yorkshire and the humber dementia & opmh network memory service slide pack... · 29 june 2017 ....

www.england.nhs.uk

• Chair: Morning – Chris North, Joint Clinical Advisor (Dementia Diagnosis

& Treatment Services), Y&H Dementia and OPMH Clinical Network

• Chair: Afternoon - Dr Tolulope Olusoga, Joint Clinical Advisor (Dementia

Diagnosis & Treatment Services), Y&H Dementia and OPMH Clinical

Network

Yorkshire and the Humber

Dementia & OPMH Network

Yorkshire and the Humber Memory Service &

Older People Psychiatrist’s Network

Screening and triage of referrals

29 June 2017

www.england.nhs.uk

Welcome, introduction & overview of

Clinical Network

Chris North (Morning Chair), Joint Clinical Advisor (Dementia


Network

www.england.nhs.uk

@YHSCN_MHDN

#yhmentalhealth

Housekeeping:

www.england.nhs.uk

What are Clinical Networks? • Support local health economies to improve the health outcomes of local

communities by connecting commissioners, providers, professionals,

patients and the public across a pathway of care/service area

• Share best practice and innovation, measure and benchmark quality and

outcomes, and drive improvement

• Coordinate / support health & care systems to reduce unwarranted

variation and improve cohesion between services within and across patient

pathways

• Enable clinical and patient engagement to inform commissioning

decisions including acting as an ‘honest broker’ to support commissioner

and provider discussions

• Provide support and guidance to health systems to review, develop and

enhance care pathways where improvements in outcomes or efficiencies

could be made

• Support commissioners and providers to develop transformational

programmes, in particular where benefits can be gained by working across

commissioning boundaries

www.england.nhs.uk

Y&H Dementia & OPMH Clinical

Network

Alison Bagnall

Network Manager

Penny Kirk

Quality Improvement

Manager

Dr Rod Kersh

Clinical Advisor Dr Sara Humphrey

Clinical Advisor

Dr Tolulope Olusoga

Clinical Advisor

Colin Sloane

Quality Improvement

Lead

Georgie Thrippleton

Quality Improvement

Lead (starting 1st Aug)

Chris North

Clinical Advisor

www.england.nhs.uk

• Twelve Dementia Clinical Networks across England

• Hosted by NHS England

• Mental Health and Dementia/OPMH Team is part of wider CN family:

Diabetes, Cancer (Alliances) and CYP MH & Maternity (incl perinatal MH)

• Focus on the 5YFV MH Taskforce Recommendations, Prime Minister’s

Challenge on Dementia, NICE guidance and new Evidence based

treatment pathways

• Provision of clinical advice, leadership and QI support/project

management

• Support CCGs and 3 Sustainable Transformation Partnerships (STPs) to

achieve required dementia and OPMH standards and deliver sustainable

transformational change

• Provide opportunities for sharing learning and resources, build

consensus, support integrated working (including across the

commissioner/provider interface) and address inequalities

Dementia/OPMH Clinical Networks

DEMENTIA ENGAGEMENT

Formal link to the group via terms of reference/governance arrangements Key

Information sharing between groups via chairs and/or joint members

Full support from CN quality improvement and administration teams

Led and managed by other organisations, with CN attendance

Formal link to the group via terms of reference/governance arrangements

SYB WY HC&V

Acute Dementia Champions’ Group

Meet every 3 months

Dementia leads from all Y&H acute trusts

Chair: CN Clinical Advisor ( secondary care)

Yorkshire & Humber

Education & Training Task &

Finish group

Led & Managed by HEE

Yorkshire & Humber Dementia

Action Alliance Meets 4 times/year

Chair: Yorkshire & Humber DAA

Project Manager

Regional Dementia Commissioning

Leads’ Group

Meets every 3 months

Chair: CCG Commissioner, Doncaster CCG

Older People’s Psychiatrists’

Forum Meets annually as a forum plus one

additional joint clinical leads meeting.

