimer Association was involved in discussions about patients’ rights and support for family carers such as Alzheimer cafés and respite care in care homes and at home.

Diagnosis, treatment and research

Issues relating to diagnosis

Timely diagnosis in the National Dementia Strategy

Work is in progress under the auspices of the Danish National Health Board to issue “National clinical guidelines for Dementia”. The guidelines will cover the issue of establishing the diagnosis. Two basic questions will be addressed: 1. Does this patient have cognitive problems (and if so) 2. what is the underlying cause?

The relevant diagnostic procedures will be described. A group of professionals will finish their work on this within a few months. The Danish Alzheimer Association is represented in the group.

The guidelines will serve as “best practice” for all the hospitals involved in diagnosing and treating people with dementia. All hospitals are expected to comply with the guidelines.

Which healthcare professionals are responsible for diagnosing dementia

In order to be refunded for AD drugs, people with suspected dementia must have a CT scan which is carried out by a specialist (a radiologist). In order to see the specialist, they must first consult a GP which means that GPs are an essential part of the diagnostic process. Sometimes, older people are diagnosed with dementia without the diagnostic processes described in the clinical guidelines having been followed. This may happen, for example, when the GP thinks that nothing can be gained from medical treatment.

There are also dementia coordinators and nurses who are employed by local communities and are responsible for ensuring that people with dementia receive the support they need. Each locality has at least one dementia coordinator.

GPs do not have a fixed consultation time but most have consultation modules of 10 minutes. Some allow patients to book a block of two modules (i.e. one after the other). However, GPs would only be paid for one consultation. They would receive extra payment for carrying out an MMSE and for having consultations with the patient’s relatives.

Type and degree of training of GPs in dementia

The amount and content of training in dementia which GPs receive as part of their professional training to become a GP differs from one faculty to the next. Also, dementia is part of the curriculum for diseases in old age. It is therefore not possible to calculate the exact number of hours as such teaching is part of that for other subjects.

In Copenhagen, for example, dementia is part of the curriculum in neurology, which is compulsory for all medical students. All students have to attend to a two hour lecture on dementia. This is followed by 1 month in a neurological department where bedside education in dementia can be given, either in the ward or in an outpatient clinic.

In Aarhus, a one-hour lecture in dementia is provided, followed by two weeks in a neurological department including one day in the outpatient clinic.

In Odense, there is a two-hour lecture in dementia, followed by two or three hours towards the end of the study.

Postgraduate education is not compulsory for Danish GPs. However, the Danish Association of General Practitioners (DSAM) has produced an E-learning programme in dementia which doctors are free to use.

Required tests to diagnose dementia

A CT scan must be carried out and assessed by a specialist.

Issues relating to medical treatment

Issues related to medical treatment in the National Dementia Strategy

The issue of medical treatment will be part of the clinical guidelines. There will be recommendations on the appropriate medical treatment for the different types of dementia.

Another workgroup under the Ministry of Social Security is trying to find ways to improve the treatment of people with dementia who are difficult to treat because of BPSD. This work will probably tackle the issue of how, as far as possible, to avoid the use of psychotropic drugs.

The availability of medicines in general

In Denmark, medicines on a special list (essentially all prescription medicines) are covered up to a certain degree depending on the overall total expenditure on medicines of a patient during a year.

If the total expenditure on medicines in a year does not exceed DKK 890, the patient covers 100% of the drug costs.

For total expenditure on medicines of between DKK 890 and DKK 1,450, the patient covers 50% of the costs.

For total expenditure on medicines of between DKK 1,450 and DKK 3,130, the patient covers 25% of the costs.

For total medicines expenditure above DKK 3,130, the patient covers 15% of the costs.

Nevertheless, for cases where there is a well-documented need for extensive and permanent treatment, the reimbursement rate can go up to 100% of the part of the total co-payment which is in excess of DKK 3,655 (approx. EUR 492).

Finally, in special cases the health service can contribute to medicines not on the list or contribute fully to medicines for people who are dying[1].

The availability of Alzheimer treatments

All AD drugs are available in Denmark and are part of the reimbursement system. Reimbursement is dependent on prior authorisation by the Danish Medicines Agency according to the following procedure.

