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Standing Committee on Health and Ageing
12/10/2012
Dementia: early diagnosis and intervention

BAUER, Dr Lyndon, Administrator, Health Promotion Central Coast

CHAIR: Welcome. Although the committee does not require you to speak under oath, you should understand that these hearings are formal proceedings of the Commonwealth parliament and giving false or misleading evidence is a serious matter and may be regarded as a contempt of parliament. I now ask you to make a brief introductory statement and then we can proceed to questions.

Dr Bauer : I represent many different aspects of the community. Firstly I would like to speak as a consumer myself as I recently looked after my father when he was dying from dementia. The recurring theme from the consumers that I see, particularly on the Central Coast, is the lack of access to GP home visits. When people choose to be cared for at home, there needs to be access to a GP who does home visits. With regard to my work in health promotion around aged care, dementia et cetera I think primary prevention is best served by community actions which address smoking cessation, overweight, obesity, diabetes et cetera and are delivered to the whole community. For bang for your buck, that is probably the best way to go. With the diagnosis of dementia, particularly if it is done earlier, there are secondary aspects whereby people can work hard at improving vascular risk et cetera and reduce the progression of the disease. From the health promotion side, for bang for your buck you must address the whole community, particularly around smoking, weight reduction, physical activity et cetera.

With the question of the diagnosis of dementia, I am going to be talking to the need for it to be based on timely diagnosis rather than early diagnosis. Strictly, if we were going to go by diagnosis as in DSM4 this would not be an issue. There are quite a lot of requirements to get a final diagnosis through DSM4; it requires impaired activities of daily life and impairment of general functioning. I have been working in this field for many years in general practice. From personal experience and from having been a bit of a zealot in the beginning and doing lots of early diagnosing—probably without that full gamut but just some indicators—I know there are some real risks in doing very early diagnosis of dementia, particularly as the progression can be variable and there are a number of false positives in a number of the tests. We need to recognise that this can severely damage the doctor-patient relationship—one of the most important things for the patient is the doctor-patient relationship and that ongoing attachment. So I think we need to be very cautious about possibly promoting overzealousness in looking for these early signs and then making diagnoses. This can have a terrible impact on people's careers and on their insurance—and often it does not even come to pass, or it may be very early stage.

So I emphasise that, by the time we are making the diagnosis, there needs to be some sort of functional impact on the person. On the horizon we now have PET scans, which can pick up amyloid being deposited in the brain. Potentially even I could be diagnosed with Alzheimer's disease process without having a full DSM4 diagnosis of Alzheimer's. The impact that that would have on my medical career and insurance et cetera would be tremendous. So I completely agree that timely diagnosis is not done at the moment and we need to focus much more on that. But we just have to be cautious that we do not go down the opposite path of being overzealous about early diagnosis. A timely diagnosis can allay the fears of people who think they might have dementia but really do not—they have been touched by dementia. It can help us avoid medications which exacerbate symptoms of dementia and cause all sorts of risks. It can help us avoid delirium. Delirium in a person with dementia is a medical emergency. It can cause falls, fractured hips, the worsening of their dementia—all sorts of nastiness.

New mental health problems in people with dementia that are undiagnosed often means months or years looking at psychiatric type solutions, which are completely inappropriate where there is an organic cause. Hospitals are very dangerous places for people with undiagnosed dementia. Anaesthetics often cause delirium. There are many reasons why we really need to be doing a timely diagnosis, but not necessarily a very early diagnosis. It is also especially relevant for carers' services.

Capacity assessment is done very poorly by doctors and by lawyers. When there is not a diagnosis then often people's capacity can be over- or understated. I would like also to talk to the whole issue around advance directives and some of the other legal issues—wills et cetera—that are so critical. So diagnosis of dementia in a timely manner gives people the ability to sort out these legal issues, and in particular the advance directive as to what sort of care they want when they are no longer able to speak for themselves.