Chair: CN Clinical Advisors

OTHER RELATED MEETINGS

CCG GP Dementia Leads Forum Meetings as required (2-times/year)

plus joint clinical leads meeting. Chair:

CN GP Clinical Advisor

Regional Dementia Consensus

Task/Finish meetings convened as

required. Attendees invited from

relevant stakeholder groups, depending

on topic for discussion.

Dementia CN Support Team

Manager/QIM/QILs

Clinical Advisors

Bi-monthly

NHSE (N) MH/D Groups

NHSE(Y&H) Programme Group

Chair: MD, DCO (Y&H)

CN Manager attends

Memory Services’ Network Chair: CN Clinical Advisor (MATs)

To address new AWTs’ standards

www.england.nhs.uk

Why get involved in the Network?

• Opportunity to work with other staff from a variety of professional backgrounds

across Yorkshire & Humber

• Helps to build relationships with CCG commissioners

• Gives insight into national/regional developments/horizon scanning

• Helps clinicians to shape their future services

• Influence STPs (x3) as Accountable Care Systems (ACSs) and/or Accountable Care

Organisations (ACOs) become a reality

• CPD /sharing best practice and learning from others

• Advise non-clinical commissioners/managers in the room to help shape better

service delivery (12th Sept opportunity)

• Provide advice/insight into the challenges of NHSE deliverables (EBTP wait times

etc.) and advise on how those barriers can be broken down

• Be a voice for patients and carers

www.england.nhs.uk

Contacts – Dementia and

OPMH Clinical Network

Memory Services Work:

Chris North, Joint Clinical Advisor (Dementia Diagnosis & Treatment Services),

[email protected]

Dr Tolu Olusoga, Joint Clinical Advisor (Dementia Diagnosis & Treatment Services)

[email protected]

Georgie Thrippleton, QI Lead for Dementia and OPMH [email protected] (from 1st

August)

Wider Dementia and OPMH team

Alison Bagnall, MH/D Clinical Network Manager: [email protected]

Penny Kirk, Dementia and OPMH Quality Improvement Manager: [email protected]

Colin Sloane, QI Lead for Dementia and OPMH: [email protected]

Dr Sara Humphrey, GP advisor

Dr Rod Kersh: Dementia Secondary Care Advisor

mailto:[email protected]






www.england.nhs.uk

National picture and evidence based

treatment pathway

Professor Alistair Burns, Professor of Old Age Psychiatry, University

of Manchester & National Clinical Director for Dementia and for Mental

Health in Older People, NHS England

Dementia Programme

Preventing well

Diagnosing well

Supporting well

Living well

Dying well

Dementia Diagnosis rates

2005-2015

Prescription of antipsychotics

2005 2015

Prescription of anti-dementia drugs

2005 2015

Dementia Programme

Dementia Diagnosis rate

CCG Improvement and Assessment Framework

Evidence Treatment Pathway – implications for memory

services

NHS Improvement

Lancet Commission

Join Dementia Research

Links to frailty

Intensive Support Offer

Right Care

www.england.nhs.uk

• Estimated dementia diagnosis rate

• Proportion of people having a F2F care plan review in

previous 12 months

Core indicators

16

www.england.nhs.uk

1. Age standardised rate of emergency inpatient hospital admissions of people (65+) with a mention of dementia per 100,000 resident population

2. Percentage of emergency inpatient admissions for people (65+) with dementia that are short stays (1 night or less)

3. Percentage of deaths of people aged 65+ with a recorded mention of dementia occurring in a hospital

4. Indicator title: Emergency readmissions to hospital within 30 days of discharge for people (aged 65+) with dementia

5. People aged 65 and over receiving prescriptions for antipsychotic medicines

Contextual indicators

17

NHS RightCare scenario:

Getting the dementia pathway right

Tom and Barbara’s story:

Dementia

Appendix 1: Summary slide pack April 2017

Tom’s story

This is the story of Tom’s experience of a dementia care

pathway, and how it could have been so much better

In this scenario we examine a

dementia care pathway,

comparing a sub-optimal but

typical scenario against an

ideal pathway.

