National Service Framework (NSF) for Older People in Wales

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National Public Health Service for Wales

National Service Framework (NSF) for Older People
in Wales:
supplementary guidance on developing
services for assessment and diagnosis of memory
loss associated with possible dementia.


Author: Sian Price


乐ep vul湥ra扬攠
慤ul瑳⁴ 慭

䑡瑥㨠㈷Lㄱ⼰7

p瑡t畳㨠:灰rov敤

s敲eio渺n4

m慧攺e
1




䥮f敮摥d⁁u摩敮c攺et敬s栠
Ass敭扬y⁇潶敲湭敮t





National Service Framework (NSF)
for Older People in Wales:

supplementary guidance on
developing services for assessment
and diagnosis of memory loss
associated with possible dementia


Author:

Sian Price
-

NPHS vulnerable adults team

Date:

30/11/ 07

Version:

4

Status:

Approved

Intended Audience:

Welsh Assembly Government

Purpose and Summary of Document:

This document has been produced by the National Public Health Service for Wales
(NPHS) vulnerable adults team to assist Welsh Assembly Government
in producing
supplementary guidance to support the
National Service Framework (NSF)

for Older
People in Wales. The paper sets out the role and good practice requirements, of
memory assessment services as advocated within the NSF.

Publication/Distribution
:



The document will be distributed to Welsh Assembly Government and be
placed on the NPHS Vulnerable Adults Team website

National Public Health Service for Wales

National Service Framework (NSF) for Older People
in Wales:
supplementary guidance on developing
services for assessment and diagnosis of memory
loss associated with possible dementia.


Author: Sian Price


乐ep vul湥ra扬攠
慤ul瑳⁴ 慭

䑡瑥㨠㈷Lㄱ⼰7

p瑡t畳㨠:灰rov敤

s敲eio渺n4

m慧攺e
O




䥮f敮摥d⁁u摩敮c攺et敬s栠
Ass敭扬y⁇潶敲湭敮t


Contents


1

Purpose of this paper

3




2

Approaches to service delivery

3

2.1

Overview

3

2.2

Memory clinics

4




3

Location an
d staffing of a memory assessment service

5

3.1

Service location

5

3.2

Staffing

5




4

Client group

6




5

Specialist memory assessment

6

5.1

Purpose

6

5.2

Assessment process

7

5.2.1

Patient history

7

5.2.2

Functional and lifestyle assessment

7

5.2.3

Physical examination

7

5.2.4

Neuroimaging

8

5.2.5

Other investigations

8




6

Care after diagnosis

8




7

Mental Capacity Act

9




8

References

10











© 2007. National Public Health Service for Wales
National Public Health Service for Wales

National Service Framework (NSF) for Older People
in Wales:
supplementary guidance on developing
services for assessment and diagnosis of memory
loss associated with possible dementia.


Author: Sian Price


乐ep vul湥ra扬攠
慤ul瑳⁴ 慭

䑡瑥㨠㈷Lㄱ⼰7

p瑡t畳㨠:灰rov敤

s敲eio渺n4

m慧攺e
P




䥮f敮摥d⁁u摩敮c攺et敬s栠
Ass敭扬y⁇潶敲湭敮t


Background


Older people, their fa
milies and health professionals may perceive mental health
problems, such as memory loss, as an inevitable consequence of ageing and not
something that can be treated or managed. The National Service Framework (NSF)
1
for Older People in Wales addresses men
tal health in older people (and includes
younger adults with dementia). The standard states;


Older people who have a high risk of developing mental health problems and
others with related diagnosis have access to primary prevention and integrated
service
s to ensure timely and appropriate assessment, diagnosis, treatment
and support for them and their carers.


For memory loss the NSF outcome identifies the following requirement:



‘Prompt access to a comprehensive range of effective and responsive mental h
ealth
services for older people when required’ and the availability of and access to
‘services for (older) people with a cognitive impairment (memory clinics)’ will be
measured.


1.

Purpose of this paper


The NSF acknowledges the importance of early identific
ation of people with
dementia. This paper has been produced as supplementary guidance to support its
implementation. The paper sets out the role, and good practice requirements, of
memory assessment services as advocated within the NSF. This guidance is
in
tended to support health care commissioners and providers in implementing the
NSF.


This guidance does not address the management of dementia or other causes of
memory loss. The management of dementia is comprehensively addressed in
recently published Nati
onal Clinical Practice Guideline
2

(NICE guidance).



2.

Approaches to service delivery


2.1.

