psychiatric causes
• treatment of co-morbidity and other conditions
• medication in line with NICE-SCIE guidelines6
• reliable instigation of pharmacological treatments
• information for individuals and families to provide them with a better explanation and understanding of the diagnosis
• access to local support services and legal and financial advice
• identification of more socially vulnerable individuals (older adults over 85, living alone, poor housing) at greater risk of admission to care
• referral to psycho-social support
• help with daily living activities
• opportunity for people with dementia and their carers to plan for the future.
6NICE-SCIE. Dementia: Supporting people with dementia and their carers in health and social care, 2006
ID1
Identification
Improved public awareness leads to self identification
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7Department of Health. Living well with dementia: A National Dementia Strategy, 2009 This group includes:
• primary care, general hospital and mental health staff
• care managers in adult care services and social care staff in the independent sector
• third sector and private providers.
Residential and nursing care home staff must be trained to recognise residents who may have dementia and ensure care plans take account of cognitive impairment and reflect person-centred care.
The setting for identifying those who are under represented or at risk is through GP practices and general hospitals.
Following the recommendations of the National
Dementia Strategy7professionals and care staff need to be able to identify individuals with possible dementia. They must also give good basic information and advice and refer appropriately to local memory services.
ID2
ID3
Improved awareness of dementia and memory services by health and social care professionals and care home staff
Identification of people from under represented or at risk groups:
• people with learning disabilities
• BME groups • people with HIV • people with delirium • patients who do not
attend planned follow-up sessions
• those with vascular conditions
• those with alcohol and substance misuse problems
• those that present at A&E and urgent care centres due to falls or delirium • those who regularly
present at A&E, to their GP or polyclinic.
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8NICE-SCIE. Dementia: Supporting people with dementia and their carers in health and social care, 2006 9NICE-SCIE. Dementia: Supporting people with dementia and their carers in health and social care, 2006 10Department of Health. Living well with dementia: A National Dementia Strategy, 2009
Refer to the NICE-SCIE guidelines for standard screening tools, e.g. Mini Mental State Examination (MMSE) and Cambridge tools8.
Memory services for the early identification and care of people with dementia should be available for local people and should provide a single point of referral. Their functions are:
• early identification and referral of people with a possible diagnosis of dementia
• a high quality service for the assessment, diagnosis and management of dementia.
To recognise signs and symptoms of delirium refer to the NICE-SCIE guidelines9.
The guidelines define delirium as:
“Delirium (acute confusional state) is a common
condition in the elderly affecting up to 30% of all elderly medical patients. Patients who develop delirium have high mortality, institutionalisation and complication rates, and have longer lengths of stay than non-delirious patients. Delirium is often not recognised by clinicians, and is often poorly managed. Delirium may be prevented in up to a third of older patients. The aim of these guidelines is to aid recognition of delirium and to provide guidance on how to manage these complex and challenging patients”.
Health and social care staff need to:
• ensure all local services promote easy access to care and treatment
• support the individual’s journey from the early stages. Based on the National Dementia Strategy, Healthcare for London recommends that all complex cases and younger people with dementia are referred10to specialist services.
ID5
Use of standard screening tools to identify symptoms that warrant referral to memory services
Recognition of the difference between symptoms of
dementia and delirium ID4
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Below is the process flow of a person with dementia:
Identification
Pr
evention and awar
eness
Person with memory pr
oblem • in community • primary car e • acute hospital.
Living well with dementia
Mild cognitive impairment r
eview
6-12 months
Assessment and diagnosis
Uncomplicated memory pr oblem • investigation/assessment • diagnosis • communications • tr eatments. Not having: • depr ession • delirium • lear ning dif ficulties.
*May need specialist
assessment End-of-life End-of-life Pr esent to primary car e Specialist memory service Memory pr
oblem complicated by:
1. Behavioural and psychological
symptoms of dementia, depr
ession.
Needs ar
e best met by mental
health services. 2. Complicated neur opsychiatric, neur opsychological, neuorlogical condition. 3 . Main concer n is physical health in the back dr op of dementia.
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11NICE-SCIE. Dementia: Supporting people with dementia and their carers in health and social care, 2006 12Royal College of Psychiatrists (2005)
As outlined in the NICE-SCIE11guidelines, these assessments need to be carried out for a diagnosis to be made.
Clinical examinations should be based on a standardised system in line with the NICE-SCIE guidelines using specified and agreed tools.
Investigations can include syphilis serology and HIV tests if indicated.
There is an increased likelihood that people with Mild Cognitive Impairment (MCI) may go on to develop dementia. It is estimated that about 15% will develop dementia every year and 90% of these will develop Alzheimer's disease12.
It is suggested that improved access to memory services will increase early identification and diagnosis.
AD1
AD2
AD3