1

4 It shows how the NHS

RightCare methodology

can help clinicians and

commissioners improve

the value and outcomes of

the care pathway.

3

2

At each stage we have

modelled the costs of care,

both financial to the

commissioner, and also the

impact on the person and

their family’s outcomes and

experience.

This document is intended

to help commissioners and

providers to understand the

implications – both in terms

of quality of life and costs –

of shifting the care pathway

19

No risk

profiling and

identification

Inappropriate

acute care

Insufficient

home care

support for

carer

• Reactive

• Limited

education

• No third

sector

involvement

• Traditional

treatment

• Several wards

• Too much time

in a secondary

care bed.

• Damage

done

• Too much

reliance on

acute care

No prevention Pillar to post Too late

Tom and the sub-optimal pathway (2)

20

Great acute

care Great home

care support

• Bespoke

treatment

• Minimum time in

bed / secondary

care

• Greater

understanding

of need

• Support

mechanisms in

place

• Trusted system

• Happier and

healthier

experience

Prevention

Focus Fast Appropriate

• Proactive

• Educational

• Third sector

involvement

Prevention focus

Early risk

awareness and

identification

Tom and the optimal pathway (2)

21

www.england.nhs.uk

IST support offer for dementia

22

The IST will undertake Diagnostic Reviews of the pathway in a local health economy which will result in a

single set of recommendations to be agreed with commissioners and providers, covering the following areas:

• Sound operational processes for reliable equitable and sustainable delivery:

• Capacity and capability issues in the implementation of recommendations, agreeing support

mechanisms and responsibilities with whole Local Health Community;

Diagnostic reviews are informed by expert clinical input which for dementia will typically involve a regional

dementia clinical lead i.e. a consultant clinical psychiatrist or clinical GP lead with a special interest in

dementia. Follow up meetings post diagnostic review , which will involve the entire health economy are

also provided to support the implementation of the review recommendations

Whilst diagnostic reviews are the key type of intervention provided by the team, the IST has had

demonstrable success in supporting workshops organised by clinical networks to support best

practice in securing sound operational processes for reliable and sustainable delivery.

www.england.nhs.uk

PHE Fingertips Tool

https://fingertips.phe.org.uk/profile-group/mental-health/profile/dementia

Clinical Commissioning Group Improvement and Assessment Framework

https://www.england.nhs.uk/commissioning/ccg-assess/iaf/

https://www.england.nhs.uk/stps/

NHS Right Care

https://www.england.nhs.uk/rightcare/intel/cfv/data-packs/

Dementia United

http://dementiaunited.net/

Dementia Advisers

https://www.alzheimers.org.uk

Dementia Pathway

https://parkinsonsacademy.co/2017/02/15/new-dementia-toolkit

NHS Benchmarking

https://www.nhsbenchmarking.nhs.uk/

Modelling Dementia

http://www.modem-dementia.org.uk

Care planning

https://www.england.nhs.uk/mental-health/resources/dementia/



























http://www.modem-dementia.org.uk/







FreeCog

Cognitive Function

Domain Question/Instruction Score Scoring guide

General Knowledge

Can you tell me anything that’s in the news at the moment?

/1

This is a general opening question to try to put people at ease, also accept recent events in sport or soap opera, if they state they don’t follow the news.

Score 1 for any key fact of current knowledge but none for a general answer

Orientation

(time)

What is the day of the week is it

today; what month, year? /3

Only allow accurate responses Score 1 point for each correct answer

Orientation

(place)

Where are we?

/3

Only allow accurate responses If in clinic/hospital score 1 for ward/ floor; 1 for hospital name; 1 for town

If in residence Score 1 for name/number of house; 1 for street name; 1 for town

Memory

(registration)

Repeat 5 words

(watch, car, man, pen, house) 0 No score, record responses, allow up to 3 attempts.

