Slide 1. Prior to the memory team there were a number of different pathways for the diagnosis and treatment of those suffering from dementia

Transcription

1 1 Talk for High Performance Conference: The Counties Manukau Memory Team Slide 1 Where did the Memory Team come from? Sue Thompson, Northern Regional Dementia Advisor for the Ministry of Health and Dr Mark Fisher, Consultant Old Age Psychiatrist from MHSOP developed the Counties Manukau Dementia Care Pathway in 2012 from which the Memory Team came. Their Pathway was visionary and wide ranging. It recommended a Diagnosis to Death service for people with memory issues incorporating early diagnosis, care coordination and support throughout the life time of the illness for the client and their families. The Memory Team is the practical response in these challenging economic times. We are funded partially from moneys from MHSOP and partially from HOP. We have been up and running now for 22 months. This is our story. Slide 2 What was here before the Memory Team Prior to the memory team there were a number of different pathways for the diagnosis and treatment of those suffering from dementia Slide 3 What are the limitations: A GP will generally see clients for 15 minutes.

2 2 The amount of time that a hospital clinician can spend with a client in clinic is necessarily limited. 45 minutes is the norm. An emergency department doctor is more flexible as to the amount of time spent per client but they are, nevertheless, still under time pressure. In this time the clinician must go through the formalities of introductions and the clients initial questions; take the client s blood pressure; complete a full physical examination; take a full medical history and review medications; complete cognitive testing and gather background information about functioning; make a diagnosis and discuss the implications of that diagnosis with the client; discuss driving and EPOA and, finally, prescribe indicated medication and make indicated referrals and interventions. The restricted amount of time available can lead to other problems. Sometimes insufficient information is gathered to enable a diagnosis to be made which means that dementia medication is not prescribed; often driving issues are not addressed or, if they are, the clinician s recommendations are not followed up. This lack of follow up is also a problem with referrals to other agencies or DHB departments unfortunately in our experience not all such referrals are acted upon. Once the client has walked out the door and the last letter/referral has been sent, the doctor/clinician/gp will not think about that client until their next appointment. Another issue is with the under 65s with a cognitive impairment. The under 65s make up a significant cohort of the Memory Team s caseload. The under 65s may not be seen by geriatric

3 3 services or MHSOP and, because of their age, a diagnosis of dementia by another service or their GP is probably less likely. In an inpatient setting delirium can often cloud the diagnosis of dementia. Delirium can affect a client for several weeks or months. A client will sometimes be given information on the Alzheimer s Society by a clinician or GP but, human nature being what it is, contacting Alzheimer s Society will generally be a very low priority for many a reluctant client and family. Slide 4 Who are we? The memory team is a multidisciplinary team. That is important because of the wide range of issues consequent on the client s impairment, exacerbating that impairment or adding to the caregiver s burdens. There can be financial problems and issues around the PPPR Act (social worker); there can be behavioural problems and neurological differentials (psychologist); there can be mental health issues clouding the diagnosis (mental health nurse); medical issues (geriatric nurse) and issues around practical assistance with functioning (Occ. Therapist). The members of the team have enough knowledge about their colleagues areas of expertise to be able to identify issues and consult appropriately. The team also has the benefit of being able to consult with a senior older person s psychiatrist and a senior geriatrician Slide 5 - Where we cover As you can see from the slide, our catchment includes two localities in the CMDHB catchment. These two localities were chosen for a number of reasons but the main reasons were the socio-economic challenges in these localities, the geographical

4 4 proximity to Middlemore Hospital and the relative concentration of the population. The orange colouring indicates the lower socioeconomic areas of South Auckland. Slide 6 - Statistics These statistics are self-explanatory. I ask you to note, however, the number of referrals we have received for clients under 70 years of age 29%. The referrals to the Memory Team are proportionate to the ethnic diversity of South Auckland. Dementia is an equal opportunity melody. Slide 7 - More statistics Also self-explanatory. Of note are the number of clients referred who we have diagnosed with dementia and the relative severity of that dementia at the time of diagnosis. The bottom graph shows that 35% of people on first presentation to the Memory Team have Moderate Dementia. I don t think this would be acceptable statistics for Diabetes, Parkinson s Disease or Cancer Slide 8 We take the time do a comprehensive assessment allocating between 2-4 hours over 2 sessions to gather a full history of the symptom, progression, likely causes, family history, medical/psychiatric history, changes in functioning ability, how the family members are coping. CT scan are routine, the assessments are discussed in a full MDT meeting. We do not make a diagnosis nor send out our report until we have gathered all the information required.

