Integrated Care Pathway for Dementia – 2012

Draft

NHS Grampian

Creator: Rozi Sweetin

Overall Dementia Pathway

Person worried about memory or

Identified through screening

Person worried about memory or

Identified through screening

GPGPRefer to Specialist

ServiceRefer to Specialist

Service

Post Diagnostic Support(Health/Social Care/Voluntary)

End of Life Care(Health/Social Care/Voluntary

Services (Health/Social Care/Voluntary) Difficulties/Concerns

Living a full life(Health/Social Care/Voluntary)

Confirm DiagnosisConfirm Diagnosis

General Hospital

Person with cognitive difficulties

GP Assessment for Dementia

GP Assessment1. History from person & reliable informant2. Cognitive function assessment3. Screen for depression & anxiety4. Physical examination to rule out any acute and/or treatable medical condition5. Investigations to rule out any acute and/or treatable medical condition6. Care needs7. Associated behaviour that may be challenging for others

Dementia suspected but could not be confirmed- Subtype could not be identified- Issues with ongoing management

Not dementia

Dementia Confirmed.-Subtype identified-Cognitive enhancer prescribed as appropriate

Consider Referral to SpecialistService

Post DiagnosticSupport

No challenging behaviouror co-morbid mental illness

Challenging behaviour and/or co-morbid mental illness present

Annual Review

1. Follow Challenging behaviour pathway 2. Manage co-morbid mental illness as appropriate3. Consider referral to Older Adults Mental Health Services for co-morbid mental illness

No further action under dementia pathway

Investigations Blood

– Full Blood Count– Urea, Creatinine, Electrolytes– Liver function tests– Thyroid function tests– Vitamin B12 & Folate assay– Serum Calcium– Blood Glucose– Lipid profile

Urine– Dipstick/Culture, if appropriate

Structural Neuro-imaging (CT/MRI brain) (No access from primary care currently)

– To exclude potentially reversible/other causes such as space occupying lesions

– To be requested if there is history of

– Sudden onset/deterioration/falls– Presence of focal neurological

signs– Seizures early on in the course

of illness– Lack of reliable information

Annual Review

Care needs identified

Refer to Social Care

Acute and/or treatablemedical condition identified

Appropriate management

GP Assessment• History from person & reliable informant• Cognitive function assessment• Screen for depression & anxieties• Physical examination to rule out any acute and/or treatable medical condition• Investigations to rule out any acute and/or treatable medical condition• Care needs• Associated behaviour that may be challenging for others

Challenging behaviour present and/or co-morbid mental illness present

GP Annual Review

1. Follow Challenging behaviour pathway 2. Manage co-morbid mental illness as appropriate3. Consider referral to Older Adults Mental Health Services for co-morbid mental illness

Continue furtherannual reviews

Continue furtherannual reviews

Assessment And Management in Older Adults Mental Health Services Community Mental Health Team Following Referral

Referral Received

Urgent Routine

Referral Criteria

For Diagnosis– Contact details for Next of kin– Onset & duration of symptoms– Current support & care needs– Physical examination & investigations to rule out other

acute/treatable conditions– Cognitive function assessment– Screen for depression & anxiety– Associated behaviour that may be challenging for others

For management of Challenging behaviour– Confirmation of steps followed in Challenging behaviour pathway

Assessment And Management in Older Adults Mental Health

Community Mental Health Team Following Referral

Routine Referral

Case allocation process

Known to Learning Disability Team

Age Under 65

NoYes

Routine Referral Received

Refer to General PsychiatryAccept

Known Dementia

Refer to Learning Disability Services

Allocation to a member of Community Mental Health Team.

First appointment within 6 weeks.

Assessment

ASSESSMENT• Psychiatric assessment• Cognitive Function assessment• Clinical supervision by consultant

FURTHER INVESTIGATIONS (if necessary)• Neuropsychology• Neuro imaging• Bloods

Dementia Diagnosis

Yes NoPost Diagnostic Support

Stabilised

Continued Community Mental Health Team involvement• Co-morbid mental illness• Active ongoing treatment• Significant behaviour that others find challenging

Discharge to Primary Care

No further action under dementiapathway

Minimum Data Set• History• Assessment of mental health• Assessment of risks• Assessment of care needs• Assessment of behaviour that may be challenging to others

Appropriate Management• Cognitive enhancers, if appropriate• Psychosocial interventions• Social care referral, if appropriate

Annual Review

Urgent Referral Received

Referral to be brought to the attention of an identified decision maker in the CMHT on the day of the referral, if received within working hours or the next working day if received out of hours

Discussion with referrer, if appropriate; allocation to a member of CMHT for assessment if appropriate; time frame for assessment as per issues identified in referral & discussion with the referrer.

Assessment And Management in Older Adults Mental Health ServicesCommunity Mental Health Team Following Referral

Urgent Referral

Post Diagnostic Support

Post Diagnostic Support to be delivered by multi-agency partnership consisting of Older Adults Mental Health Services, Social Care, Primary Care & Voluntary agency (Alzheimer Scotland). A Steering Group

to be set up to implement & monitor delivery of Post Diagnostic Support.

