Transcript The Problem with Memory - Ipswich and East Suffolk CCG

THE PROBLEM WITH MEMORY
Dr Gillian Collighan
OVERVIEW
The main problems at the beginning, and at the end of the dementia pathway
•Present detection rate
•Why is detection rate so low
•Red Flags for dementia
• Behavioural and Psychological Symptoms of Dementia
(BPSD)
KEY FACTS
•One in three people over the age of 65 will end their lives with
dementia
•Only 48% of people living with dementia, living in the UK ever
receive a diagnosis
• Diagnosis rates vary from as low as 35% in Southwest England,
to over 70% in parts of Scotland and Northern Ireland
•Without a diagnosis, people with dementia cannot receive the
support, information and treatment that they need to live well
with dementia
•State of the Nation Report ( DOH November 2013 )
DEMENTIA DIAGNOSIS RATES
LOCALLY
•NHS East Suffolk and Ipswich CCG 46.09%
•NHS West Suffolk CCG 41.84%
•NHS West Norfolk CCG 34.9%
•NHS Norwich South CCG 43.85%
•NHS North Norfolk CCG 42.6%
•NHS Great Yarmouth and Waveney CCG 49.22%
Data: 2012/13, re-baselined from pre-April 2013 PCT data
THE NATIONAL GOAL SET BY
NHS ENGLAND
•Set to improve diagnosis rates, so that by March 2015
2/3rds of the estimated number of people with
dementia should receive a diagnosis of dementia .
•From 2013/2014 an enhanced service contract will
help improve diagnosis in high risk groups,
cardiovascular risk, long term neurological conditions,
and people with learning disabilities
WHY DO WE MISS THE
DIAGNOSIS?
1. Heterogeneity of disease and presentation
2. Screening tools too blunt and memory focussed
3. Patient factors
4. Problems with the relatives and informant history
5. Social factors
6. Medical profession attitudes
7. Problems within secondary care
PREVALENCE OF DEMENTIA SUBTYPES IN
OVER 65’S by diagnosis
Alzheimer’s Society
PREVALENCE OF DEMENTIA
SUBTYPES IN OVER 65’S By Pathology
Alzheimer's Disease 60%
Vascular 20%
Lewy Body 15%-20%
SUBTYPES OF ALZHEIMER’S
•Amnesic Type Alzheimer’s
•Aphasic (Logopenic) Type Alzheimer’s
•Frontal Type Alzheimer’s
•Posterior Cortical Atrophy Type Alzheimer’s
DEMENTIA
Types of dementia
Cortical
Subcortical
Mixed
CORTICAL DEMENTIA
Alzheimer’s
•Presents with degrees of amnesia, aphasia, apraxia and agnosia
•Memory, language, skills, geographical disorientation
SUBCORTICAL DEMENTIA
Vascular Small Vessel Disease and Lewy
Body/Parkinson's Disease
•Slowing, lack of spontaneous movement, paucity of facial expression,
•Difficulties in retrieval of words ‘tip of the tongue’
•Executive Dysfunction -problems with high end skills
•Problems with gait and continence as disease progresses
FRONTAL/EXECUTIVE DYSFUNCTION
Five circuits link the subcortex to the frontal lobes
•Apathy and Inertia
•Attention and Concentration
•Reasoned Judgement
•Decision Making
•Sequenced Activities
•Error Checking
•LOSS OF INSIGHT
SOCIAL FAÇADE AND MEMORY FAIRLY GOOD
VASCULAR COGNITIVE IMPAIRMENT
AND SMALL VESSEL DISEASE
•Traditionally Multi infarct dementia has held centre stage
•Commonest vascular dementia in memory clinics is small vessel
disease
•Spectrum disorder, ranges from vascular cognitive impairment
(MCI) to full blown dementia
•Characterised by slowness, apathy, inertia, progressing to gait
(Marche a petit pas) and continence difficulties
•Often have marked executive dysfunction
LEWY BODY DEMENTIA
•May present with subtle cognitive symptoms
•Slowing, ‘tip of the tongue’, apathy and inertia
•Poverty of facial expression and spontaneous movement- no tremor
•Visual hallucinations may not be apparent initially
•Additional clues-REM sleep disorder, anosmia, often long history of
constipation or IBS symptoms, frequent mood disorder predating other
symptoms by years. Marked fluctuation from day to day
•Cognitive change will be picked up by MOCA and ACEIII
COMMON SCREENING TESTS
•GPCOG- Tests memory and visuospatial skills
•6-CIT-Tests memory, orientation and mental manipulation
•AMTS-Test of memory only
(Memory weighted tests designed to pick up Alzheimer’s)
•MOCA-Tests memory, executive function and
visuospatial
•ACE-III-Tests memory, language, visuospatial and
executive function
MISSED AND DELAYED
DIAGNOSIS- PATIENT FACTORS
•Loss of insight
•Social façade maintained until late in the disease process
•Patient less likely to present as disease progresses
•PARTICULAR PROBLEMS WITH DELAYED DIAGNOSIS IF PATIENT
HAS A PROBLEM WITH MOBILITY, EYESIGHT OR HEARING
