Dementia Diagnosis and Referral

 

Dementia is a progressive and largely irreversible clinical syndrome that is characterised by a widespread impairment of mental function. Although many people with dementia retain positive personality traits and personal attributes, as their condition progresses they can experience some or all of the following: memory loss, language impairment, disorientation, changes in personality, difficulties with activities of daily living, self-neglect, psychiatric symptoms (for example, apathy, depression or psychosis) and out-of-character behaviour (for example, aggression, sleep disturbance).

Contrary to social misconception, there is a very great deal that can be done to help people with dementia, so it is important that dementia is diagnosed in a timely manner to enable people with dementia and their family carers to receive the treatment, care and support following diagnosis that will enable them to live as well as possible with dementia.

Some patients may be are unwilling or unable to attend the Memory Assessment Clinics should not be deprived of advice and support but it should be remembered that an early diagnosis can help people with dementia get the right treatment and support, and help those close to them to prepare and plan for the future. People who are assessed for the possibility of dementia should be asked if they wish to know the diagnosis and with whom this should be shared..

Assessment Before Considering Referral

Cognitive and mental state examinations suitable for assessment in primary care include:


History and Physical Examination

History and physical examination should be used to assess for medical co-morbidity and psychiatric features associated with dementia, including depression and psychosis.  There should be a long history reflecting the progressive and insidious course of dementia. It may not be possible to diagnose dementia in a single consultation but rather after a period of current and historic review of the patient. The diagnosis should usually include input from the carer or relative which collaborates the history and demonstrates the negative effect of the memory loss on the functional abilities or personality of the patient over a prolonged period.

What are the main differential diagnoses / potential contributing factors? The Three Ds:

  1. Depression which may be contributing to the presentation in a patient with dementia.
  2. Drugs with strong anticholinergic activity such as tricyclic antidepressants (e.g. Amitriptyline), older drugs for bladder problems (e.g. Oxybutynin) and first generation antihistamines (promethazine, chlorphenamine) should be stopped if possible or substituted for a drug with less anticholinergic activity. All opiates affect cognitive function-consider regular paracetamol or topical analgesia or use the lowest possible dose of opiate.
  3. Delirium – The diagnosis should be clear from the timescale (starts suddenly and stops suddenly) and the general condition of the patient (i.e. they look unwell). A symptomatic bacteriuria is unlikely to be a significant cause of delirium.

The above information and further advice can be found in the 'Dementia diagnosis and management. A brief pragmatic resource for general practitioners' guide (NHS England).

Reviewed June 2019 by the East Kent Mental Health Commissioning Team. For content suggestions, updates or information please email: EKmentalhealth.commissioning@nhs.net.

Cognitive and mental state examinations (suitable for assessment in primary care) include:

These tools can all be found in the 'Helping you assess Cognition: A practical toolkit for clinicians' toolkit (Alzheimer's Society).

Diagnosing dementia in younger people: A decision-making tool for GPs Published by Young Dementia Network UK

Blood tests / Phlebotomy

If your practice does not have a practice nurse who is trained to take bloods, you can refer a patient to the Pathology Department at East Kent Hospitals for a blood test (find details here)

Alternatively, Buckland Hospital (Dover) and the Royal Victoria Hospital (Folkestone) both operate a walk-in service where no appointment is necessary, except for if the patient requires a Glucose Tolerance Test (GTT).  In the event that a GTT is required, please call 01304 222552 (for Buckland) and 01303 854484 (for Royal Victoria) to arrange a suitable appointment

Please ensure that the patient remembers to take with them their blood test form to the walk-in centres
.
MRI Scans

  • Use MRI as first choice especially in early onset dementia.
  • When requesting MRI head scan for dementia assessment, add “Dementia Protocol – Dr Bertoni” to the form. The detailed view of the mesial-temporal lobe and hippocampi obtained enables reporting to include grading scales of various atrophic changes and vascular lesions. This supports a more precise diagnosis and thereby improves the quality of assessments.

July 2018 Update: Historically there has been an expectation that ECGs are done as part of the referral process for the memory assessment pathway. At the request of the CCGs, KMPT have explored the clinical indication for this and agreed GPs will no longer be required to provide an ECG as part of the referral. Where an ECG is required, the CMHSOPs will arrange for this to be undertaken themselves.

To avoid unnecessary delays in the care pathway, it is preferred that the GP requests a dementia protocol MRI at the point of deciding to refer, unless:

  • The patient has known Parkinson’s disease
  • The patient has a known contraindication to MRI where a dementia protocol CT brain would be indicated
    The patient is over 90 where the background prevalence means the added value of imaging is diminished in most cases
  • The patient is known to have had a MRI brain in the past 12 months
  • The GP has doubts about the appropriateness of brain imaging and wishes to delegate this decision to the psychiatrist. This would include people with Down syndrome and moderate or severe learning disability.

Information on request form should include sufficient preliminary detail to aid the radiologist. This would include key symptoms, objective evidence of cognitive impairment such as test scores, relevant past medical history (such as hypertension, diabetes, ischaemic heart disease, cerebrovascular disease, AF, hypercholesterolemia, alcohol excess, head injury, etc.) and preliminary thoughts on clinical diagnosis.

For more information see:

GP Led Diagnosis

In some cases, it may be appropriate for the patient’s GP to lead on the diagnosis of dementia, or to reach a diagnosis through consultation with the local psychiatrist, via a scheduled telephone call or meeting with the practice. This will largely be determined by the GP’s confidence.  This is most likely to be applicable where the diagnosis of moderate to severe dementia is self- evident from history taking and very manifest on basic interview necessitating only limited mental state examination.

It is hard to legislate on when and how it should happen other than to say that the usual provision of blood tests, timeliness, pre-diagnostic discussion, respect of best interests in non-capacitous patients, and adequate provision of onward care is needed.  GP strengths include their existing relationship with patients and families, and confidence in conveying diagnoses.  The need for subsequent review by a psychiatrist and active care coordination by the community mental health team for older people will be largely determined by the complexities of dementia and any behavioural or psychological symptoms that may require specific treatment.

There should be direct access for the standard aftercare package including information for families and signposting to the local Age UK Dementia Outreach Manager/ Alzheimer’s Society/ Carer’s Support and other organisations.

Post diagnostic groups as per existing memory services, are equally available where the diagnosis is made by the GP in primary care.

A number of patients that might fall into the category described above could be living in residential or nursing care homes. When considering diagnosing such patients this needs to be supported by a clear statement of what a good aftercare package should look like in this setting and careful consideration of Best Interest.

For more information see:  Dementia Assessment, Diagnosis and Treatment Framework East Kent.

Memory Assessment Clinic & Community Mental Health Team for Older People South Kent Coast CCG
Dover:

Folkestone: 

Thanet:

Additional Referral Services:

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