Diagnosis delivered to the person with dementia &/or carer with an offer to opt-in

Information regarding• Diagnosis• Medication• Driving• Other information as appropriate given at the time of diagnosis

• Psycho-social interventions for cognitive impairment in dementia• Further information & support as per the 5 pillar model provided as per local arrangements

• Understanding the illness & managing symptoms• Planning for future decision making• Supporting community connections • Peer support• Planning for future care

Information

Information for PatientsInformation for Patients

Information for CarerInformation for Carer

Clinical InformationClinical Information

Legal InformationLegal Information

ServicesServices

Facing Dementia HandbookAlzheimer Scotland WebsiteAlzheimer Scotland Helpline

Coping with DementiaAlzheimer Scotland WebsiteAlzheimer Scotland Helpline

Benefit Agency Website

Quick Reference to SIGN 86

Guidance to NICE 42

Mental Health (Care & Treatment) (Scotland) Act 2003

Adult With Incapacity (Scotland) Act 2000

Adult Support and Protection (Scotland) Act 2007

Aberdeen CityAberdeenshire

Moray

Dementia Making Decisions

Shetland

Telecare services

Cognitive Enhancer: Prescription & Monitoring

Person with dementia of following types:-• Alzheimer disease• Mixed vascular & Alzheimer disease• Dementia in Lewy Body disease• Parkinson’s disease dementia

Cognitive enhancer not indicated

Trial of cognitive enhancer to be considered

Does the person with dementia have capacity to consent totreatment with cognitive enhancer?

Yes No

Yes

No

Complete Section 47 AWIA form & treatment plan

Involve legal proxy in discussion, if appropriateConsent to treatment obtained

No Yes

• Review• Discuss other psychosocial support

Initiate Cognitive enhancer treatment process

Caution in: For ACheI• Heart disease, sick sinus, supraventricular arrhythmias, Bradycardia, AV Block, prolonged QTc interval• Peptic ulcer disease• Asthma & COPD• Hepatic impairment• Seizures• Renal impairment• GI obstruction

Caution in: For Memantine• Prolonged QTc interval• Renal impairment

Suitable for Cognitive enhancers Unsuitable for Cognitive enhancers• Review• Consider otherpsychosocial support

Cognitive Enhancer Treatment Process

Check ECG, medical history & investigations

Suitable for Cognitive enhancers

Prescribed as per BNF guidelines

Review in 3/12 to assess for side effects & adherence issues

Consider support to ensure adherence

Consider alternativeCognitive enhancers

Unacceptable side effects

Yes No

Review 6-12 months• Side Effects• Cognitive function• Activities of daily living/care needs• Behaviour that others may find challenging

Benefit

No Yes

Further annual review in Primary Care

Alzheimer Scotland Dementia Helpline

Challenging Behaviour Pathway

Challenging Behaviour in Dementia

Initial assessment and investigations to include:-• Delirium• Other physical problems that can cause behavioural change e.g. constipation, pain, dehydration, medication, etc.

Physical Problem identified

Yes No

Manage appropriately

Challenging Behaviour Settled

Yes

No

Monitor and prevent future recurrences

Challenging Behaviour Assessmentand management

Initial Assessment to exclude common medical problems including

Issues identified that can be managed in primary care?

Medical problems identified?

Behaviour that Challenges Assessment

Principles: 1. Identification of behaviours; 2. Identification of impact of behaviours on the person with dementia & others; 3.

Identification of risk

Explore potential physical, psychological, inter-personal, environmental triggers

Prevention

Medical review

Person centred care

Recognition of triggers

and early signs

Environmental issues

Information sharing

Assistive technology

Medical review

Care plan

Person-centred care

Environment

Risk assessment

Watchful waiting (4 weeks)

Consultation with family

First line interventions

Non- pharmacological interventions

Person centred

Optimising care

Second line interventions

Behavioural management

Reviewed as appropriate

Consider pharmacological management of BC

BC appropriately managed?

Third line interventions

Comprehensive Behavioural

Management Plan

Medication review

Review behavioural

management plan.

BC appropriately

managed?

BC appropriately

managed?

BC resolved?

Monitor and prevent future recurrences of physical health issues.

Manage appropriately

PAIN CONSTIPATION DEHYDRATION MEDICATIONDELIRIUM

NOYES

NO YES

YESNO

YES NO YES NOYES NO

1 2 3

Multidisciplinary review

BC appropriately managed?

YES NO

Refer to Specialist

Service

Annual GP reviews

Challenging Behaviour Assessment And Management

Medical review To detect any general health problems

– Delirium– Pain – Infections– Dehydration– Constipation– Malnourishment

Medication review– Anticholinergic burden– Antipsychotic & benzodiazepam

Depression/Anxiety

Care Plan for Challenging Behaviour

Person-centred care

Is the person treated with dignity and respect? Do you know about their history, lifestyle, culture and

preferences? Do the carers try to see the situation from the perspective

of the person with dementia? Does the person have the opportunity for relationships with

others? Does the person have the opportunity for stimulation and

enjoyment? Has the person’s family or carer been consulted? Does the person’s care plan reflect their communication

needs and abilities?

