Standard 5.1 Dementia and Mild Cognitive Impairment Aims To reduce the gap between expected and actual dementia prevalence and the variance between practices. To improve the assessment of all patients presenting with memory problems by standardly using a validated assessment tool. To improve the physical and mental health of patients with dementia and their carers by ensuring that they receive a comprehensive annual health check. Rationale In 2012, the Department of Health prioritised dementia through the Prime Minister s Dementia Challenge (Department of Health (DH), 2012). The challenge was to diagnose earlier, drive improvement in care, create dementia friendly communities and improve research. It was recently estimated that there were 850,000 people living with dementia in the UK today, including 700 000 people in England and approximately 2500 in Salford. This number is forecast to rise rapidly as the population ages, reaching over one million by 2025 (Alzheimer s Society, 2014b). The current cost to the UK economy for dementia is over 24 billion a year, through a combination of health and care costs and carer contributions. In recent years there has been a national drive to improve the prevalence rate for dementia. NHS Salford CCG has a current prevalence rate of 82%, which is the highest in Greater Manchester. Moreover, NHS Salford CCG is committed to year on year improvement to reduce the gap between expected and actual prevalence rates. Presently, there is insufficient evidence of benefit to justify population screening (Lafortune, 2013, cited in Alzheimer s Society, 2104c). However, several documents highlight the significant role which primary care can play to increase diagnosis rates, by recognising early signs and symptoms and screening at risk groups. (Royal College General Practitioners, 2012; DH, 2014a). A key recommendation from UK dementia policy is the fact that everyone who works in primary care has an important part to play, including receptionists. This will mean all staff having access to dementia education, which is consistent with their roles and responsibilities (DH, 2014b). Current guidelines require GPs to annually review both the physical and mental health needs of patients with dementia who are registered with their practice. (NICE, 2007). Evidence suggests that although the number of people in the UK recorded as having a review is high, the quality of these reviews is, on the whole variable. This standard seeks to address this variation in quality of care.
Patients diagnosed with mild cognitive impairment are at increased risk of developing dementia with an annual conversion rate of 10% (Petersen et al, 2001; DeCarli, 2003; Bruscoli & Lovestone, 2004; Petersen, 2004a; Panza et al, 2005). Currently, this cohort is actively followed up by the Salford Memory and Assessment Service (MATS) for a 2 year period following diagnosis. Practices are required to develop MCI registers prospectively from 1 st April 2016 so that in future years, the register may be used to organise structured follow up of such cases once discharged from the MATS service. Delivery Practices will be expected to: Opportunistic offer of assessment for dementia Following the establishment of patient consent to an enquiry about their memory, the practice undertakes to make an opportunistic offer of assessment for dementia to 'at-risk' patients on the practice s registered list, where the attending practitioner considers it clinically appropriate to make such an offer. For the purposes of this standard, 'at-risk' patients are: patients aged 60 or over with cardiovascular disease, stroke, peripheral vascular disease or diabetes; patients who are over 60 and have a high-risk of CVD, for instance because of smoking, alcohol consumption or obesity; patients who are over 60 with a COPD diagnosis; patients aged 40 or over with Down's syndrome; other patients aged 50 or over with learning disabilities; patients with long-term neurological conditions which have a known neurodegenerative element, for example Parkinson s disease. The assessment for dementia offered to consenting at-risk patients shall be undertaken following initial questioning to establish whether there are any concerns about the attending patient s memory. (GP, patient or family member). If a concern is expressed, further assessment will be undertaken as detailed below in Primary Care dementia assessment. Primary Care dementia assessment The assessment for dementia will be undertaken using one of: the General Practitioner assessment of Cognition (GPCOG); Six Item Cognitive Impairment Test (6CIT), Mini-Cog Assessment Instrument or the Salford Learning Disability Dementia Screen Questions in primary care, by a healthcare professional with knowledge of the patient s current medical history and social circumstances. If as a result of the completed assessment the patient is suspected as having dementia the practice should follow the local Dementia Referral Pathway.
