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Health & Social Care Protocol for the Assessment, Care and Management of PEOPLE WITH MEMORY CONCERNS (DEMENTIA)

GHCCG QOF QP PATHWAY Pathway name: Dementia – Memory Monitoring Aim: To ensure appropriate outpatient referrals and reduce variation • • • •


By: Promoting updated Protocol for the Care and Management of patients ≥70 with query Dementia to ensure appropriate outpatient referrals to Memory Monitoring Ensuring awareness of all available contact details of various support agencies for patient with dementia and their carers Providing links to e-learning package Including all care-home patients where appropriate

Specific Outcome: OUTCOME


Promote updated Protocol for Care & Mgmt of patients ≥70 with query dementia

Increase awareness of appropriate tests and treatment options for patients with ?dementia

Undertake 6 CIT test for patients ≥70 during reviews for CHD and Diabetes.

To undertake 6 CIT test during standard reviews for patients with CHD and Diabetes.

Raise awareness of support agencies.

List of contact details altogether with the pathway to assist GPs in signposting to the patient and carer.

Raise awareness of elearning packages

7 e-learning packages available for staff, patients and carers to raise awareness of dementia its causes and impact


Increase the number of patients appropriately referred to Memory Monitoring

Health & Social Care Protocol for the Assessment, Care and Management of PEOPLE WITH MEMORY CONCERNS (DEMENTIA) Outcome measure: 1.

Measure Number of patients aged ≥70 registered on 8th October 2012:



Number of patients aged ≥70 who had a 6 CIT test between 8th October 2012 and 28th February 2013 :


Number of patients referred to memory monitoring as a result of 6 CIT test:


If patient met criteria but was not referred to memory monitoring why?:


Number of times the pathway was followed between 8 th October 2012 and 28th February 2013:

Read codes: The below read codes may be used to assist you with the reporting of use of this pathway, if appropriate for your practice: Read code Referral to memory clinic 6 Item cognitive impairment test


SystemOne XaJua



Pathway must be reviewed alongside ‘Dementia protocol’ document at the end of this pathway.



Health & Social Care Protocol for the Assessment, Care and Management of PEOPLE WITH MEMORY CONCERNS (DEMENTIA) Presenting symptoms – there are some symptoms/changes/behaviours you may notice in someone who may have dementia • • • • •

Disorientation, not knowing time, place and people (including family) Memory loss/impairment Rapid onset of confusion Communication difficulties Changes in personality

• • • • •

Disinhibition Irritable, anxious, lowered mood and withdrawn Changes to person’s normal behaviour Self neglect Changes in sleep pattern

• Prominent visual changes (hallucinations/illusions) • Inability to carry out routine activities of daily living (eg, getting mixed up with finances, cooking skills, dressing) • Frequent or increased falls • Consider learning disability

Initial assessment – consider treatable potential causes/high risk groups or factors. Initial assessment should be carried out by the appropriate professional depending on each circumstance.


Physical • Infections (urine, chest, other) • Anaemia • Stroke • TIA’s (mini stroke) • Thyroid • Side effects of medication • Constipation, diabetes and dehydration • Family history • Sensory impairment

Emotional • Previous history of depression • Family history (dementia or depression and neurological) • Bereavement of main carer

Social • Relationship problems/conflict with family, neighbours or other carers • Lack of confidence • Living alone • Isolation • Drug/alcohol increased use or misuse • Moving into long term care • Lack of activity and stimulation

Risk Factors • Mild cognitive impairment • Down’s syndrome/ other LD • History of psychiatric problems • Lack of exercise • Limited social network • Older age • Genetic predisposition • History of head trauma • Hypertension • Obesity • Diabetes • AF • Smoking • Alcohol • History of depression

Screening Test - key questions - 6 CIT ( template available on systemone) • • •

What year is it now? (correct: 0 points, incorrect: 4 points) What month is it now? (correct: 0 points, incorrect: 3 points) Repeat this phrase: “Mr John Brown, 42 West Street, Sheffield”

• • • •

What time is it now? (correct: 0 points, incorrect: 3 points) Count backwards 20 to 1 (correct: 0 points, 1 error: 2 points, more: 4 points) Say the months in reverse order (correct:0 points, 1 error:2 points,more:4 points) Repeat the memory phrase (correct:0 points, 1 error:2 points,more:4 points)

If score is more than 8, continue medical assessment/ screening

Refer for medical assessment/screening • Patient in community = refer to primary care for completion of medical investigation • Patient in acute hospital = refer to admitting consultant


Physical investigations • FBC, U&E’s, TFTs, LFTs, CRP • B12/folate • Blood glucose • Urinalysis • Neurological assessment • Medication review • ECG • Calcium • VDRL- only if specifically indicated.