THE SOCIALLY ISOLATED PATIENT
•1/3 of people with dementia live alone
•Common from the age of 80 years onwards
•Partner has predeceased them
•May have no children, or little contact with them
Often present in crisis, as no-one to advocate on their
behalf
•Present in secondary care following falls and delirium
PROBLEMS WITH RELATIVES AND
THE INFORMANT HISTORY
•Relative may be more impaired than the patient
•Spouse is the non-dominant partner, and cannot get the
patient to attend clinic
•Spouse is physically unwell and reliant on the patient
•Spouse has always done everything so patient is not tested
•Beliefs and assumptions that this is part of normal ageing
•INVESTED INTEREST IN KEEPING THE PATIENT AT HOME/ OR
DRIVING
PHYSICIAN ATTITUDES
•Concern that telling the patient the diagnosis will upset
them, and nothing can be done anyway
•Concern that post diagnostic support is insufficient
•Concern it may be time consuming
ATTITUDES IN SECONDARY CARE
•PBR has changed the way we work
•Treat the presenting complaint only-tunnel vision
•Often recognised that patient is confused, but nothing done until
third or fourth readmission
•Concern that onward referral for memory assessment will delay
discharge
There is now an enhanced Liaison Team and Dementia Intensive Support
Team (DIST) in the General Hospital
RED FLAGS
•Medication mix ups
•Unexplained weight loss
•Poor control of chronic illness
•Episodes of delirium with minor insult
•Post bereavement acopia
•Late onset mood disorders
CHRONIC ILLNESS
•Parkinson’s Disease
•REM Sleep Disorder
•Multiple Sclerosis
•Motor Neurone Disease
•Learning Disability
•Diabetes
•Cardiovascular Disease
BEHAVIOURAL AND PSYCHOLOGICAL
SYMPTOMS OF DEMENTIA (BPSD)
Main subtypes;
•Physically aggressive behaviour
•Physically non-aggressive
•Verbally non-aggressive
•Verbally aggressive
•Psychosis related behaviour
•Mood related behaviour
REPORTED FREQUENCY OF BPSD
Perceptual
•Delusions 20–73%
•Misidentifications 23–50%
•Hallucinations 15–49%
Affective
•Depression up to 80%
•Mania 3–15%
(Finkal et al 1998)
BEHAVIOURAL AND PSYCHOLOGICAL
SYMPTOMS OF DEMENTIA
•90% of dementia patients experience BPSD
•Mild to moderate BPSD has potentially reversible
causes, often resolves within four weeks
•Delirium must be excluded
•Physical problems such as dehydration, pain, infection,
electrolyte imbalances, constipation and polypharmacy
ASSESSMENT OF BPSD
•Various rating scales
•Underlying dementia diagnosis and severity
•Psychological and psychosocial assessment
• Physical health problems, excluding delirium
•Review of medication
ASSESSMENT OF BPSD
•Charting of behaviour (ABC)
•Assessment of environment
•Assessment of communication and carer interaction
•Assessment of safety
MANAGEMENT OF BPSD
•Psychological
•Behavioural
•Environmental
•Pharmacological
PHARMACOLOGICAL
INTERVENTIONS-DRUGS USED
•Antidepressants
•Benzodiazepines
•Acetyl cholinesterase inhibitors
•Memantine NMDA receptor inhibitors
•Antipsychotics UNDER SPECIAL CONDITIONS
SEVERE BPSD-WHEN TO GIVE
MEDICATION
•Where there is significant distress to the individual, or
aggression that results in significant risk to patient or
others
•Where non-pharmacological treatments have failed
•It is required in order to assess and investigate patient
for
delirium –physical exam , BP, pulse and blood screen
PHARMACOLOGICAL INTERVENTION
•Changes in cognition should be assessed and recorded
•Initial low dose and titrated upwards
•Treatment time limited and reviewed (every three
months or according to clinical need)
PHARMACOLOGICAL INTERVENTION
•Risperidone antipsychotic of choice (NICE) for use in
BPSD of Alzheimer's disease
•Treatment rationale and side effects should be
discussed with patient and relatives
•Target symptoms must be described, and reviewed
ANTIPSYCHOTIC USE IN
DELIRIUM
•In hyperactive delirium patient can be very agitated
•In these cases Haloperidol or Olanzapine, and/or
lorazepam are recommended (NICE)
•Important to decide whether you are dealing with
delirium or BPSD as different Antipsychotics
recommended
BPSD AND CAPACITY
•May not have capacity to consent to treatment
•Relevance to mental capacity act must be considered
and documented
•When medication given need to consult with patient,
relative and carers
•If covert medication is used this must follow local
policy
THE END
Community Memory Assessment
Service
Helen Whight: Community Services Manager, NSFT
