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Integrated Care Pathway for Dementia – 2013
NHS Grampian
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Overall Dementia Pathway
Next Person worried about memory or Identified through screening Refer to Older Adults Mental Health Service GP General Hospital Confirm Diagnosis Post Diagnostic Support (Health/Social Care/Voluntary) Services (Health/Social Care/Voluntary) Living a full life (Health/Social Care/Voluntary) Difficulties/Concerns End of Life Care (Health/Social Care/Voluntary
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GP Assessment for Dementia
Next GP Assessment History from person & reliable informant Cognitive function assessment Screen for depression & anxiety 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 Person with cognitive difficulties Dementia Confirmed. -Subtype identified -Cognitive enhancer prescribed as appropriate -Psychosocial management of cognitive impairment. Post Diagnostic Support Dementia suspected but could not be confirmed Subtype could not be identified Issues with ongoing management Not dementia Consider Referral to Older Adults MHS No further action under dementia pathway No challenging behaviour or co-morbid mental illness Challenging behaviour and/or co-morbid mental illness present Follow Challenging behaviour pathway Manage co-morbid mental illness as appropriate Consider referral to Older Adults Mental Health Services for co-morbid mental illness Consider Anticipatory Care Plan / Key Information Summary/Getting to Know Me Annual Review Back to Overall Dementia Pathway page
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Back to GP Assessment page Back to Overall Dementia Pathway page
Investigations Next Blood Full Blood Count Urea, Creatinine, Electrolytes Structural Neuro-imaging (CT/MRI brain) (No access from primary care currently) Liver function tests Thyroid function tests To exclude potentially reversible/other causes such as space occupying lesions Vitamin B12 & Folate assay Serum Calcium To be requested if there is history of Blood Glucose Lipid profile Sudden onset/deterioration/falls Urine Presence of focal neurological signs Dipstick/Culture, if appropriate Seizures early on in the course of illness Lack of reliable information Back to GP Assessment page Back to Overall Dementia Pathway page
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GP Annual Review Annual Review GP Assessment
Next GP Assessment History from person & reliable informant Cognitive function assessment Screen for depression & anxiety 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 Discuss/consider Anticipatory Care Plan/Key Information Summary Care needs identified Acute and/or treatable medical condition identified Challenging behaviour present and/or co-morbid mental illness present Refer to Social Care Appropriate management Continue further annual reviews Continue further annual reviews Follow Challenging behaviour pathway Manage co-morbid mental illness as appropriate Consider referral to Older Adults Mental Health Services for co-morbid mental illness Back to GP Assessment page Back to cognitive enhancers page Back to psychosocial intervention page Back to Older Adults MHS Team Assessment page Back to Challenging Behaviour Assessment & Management page Back to Phamacological Management page
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Back to GP Assessment page
Assessment And Management in Older Adults Mental Health Services Community Mental Health Team Following Referral Next Referral Received (Via SCI Gateway) Urgent Routine Back to Phamacological Management page Back to GP Assessment page Back to Overall Dementia Pathway page
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Referral Criteria For Diagnosis
Next 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 Back to Referral page
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Assessment And Management in Older Adults Mental Health Services
Next Assessment And Management in Older Adults Mental Health Services Community Mental Health Team Following Referral Urgent Referral 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 OAMHS Team for assessment if appropriate; time frame for assessment as per issues identified in referral & discussion with the referrer. Back to Referral page
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Assessment And Management in Older Adults Mental Health
Community Mental Health Team Following Referral Routine Referral Next Routine Referral Received Case allocation process Age Under 65 Known to Learning Disability Team Allocation to a member of Community Mental Health Team. First appointment within 6 weeks. Known Dementia Refer to Learning Disability Services Yes No Refer to General Psychiatry Accept Assessment Back to Referral page
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No further action under Discharge to Primary Care
OAMHS Team assessment Psychiatric assessment Cognitive Function assessment Clinical supervision by consultant Next Minimum Data Set History of cognitive impairment Assessment of mental health Assessment of risks Assessment of care needs Assessment of behaviour that may be challenging to others FURTHER INVESTIGATIONS (if necessary) Neuropsychology Neuro imaging Bloods Post Diagnostic Support Dementia Diagnosis Yes No No further action under Dementia pathway Appropriate Management Cognitive enhancers, if appropriate Psychosocial interventions Social care referral, if appropriate Ongoing Community Mental Health Team involvement needed: Co-morbid mental illness Active ongoing treatment Significant behaviour that others find challenging No Review Yes Stabilised Discharge to Primary Care Annual Review Back to Referral page
