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France

National Dementia Strategies (diagnosis, treatment and research)

Background information about the National Dementia Strategy

Status and historical development of the National Dementia Strategy

Three main stages can be identified in the development of a National Dementia Strategy in France resulting in three successive plans. A detailed article on these three plans has been written by Marie-Jo Guisset-Martinez (2012). A few points are mentioned here. The first plan stemmed from a report written by Girard and Canestri in 2000 in which the problem of stigma was highlighted and the need to develop a dedicated strategy to address dementia. Four key issues were highlighted as needing particular attention. These focused on problems related to diagnosis, the lack of services, inadequate coordination within the healthcare sector and the provision of information to the public (Guisset Martinez, 2012). A set of recommendations by Girard (2001) led to the adoption by the French Ministry of Health of the “Programme of people suffering from Alzheimer’s disease and related disorders”. This was the first national Alzheimer plan which ran from 2001 to 2004 and covered the implementation of a network of memory consultants, the creation of day care centres and measures to improve the quality of residential care for people with cognitive impairments.

The second plan was launched in 2004 with the aim of building on the progress made during the first plan. According to Guisset Martinez (2012), it is difficult to assess how successful this was as there was no specific budget allocated to it. Nevertheless, 2007 was the year in which Alzheimer’s disease was declared a major national cause (Alzheimer Grande Cause Nationale).

The third plan resulted from the work of a national expert committee led by Professor Joël Ménard (Guisset-Martinez, 2012). This committee organised a nation-wide consultation involving working groups, interviews and audits with family carers, advocacy groups, service providers, professional bodies and academic and research experts. The report was presented by Prof. Ménard to the President of the French Republic in 2007 accompanied by a series of recommendations. The third plan was launched in 2008. It has 11 objectives and 44 measures.

Duration of the National Dementia Strategy

The three plans cover a period of time stretching from 2001 to 2012, namely 2001 – 2004, 2004 – 2007 and 2008 – 2012.

How the National Dementia Strategy is funded

The third Alzheimer plan had an initial budget of EUR 1.6 billion.

Provisions or procedure for implementing the Strategy

The “Plan Alzheimer Mission” was set up to evaluate the implementation of the plan and to oversee the use of funding for the achievement of the objectives of the plan. 

Procedure for monitoring progress made in achieving the goals set

A National Steering Committee was set up to monitor the achievements and barriers to the achievement of the actions outlined in the third plan.

Diagnosis, treatment and research

Issues relating to diagnosis

Timely diagnosis in the National Dementia Strategy

Measure 8 of the third plan addressed the preparation and implementation of a system for disclosing the diagnosis and providing counselling. The objective was to improve the conditions surrounding the disclosure of the diagnosis and the provision of support thereafter. This was to be achieved by drafting and validating a reference system for communicating the diagnosis and for the associated support (which was published in November 2009); establishing training for the professionals concerned, implementing a system of disclosure in specialist units and implementing measures for disclosure and support with primary care doctors.

A working group was set up to draft the arrangements which would be validated by a consensus group working with the HAS (Haute Autorité de Santé). A reference system was to be produced and specific training created along with an adaptation of pricing where necessary. The arrangements were due to be implemented within and outside hospitals between 2009 and 2012.

In order to make and disclose the diagnosis, as well as to provide support, the HAS has taken the following measures:

-    A first recommendation in March 2008 on the diagnosis and care of people Alzheimer’s disease and related disorders;

-    a guide for doctors on long-term medical conditions in May 2009, which permits people with dementia to have 100% of their care for this condition covered;

-    a recommendation on the disclosure of the diagnosis and support in November 2009.

These documents were distributed by the ”Caisse Nationale d’Assurance Maladie” to 40,000 doctors in December 2010.

In April 2012, the HAS and the ANESM (the national agency for the evaluation and quality of social and medico-social establishments and services) also elaborated a summary of the measures for support: linked to the disclosure of the diagnosis, the development of a care plan, support at home and within care establishments.  A plan for support to be effective from the moment that a diagnosis is made and which creates a link between doctors and the MAIA (Maison pour l’Autonomie et l’Intégration des malades d’Alzheimer) has been elaborated:

-    the tool for communication between specialits and GPs was published in October 2011 (annex 5 of the Communication of 20 October 2011 regarding the organisation of the diagnosis and the follow-up of people with Alzheimer’s disease and related disorders);  

-    a long consultation at home in the presence of the carerwas decided upon (inscription in the convention of general practitioners - CNAMTS (Caisse nationale de l'assurance maladie des travailleurs salariés) – signed on 26 July 2011) and became operational at the beginning of 2012;

-    a tool for doctors elaborated by the INPES (Institut national de prévention et d'éducation pour la santé) called ”Repères pour votre pratique. Maladie d’Alzheimer – Réaliser une visite longue”  (guidelines for your practice. Alzheimer’s disease – carrying out a long visit). This is a guide to carrying out a meeting in order to better discern the situation of the patient and his/her carer.