Annual health check Patients diagnosed as having dementia will be offered an annual general health review that will cover the following areas: an appropriate physical, mental health and social review for the patient; a record of the patients wishes for the future (document pending); communication and co-ordination arrangements with secondary health (if applicable); identification of the patients carer(s); and obtain appropriate permission to authorise the practice to speak directly to the nominated carer(s) and provide more detail of the support services available to the patient and their family, if applicable, the carer s needs for information commensurate with the stage of the illness and his or her patient s health and social care needs, as appropriate, the carers should be included in the care plan or advanced care plan discussions, as appropriate, the impact of caring on the care-giver, offer the carer a health check to address any physical and mental health impacts, including signposting to any other relevant service to support their health and wellbeing. If the carer is registered with a different practice, the patient's practice will inform the carer that they can seek advice from their own practice. Practice leadership and workforce development The practice will identify a dementia champion within the practice who might be a receptionist, manager or a clinician acting as an advocate for dementia through the practice with a focus on supporting front facing staff, attending any relevant training commissioned by NHS Salford CCG and cascading learning as appropriate throughout the practice. Key Performance Indicators Have a Dementia register in place (100%). Have a Mild Cognitive Impairment register in place (100%). Assess the effectiveness of the practice to refer patients for diagnosis Dementia diagnosis rate (number of patients with a dementia diagnosis as a percentage of the expected prevalence for the practice) for the preceding 12 months. 70%* = achieved; <70%* - 60% = acceptable; < 60% - 50% = Improvement Plan; <50% = trigger. *this will rise to 80% in 2017/18
Improve the identification of patients at risk of dementia Read code the number of patients identified from the list a-f (above), so that we can set a baseline for 2016/17. Improve the care plans for dementia patients Percentage patients with dementia whose care plan has been reviewed with a face-to-face review within the preceding 12 months. 90% = achieved; <90% - 80% = acceptable; < 80% - 60% = Improvement Plan; <60% = trigger. Improve provision of giving appropriate information to patients Percentage of patients with a newly diagnosed dementia being given information about local services. 90% = achieved; <90% - 80% = acceptable; < 80% - 60% = Improvement Plan; <60% = trigger. Dementia Champion to attend training and cascade information to practice staff Annual declaration of the practice s dementia champion attendance at training events and how this learning is then cascaded throughout the practice. Measures: Practice to supply declaration of attending training event if requested by the CCG. Monitoring: Annual audit. CCG Support Contacts The CCG will: Ensure sufficient commissioned capacity in the MATs clinic to receive referrals. Provide information about local resources that patients and carers can be sign-posted to commission dementia training for practice staff. Clinical Lead: Dr Tom Tasker; tom.tasker@nhs.net CCG Lead: Integrated Commissioning Manager: Paul Walsh paul.walsh@salford.gov.uk References Alzheimer s Society, (2014a) Prime Minister's Challenge on dementia
Alzheimer s Society (2014b), Dementia 2014: Opportunity for change Alzheimer s Society (2014c) Lafortune, L., Martin,S., Fox, C., Cullum, S., Dening, T., Rait, G., Katona, C., Brayne, C., (2013) There is no evidence supporting population screening for dementia Reporting on a systematic review of costs and benefits Connolly, A., Iliffe, S., Gaehl, E., Campbell, S., Drake, R., Morris, J., Martin, H., Purandare, N. (2012a,b) Quality of care provided to people with dementia: utilisation and quality of the annual dementia review in general practice British Journal General Practice 62 (595) Department of Health (2009) Report. Living well with dementia. A national dementia strategy Department of Health (2012) Prime Minister s Challenge on Dementia. Department of Health (2013) Improving care for people with dementia Department of Health (2014a,b) Dementia Revealed What Primary Care needs to know London NICE clinical guideline 42 Robertson, J., Roberts, H., Emerson E. (2010) Health Checks for People with Learning Disabilities: A Systematic Review of Evidence Learning Disabilities Observatory Royal College of General Practitioner (2012) Dementia: diagnosis and early intervention in primary care London Royal College of Psychiatrists (RCP), (2013) The financial case for reinvesting in mental health The Health Foundation (2011) Highlight: Dementia Care London 2015/16 General Medical Services (GMS) contract Quality and Outcomes Framework (QOF) Enhanced Service Specification Facilitating timely diagnosis and support for people with dementia 2015/16