Drs O’Loughlin & Darley suggest that the rate of referral of older adults with dementia has increased since the launch of acetylcholinesterase inhibitors and the publication of the National Institute for Clinical Excellence (NICE) guidelines for their use (Psychiatric Bulletin, April 2006, 30, 131–134). Although the authors acknowledged the limitations of their findings, there are serious ethical and practical objections to the conclusions drawn.

We are not clear whether the 42 000 people aged 65 years and over in the catchment area was for 1996 or 2003. Fluctuation in the size of this population could easily affect the referral rate. Moreover, the authors do not define criteria used for the diagnosis of dementia in either period.

Mini-Mental State Examination (MMSE) scores are dependent on the person administering the test, age and particularly education (Reference Crum, Anthony and BassettCrum et al, 1993). The difference in the mean MMSE scores between the two groups reported by O’Loughlin & Darley is just 2.8. Other cognitive scales such as the Alzheimer’s Disease Assessment Scale - Cognitive subscale (ADAS–COG) or Mini-Cog have greater reliability and validity (Reference Borson, Scanlan and WatanabeBorson et al, 2005).

Hence, unless the above have been satisfactorily answered, we cannot support the tentative conclusion that more patients are being referred earlier in the course of illness to old age psychiatric services following the launch of anticholinesterase inhibitors and publication of the NICE guidelines.