CHAIR: I might start off with a couple of things you have mentioned—one was about false positives. First of all I thank you for coming to give evidence and certainly for giving us an overview of timely diagnosis, which is really important. I know that we have used the phrase 'early diagnosis' but I think you have clarified it really well today by getting us to think about that timely diagnosis. What might be early diagnosis for some may not be the case for other people.

Dr Bauer : Yes.

CHAIR: I think it is really important that we focus on that, and I think it is really good that we get an understanding of timely diagnosis. That is really important because, as you said, for some people the early diagnosis could be detrimental.

There are two things I would like you to give us a bit of an explanation about. Firstly, what could be a false positive? Secondly, we have heard the word 'delirium' quite a bit this morning and I was just speaking to our secretariat about it. Could you give us a description of delirium so that we can have in our minds what we are talking about. Could you explain those two things to us?

Dr Bauer : Yes. A false positive comes when you do a test that gives you a positive result where the actual condition is not there.

CHAIR: Yes.

Dr Bauer : For example, if you do a mini mental-state screen on everyone over 75 because there is an MBS item number to do it—I am not going to quote the numbers because the exact numbers don't come to mind—you will find that a surprisingly high number of patients, if you randomly select them from your practice without them having any sort of underlying problem, will come up positive. There are number of different reasons why this might be: the stress around taking the test, their literacy levels et cetera, and because the tests are not so good. Many of the tests have weaknesses. If we then take that percentage of people—it is a large number; let's say it is 35 per cent but I am only guessing—and put that pressure on them, 'Gee, you've come up positive for dementia,' that can be very damaging.

If you take people who have come in with a set of symptoms that are affecting their lifestyle and apply the test there, then the proportion of false positives that come up is much lower. One example for me—this is off topic but it gives you a much better understanding—is a pregnant women. If she comes to me I am obliged to do an HIV test. Now, in our low-risk community the chances of that test coming back positive and her having HIV are less than the chances of that coming back positive and its being mistake. Now, if I do not tell that woman upfront that in her setting that very, very rare outcome of a mistake in the test is actually more likely that her really having HIV, then it is very hard to try and explain that once the test comes back positive.

Similarly, if you are looking at a group of people who already have a high risk then the number actually come up with false indications becomes much less.

You get similar tests for instance with CT scans, which show cerebral atrophy, or MRIs cetera. All of these tests can show signs which may well be in line with a diagnosis of dementia, particularly if it is supported by other symptoms and you put together a case—it is almost like putting together a legal case. Eventually you have enough things to put together to diagnose dementia but the risk of any one of them being a diagnostic is not good.

CHAIR: And the other one I have is delirium.

Dr Bauer : Delirium is an acute—which means rapid onset—fluctuation of your cognitive ability. The best way to think of it is a child who is delirious with a fever, getting hallucinations and has lost touch et cetera. Older people go back to being at risk at getting that sort of delirium but there are more types of delirium that you get in older people. People with dementia, even very mild dementia, are very much more at risk of having a delirium than people who do not have any dementia whatsoever. There are different things that are typical in delirium. Delirium is more typically going to have visual hallucinations that are not likely in most types of dementia. Delirium has a rapid onset generally, although with some types of medication causing delirium, it can be a fairly slow onset. Some medications can cause delirium. Once an older person has delirium they are at risk of all sorts of accidents et cetera. Their urinary tract infection, which has caused their delirium, can mean it takes six months to recover their cognitive function which was knocked off during the time when they had delirium. Delirium is reversible. Sometimes it takes a long time for the reversibility to come back; dementia is not. We say that delirium is a medical emergency because the more quickly it can be identified and treated, the better the outcome for the patient.

Ms O'NEILL: It is becoming more and more apparent how challenging this sort of a diagnosis is and I, too, want to thank you for the term 'timely' and for the caution about the impact on careers and insurance implications of a diagnosis that is a premature and perhaps prejudicial label that prevents people from living out their lives with an illness.

