Judy Rubinsztein FRCPsych, PhD (Cantab)

Who is this?

And This?

What did he suffer from and when did it start?

Outline of Talk

 Why YOU need to know about Memory Clinic Services ( MCS)  Background to development of MCS  Controversies in MCS: what works/ does not work  Examining Quality and Costs of service Models  Essential elements of a MCS  MCQs

Why do you need to know about MCS?

 700-800 000 people with dementia in UK  Numbers are set to double to 1.4 million in 30 Years time

Counting Cost of Dementia Care  Costs: dementia report ( 2012) estimates costs at £23 billion  Costs: set to increase to 50 billion by 2038  Counting the costs of service provision is NB

Background

Living well with dementia: A National Dementia Strategy (2009) “Putting People First”

Memory Clinic Services

 Proliferated across UK  since advent of anti dementia drugs : 1997  131 in England in 2006

NSF for Older People (2001)/ National Dementia Strategy (2009) Role of MCS: Early diagnosis and intervention access to treatments Planning of future care Helping families to come to terms with prognosis Helping understanding of changes to memory, behaviour and personality

~NSF for older people

Other: Improved quality of life for pts/ carers Information and education for patient and carer Intro to appropriate services, esp voluntary sector Delayed entry to institutional care Educational role of clinics for students/ PG staff, GPs Research and audit

The case for MCS?

 Divide into groups

The Case for Change

 Only 1/3 of patients currently receive a diagnosis.

 National Audit Office: “spend to save”  Early intervention is cost effective and improves quality of care for patients and their relatives  Memory Clinics reduce stigma

Banerjee and Wittenberg ( 2009): MC Economics  Economic model : delayed admissions to care homes  modest increase in average quality of life of people with dementia  plus a 10% diversion of people with dementia from residential care to be cost effective.

Value of early intervention

 Early provision of support can decrease institutionalisation by 22% ( Gaugler et al. 2005).

 Even in complex cases, care mx can reduce admissions by 6% ( Challis, 2002)  OPMHS help with BPSD and reduce need for institutionalisation (Gilley et al. 2004)

Value of early intervention

 Carer Support and Councelling can reduce care home placement by 28% (Mittleman et al. 2007)  improves quality of life of people with dementia ( Banerjee, 2007)  Early intervention has positive effects on the quality of life of family carers ( Mittleman et al. 2007)

Global and Cognitive Outcome measures ( ITT analyses)

Agent Duration CIBIC Drug/ Placebo difference Significan ce ADAS-Cog D/P difference Significan ce

Rogers et al. 1998 24 Placebo 5mg 10mg 0.36

0.44

0.005

<0.0001

2.49

2.88

<0.001

<0.001

Psychosocial interventions

 Metanalysis ( Brodaty) ( studies up to 2001):  5/7 report delays of 53-329 days

Effects on carers

 QOL of carers improved but no differences in carer psychological morbidity, care giver burden or knowledge ( LoGiudice, 2001)  Interventions must be aimed at patients and Carers (focussing on patients alone does not work (Knight. 1993)

Psychosocial Interventions

 Brodaty (1997) intensive 10 day psychoeducational programmes for families following diagnosis, some ongoing support, effects maintained  Knight ( 1993): interventions must be aimed at patients and Carers( focussing on patients alone does not work)  DAISY study ( BMJ, 2012): Effects of psychosocial interventions in Mild AD: NS

The case against

 Taking money out of service ( Pelosi, 1996), other services suffer...  Efficient CMHTs ensure 2 week response rates and offer excellent care  MCs do not incentivise GPs to take an interest in dementia (Simpson et al. 2004)  Why screen patients for dementia if drugs effects are limited Coombes (2009)

O’Conner 1991

 GPs referred patients with moderate to severe dementia to a team and offered a wide range of services vs treatment as usual...  No change in institutionalisation rates

Essential Elements of a MCS?

 Pre-Diagnostic Councelling  Assessment: At home/ Clinic By Dr/ Nurse/ OT/ Psychologist  Post Diagnostic Advice  Post Diagnostic Councellling (?)

Different Models

 DV based medical service with CMHT referral if needed  Banerjee model: All team led diagnoses, with medical input on advisory basis.  Combination nurse/ medical led service with Office based diagnosis and other elements at home.

Two Models

 Traditional: seamless service. ? More costly  Memory Clinic model:  less stigmatised service: lower refusal rates  Offers pre and post diagnostic councelling  Audit/ research can thrive

MSNAP Accredited services

PRE • Referrals Screened/ Dementia blood screening • Pre-diagnostic Councelling Dx • Diagnostic interview • Imparting diagnosis skilfully/ Management Decisions POST • Post Diagnostic Support • Compliance with medication • Social care interventions/ Third sector

What is offered in MSNAP approved service: PRE  Referrals screened:  Dementia blood screen looking for reversible causes/concomitant conditions affecting cognition( 61%)  Questionnaires to Carers before clinic re memory complaint and behaviours, General Functioning  In Clinic: ( with nurse)  Pre-Diagnostic Councelling  ACE-R

Essential Elements of a Diagnostic Assessment

Essential elements of diagnostic assessment:  Assessment with Patient and Carer  Or may see individually  History (all cognitive difficulties, behavioural problems, functioning ( ADLS), risk assessment  Driving  Advanced decision making issues  MSE, Review of ACE-R.  Review of need for scan or of available scan

Diagnostic Discussion

 Diagnostic discussion:  May need further scans, neuropsychology, blood tests  Consideration for anti-dementia drugs/ Cognitive Stimulation Therapy  Discussion re psychosocial approaches to behaviour management  Referral to Third Sector  Referral to Social Services: Day care/ carers/ placement

Elements of diagnostic assessement  Letters to referrer  Letter to patients/ carers ( careful consideration)  Other services enlisted ( neurologists/ Ots/ District nurse)

Post Dx

 Post diagnostic visit: Questions post diagnosis to clarify diagnosis Check on home situation  Medication follow-up/ compliance  Psychosocial advice to carers  Further post diagnostic councelling  Cognitive Stimulation Therapy

MCQs

 A dementia diagnosis is established in 50% of people over the age of 65 in the UK  Dementia drugs are effective in 68% of patients seen  Discussion about whether the patient drives is not your responsibility as a memory clinic Dr.