5 5 Slide 9 We place a priority on getting collateral information from family or cares. Sometimes we have to hunt for the person who can give us collateral information. Due to insight issues what the client tells you often differs from what others have to say Slide 10 We do Home Visits It s obvious you cannot see inside someone s fridge from a clinic at a hospital. When you do home visits you can see clutter, environmental risks, poverty, the state of the kitchen. We have seen people who live and sleep in a chair in the kitchen, whose cat has peed and pooed everywhere, empty fridges and cupboards with only bread and biscuits. Home visits mean we can also catch those people who don t show up to clinics Slide 11 Time is taken to get a full picture at the appropriate time so if someone has a delirium or has just had a TIA we wait and assess them at their best. Quality cognitive assessments are done We use the Addenbrooke s, The Frontal Assessment Battery, or the RUDAS or occasionally the MOCA Slide 12 We give a clear and direct diagnosis - We do not pussy foot around, we don t fluffy it, we are up front honest and direct. We use the D word and The A word. We talk about the diagnosis and its implications for the future, just as an Oncologist would with

6 6 cancer. We discuss EPOA, Advanced Care Plans, carer stress, risk of delirium etc. Involving the family in the feedback this is vital to the process. Where I worked in the past the family meetings were set up around the doctor s time. At the Memory Team we make the Family meeting around when the families are available. We have meetings at 6.30am before they go to work or at 4.30 after work. Slide 13 Comprehensive Interventions/Follow up we are structured so we can follow through with our recommendations. What s called the intensive phase. This is where things are actually achieved. Care Coordination often means connecting the dots helping clients make the connection between their diabetes, cardiovascular disease or renal failure and their memory problems. Finding ways to help the GP manage diabetes medications or warfarin better for people with memory loss. We follow through we safety to drive firmly insist on people having a driving assessment, taking away people licenses if necessary. Slide 14 Admissions we focus on preventing unnecessary admissions, facilitating appropriate admissions and helping wards with faster turn arounds and discharges. Slide 15 Offering a better service for younger people. Our psychologist Dr Susan Yates has developed a niche market for assessing and assisting younger people with memory loss. They have issues

7 7 that our older clients don t necessarily have they are often still working, have young children or teenagers, and their spouses are still working. We have had clients with moderately advanced dementia who have been harassed by WINS to keep job seeking. Follow up with Alzheimer s Auckland when the intensive phase is over we hand over the follow up to Alzheimer s Auckland. Slide 16 What are the challenges? - Dementia is often only one of multiple issues We have a Complex population 23% live alone 37% have complex family / social situations 47% have high carer stress, and 30% have no knowledge of dementia 59% have little / no insight 51% have multiple other co-morbidities We see families where issues of poverty, domestic violence, unemployment, alcohol abuse, lack of transport are far more of an issue than grandma s dementia. - There are limited services / supports for under 65s. People under 60 struggle to accept their diagnosis, their families and employers struggle to understand it they neither fit into older adults or adult services. - We have become the Driving police. A role Mark Fisher

8 8 describes as doing the shitty bits that no one else wants to do. We have removed (or restricted) 115 driving licenses. In many cases these individuals had moderate-to-severe dementia - Enduring Power of Attorney is a great idea, but too expensive for many of our clients. There are huge cultural dimensions to appointing someone younger to be in charge of a more senior member of the family - That demand is far greater than the service we can provide Last word Working in the memory team is a fantastic experience. We have a great team, an amazingly knowledgeable and helpful Geriatrician, a visionary Old Age Psychiatrist We have a flexible and client manager and above all the most amazing people to work with. We would like to thank all the clients and their families in South Auckland who have let us into their homes and into their lives for a period of time to try to make a difference. Thank you