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Post Diagnostic Support
Next Post Diagnostic Support to be delivered by multi-agency partnership consisting of Primary Care, Social Care, Voluntary agency such as Alzheimer Scotland and Older Adults Mental Health Services. Diagnosis delivered to the person with dementia &/or carer Information provided at the time of diagnosis 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 pillars model provided as per local arrangements with option to opt out:- Understanding the illness & managing symptoms Planning for future decision making Supporting community connections Peer support Planning for future care Getting to Know Me Back to Overall Dementia Pathway page Back to Older Adults MHS Team Assessment page Back to Psychosocial Intervention page
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Cognitive Enhancer: Prescription & Monitoring
Next Person with dementia of following types:- Alzheimer disease Mixed vascular & Alzheimer disease Dementia in Lewy Body disease Parkinson’s disease dementia Yes No Cognitive enhancer not indicated Trial of cognitive enhancer to be considered Does the person with dementia have capacity to consent to treatment with cognitive enhancer? No Yes Complete Section 47 AWIA form & treatment plan Consent to treatment obtained Involve legal proxy in discussion, if appropriate No Yes Annual Review Discuss other psychosocial support Initiate cognitive enhancer treatment process Back to GP Assessment page Back to Older Adults Team assessment page
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Cognitive Enhancer Treatment Process
Next Check ECG, medical history & investigations 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 Suitable for cognitive enhancers Unsuitable for cognitive enhancers Annual Review Consider other psychosocial support Back to cognitive enhancer prescription & monitoring page
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Suitable for cognitive enhancers
Next Consider support to ensure adherence Prescribed as per BNF guidelines Review in 3/12 to assess for side effects & adherence issues Consider alternative cognitive enhancers Unacceptable side effects No Yes 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 Back to Phamacological Management page Back to cognitive enhancer treatment process
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Challenging Behaviour Pathway
Next 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 assessment and management Challenging Behaviour Settled No Monitor and prevent future recurrences Yes Back to referral criteria page Back to GP Annual review page Back to GP Assessment page
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Challenging Behaviour Assessment And Management
Initial Assessment to exclude common medical problems including Next DELIRIUM PAIN CONSTIPATION DEHYDRATION MEDICATION 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 Assessment scales Explore potential physical, psychological, inter-personal, environmental triggers NO YES Manage appropriately Annual GP reviews BC resolved? Refer to OAMHS Medical review Person-centred care Environment Risk assessment Watchful waiting (4 weeks) Consultation with family 1 First line interventions Non- pharmacological interventions Person centred Review care needs NO YES 2 3 Third line interventions Comprehensive Behavioural Management Plan Medication review Review behavioural management plan. Second line interventions Behavioural management Reviewed as appropriate Consider pharmacological management of BC Prevention Medical review Person centred care Recognition of triggers and early signs Environmental issues Information sharing Assistive technology Monitor and prevent future recurrences of physical health issues. BC appropriately managed? BC appropriately managed? BC appropriately managed? BC appropriately managed? Multidisciplinary review ongoing YES NO YES NO YES NO YES NO Back to GP Assessment page Back to Challenging Behaviour Pathway
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Challenging Behaviour Assessment
Next Complete assessment tools depending on symptoms:- Cornell (Depression) Cohen-Mansfield Challenging behaviour checklist Abbey pain Scale (Pain) Functional Assessment (ABC) NPI Pittsburgh Agitation Scale No BPSD Mild to moderate BPSD Severe BPSD Extreme Risk/Distress Prevention Medical Review Person Centred Care Recognition of triggers and early signs Environmental issues Information sharing Assistive technology First line intervention Psychosocial or Non-pharmacological intervention Consider referral to Older Adults Team Ongoing medical review Consider pharmacological intervention Ongoing Assessment Care plan Watchful Waiting Consultation with family Unresolved Resolved Back to Challenging Behaviour Assessment & Management page
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Medical review To detect any general health problems Medication review
Next To detect any general health problems Delirium Pain Infections Dehydration Constipation Malnourishment Others Medication review Anticholinergic burden Antipsychotic & benzodiazepines Depression/Anxiety Back to Challenging Behaviour Assessment & Management page Back to Challenging Behaviour Assessment page
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Person-centred care Is the person treated with dignity and respect?