Dr Bauer : Absolutely, and we do see these diagnoses are relatively young ages—certainly not that uncommonly in the fifties. One of the tremendously impressive participants at the Canberra meeting, Cate, represented herself. She was first diagnosed at 48. So it is a full spectrum; it is not just 80-year-olds.

Ms O'NEILL: I think you are the first witness I have heard say 'dying from dementia'. We hear 'living with dementia' and 'managing dementia', all of these sorts of terms as a way of softening the blow. I really do not understand because happily I have had not had the experience of someone in my family suffering from this form of illness. Can you walk me through? You spoke about a 48-year-old with a early diagnosis who continued to function in their profession for how long? Then what happens? What is the whole process?

Dr Bauer : The type of dementia will determine the speed of the progression and then as well if, for instance, there is a vascular dementia and they get all their vascular issues under control, it may progress very very slowly over a substantial number of years. It may be more than a decade. Whereas some other types of dementia—Lewy body dementia, for instance, can progress very quickly.

CHAIR: What was that one?

Dr Bauer : Lewy body dementia, which is vaguely related to Parkinson's disease.

CHAIR: The body just wastes away?

Dr Bauer : Lewy bodies other the types of pathological features found on autopsy in the brain, so it is just the name of the condition. It is one of the interesting dimensions which are more likely to present with visual hallucinations, whereas most of the others do not present with visual hallucinations.

Dementias, I would say pretty much universally, if the person does not die from something else, will ultimately be terminal. It is a terminal illness. Most of them will be terminal probably within 10 to 20 years, depending on how early you pick it up and how quickly they progress. For someone that you have protected from all the other types of issues, the things that happen towards the end are that they lose the ability to swallow. You can do a PEG feed, which is a percutaneous gastric feeding tube. There are still surgeons that offer that. Many of the people involved in dementia care are very much against that because we feel that that is probably not a practical path to go down, but when that is offered families often do want to take that up to keep the person going even though they are unable to swallow. Eventually, they are unable to walk, which means that they are suffering from bedsores, which can sometimes cause their demise. Ultimately they are unable to protect their airway. It is very rare to get to this extreme point, because usually something else has taken them out, like a pneumonia, because they are unable to protect their airway, but eventually their breathing becomes erratic and their ability cognitively to continue breathing is impaired, so they will die.

CHAIR: It is a bit like the brain shutting down gradually—

Dr Bauer : It is a progressive degenerative disease.

CHAIR: and the functions that keep us going shutting down.

Dr Bauer : Yes, absolutely.

Ms O'NEILL: Thank you. I am not happy to hear that, really, but it is important, certainly, for me to understand that and get it on the record. The other point that you made in your earlier comments was about the problems that you could see. You spoke about hospitals being dangerous places. You particularly mentioned anaesthetists and the risk—

Dr Bauer : Anaesthetics.

Ms O'NEILL: okay, anaesthetics and the risk that is involved for them. I would like to know a little bit more about anaesthetics and what that college of professionals is doing in terms of dementia, their role in picking up intervening or processes of care, and then generally other risks in hospital.

Dr Bauer : I cannot speak to what the College of Anaesthetists is doing in this field, but it is well recognised by the anaesthetists and particularly by the surgeons who go and look after the people afterwards, and then by the GPs, that people with any level of dementia frequently develop a delirium with any level of exposure to an anaesthetic. The anaesthetic drugs go into the nervous system. You or I wake up from an anaesthetic and within a day or so we are back to our normal function. It can take many months for someone with a dementia to be back to their level of function, even if you just give them an anaesthetic and do nothing to them in terms of surgery. In recovery back to whatever that functional level was—being able to feed themselves, dress themselves or whatever; being able to toilet without having an accident et cetera—those things come back, but sometimes it takes an awfully long time for them to come back. So you do not launch into an anaesthetic in someone with a moderate dementia lightly, because really that person's level of function is likely to have an impact for some time, certainly weeks but sometimes longer. And, in that immediate post-anaesthetic period, the risk of them being confused and wanting to wander around, falling and fracturing a hip or disappearing from the ward is greatly increased. They may well go into hospital not having any sign of any of those sorts of risks. They have their anaesthetic, and then all of a sudden you are dealing with a patient that now is very confused and very hard to nurse.