Conditions surrounding the prescription and reimbursement of AD drugs

An application for reimbursement has to be sent to the Danish Medicines Agency and any doctor can apply for reimbursement for a patient. Nevertheless, reimbursement is only granted if a specialist in neurology, psychiatry or geriatrics has made the diagnosis.

For patients with mild to moderate dementia a CT (or MR scan) of the brain has to be performed first. The physician also has to state that causes other than Alzheimer’s disease are excluded. The system does not provide upper or lower MMSE limits for treatment with different AD drugs, but reimbursement is dependent on a clinical grading. Reimbursement for donepezil, rivastigmine and galantamine is only granted to patients in mild to moderate stages and memantine to patients in moderate to severe stages.

The application has to be renewed every 12 to 15 months. Renewal of reimbursement of memantine depends on a statement by the physician that a continuous effect in the individual patient is still observed. There are no restrictions as to the access of people living alone or in nursing homes to available AD treatments.

Prescription and reimbursement

Donepezil

Rivastigmine

Galantamine

Memantine

Available

Yes

Yes

Yes

Yes

Reimbursed

Yes

Yes

Yes

Yes

Initial drug reimbursed if prescribed by

Specialist

Specialist

Specialist

Specialist

Continuing treatment reimbursed if prescribed by

No restrictions

No restrictions

No restrictions

No restrictions

Required examinations

Diagnostic protocol

Diagnostic protocol

Diagnostic protocol

Diagnostic protocol

MMSE Limits

None

None

None

None

Issues relating to research

The issue of research is only very briefly addressed in the National Dementia Strategy. However, it was decided to allocate money for “National Knowledge Centre for Dementia” which is initiating scientific research, both in the clinical field and in basic science subjects. At the same time, the Centre runs a range of courses for doctors, nurses, carers and other people with an interest in dementia.

The National Knowledge Centre has set up a network between all memory clinics in Denmark. Jointly they should have the capacity to carry out investigative research. A big project has started known as “ADEX” which is about exercise in people who have been recently diagnosed with dementia but who are still in good health. It is difficult to estimate how much money the government allocates to dementia research as The Knowledge Centre encompasses more than dementia research.

Denmark has a bio-bank and there are a lot of projects running in the psychosocial field. These projects face the same challenges as in other countries in that often, once they are completed, nothing is done with them. In order to prevent the projects just “disappearing”, the dementia strategy includes a provision that the Ministry of Social Security should collect all the information from these projects in order to establish good practices and to try to make the results available. 

In Denmark, everyone has a number which consists of their birthdate and four digits. It is unique for each person and everyone must have one. This enables a diagnostic registry to be kept whereby each diagnosis is registered in a central register. Requests can be made for specific searches to be made (e.g. for the number of people diagnosed with dementia). The last four numbers are erased for anonymity.

Denmark is involved in the EU Joint Programme – Neurodegenerative Disease Research (JPND) but not in the Joint Action “Alzheimer Cooperative Valuation in Europe (ALCOVE)”. It is a prominent partner in the JPND project about biomarkers.

There are some Alzheimer research funds from a special fund called “The Alzheimer Research Fund” but these are very small and just cover the costs of a few PhD projects or contribute to them. The fund should be used to promote new PhD students and recruit new PhD students for future work.  The PhD projects running at the moment include 1. Downs syndrome and Alzheimer’s disease, and 2. Dementia and pain. There was a study on ethnic minorities which resulted in an approved thesis.

Acknowledgements

Anne Arndal, Chair, Danish Alzheimer Association

[1] European Commission (2012): MISSOC – Mutual information system on social protection : Social protection in the Member States of the European Union, of the European Economic Area and in Switzerland : Comparative tables

 

 
 

Last Updated: Tuesday 14 May 2013

 

 
  • Acknowledgements

    The above information was published in the 2012 Dementia in Europe Yearbook as part of Alzheimer Europe's 2012 Work Plan which received funding from the European Union in the framework of the Health Programme. Alzheimer Europe gratefully acknowledges the support it has received from the Alzheimer Europe Foundation for the preparation and publication of its 2012 Yearbook.
  • European Union
 
 

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