Dementia – assessment & diagnosis - South Hams & West Devon

Scope

This pathway is for the initial assessment and primary care diagnosis of people presenting with cognitive problems suggestive of possible dementia.

People with mild dementia (MMSE greater than 20/30, GP-COG 9-11/15 or normal cognitive test but also with functional impairments) or people presenting below the age of 65 should generally be referred to the Memory Clinic for detailed assessment.

People with moderate or advanced dementia (MMSE less than 20/30, GP-COG less than 9/15) may be diagnosed in primary care by their GP without referral to specialist services.

The following patient groups are more at risk of developing dementia and may be specifically targeted for assessment by primary care services:

  • People with a background of stroke or transient ischaemic attacks.
  • People with a background of ischaemic heart disease especially after a heart attack.
  • People with Parkinson's disease.
  • People with significant risk factors for cardiovascular disease (which are also risk factors for vascular dementia and Alzheimer's disease).
  • People who have a history of significant head injury.
  • People with a history of alcohol overuse or dependency.
For those patients whose learning disability precludes them from completing the tasks required in the ACE III, please refer straight to the local learning disability service (now known as IATT: the Intensive Assessment and Treatment Team for Adults with a Learning Disability) for an adapted dementia assessment.

Out of scope

Normal cognitive test and no functional impairments or evidence of alternative diagnosis.

The Alzheimer's Disease Risk Index may be useful for patients who are worried about their risk of developing dementia (for example if they have a family history of dementia) but who currently have no objective evidence of cognitive decline. It is free to use and involves completion of a 10-15 minute lifestyle questionnaire online before a personalised risk score is produced. Information is provided to help interpret the risk score and highlight modifiable lifestyle risk factors.

Assessment

History and Examination

History

A detailed history is very helpful in making a diagnosis of dementia and which type of dementia is most likely. Timing of first awareness of symptoms, how the decline is progressing and which cognitive tasks are most challenging is crucial. Additional features to check for include: history of stroke or head injury, presence of visual hallucinations, whether word-finding or short term memory is more of a problem, emotional liability or inappropriate behaviour.

Examination

Any suggestion of focal neurological deficits should be explored by examination as they may support a diagnosis of vascular dementia or point to an alternative diagnosis than dementia.

The presence of a coarse resting tremor might support the possibility of Dementia with Lewy Bodies or Parkinson's disease dementia.

It is strongly advised that the patient's GP raises the possibility of dementia with the person presenting (and their carer/family member present).

This will:

  • Reassure the patient that dementia as a possibility is being considered (very often they are already worrying about it)
  • Prepare the person for a possible future diagnosis
  • Help explain why there might need to be a referral to the local Memory Clinic

Investigations

Tests in primary care are now a QOF requirement (must be undertaken within 6 months before or after first coding a diagnosis of dementia on the person's record):

  • FBC
  • U&Es
  • Glucose
  • Calcium
  • TSH
  • B12
  • LFT

A cognitive test:

MMSE (The mini-mental state examination was originally distributed free, but the current copyright holders will not grant permission to include or reproduce an entire test or scale in any publication.)

Dementia is more likely if:

  • Cognitive test score is reduced (e.g. MMSE less than 28/30, GP-COG less than 12/15)
  • Cognitive test is normal but there are functional impairments
  • Pre-existing stroke or head injury (especially if symptoms of cognitive decline began within 3 months of a stroke)
  • Co-existent Parkinson's Disease
  • Co-existent Learning Difficulties
  • People with mild dementia (MMSE greater than 20/30, GP-COG 9-11/15 or normal cognitive test but also with functional impairments) or people presenting below the age of 65 should generally be referred to a specialist for detailed assessment.

Management

It is important to ensure that the person diagnosed is suitably read coded in their Primary Care computer record. The Dementia Support Service can be contacted on 0300 123 2029.

It is recommended that all patients diagnosed with dementia are referred to the Devon Dementia Support Worker Service for information, advice and signposting when necessary.

Identification of the carer for a person with dementia is crucial. It provides opportunities for:

  • Offering a Carer's Check
  • Engaging with patient and carer to fulfil forward planning needs
  • Improved communication particularly when the patient loses capacity
  • Proactive support for carer health needs including stress and depression

An annual Dementia review in primary care is a Quality and Outcomes Framework requirement. Although QOF is not specific about what should be done during the review, the following should be considered:

  • A review of all medications with specific attention to those which may exacerbate dementia such as the anti-cholinergic group of drugs
  • A review of any problems experienced and identified solutions, to document for future reference
  • A check of physical health with emphasis on cardiovascular risk reduction
  • A check of mental health particularly mood
  • Discussion about advance decision making if not already done and documentation where necessary
  • Updating of Adastra DevonDocs handover information, include details of any successful interventions for behavioural problems
  • A repeat cognitive test particularly if the patient is taking a acetylcholinesterase inhibitor
  • If there are any identified problems with acetylcholinesterase inhibitors, or if cognitive testing suggests withdrawal or a change to Memantine is indicated (MMSE <10), consider liaison with the local CMHT for advice.

For advice on the management of severe behavioural or psychological problems displayed by people with dementia please see the following very useful Pharmacological Management of Severe Behavioural & Psychological Symptoms of Dementia (BPSD)

See Joint Formulary: 4.11 Dementia

Dementia Roadmap

Referral

Referral Criteria

When deciding to refer to the Memory Clinic the GP should provide the patient with written information on what to expect.

Please include the following information in the referral proforma:

  • Cognitive test score (see investigations above)
  • Confirmation that blood tests have been undertaken and attach results if available (see investigations above)
  • Confirmation that a physical examination has been done
  • Any pertinent social factors including the name and contact number of a close family member or carer who is able to attend the Memory Clinic appointment with the patient being referred. This is crucial because assessment at Memory Clinic and dementia diagnosis cannot be undertaken without collateral information being provided by someone who has known the patient for some time, and can therefore reliably report on observed cognitive and/or functional decline
  • That depression and/or anxiety have been checked for and treated where necessary
  • That the possibility of dementia has been discussed with the patient and carer/family member where possible

Referral Instructions

Referral to Devon Memory Service
  • e-Referral Service Selection
    • Specialty: Mental health adults of all ages
    • Clinic Type: Memory problems
    • Service Name: DRSS-South Hams & West Devon-Adult Mental Health Service-NEW Devon CCG- 99P/DRSS-South Hams & West Devon-Adult Mental Health Service-Older Person-NEW Devon CCG- 99P

For those patients whose learning disability precludes them from completing the tasks required in the ACE III, please refer straight to the local learning disability service (now known as IATT: the Intensive Assessment and Treatment Team for Adults with a Learning Disability) for an adapted dementia assessment.

Supporting Information

Patient Information

Pathway Group

This guideline has been signed off by the Devon Partnership Trust.

Publication date: March 2018

 

Home > Referral > Western locality > Mental Health > Dementia – assessment & diagnosis - South Hams & West Devon

 

  • First line
  • Second line
  • Specialist
  • Hospital