On hospitals being dangerous places: nursing homes are experts at looking after people with dementias. They are very good at letting those people mobilise and stay physically fit but do that in a safe way. Hospitals cannot do that. They are not expert at all in letting people continue to move around. They are not experts at all in keeping people safe from falls. Hospitals are quite understaffed for looking after people with this level of need, so they often do not eat. The food may well be left right next to them and they are just not able to eat or to feed themselves. They will often become incontinent, get upset about the fact that they are dirty and, rather than do the appropriate thing, which is press the buzzer and wait for the nurse to come, they will go off wandering to try and fix it themselves, which can end up causing all sorts of problems. Then there are all the other sorts of risks of hospital acquired infections, because the germs in hospitals are often more likely to be resistant to a lot of the antibiotics.

So, all in all, for a patient with dementia that I am looking after, if I can possibly nurse them in site, either at home or in their residential facility, I find that a much safer way of delivering their care, even if that involves getting someone to come in site to give a drip or an intramuscular injection of antibiotics et cetera. If it is the choice of everyone that that is what the person needs, I think it is safer to do that in their facility, where they are known. Also there is the issue that someone with dementia does not adjust to new surroundings well at all. They are used to the surroundings that they are in. They know where the toilet is. They do not get upset and panic about where they are. In new surroundings, it does not matter how many times you tell them where the toilet is, they will not know.

Essentially, that is why I am saying that, in general, if you can possibly avoid having someone with a dementia in hospital, you should avoid it. Hospitals are not expert; residential facilities and the good old carer are experts at that particular person.

CHAIR: Whereas a hospital just is not geared up for them.

Dr Bauer : No.

CHAIR: Getting back to the timely diagnosis, how do you know when it is timely to diagnose someone with dementia? Secondly, at what stage in the disease process should a person develop their advance directives?

Dr Bauer : As I mentioned earlier, if you go for a proper DSM-IV diagnosis—a DSM-IV is the set-out of all of the things you need before you can formally say that this person has dementia—it does include impaired activities of daily life in some way. If we were going to all agree that we would never make the diagnosis without doing that, then early diagnosis would be fine, but it just does not happen that way. For mine, the timely diagnosis comes when the condition is impacting on that person's lifestyle in some way. They are now having trouble doing something reasonably important which they used to be able to do and they cannot do any longer. They might still be able to drive, although there are all sorts of questions now about whether we legally should be allowing that. They might still be able to manage the ATM. But they are now having problems with X, whatever it is in their life that they used to be okay with. I believe that then is a timely time to drag in all these other tests and make the diagnosis of dementia.

But, just because someone is a bit forgetful, that is not necessarily having an impact on their activities of daily life. What I would do with that person is say to them: 'Look, this is one of the possibilities. We need to just keep looking at you, keep an eye on you. These are some of the things which you can do which are great for your health anyway and which can stave off anything that might be coming along.' But, until it is actually having an impact on their day-to-day life in some way, I would be reluctant to formally say, 'You have dementia,' or, 'You have Alzheimer's disease.'

CHAIR: So really it is the point when it starts to impact on their life whilst doing things that they have done—

Dr Bauer : Yes. Something in their life that they used to be able to do and now they are having problems with.

CHAIR: And in terms of advance care directives?