Another measure which should affect timely diagnosis was the creation of more memory units, particularly in areas not yet covered. This was measure 11 of the third plan. There were 366 memory units in 2006 located in short-stay institutions throughout the country and it was envisaged in the third plan to create a further 38 memory units for which EUR 6.68 million was set aside for this task. In 2010, an additional 21 units had been created (Official Press Release, 2010).

In 2008, there were 25 CMRRs (memory resource and research centres) in 23 regions of France which provided diagnosis in the most complex cases and for the earliest forms of dementia. Measure 12 of the third plan envisaged the creation of new centres to be set up in Auvergne, Corsica and Limousine. EUR 1.14 million was set aside for the creation of these new centres. The centres in Auvergne and Limousine were set up in 2008 and the one in Corsica was planned for 2011 (Official website update, 2010). In addition, a national reference centre for young people with Alzheimer’s disease (i.e. under the age of 60) was set up in February 2009. This has a network of contacts all over France who are able to provide specific advice.

As some of the memory units were particularly busy, it was considered necessary to provide them with more funds so as to reduce the time taken to obtain a specialist memory assessment and guarantee the quality of the service provided, particularly with regard to the disclosure of the diagnosis. This resulted in allocating additional resources (amounting to EUR 12.3 million in total) to 122 approved memory units. Eventually, 202 centres were given additional support. The success of this measure was estimated as being satisfactory in 2009 with the average waiting time being an average of 51 days and 4 out of 5 people receiving an appointment in less than three months (Official Press Release, 2010).

Other measures linked in the plan to improving access to diagnosis and care pathways include the creation of an Alzheimer’s disease information card for each patient and experimentation with new payment terms for health professionals.

Which healthcare professionals are responsible for diagnosing dementia

GPs are authorised to carry out a pre-diagnosis before orientating patients towards specialists in memory centres or to independent specialists such as neurologists, geriatricians or psychiatrists. GPs cannot make the initial prescription of AD drugs unless they have obtained qualifications in geriatrics in which case they would have become geriatricians.

The specialists who are mainly responsible for diagnosing dementia are neurologists, geriatricians and, to a lesser extent, psychiatrists.

GPs do not have set consultation times for the pre-diagnosis of dementia. Consequently, they would not receive additional payment for a longer consultation. However, since 2012 they can carry out one long consultation per year for each person with dementia and his/her carer.  GPs receive a higher payment for this compared to their standard consultations.

Type and degree of training of GPs in dementia

GPs receive initial training followed by a module in geriatrics plus 12 additional hours of practice which include the use of tests.

Continued education exists but is not obligatory. The Regional Union of Healthcare Professionals (Union Régionale des professionnels de santé) has been offering for some time now training by doctors for GP practices.

Issues relating to medical treatment

Medical treatment in the National Dementia Strategy

Measure 15 of the third plan is to improve the correct use of medical drugs. The objective is described as being “to improve the quality of practice and the use of psychotropic drugs in this disease”. This was to be achieved by:

  • drafting clinical practice recommendations about sedation for behavioural problems in difficult situations and on how to handle behavioural problems;
  • by drafting and circulating programmes to evaluate and improve professional practice in the effective use of medication, including psychotropic drugs, in elderly patients including those with Alzheimer’s disease.

A working group was to be set up to draft those recommendations in 2008 with implementation planned in 2009. The recommendations of the HAS on the diagnosis and care of people with Alzheimer’s disease and related disorders were published in March 2008. In May 2011, these recommendations were withdrawn for formal legal reasons (des raisons juridiques formelles). This caused some disturbance amongst both patients and professionals. The Commission for Transparency, which was in charge of evaluating AD drugs for the HAS, concluded on 27 October 2011 that AD drugs had limited therapeutic benefit and recommended limiting their prescription to one year, renewable subject to strict conditions being fulfilled. In November 2011, the HAS therefore published a new recommendation on the diagnosis and care of people with Alzheimer’s disease and related disorders in order to bring up to date its chapter on medical treatment according to the new declaration of the Commission for Transparency. Moreover, the recommendations for the management of acute confusion in elderly people of disturbing behavioural symptoms were published in May 2009.

A warning indicator measuring the exposure of people with Alzheimer’s disease to neuroleptics was set up by the HAS. A reduction in the use of neuroleptics at national level has been noted of 16.9% to 15.5% between 2007 and 2010. This indicator is not being followed in the MAIA territories, at regional level, at national level and at European level (as a joint action with ALCOVE). It will also be retained as a quality indicator in care homes.

The availability of medicines in general

France has different reimbursement levels for medicines depending on the efficacy of the medicines and the seriousness of the disease or symptoms. Patients may have to contribute between 0% and 85% towards the cost of medication depending on the recognition of the medical service provided plus a flat-rate co-payment of EUR 0.50 per package of medicine with a limit of EUR 50 per year per person[1].

The availability of Alzheimer treatments

All four AD drugs are available.