Environment

If the person is being cared for in a bed or chair, are they comfortable and free of pressure sores?

Is the TV or radio playing something that the person can relate to and enjoy?

If the person is mobile, can they move around freely and have access to outside space?

Does the person recognise the environment as home? Does it contain things to help them feel at home?

Could assistive technology be used to improve freedom or safety? Does the person have the correct eye glasses, and are they clean? Is their hearing aid turned on and working correctly? Is it too hot or too cold? Is the person hungry? People may forget to eat

Non-pharmacological interventions

Soothing and creative therapies– Aromatherapy– Massage– Warm towels – Smells of cooking– Having one’s hair brushed – A manicure– Music can help improve a person’s mood.– Singing and dancing

Simple non-drug treatments– developing a life story book– frequent, short conversations (as little as 30 seconds has proven effective)– using personal care as an opportunity for positive social interaction.

Sleep hygiene– reducing daytime napping– increasing activities during the day– agreeing realistic expectations for sleep duration.

Challenging Behaviour AssessmentComplete Assessment tools depending on symptoms:-

• Cornell (Depression)• Cohen-Mansfield• Challenging behaviour checklist• Abbey pain Scale (Pain)• Functional Assessment (ABC)• MPI• Pittsburgh Agitation Scale

No BPSD Severe BPSD Extreme Risk/DistressMild to moderate BPSD

Prevention• Medical Review• Person Centred Care• Recognition of triggers and early signs• Environmental issues• Information sharing• Assistive technology

First line intervention Psychosocial/Non-pharmalogical intervention

Ongoing medical review

Ongoing Assessment• Care plan• Watchful Waiting• Consultation with family

SridharYou need to decide if you want to include this slide or not as some information are already on slide 17 from Angus.

ThanksRozi

Pharmacological Treatment of BC

Initial assessments, watchful waiting & first line interventions including non-pharmacological approach

have been attemptedNo Yes

Refer to guidance on management of challenging

behaviour

ResponseYes NoPrevention & annual GP reviews

Screen for:-• Pain• Depression• Delirium• Sleep disturbance

PainOptimise analgesic dosee.g. Paracetamol 1g 4 times/day

DepressionConsider low dose anti-depressantfor 6/12. Caution: hyponatraemia; GI Bleeding (all SSRIs); prolonged QTc with Citalopram

DeliriumInvestigate for cause and manage appropriately

Sleep disturbanceConsider sleep hygiene; if not successful, short course(4/52) of Zopiclone/Zolpidem(as per BNF).

Improved

Yes

No

If open to OAMHS,review & discharge

to Primary Care

Annual GP Review

If suitable for cognitive enhancers,consider use or optimise dose or check adherence.

Response No response

Consider Risperidone 0.25mgTwice daily (max 1 mg/twice daily).Caution: in Parkinson Disease,Dementia in Lewy Body– avoid where Benzodiazepines may need to be used.Review every 2 weeks & considertapering in 6-12 weeks

Psycho-social Interventions For Cognitive Impairment in Dementia

Person with dementia & carer or family members

GP

Post Diagnostic Support

Specialist service

Availability of following intervention discussed with the person with dementia& their carers/family members;appropriate intervention to be offered.• Carers education on dementia & management• Environmental adaptation & dementia friendly design• Assistive technology• Physical activity• Falls prevention• Recreational activity• Life story work

In addition to interventions offeredwith the PDS, following can beoffered by specialist service, if appropriate;• Carer stress management• Specific carer interventions i.e. Tailored Activity Programme• Cognitive Stimulation Therapy• Self management for people with dementia

Review by GP

Stable

Yes No

Annual ReviewConsider referral toSpecialist service

Review by Specialist service

Stable

Yes No

Discharge to Primary Care

Consider alternativemanagement strategies

• Use Supportive & Palliative care Indicators Tool (SPICT) as indicator tool and if appropriate, patient should be added to palliative care register• Use Palliative Performance Scale (PPS) to assess functional status. Take into account – Functional Decline (functional assessment), weight loss, Cognitive Decline, unplanned admission to hospital, recurrent infections, increasing care needs, BPSD, inappropriate vocalisation.• Care plan completed to reflect needs and assess unmet needs • Consider Carer needs – Carer assessment.• Assess Capacity – if appropriate complete Section 47 Adults with Incapacity Act form and Treatment Plan• Involve legal proxies if available in discussions

Ongoing Review and Care• Review Capacity• Consider –Anticipatory care plan• Symptom management - Treat reversible causes of decline• Consider “Just in case box”• Complete/update ePCS• Consider/review DNACPR• Consider GMED out-of-hours alert sheets• Care plan reviewed to reflect needs• Carer needs reassessed

Holistic approach – consider physical, psychological, spiritual and social needsCarer needs – Enable family/carer etc. to express their concerns

Anticipatory care prescribing – for pain, nausea, agitation, BPSD, breathlessness, respiratorytract secretions. Comfort care measures.

End of Life Care

End of Life Care

Living and Dying Well

End of Life Care