Emotional and cognitive • Collateral history from carer • Risk assessment (informal) • Depression assessment -PHQ-9

Initial management by GP

Good practice

• • • • • •

• • •

Investigation findings discussed with patient and carer Discuss referral for specialist assessment Treat physical causes Pain management Review medication Nutritional requirements


Social/functional • Consider therapy assessments, eg, O/T, physio, speech & language, dietetics • Family history • Carers needs assessment to be completed by social worker

Consider separate appointment time for carer Consider advanced directives Review at least once in 12 months by the GP or other responsible practitioner Consider specialist needs for users from black/ minority ethnic groups

Health & Social Care Protocol for the Assessment, Care and Management of PEOPLE WITH MEMORY CONCERNS (DEMENTIA) • • •

Counselling Depression (refer to depression protocol for initial management) Encourage carers to access services/and carers assessment

• •

Training, advice and information for service users, carers and staff Access to education support programmes for carers and patient


Committee page. Refer to Other Services (please state whether urgent or routine ) Refer to Kirklees Single Point of Access for memory service and specialist mental health services for complex/ high risk cases • • • • • •


Treatment not leading to improvement Confirmation of diagnosis Care management advice Further specialist psychiatric assessment Assessment of risk to self and to others Support to patient and carer in coping with and managing symptoms Referral to appropriate sector CMHT/ Consultant Psychiatrist/ Memory service/ Crowlees Team/ Day Services/ Admiral nurses/Care Home liaison

Refer to Adult Services (for specific social care needs to be addressed) • • • • • •

Routine and urgent referrals for social care assessment Support at home Day time activities Financial support Carers need assessment Respite

Kirklees Mental health services (SWYPFT): SPA: 01924 284555

How to refer … Complete SPA referral form for all services: • By telephone for 4 hour response : 01924 284555 • Fax/postal for routine response: 01924 284576, 2nd Floor, Beckside Court, 286 Bradford Road, Batley, WF17 5PW

How to refer… By telephone via Gateway to care – tel: 01484 414933 Client can attend in person

Refer to Independent Sector

How to refer…

• • • •

By telephone or drop in

For information and advice Carers support Self help and support Creative arts, singing, dance, sports & physical activities

Consider referral to other specialist services (eg: neurology, pain clinic) For treatment and assessment, eg, memory problems associated with neurological symptoms such as suspected Parkinson’s disease, visual disturbance, sensory loss”


Direct Contact Details:

How to refer… According to relevant protocols via primary or hospital care

Safehaven fax: 01924 284567 Huddersfield CMHTs OPS: 01484 434646 or North Kirklees CMHTs OPS: 01924 284551 Care Home Liaison Team: 01924 284553 Admiral Nurse Service: 01484 434638 Memory Service: 01484 434630 Gateway to Care contact details: Tel: 01484 414933 Outside of office hours: 01924 326489 Independent Sector Contact Details Alzheimers Society: North and South Kirklees: 01484 429865 Breathing Space: Creative Arts programme: 01484 516224 Steps4Life :Physical activity programme : 01484 234095 Dementia Cafes: 0113 270 8316 Carer Support: Kirklees Carers Gateway: 01484 226050 Admiral Nurse Service: 01484 434638 Admiral Nurse Direct Helpline:08452579406 Looking After Me course: 01484 226050 Positive Steps Education Programme: Expert Patients Programme: 01484 464441 Changes Programme: ?? Looking After Me course: 01484 226050 E-learning: ia/index.asp The Kirklees Dementia Guide: Other Specialist Referrals: Mid Yorkshire Hospital NHS Trust: 0844 811 8110 or 01924541000 Calderdale & Huddersfield Hospital NHS Trust: 01484 342000


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