Calculation Take 6 away from 70 and keep

subtracting until I say stop /3

64, 58, 52, 46, 40, then stop Score 3 = 5 or 4 correct; Score 2 = 3 or 2 correct Score 1 = 1 correct; Score 0 = 0 correct

Attention Spell “plate” backwards /2

Check first they can spell “plate” then ask to spell it backwards Score 2 = 5 or 4 letters in correct order Score 1 = 3 or 2 letters in correct order Score 0 = 1 or 0 letters in the correct order

Memory (recall) Repeat 5 words

(watch, car, scarf, pen, house) /5

Record responses Score 1 point for each correct answer

Visuospatial

In this circle draw a clock face

with numbers and with hands set to ten past eleven

/3

Draw a circle for the patient Score 1 point for each correct part: All numbers present = 1 point All numbers placed correctly = 1 point Hands placed correctly = 1 point

Language Name ear and fingernail /2 Point to ear then fingernail

Score 1 point for each correct answer

Fluency Task

Name as many different animals

as you can in 1 minute /1

Time one minute and record the responses Do not count different breeds of the same animal (eg corgi, spaniel, Cockapoo, Alsatian etc). Score 1 = if 10 or more correct responses Score 0 = if <10 responses

Repeat a Sentence

Repeat this sentence

“Don’t beat about the bush”

/1 Score 1 for repeated fully correctly

Write a

Sentence Write a sentence /1

Sentence needs to be understandable – ignore minor grammatical and spelling errors; Score 1 if fully correct

Executive Function

Domain Question Score

Scoring guide These questions are to test the person’s ability to plan and describe

sequences. Scoring is based on clinical judgement, non-leading clarifying questions may be asked if answers are tangential/ circumstantial

Social

If you wanted to send someone a

birthday card in the post – please tell me how you would do it?

/1 Score 1 = complete enough for the card to arrive Score 0 = incomplete answer (i.e. card would not arrive)

Travel If you were going to take a bus (or train) what would you need?

/1 Score 1 = if answer indicates need for a ticket or bus pass Score 0 = if they fail to mention ticket or bus pass

Home Could you tell me how you would make a cup of tea or coffee for

yourself?

/1 Score 1 = if answer leads to a drinkable cup of tea/coffee Score 0 = if answer does not lead to a drinkable cup of tea/coffee

Emergency If you discovered a fire at home,

what would you do? /1

Score 1 = if answer indicates the person would be appropriate and safe in their response; Score 0 = if they do not

Care

Could you tell me the steps you

took in order to get dressed as

you are today?

/1 Score 1 = plausible story, consistent with the clothes they are wearing Score 0 = incomplete and seems inconsistent with the clothing they are wearing

Total /30

Free-Cog Novel, Hybrid, Scale For Cognition

www.england.nhs.uk

Evidence and trends: the good news

We are living longer, are happier and there’s lots of advice around

Older people are generally:

• more satisfied

• feel more worthwhile

• happier and

• less anxious

than younger people.

But, this drops off after age 80.

Insights into Loneliness, Older People and Well-being, 2015,

Office for National Statistics

Half of babies born in the UK in

2007 will reach 103

From “The 100 year life”: Gratton and Scott;

www.mortality.org

5 things to prevent depression

1. Smile

2. Keep busy

3. Talk to someone

4. Help others

5. Live in the moment

Ten ways for healthy living

Eat and drink well

Attend to your teeth

Stay active

Consult your GP

Vitamin boost

Look after your feet

Sleep well

Take the check ups

Stay in touch with people

Give up smoking

www.england.nhs.uk

18% of the population are over 65 – 10 million people in England.

For every 1000 people over the age of 65, 250 will have a mental illness,

135 will have depression, of whom 115 will receive no treatment1.

In a 500 bed general hospital, 330 beds will be occupied by older people

of whom 220 will have a mental disorder, 100 each will have dementia

and depression and 66 will have delirium1.

6% of people aged 65 and over live in care homes where the majority of

residents have a mental disorder2.