Dr Bauer : Advance directives can happen at any stage during your life. The thing is that, when you develop an illness which gives you more information about where you might be headed, then it is easier to make a more insightful advance directive. We are not allowed, even for someone with an advance directive, to do something that would lead towards them dying. That is euthanasia. But we can make choices about the type of care that that person might want to be given. In cancer care, for instance, you can choose whether you want to have chemotherapy or not have chemotherapy, and everyone can see that distinction fairly easily. But, for instance, if someone has a problem with their breathing, they might choose to either try the best they can with just oxygen, or they might say, 'No, I would allow you to put a tube in and put me on a breathing machine.'

You might say, 'No, under no circumstances do I want a tube; do everything you can without the tube and the breathing machine,' but that is all you are allowed to do. That contains no way of bringing death upon that person—it does not mean removing any other of their treatments—it is saying that that particular type of treatment would be withdrawn in that case.

Someone with a diagnosis of dementia might say they want surgery only to relieve discomfort or pain and not to aim to extend their life in any way. For instance, if it was diagnosed that they have an aneurysm that might or might not pop, as we have said, operations in this group of patients can often knock them around for a tremendously long time. Personally, I would not want to have that operation. I would take my chances on it popping and would not want the burden of having that operation given what I know. I would be happy to write an advanced directive saying, 'No operations for Lyndon Bauer other than if I need it to relieve pain in some way.' Maybe if I broke a hip I would need that fixed up, but no other operations. I may say that I do not want CPR, which is someone jumping on my chest, because I feel that once I get to that point all we are doing is causing me a lot of pain and suffering from all the CPR, and there is not much likelihood of it giving me any real value or extra time. I might say I do not want to have a PEG feed, so if I get to that point it is not something that I want.

This law did not come about from people with dementia; it came about from a religious cause where an Alzheimer's patient who was a Jehovah's Witness refused under any circumstances to have dialysis. It went to the High Court, which found that a person is able to say in advance that they do not want this particular type of treatment. Since then we have interpreted that to say, 'We could apply this now to people with dementia, for instance, in saying what sorts of treatment they want later in their lives.'

CHAIR: I suppose that decision is made by that person earlier on.

Dr Bauer : That is something I would like to draw to your attention—

CHAIR: Say that down the track this person obviously does not have the capacity to make any more decisions, and there is need for intervention, whatever it may be—I suppose you have to honour the wishes of that particular person. How do you bring it down narrowly? You named a whole range of things there—no resuscitation or breathing machine et cetera—do you have to specify directly each and every thing?

Dr Bauer : The website that I have been involved with—

CHAIR: Or is it broad?

Dr Bauer : has developed this form that helps people. These are the likely outcomes.

CHAIR: We will table this form so it can become part of the evidence.

Dr Bauer : It is a two-case scenario: (1) if you are as you are now, and (2) if you have developed an unacceptable type of illness. You define for yourself what comprises an unacceptable type of illness.

CHAIR: But you may miss one, or there may be one you do want to be treated for and one you do not wish to be treated for.

Dr Bauer : It really is very comprehensive if you go through it. All of the very likely—

CHAIR: Then who makes that decision if it is not on this list?

Dr Bauer : If there is not an advanced care directive, or if the advanced care directive does not cover something that comes up, then we go back to the old system which has always been there; the person responsible can in an acute setting make a substitute decision for that person given all of the information in that particular setting.

CHAIR: Understood. Thank you.

Dr Bauer : The thing that I am concerned about is that now we are seeing forms that, rather than being the form of the patient, are medical orders, which are the form of the doctor or the nurse et cetera, that are attempting to do the same thing but are getting permission from a relative. The big question is this. The relative certainly can give that permission in the acute setting where there is no-one else to give it—

CHAIR: Not if this form has been completed by the patient.

Dr Bauer : That is right. But this form now is trying to give that permission in advance, and I am concerned about that because I do not believe that that is—

CHAIR: So, when you say 'in advance', they are trying to give it in advance to the relatives before the patient does not have the capacity to make those decisions?

