DGH Cognitive Impairment Pathway

The DGH Cognitive Impairment Pathway has been designed to support the treatment and care management for people with cognitive impairment and dementia who enter the emergency and acute medicine stream. The Pathway begins at the point of admission and aims to better identify patients with cognitive impairment and dementia and following them through their hospital journey, to the point of discharge planning.

The Pathway has been specifically developed to support the UHB’s response to the Dementia Intelligent Target for General Hospital Care - see attached Driver Diagram and narrative. There will be significant audit activity further to implementation of the Pathway, as high level indicators emanating from the Pathway will be reportable under the All Wales Quality Framework.

Contents of the Pathway and explanation of each component’s purpose follows.

DAY OF ADMISSION

Ward/Unit where Pathway initiated

It is important to note admission ward and subsequent wards where care is provided, as there is an aim to reduce internal transfers for patients with cognitive impairment/dementia as they can be disorientating and exacerbate confusion related problems.

Is there a Lasting Power of Attorney or Court Appointed Deputy (for Health and Welfare)?

It is important to identify whether an LPA or CAD is in place at the outset of the admission, as there will be a legal requirement to consult with the LPA or CAD and to seek their consent for major decisions such as serious medical treatment or change of accommodation.

Is there an established dementia diagnosis?

It is important to find out whether there is an established dementia diagnosis, as this will influence treatment decisions. Take a history from the carer or the person attending with the patient. Try to identify the date of diagnosis and which specialist or team provided the diagnosis.

Is there a history of ongoing memory problems or is this acute confusion, with onset over several days?

It is important, if there is not a dementia diagnosis, to ask the carer when the onset of confusion started. If it appears to be acute confusion, the NICE Delirium guideline will need to be followed - this is provided in the Toolkit for reference. If it appears to be longstanding cognitive impairment but no dementia diagnosis, at the point of discharge referral to Cardiff Memory Team will need to be facilitated (or to Old Age Psychiatry Services if there are significant behaviour or psychiatric symptoms).

Is the patient known to specialist services?

It is important to determine whether the patient is known to specialist services, including Cardiff Memory Team, Community Mental Health Teams for Older People or Hospital Old Age Liaison Psychiatry Services. If the person has a history of contact with these services, it is important to inform those services of their admission.

REQUIRED WITHIN FIRST WEEK OF ADMISSION(All tools are provided in the Toolkit)

Getting To Know You Form

If there is cognitive impairment or an established dementia diagnosis, it is important to gather information about the patient’s personal life history, their likes and dislikes and their normal habits and routines. This knowledge will inform the development of person-centred care plans and provide a basis for communicating positively with the patient. The carer should be asked to complete and return this communication aid, as they know the patient best and can provide useful insights with regard to how best to meet their needs.

AD8 Dementia Screening Interview

This assessment should be completed by the ward doctor and is a brief assessment to identify cognitive impairment. It should not be used if there is an established dementia diagnosis. It’s use will inform the implementation of the NICE Delirium guideline.

Montreal Cognitive Assessment

This assessment replaces the MMSE, which has been withdrawn from practice due to copyright restrictions. It seeks to identify the degree of cognitive impairment and is a useful tool to identify improvements in functioning after treatment for acute medical conditions. It also is valuable as a measure of the progression of dementia.

PHQ9

The PHQ9 is a depression screening tool advocated in the Depression Intelligent Target. It is a brief questionnaire which aims to identify key features and degree of depression. The value of using this tool in a cognitive impairment pathway is that there is frequently undiagnosed comorbid depression in patients with dementia. If there is a high score, i.e. above 20, then referral to the Hospital Old Age Liaison Psychiatry Service should be made.

Butterfly Scheme

This scheme, developed by a carer and supported by many dignity champions, aims to identify to staff across the whole care team which patients have a cognitive impairment or established dementia (an outline butterfly symbol for cognitive impairment, a filled butterfly for established dementia). The Butterfly symbol by the bedside and on patient boards coveys to staff which patients may need more assistance and observation, for example in respect of their fluid and nutritional intake. It is important to inform the carer of the purpose of this identification.

Review anti-psychotics

If the patient is on anti-psychotics when they are admitted, it is important to review the appropriateness of the prescription and reduce the prescription where possible. If there is a complex prescription or advice on withdrawing anti-psychotics is required, a referral can be made to the Hospital Old Age Liaison Psychiatry Service - see referral form in Toolkit.