Overview


Some of the initial assessment of individuals with memory impairment may be
undertaken in primary care, for example completion of the Mini Mental State
examinati
on and routine blood tests, but referral to a specialist memory service is the
most appropriate method of ensuring that the extent and probable causes of memory
loss and causes of dementia are identified. Specialist assessment may be provided
by a stand al
one service with this specific function or as part of services provided by
a community mental health team (CMHT) for older people.


In order to facilitate access the model developed will need to take into account local
geography, demography and existing se
rvice provision. There should be close
National Public Health Service for Wales

National Service Framework (NSF) for Older People
in Wales:
supplementary guidance on developing
services for assessment and diagnosis of memory
loss associated with possible dementia.


Author: Sian Price


乐ep vul湥ra扬攠
慤ul瑳⁴ 慭

䑡瑥㨠㈷Lㄱ⼰7

p瑡t畳㨠:灰rov敤

s敲eio渺n4

m慧攺e
4




䥮f敮摥d⁁u摩敮c攺et敬s栠
Ass敭扬y⁇潶敲湭敮t


working links with other relevant services, especially care of the elderly, old age
psychiatry and rehabilitation.


A number of models for delivering specialist memory assessment are currently in
use. These include;




A specialist, assessment and diagnostic team who provide interventions and
follow up if indicated



A service provided as an integral part of the Older Persons CMHT



A specialist, stand alone service providing assessment and diagnosis without
being directly

responsible for interventions and follow up. This
model is
dependant on the development and implementation of clearly agreed

referral
routes and protocols
with
other services.


A dedicated memory clinic is one example of a service model providing special
ist
memory assessment.


2.2.

Memory clinics


The first memory clinics in the UK were set up in the 1980s. They are widely seen as
a useful instrument for identifying, investigating and treating memory disorders,
including dementia. They are provided in a varie
ty of settings (for example psychiatry,
neurology, geriatric medicine, and primary care) with the operational policy of each
clinic being determined by its setting. (Memory clinics not associated with mental
health services are seen by some as avoiding the

stigma that may be attached to
such services).


Their overarching purpose is to facilitate early referral of patients. There is some
evidence that suggests that where memory clinics are available patients with
dementia are seen at least 2 years earlier i
n the course of their disease
3
.


The benefits of memory clinics for patients and families are considered to be
4
;




Early identification and intervention



Specialist assessment and robust diagnosis, including non
-
dementia illness



The effective targeting, mon
itoring (and cessation where appropriate) of anti
-
dementia drugs



Education and support for patients and carers



Anxiety management



Advice on memory aids and memory training



Access to research studies



The benefits for service providers have been describe
d as
4
;






Encouragement of earlier referral and development of awareness of dementia
in primary care



Standardised assessment and diagnosis within a multidisciplinary setting

National Public Health Service for Wales

National Service Framework (NSF) for Older People
in Wales:
supplementary guidance on developing
services for assessment and diagnosis of memory
loss associated with possible dementia.


Author: Sian Price


乐ep vul湥ra扬攠
慤ul瑳⁴ 慭

䑡瑥㨠㈷Lㄱ⼰7

p瑡t畳㨠:灰rov敤

s敲eio渺n4

m慧攺e
R




䥮f敮摥d⁁u摩敮c攺et敬s栠
Ass敭扬y⁇潶敲湭敮t




Efficient targeting and monitoring of medication



Facilitation of audit and ev
aluation of services



A response to the increasing demand for expert diagnosis and treatment



A focus on research activity


3.

Location and staffing of a memory assessment
service


3.1.

Service location


The location of specialist memory services and the provision
of dedicated clinics or
sessions should be appropriate to local need and circumstances. There will inevitably
be differences in the delivery of the service between rural and more urban
communities.


Clinics could be located or sessions delivered in
5
;




Gene
ral hospitals



Community hospitals



Primary care facilities



CMHT bases



Day hospitals


The clinic/session location will need to provide accommodation to allow several
clinicians from different disciplines to undertake assessments in privacy and a room
big eno
ugh to allow team members to discuss their findings. It may take between 1
and 1 ½ hours to assess each patient, reach a diagnosis and agree initial
management
6
.


3.2.

Staffing


Staffing of the memory assessment service will depend on the particular approach
a
nd model adopted. The service will need to be lead by a clinician with specialist
knowledge, skills and experience in this area. This might be a psychiatrist, physician
or neurologist
5
.


Ideally in all complex cases a cognitive assessment would be underta
ken by a clinical
psychologist, However
,
other members of the multidisciplinary team with appropriate
training and supervision (e.g. psychology technician, specialist nurse, speech and
language therapist, occupational therapist) can undertake this role in
straightforward
assessments.


Specialist nurses (with experience of psychosocial interventions) to support patients
and carers in the clinic and by home visit
s

in the period following diagnosis and
disclosure should be part of the team.