Conditions surrounding the prescription and reimbursement of AD drugs

All AD drugs are available in France and are fully reimbursed at 100% through the reimbursement system. However, full reimbursement has recently been called into question.

There are no specific examinations which are specified by the reimbursement system, but reimbursement of acetylcholinesterase inhibitors is limited to people with Alzheimer’s disease with an MMSE score ranging between 26 and 10 and memantine to patients with an MMSE score below 15.

The French system requires the initial treatment decision and prescription to be carried out by a specialist (a neurologist, psychiatrist or geriatrician), whereas continuing treatment prescriptions can be filled in by GPs as well. There are no restrictions as to the access of people living alone or in nursing homes to available AD treatments.

France Alzheimer clarified that although the market authorisation for all four products is for Alzheimer’s disease, the French system also has a system of temporary authorisations (“autorisations temporaires d’utilisation”) for diseases for which no treatment is available. Under that system, some people with Lewy body dementia, vascular dementia and Parkinson’s disease dementia also have access to these treatments.

Prescription and reimbursement

Donepezil

Rivastigmine

Galantamine

Memantine

Available

Yes

Yes

Yes

Yes

Reimbursed

Yes

Yes

Yes

Yes

Initial treatment decision

Specialist (neurologist, psychiatrist or geriatrician)

Specialist (neurologist, psychiatrist or geriatrician)

Specialist (neurologist, psychiatrist or geriatrician)

Specialist (neurologist, psychiatrist or geriatrician)

Continuing treatment decision

Specialist or GP

Specialist or GP

Specialist or GP

Specialist or GP

Required examinations

None but reimbursement depends on MMSE score

None but reimbursement depends on MMSE score

None but reimbursement depends on MMSE score

None but reimbursement depends on MMSE score

MMSE limits

26 - 10

26 -10

26 - 10

Below 15

Issues relating to research

Research in the National Dementia Strategy

Objective 7 of the third plan was to make unprecedented efforts in research. The following 13 measures (as numbered in the Plan) were designed to achieve this objective:

  1. Creating a foundation for scientific cooperation to stimulate and coordinate scientific research: This was created in June 2008 with public and private funding.
  2. Developing clinical research into Alzheimer’s disease and improving the evaluation of non-drug therapies. Each year the Fondation Plan Alzheimer launches calls for clinical research projects.
  3. Providing doctoral and post-doctoral grants: In the period 2008-2010, 146 theses on Alzheimer’s disease were identifified and 36 post-doctoral studies financed. The survey was renewed in November 2012.
  4. Creating new assistant surgeon and hospital teaching assistant positions: Calls for applications have been made since 2008 which led to the appointment of new heads of clinics/assistants.
  5. Providing support for research groups working on innovative approaches: There were four calls for project in 2012 and four in 2010.  
  6. Providing support for methodological research groups in human and social sciences: In May 2010 a methodological group was set up.
  7. Creating a body of research into automatic image processing: In June 2010, a centre for the acquisition and computerised treatment of images was established.
  8. Studying large patient populations (cohorts) with long-term monitoring: A cohort (3C) stretching back over 10 years and involving 6,000 subjects aged 75 and over is being followed up. However, there is a risk of not reaching the objective for 2012.
  9. Organising a high-speed genotyping project: Considerable progress has been made. Two new genes affecting susceptibility were identified (CLU and CRI), the study was replicated in the United States of America and in 2011 the International Genomic Alzheimer Project was launched involving 30,000 people with Alzheimer’s disease and 60,000 controls. 
  10. Exploiting the genome sequencing of the microcebe (which is a lemur): Between 2009 and 2011, ten projects were financed at a cost of EUR 3 million.
  11. Promoting training in clinical epidemiology (in order to increase the number of doctors taking part in research protocols): 637 people have been trained since 2009 and a further 189 have completed e-training courses.
  12. Developing links between public research and industry: A DIU (Diplôme interuniversitaire) has been created and congresses organised involving the private and public domains  as well as enquiries into the ongoing clinical studies.
  13. Promoting research in human and social sciences: Every year, the Fondation Plan Alzheimer launches calls for research projects in the human and social sciences. Seventeen projects have been selected between 2009 and 2012.

By 2010, 61 research projects had received funding (total amount EUR 30 million). The studies covered basic, clinical and therapeutic research, as well as research into new technologies and human and social science research. In addition, 54 new researchers were recruited over two years. 

European involvement in research

France is involved in the EU Joint Programme – Neurodegenerative Disease Research (JPND) and is an Associate partner in the Joint Action “Alzheimer Cooperative Valuation in Europe (ALCOVE)”.

References

Guisset-Martinez, M-J. (2012), Three Alzheimer plans in France (2008-2012). In Innes, A., Kelly, F. and McCabe, L.,Key issues in evolving dementia care: international theory-based policy and practice, London, Jessica Kingsley, pp.122-136

Acknowledgements

Judith Mollard, Expert Psychologist, Association France Alzheimer

Fanny Gaspard, Public Policies Executive, Association France Alzheimer

[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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