ONGOING - AS REQUIRED

Formal Test of Capacity/Best Interest Assessment

For all patients with moderate to severe cognitive impairment, a Formal Test of Capacity and Best Interest Assessment will be required to support decision-making regarding major decisions such as serious medical treatment or change of accommodation. The UHB Consent Policy should be followed in this respect and the required forms are provided in the Toolkit.

Bristol Activities of Daily Living

This functional assessment is included in the Toolkit as it is recognised that patient’s functional abilities may significantly deteriorate when there is acute medical illness, or for example secondary delirium overlaying mild cognitive impairment. The tool is intended to be completed by the carer, based on previous level of functioning before the person became acutely medically unwell. Thus it will be helpful in highlighting to the team the rehabilitation potential of the patient.

24 Hour Behaviour Monitoring Forms

The 24 Hour Behaviour Monitoring Forms are included as they can be very helpful in establishing the frequency and severity of behavioural and psychiatric symptoms of dementia. Perhaps most importantly, detailed analysis of behaviour can help identify triggers and successful methods of avoiding triggering and managing challenging behaviours. The completion of this tool over several days is required should there need to be a referral made to the Hospital Old Age Liaison Psychiatry Service, as it will assist the team in identifying non-pharmacological approaches to respond to challenging behaviours and indicate when medication management is necessary.

Abbey Pain Scale and Wong Faces

The Abbey Pain Scale is specifically designed to identify pain in patients with cognitive impairment/dementia who are unable to easily communicate their pain experience. The Wong Faces tool is a simple pain thermometer to use with the patient who may be able to rate their pain experience. Both tools are crucial to use, especially if there are any medical diagnoses which may result in pain, as patients with severe cognitive impairment are often unable to communicate their pain experience and express it in behavioural ways. If there is any potential pain experience and challenging behaviours are present, it may be worth trialling analgesia and noting effects on 24 Hour Behaviour Monitoring Forms.

Care Plan Templates and Top Tips for Care

Within the Toolkit are a set of helpful guidelines for staff involved in providing direct care to support them in delivering person-centred care and a set of care plan templates to follow when planning care. These are aimed at supporting staff to manage common areas of difficulty, for example resistiveness to care, wandering, reduced nutritional intake and aggression. Training sessions will be provided around these key documents to support staff in their implementation of the Pathway. There is a requirement to involve carers in care planning.

DISHCARGE PLANNING

Carers Assessment (UA)

There is a requirement to engage carers in discharge planning. Carers assessment will be critical in supporting decision making. The key questions to ask of the carer are (if they have not been previously placed) their ability and willingness to provide care and their service needs.

Discharge destination

The carer must be involved in decision-making with respect to discharge destination and be informed in advance of the planned date of discharge.

Vulnerable Adult Patient Transfer/Discharge Protocol

The Vulnerable Adult Patient Transfer/Discharge Protocol must be followed when discharge plans are made and especially on the day of discharge. Vulnerable Adult Patient Transfer/Discharge documents must be completed as required. Consideration should be given to nurse escorted transfers if the patient is moderately to severely cognitively impaired.

Community Care

A community care package must be in place, if assessed as required, before the planned date of discharge. The Social Worker/Community Psychiatric Nurse or other Case Manager must be informed of the discharge.

Signpost to specialist services

The discharging nurse should refer the patient to Cardiff Memory Team if there is cognitive impairment but not an established dementia diagnosis.

If the patient has an established dementia diagnosis and behavioural or psychiatric symptoms and they are not known to psychiatric services, they should be referred to the Community Mental Health Team for Older People - within the Toolkit the Directions Directory of Services is provided and lists key contact details.

CARERS SATISFACTION SURVEY QUESTIONNAIRE

The Carers Satisfaction Questionnaire should be given to the carer on the day of discharge and a stamped addressed envelope provided for its return. This questions their satisfaction with standards of care and especially of perceived dignity and respect in care.

A COPY OF THE COMPLETED PATHWAY MUST BE SENT TO THE DEMENTIA CARE ADVISOR ON THE DAY OF DISCHARGE

DEMENTIA INTELLIGENT TARGETS - Extracts from the Dementia How To Guide