Karen Blades: IESCCG Clinical Lead for Dementia
Remodeling the Memory Assessment Service
Patient Feedback about the Current Service
• The process of memory assessment takes too long
• That it can be difficult to get to the offices where the memory
assessment specialists are based
• The pathway is confusing with unclear steps and processes
External Factors
• National drive to achieve 67 per cent diagnosis rate
• Achievement of local targets has a financial reward (Quality Premium)
IESCCG Response
• Increased investment in memory assessment
• Working with NSFT to remodel the service to offer shorter pathways in
primary care locations delivered by primary and secondary care
clinicians
Principles of Community Memory Assessment
•
What
It Means for Patients and Families
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Working towards a 6 week referral to diagnosis pathway
Appointments in primary care settings
The right appointments with the right clinician in the right sequence
Follow up appointment with dementia specialist after diagnosis
Increased capacity, providing up to 1500 assessments per annum
What it Means for Primary Care
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•
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Memory assessment clinics hosted in primary care venues
Lead GPs from 10 practices working alongside consultants to diagnose dementia
Specialist dementia practitioners (nurses and OTs) providing assessment & advice
Clear referral pathways and criteria
What it Means for NSFT
• NSFT contracted to deliver the service
• Working in partnership with primary care to deliver the service, supporting and
working with lead GPs and working with practices to host the clinics
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PATHWAY : KEY FEATURES
In partnership with IESCCG, NSFT is working with GPs to establish 10 new
locality clinics (referred to as Lead GPs) which are distributed across the
region.
The service will work alongside existing organisations, such as Age UK,
Alzheimer’s Society, Suffolk Family Carers and Sue Ryder, to support
dementia-related activities and initiatives and support people to access local
provision.
Specialist dementia practitioners, employed to deliver the service, will spend
a good proportion of their time in GP Practices. This will enable them to raise
awareness of dementia and improve the skills of practice staff in spotting early
signs of dementia.
Patient Pathway
Primary Care
Screening, Tests and
Referral
CMAS MDT Triage
Dementia
Practitioner
Assessment
Additional Tests,
including CT Scan
Diagnosis
Appointment with
Consultant or Lead
GP
Follow Up
Appointment PostDiagnosis
6 Week Target from Referral to Diagnosis
How to Refer to the Service
•
Referral
Requirements
• There is no change to the screening, bloods and other information
required to make a referral
Referral Process
• SystmOne practices will be able to make a SystmOne referral, if
the patient consents. This will enable data sharing and pull data
through to the referral template
• It will be possible to continue using a referral form, which can be
emailed securely to NSFT
Diagnosis Reporting
• A letter will be sent confirming the outcome from the diagnosis
• SystmOne Practices will be able to see the outcome of the
assessment and diagnosis (if the patient consents)
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Referral Form
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•
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SystmOne Practices can
use an online referral
template
It can only be used if the
patient consents to share
their data with NSFT
If consent is given many
of the fields are prepopulated
Location of template can
be managed by each
practice
Alternatively secure email
to CMAS.
Referrals made to Access
and Assessment will be
sent on
Distribution of Lead GP Practices
Leiston
Stowmarket
Orchard St
Hadleigh
Debenham
Barrack Lane
Ravenswood
A143
Diss
Eye
A14
Bury St
Edmund
s
A12
A140
Debenham
Stowmarket
Wickham Market
Leiston
Bildesto
n
Sudbury
Hadleigh
Negotiations with
a further three
practices are
ongoing
Ravenswood
Felixstowe
Ipswich IDT
Central IDT
Coastal
IDT
Timescales 2014
Timescales
• June:
• Training, development and preparation
• July:
• Launch of practitioner assessments in primary care
• SystmOne referral process available
• August:
• Launch of diagnosis clinics in primary care
• Communications and publicity