A Study of the Geographic Accessibility of Outpatient Memory Clinics in Germany

Healthcare provision for people affected by dementia syndromes presents increasing challenges for society on the background of an ageing population. According to calculations, a worldwide increase in the number of dementia patients is expected from currently just under 57 million to more than 150 million by 2050 (1). It is not surprising that medical research is focused on potentially preventive and curative approaches. The nationwide foundation of research centers, such as the German Center for Neurodegenerative Diseases (DZNE), set an important milestone for supporting/funding translational approaches in dementia research in collaboration with university hospitals. Furthermore, established memory clinics provide much needed medical care for a multitude of affected persons. In the future, the question will arise: How, in view of a growing number of patients, can we guarantee early and multimodal nationwide diagnostic evaluations while at the same time making potential therapeutic approaches available in a timely and efficient manner to those affected. Affected patients, due to their typical age structure and disease-related limitations, often depend on support from their environment. Therefore, it makes sense to provide care in specialized centers that are geographically close.

The present study aimed to identify the need for and accessibility of specialized structures for dementia treatment on the basis of a geographic analysis. In addition to the geographic analysis of the accessibility of existing outpatient memory clinics, we also analyzed which medical specialties are involved in the specific diagnostics and therapy of patients with memory impairments.

Methods

We calculated the geographic distance from/to specialized structures in the dementia field. Data on locations of outpatient memory clinics were retrieved from the relevant websites (www.alzheimer-forschung.de/alzheimer/diagnose/gedaechtnisambulanz/; www.dzne.de/ueber-uns/standorte/, www.dga-netz.de/ambulanz/-ber-uns.html) on 31 October 2022. For the purpose of geographic accessibility analyses we calculated so called isochrones by means of a local installation of openrouteservice. Isochrones are areas or regions that can be accessed from a certain location point by means of pre-defined public transport in a defined amount of time. For combined passenger car specific isochrones on the different network structures, we used a publicly available dataset, the Global Human Settlement Population Grid 2019, to calculate the population covered for the year 2015 (the most recent available year).

Results

166 outpatient memory clinics were listed in the sources in Germany at the time of our analysis. The isochrone maps (Figure 1) show clearly that the transport time of 30 minutes to a specialized institution cannot be realized in some regions and can thus be assumed for only 63% of the population in the current healthcare landscape. Within an hour, however, relevant centers can be accessed in Germany on an almost nationwide basis, which means that 90% of the population are covered. The exceptions are individual regions, mostly located in the north east of Germany. Affected persons have to tolerate a transport/transfer time of 120 minutes in some cases. The psychiatric specialty covers most of the relevant specialist institutions, with institutions led by neurologists and specialists in internal or geriatric medicine in the minority.

Figure 1.

Geographic accessibility in Germany of outpatient memory clinics by transport/drive time. The figure shows Germany‘s respective geographic accessibility for outpatient memory clinics for different transport times. Accessible within a given transport time are those areas that are tinted in the respective color.

Discussion

The present analyses show that a majority of the population has access to relevant specialist institutions in an adequate transport/transfer time. Given the predominantly older age of those affected and their disease-associated cognitive impairments, it is important to note that in some regions, significant transport distances have to be covered to access specialized centers. Furthermore, the actual number of these institutions is probably insufficiently high in terms of meeting the growing need for specialized treatment. When comparing these institutions with the care provision for patients with multiple sclerosis, for example, more than 200 certified institutions are available for more than 250,000 patients, which can provide new therapeutic approaches (2). In France, far more specialized institutions exist for dementia syndromes relative to the land area (3). A limitation we should mention is that the present analyses did not include demographic distributions, which would certainly be helpful in analyzing the need for dementia-specific care institutions. Especially when considering amyloid antibody therapy for the treatment of Alzheimer’s disease—which is expected to become available in Europe in the near future—this could become a challenge in terms of providing care for patients (4). From the time of market authorization, the importance of diagnostic evaluation in the early or preclinical stages of the disease will once again increase drastically. Time consuming neuropsychologic examinations, as well as the thus far obligatory CSF exams or PET scans to confirm amyloid pathology, are associated with a notably higher resource use. Future analyses should therefore examine the current healthcare structure in both general practice and specialist settings. This is crucial because once a treatment is authorized, its wideranging use might quickly need to be implemented. To ensure specialized dementia treatment, resources will need to be adapted to accommodate the increased need for and extension of relevant centers and patient pathways. Telephone consultations or dementia boards may be helpful in this setting. Digital applications to detect early cognitive impairments can also provide a timely and easily implementable solution. Clinical Alzheimer studies also show an increasing use of digital health technologies—for example, to monitor cognitive changes more closely (5).

Figure 2.

Outpatient memory clinics in Germany. The figure shows outpatients memory clinical in Germany by medical specialist management.