Next 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? Back to Challenging Behaviour Assessment & Management page Back to Challenging Behaviour Assessment page
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Environment Next 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 Back to Challenging Behaviour Assessment & Management page Back to Challenging Behaviour Assessment page
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Non-pharmacological interventions
Next 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. Back to Challenging Behaviour Assessment page
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Pharmacological Management of Behaviour That Challenges
Next Initial assessments, watchful waiting & first line interventions including non-pharmacological approach have been attempted Yes No Yes Response No Refer to guidance on management of challenging behaviour Prevention & annual GP reviews Screen for:- Pain Depression Delirium Sleep disturbance Pain Optimise analgesic dose e.g. Paracetamol 1g 4 times/day Depression Consider anti-depressant (start low, go slow) for 6/12. Caution: hyponatraemia; GI Bleeding (all SSRIs); prolonged QTc with Citalopram Sleep disturbance Consider sleep hygiene; if not successful, short course (4/52) of Zopiclone/Zolpidem (as per BNF). Delirium Investigate for cause and manage appropriately Improved No Yes If open to OAMHS, review & discharge to Primary Care Annual GP Review Back to Challenging Behaviour Assessment & Management page Back to Challenging Behaviour Assessment page
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Pharmacological Management of Behaviour That Challenges
Next If suitable for cognitive enhancers, consider use or optimise dose or check adherence. Response No response Consider Risperidone 0.25mg Twice 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 for response. Response No response If open to OAMHS, review & discharge to Primary Care Consider referral to OAMHS Consider tapering 6-12 weeks Annual GP Review Back to previous page
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Psycho-social Interventions For Cognitive Impairment in Dementia
Next Person with dementia & carer or family members Older Adults MHS GP Post Diagnostic Support 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 offered with the PDS, following can be offered 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 Review by Older Adults MHS Stable Stable Yes No Yes No Annual Review Consider referral to Older Adults MHS Discharge to Primary Care Consider alternative management strategies Back to Post Diagnostic Support page Back to Challenging Behaviour Assessment page
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End of Life Care Next 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 needs Carer needs – Enable family/carer etc. to express their concerns Anticipatory care prescribing – for pain, nausea, agitation, BPSD, breathlessness, respiratory tract secretions. Comfort care measures. Back to overall pathway page
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Back to overall pathway page
End of Life Care Next Living and Dying Well Grampian Integrated Palliative Care Plan DNACPR Back to overall pathway page Back to End of Life Care page
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Cognitive Function Assessment Tools
Next MoCA Test or MoCA Alternative Version Standardised MMSE 6CIT Addenbrooke’s Cognitive Examination – ACE-R Abbreviated Mental State Test 4AT Back to GP Assessment page Back to GP Annual Review page Back to referral criteria
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Screen for Depression & Anxiety
Next NICE Guideline for Depression NICE Reference Guide GDS Short Form HADS Back to Phamacological Management page Back to GP Assessment page Back to GP Annual Review page Back to referral criteria
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Challenging Behaviour Assessment Tools
Next NPI CMAI Abbey Pain Scale, PAIN AD ABC Cornell Pittsburgh Agitation Scale Challenging behaviour checklist Back to Challenging Behaviour Assessment & Management page Back to GP Assessment page Back to Challenging Behaviour Assessment page
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Living a full life 8 pillars model Living well with Dementia
Next 8 pillars model Living well with Dementia Alzheimer Scotland Back to Overall Dementia Pathway page
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Pain Next Often patients with delirium/dementia will not be able to say that they are in pain Be alert to the possibility of pain Regular analgesics would be more beneficial Back to Challenging Behaviour Assessment & Management page Back to Challenging Behaviour Assessment page
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Constipation PR exam? ..............(If impacted, consider enema)
Next PR exam? (If impacted, consider enema) Stop/reduce contributory drugs if able (opiates, iron, calcium channel blockers, amitriptyline) Laxatives Initially Movicol 1 sachet twice daily + Senna 2 tablets at night Once bowels cleared, stop movicol and consider senna +/- other laxative Back to Challenging Behaviour Assessment & Management page Back to Challenging Behaviour Assessment page
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Dehydration Clinically dehydrated?