Dr Bauer : Well, presumably the person did not have the capacity, but there is nowhere in this form that actually records that. So what we actually have is someone who is in a nursing home who has these medical orders that say, 'You are not to do this,' and say, 'First follow these orders before you contact a doctor,' et cetera, and say 'No CPR,' or 'No antibiotics,' or whatever—all the different tick-a-boxes. All those things, to my mind, are fine if it is an advance directive from the individual patient, but these are advance directives from the medical team with a consent from a person responsible, and I do not believe that that is—well, I actually do not believe it is legal, but I am concerned about it as a way of going. It certainly is reasonable in an acute setting where no-one else is able to make that decision, but making those sorts of decisions in advance I am very concerned about.

CHAIR: If those decisions were made in advance, what would normally happen? You would pick up the phone, call the relative and say, 'Your mum or your dad has just had a stroke and they need XYZ'—

Dr Bauer : 'What shall we do?'

CHAIR: and you would go through this scenario, 'They are in their 90s' and so on—

Dr Bauer : Yes.

CHAIR: I have heard of—and again, I will reiterate things that I have heard when we do this, as we do all the time, in our own electorates—a woman who was a diabetic on insulin, which is manageable. She was in her 80s. When you are on insulin, as you would know, you have highs and lows; if your sugar drops you have a glass of Coca-Cola or some sugar and it goes back up to the normal level. This woman went into a coma, and the facility said, 'Oh, look, she's in her 80s …' and the family, who understood the disease very well, got very angry and said, 'You give her a shot of glucose and she'll be fine!' So there is a situation where there is something very simple that is treatable, but the views of the people who were caring for her at the time—that is very serious, I think. There you go. I thought I would raise that.

Dr Bauer : These are the issues that we are dealing with all the time. I think the first thing is to give the individual themselves the opportunity to make these statements by diagnosing their dementia early and encouraging them and giving them access to the ability, in advance, to talk, themselves, about what they want. As to the other way of going about it, I have seen instances where the wrong person signed the form; where, for instance, the husband, who wants the wife to get everything, is not asked and they ask somebody else—the daughter, who is willing to sign the form. I have seen instances where the person themselves is completely capable of signing the form, because they have the capacity, and yet it has been signed by somebody else, some relative. It is stuff that gives me great concern. So I am very supportive of it coming back to the person themselves making statements about the sort of care they want, in advance, and that comes down to being able to diagnose the dementia early and give people opportunities to make these choices for themselves. But when we make these choices for someone else, that is what concerns me.

Ms O'NEILL: My question was about the early/timely divide there. We have heard evidence about the positive impact of engaging in a drug based medical therapy, if we can find out early enough that a person has dementia. While that might have negative impacts in the way that you have outlined in terms of career and also insurance, what is the trade-off there? What is the risk of not identifying early enough? And what is the medical therapy, the drug treatment therapy, and how efficacious is it?

Dr Bauer : You are talking mainly about cholinesterase inhibitors there that increase the amount of acetylcholine, which is one of the drugs in the synaptic cleft which becomes low in Alzheimer's disease. These drugs can increase that. The effectiveness is very variable; on average you see a slowing of the deterioration but really not much improvement. Occasionally you see people who get noticeable improvement, possibly winding the clock back by about six months; they go back to how they were about six months ago. But this is unpredictable and I would say that in my experience it might be, say, one in five who improve that much. An equal number would have no impact whatsoever from the medications.

The medications, to show that sort of improvement, will work best if they are delivered when there is some sort of a problem. They do not have a second life later on if you use them then add more of them; all you do is get more side effects. Using them before there are any sorts of functional problems is really a waste of time—not even the drug companies are suggesting that. Really, the bang for the buck is to use them when there are problems. In some circumstances you can wind the clock back for, let us say, six months, to how they were a little while ago.