National Public Health Service for Wales

National Service Framework (NSF) for Older People
in Wales:
supplementary guidance on developing
services for assessment and diagnosis of memory
loss associated with possible dementia.


Author: Sian Price


乐ep vul湥ra扬攠
慤ul瑳⁴ 慭

䑡瑥㨠㈷Lㄱ⼰7

p瑡t畳㨠:灰rov敤

s敲eio渺n4

m慧攺e
S




䥮f敮摥d⁁u摩敮c攺et敬s栠
Ass敭扬y⁇潶敲湭敮t


(Whatever model /s
taffing mix is provided there is a need to ensure that clear care
pathways are established to ensure appropriate referral on and continuity of care
Some users of memory assessment services will inevitably require formal
intervention from mental health serv
ices, often at a late stage in their illness. Where
assessment services are not integrated with mental health services or there are not
established pathways for referral that ensure continuity of care, problems may occur).


4.

Client group


Clients who will n
eed a comprehensive assessment of apparent memory loss will
usually be;




Individuals with suspected dementia



Those with mild cognitive impairment of any cause, e.g. organic disease or
alcohol misuse



Those with significant mood related problems presenting
as memory
impairment



Rarely the ‘worried well’, who appear not to have quite as good as memory as
their peers and are anxious they are have dementia, and have repeatedly
failed to be reassured by initial cognitive assessment

.in primary care.


5.

Specialist m
emory assessment


5.1.

Purpose


The purpose of specialist memory assessment is to
4, 5
;




Identify individuals with mild cognitive impairment and dementia at an early
stage of the disease



Provide direct advice, information and support to the patient and their
f
amily/carer and refer them to other sources of advice/information/support



Provide advice on management and support to the referrer



Exceptionally to reassure the ‘worried well’ who do not have dementia but
remain exceptionally anxious


In addition memory cl
inics will usually
4, 5
;




Initiate and monitor pharmacological treatment



Provide psychosocial interventions



Follow up and review those with dementia



Ensure timely referral to other specialist health and social services as needed



Promote the involvement of
patients and their family/carers in appropriate
clinical research.






National Public Health Service for Wales

National Service Framework (NSF) for Older People
in Wales:
supplementary guidance on developing
services for assessment and diagnosis of memory
loss associated with possible dementia.


Author: Sian Price


乐ep vul湥ra扬攠
慤ul瑳⁴ 慭

䑡瑥㨠㈷Lㄱ⼰7

p瑡t畳㨠:灰rov敤

s敲eio渺n4

m慧攺e
7




䥮f敮摥d⁁u摩敮c攺et敬s栠
Ass敭扬y⁇潶敲湭敮t


5.2.

Assessment process


Bayer and Reban
4

recommend a comprehensive memory assessment which is
summarised below. The recently published NICE document also contains guidance
on the diagnos
is and assessment of dementia
2
.


5.2.1.

Patient history


Information should be sought from the patient and another reliable informant, ideally
a close relative or friend. The following elements should be included;




Presenting symptoms



Other symptoms of organic br
ain disturbance



Psychiatric/behavioural symptoms



Ability to carry out day to day activities



Past and present medical status



Current medication



Family history



Education and occupational history



Past and present alcohol intake



Smoking habit



Previous personal
ity and coping ability (and any recent change)



Social background.



5.2.2.

Functional and lifestyle assessment


The following domains should be covered;




Cognitive assessment, using a standardised test schedule (e.g. Mini
-
mental
State Examination, Addenbrooke’s C
ognitive Assessment) and supplemented
with more detailed neuropsychological testing as needed.



Neuropsychiatric assessment. Psychiatric problems such as anxiety and
depression can interfere with cognitive function and may be confused with
dementia. In addi
tion people with dementia may also have depression.



Activities of daily living



Quality of life, global assessment and dementia staging



Assessment of carer well
-
being.


5.2.3.

Physical examination




This may help to clarify the cause of the illness, identify its ph
ysical
consequences and identify coexisting morbidities. Medical examination should
focus on the cardio respiratory system, central nervous system, gait and vision
and hearing.



National Public Health Service for Wales

National Service Framework (NSF) for Older People
in Wales:
supplementary guidance on developing
services for assessment and diagnosis of memory
loss associated with possible dementia.


Author: Sian Price


乐ep vul湥ra扬攠
慤ul瑳⁴ 慭

䑡瑥㨠㈷Lㄱ⼰7

p瑡t畳㨠:灰rov敤

s敲eio渺n4

m慧攺e
8




䥮f敮摥d⁁u摩敮c攺et敬s栠
Ass敭扬y⁇潶敲湭敮t


5.2.4.