Next Clinically dehydrated? Biochemically dehydrated? Urea>Creat; Na ( = severe) Push oral fluids: Maintain & monitor fluid intake chart Intravenous fluids if severely dehydrated (clinically/biochemically) or if poor oral intake Back to Challenging Behaviour Assessment & Management page Back to Challenging Behaviour Assessment page
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Medication Next Review drug chart & attempt to stop/reduce drugs that may precipitate or worsen delirium Common offenders include Bladder stabilisers (Oxybutynin, Tolterodine, Solifenacin) Tricyclic antidepressants (Amitriptyline, Imipramine)* Anticholinergics (Hyoscine/Buscopan, atropine eyedrops) Benzodiazepines (diazepam, lorazepam, Zopiclone)* Antihistamines (particularly sedative antihistamines) Digoxin (check blood levels) Lithium (check blood levels) Opiates (morphine, codeine, Tramadol)* High dose Steroids* (*may be dangerous to withdraw abruptly) Back to Challenging Behaviour Assessment & Management page Back to Challenging Behaviour Assessment page
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Information Information for Patients Information for Carer
Next Information for Patients Facing Dementia Handbook Alzheimer Scotland Website Alzheimer Scotland Helpline Telecare services Information for Carer Coping with Dementia Alzheimer Scotland Website Alzheimer Scotland Helpline Benefit Agency Website Dementia Making Decisions Clinical Information Quick Reference to SIGN 86 Guidance to NICE 42 Legal Information Mental Health (Care & Treatment) (Scotland) Act 2003 Adult With Incapacity (Scotland) Act 2000 Adult Support and Protection (Scotland) Act 2007 Services Aberdeen City Aberdeenshire Moray Back to Post Diagnostic Support page
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Back to Post Diagnostic Support page
5 Pillars Model Next Back to Post Diagnostic Support page
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Alzheimer Scotland Dementia Helpline
Back to Information page
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8 Pillars Model Back to Living a full life page
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This page is under construction.
Telecare Service This page is under construction.
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Aberdeen City Services This page is under construction.
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This page is under construction
Moray Services This page is under construction
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Carers & Family Alzheimer Scotland Aberdeenshire Dementia Services
Back to Psychosocial Intervention page
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Thank you to those involved in the work to produce this ICP.
ICP Development 2006 – Large scale workshop to gauge interest in developing Grampian Wide managed care network hosted by Old Age Psychiatry leading to the creation of ICP Dementia Steering Group. 2008 – Launch of “Developing For Mental Health” and Commitment 6. 2009 – Appointment of Mrs Rozi Sweetin as ICP (Dementia) Coordinator. 2010 – Development of Minimum Data Set and process flow. 2011 – Agreement with Primary Care Leads achieved for the “front” page generic pathway. – Development of the MS PowerPoint based hyperlinked ICP. 2013 – Launch of ICP at AECC 2014 – Transfer of ICP to CGI The ICP could not have been produced without the support and direction from the 3 Clinical Directors, Mr Alasdair Walker, Dr Donald Mowat and Dr Sridhar Vaitheswaran, but the technical expertise provided by Mrs Rozi Sweetin was critical to the its delivery as a useful clinical tool. Thank you to those involved in the work to produce this ICP.
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