On average, probably what you do mainly is to hold them steady for a little while. I think there was one study that showed that overall there was an average of six months delay in people being put into nursing homes because of the use of this drug. So there certainly is a wonderful improvement, but it is not a miracle drug.

Ms O'NEILL: Can I go to the primary prevention that you so encouraged us to look at as the critical thing, and that is an area of expertise that you have considerable skill in. I have read some of your work before and been very impressed by that.

Dr Bauer : Thank you.

Ms O'NEILL: What would you recommend if we were to undertake a significant health promotion on a national scale? What might it look like and how would it integrate with other health promotion vehicles that are already on the road?

Dr Bauer : It is not terribly exciting, but it is more of the same—unfortunately! I wish I could come up with something very exciting for you. Interestingly, when they do the MRIs which show a great deal of detail in the brains of people with Alzheimer's—what we thought were pure Alzheimer's—most of them have mixed vascular disease as well. So the most accessible component of that disease is the vascular component. The vascular component, over and above everything, is their smoking, but then secondary to that is their obesity and their sedentary behaviour. You could say, 'Let's get really active in diagnosing dementia early and going—

CHAIR: 'Let's get really active and work it out generally—

Dr Bauer : Yes—going hell for leather in those people who we diagnose early and making sure that we do all those things for them. And we absolutely should, and we probably should use more anticholesterol medications and more aggressive blood pressure control et cetera in those people. But I think that overall what we should be doing, if we do a little bit of a lot of things, is just putting more emphasis into the general smoking cessation, overweight and obesity behaviour—

CHAIR: All the common sense—

Dr Bauer : Yes. For everyone, because everyone is at risk of dementia. That is a sort of negative—I am not saying through health primary promotion that we need to do an early diagnosis of dementia; we just need to do a little bit more of that stuff for everyone. That will help everyone.

Ms O'NEILL: When we look at this in the general community as a general message, that is one layer. What success, internationally, has there been with workplaces, businesses and schools being involved in the development of opportunities for greater health in the vascular system? Are there models of promotion for it?

Dr Bauer : With schools, for instance: when I first became involved in health promotion on the Central Coast in 1993 we surveyed four of the local high schools and found that 25½ per cent of all students reported smoking regularly. We are now down to 6 per cent from 25 per cent.

That has been multifactorial as to how that has been achieved. We believe that a big part of it was the work we have done on restricting the sales to minors by fining the stores that we find do sell tobacco to minors. But there is all the background stuff with the movies and everything else, the sales and the packets—all the work that has been going on. All of that helps. Many of those kids who are no longer taking it up would have gone on to smoke throughout their whole lives and ended up being at more risk of dementia later in their lives because of not being able to quit smoking. It is tremendously addictive once you do take it up.

But there is still a decent proportion of people, particularly in our poorer socioeconomic demographic—even in their older years—who are continuing to smoke and who are not accessing Quitline, Champix et cetera. They are our harder targets because of the lower socioeconomic demographic. Many of them would be able to quit smoking and, really, compared with putting them on a cholinesterase inhibitor, quitting smoking is way more effective in stopping the progression of their Alzheimer's disease.

Ms O'NEILL: Are there any sites of international best practice in this area for health promotion that are actually looking like they are scoring goals in even reducing dementia?

Dr Bauer : I can look that up, but I am sorry: for dementia itself and international best practice, I am not certain I could come up with that. For many years Australia was one of the leaders in tobacco control, but with the dementia aspect though—I am sure that there is somewhere but I am not able to speak to that immediately.

CHAIR: Thank you very much for giving evidence today. It is much appreciated. As I have said to the other witnesses, if there is anything that we feel we may require from you we will be in touch with you again. And vice versa: if you feel that there is something that was not raised today that was very important and which should be raised, feel free to palm it off to us and we will still use it as evidence in the inquiry.

Dr Bauer : Thank you very much, I appreciate that.

CHAIR: We will now take our lunch break.

Proceedings suspended from 12:17 to 12: 47