Neuroimaging




Where clinically indicated this may contribute to differentia
l diagnosis and
provide prognostic information. MRI is preferable, but CT scanning could be
used.




5.2.5.

Other investigations





Routine blood tests (haematology, electrolytes, calcium, glucose, renal and
liver function, thyroid function and serum vitamin B12 a
nd folate levels). These
could be done in primary care prior to referral.



Chest X
-
ray, ECG and midstream urine test as determined by presentation.



For younger people with dementia, those with atypical presentations or
evidence of systemic illness a more ex
tensive range of investigations (e.g.
EEG, syphilis serology, cerebrospinal fluid etc) may be indicated.


6.

Care after diagnosis


Opinions on the appropriateness of disclosure of a diagnosis of dementia vary.
Generally it is good practice to ask people who a
re being assessed for possible
dementia whether they wish to know the diagnosis and with whom it should be
shared. The following are situations when disclosure of diagnosis might be
considered inappropriate
4
;




When dementia is severe and the person is unli
kely to understand the
diagnosis



When the patient is severely depressed



When the patient clearly states they do not wish to know.


When disclosing the diagnosis the following recommendations have been made
4
;




Communication about the diagnosis should normal
ly take place in a joint
meeting with the patient and their family (with the patient’s consent)



Simple language should be used and jargon avoided



Using a graded approach allows the information given to be matched with
what the patient wants to know



Suffici
ent time should be available to explain and answer questions



The patient and their families understanding should be assessed



Arranging follow up allows information provided to be reinforced,
misunderstandings clarified and outstanding questions answered



Us
e of the term ‘Alzheimer’s Disease’ (or other appropriate medical diagnosis)
rather than just the term dementia helps to ensure understanding of both these
terms



Conveying the feeling that ‘nothing more can be done’ should be avoided.
Information about ava
ilable therapies (not just drugs) should be given

National Public Health Service for Wales

National Service Framework (NSF) for Older People
in Wales:
supplementary guidance on developing
services for assessment and diagnosis of memory
loss associated with possible dementia.


Author: Sian Price


乐ep vul湥ra扬攠
慤ul瑳⁴ 慭

䑡瑥㨠㈷Lㄱ⼰7

p瑡t畳㨠:灰rov敤

s敲eio渺n4

m慧攺e
9




䥮f敮摥d⁁u摩敮c攺et敬s栠
Ass敭扬y⁇潶敲湭敮t




The patient should be given information about the possibility of taking
decisions about their future.


The patient and their family/carer should be given face
-
to
-
face advice and information
on interventions
, prognosis and the sources of help and support available to them.
This may be an appropriate role for a specialist nurse.


Verbal information should be backed up by written information and recommendations
for further reading.


7.

Mental Capacity Act 2005


T
he implications of the Mental Capacity Act on services such as this have yet to be
fully established
7.

NHS Trusts will need to ensure that all their staff are trained to
work within the requirements of the Act and within Trust policies.

National Public Health Service for Wales

National Service Framework (NSF) for Older People
in Wales:
supplementary guidance on developing
services for assessment and diagnosis of memory
loss associated with possible dementia.


Author: Sian Price


乐ep vul湥ra扬攠
慤ul瑳⁴ 慭

䑡瑥㨠㈷Lㄱ⼰7

p瑡t畳㨠:灰rov敤

s敲eio渺n4

m慧攺e





䥮f敮摥d⁁u摩敮c攺et敬s栠
Ass敭扬y⁇潶敲湭敮t


8.

References


1.

Welsh

Assembly Government.
National service framework for older people in
Wales
. Cardiff: WAG; 2006.


2.

National Institute for Health and Clinical Excellence
Dementia: supporting people
with dementia and their carers in health and social care
. London: NIHCE; 2006
.
Available from
http://www.nice.org.uk/guidance/index.jsp?action=byID&r=true&o=10998

[Accessed 22
nd

Nov 2007]


3.

Luce A, McKeith I, Swann A, Daniel S, O’Brien J. How do me
mory clinics
compare with traditional old age psychiatry services?
Int J Geriatr Psychiatry
2001; 16: 837
-
845.


4.

Bayer A, Reban J eds.
Alzheimer’s disease and related conditions. A
dementologists handbook.
. Prague: Medea Press; 2004.


5.

Jolley D, Benbow S M,
Grizzell M. Memory clinics.
Postgrad Med J

2006; 82: 199
-
206.


6.

Lindesay J, Marudkar M, van Diepen E, Wilcock G. The second Leicester survey
of memory clinics in the British Isles.
Int J Geriatr Psychiatry

2002; 17: 41
-
7


7.

Mental Capacity Act 2005.
(c9). Lond
on: TSO; 2005