Mental disorders in older people reduce quality of life, increase use of

health and social care facilities and are associated with a range of

adverse outcomes when co-occurring with physical disorders.

Mental health in older people

1: Royal college of Psychiatrists report 2009.

2. SCIE report 2006

www.england.nhs.uk

Depression

Between 10 and 20% of older people have

significant depressive symptoms, a figure which

doubles in care homes and hospitals and trebles

in the presence of physical illness.

In addition to this, the same numbers have

depressive symptoms which are less severe and

time limited.

50% of younger people with

depression are referred to mental

health services, only 6% of older

people are.

85% of older people with depression

receive no help from the NHS.

Older people are a fifth as likely as younger age

groups to have access to talking therapies but six

times as likely to be on medication.

Prevention of depression is feasible

Depression and loneliness in older people

Loneliness

8.5% (975,000) of older people often or always feel

lonely

1.7% (200,000) of older people have not had a

conversation with friends or family for a month

31.4% (3.6 million) of older people say television

is their main form of company

Loneliness can increase risk

of premature death by a quarter.

Loneliness can be as harmful as

smoking 15 cigarettes a day

People with a high degree of loneliness are twice

as likely to develop Alzheimer’s disease

(Age UK, June 2016)

Loneliness can be

• a cause of

• a result of

• a symptom of

depression in older people

70,000 more children will access evidence based mental

health care interventions

280,000 people with SMI will

have access to evidence based physical health checks and

interventions Older People

Intensive home treatment will be available in every part of England as an alternative to

hospital. Older People

No acute hospital is without all-

age mental health liaison services, and at least 50% are meeting the ‘core 24’ service

standard Older People

The number of people with SMI who can access evidence based

Individual Placement and Support (IPS) will have doubled

60% people experiencing a first episode of psychosis will access NICE concordant care within 2

weeks including children

10% reduction in suicide and all

areas to have multi-agency suicide prevention plans in

place by 2017 Older People

At least 30,000 more women each year can access evidence-

based specialist perinatal mental health care

Increase access to evidence-

based psychological therapies to reach 25% of need, helping 600,000 more people per year

Older People

New models of care for tertiary MH will deliver quality care

close to home reduced inpatient spend, increased

community provision including for children and young people

Inappropriate out of area placements (OAPs) will have

been eliminated for adult acute mental health care

There will be the right number of CAMHS T4 beds in the right place reducing the number of

inappropriate out of area placements for children and

young people

www.england.nhs.uk

Despite IAPT services being open to all adults, older people are underrepresented among the population accessing IAPT.

The proportion of people over 65 years old referred to IAPT (8.2%) is improving, but lower than their share of the general population (approx. 12%).

2017/18 and 18/19 Quality Premium includes an incentive for CCGs to improve access for older people

Improving Access to Psychological

Therapies (IAPT)

Accessing treatment

Once referred, a similar proportion of older

adults complete treatment compared to their

working age counterparts.

Recovery rates for older people consistently

outperform working age people: 62.2% in Q2

2016/17 compared to 47.6% for working age

adults.

IAPT Recovery

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

10.0%

0

5,000

10,000

15,000

20,000

25,000

Q114/15

Q214/15

Q314/15

Q414/15

Q115/16

Q215/16

Q315/16

Q415/16

Q116/17

Q216/17

Numbers and proportion of referrals for older people

20.0

30.0

40.0

50.0

60.0

70.0

80.0

Q114/15

Q214/15

Q314/15

Q414/15

Q115/16

Q215/16

Q315/16

Q415/16

Q116/17

Q216/17

IAPT Recovery % for working age and older adults

18 to 64

65 and over

THE TIMES FEBRUARY 2017

Dementia Research – Getting Involved

Wendy Neil

Consultant Psychiatrist

Leeds and York Partnership Foundation Trust

Clinical Research Network

Yorkshire and Humber

Clinical Research Network Yorkshire and Humber

• Good for participants

• Good for teams

• Good for organisations

Why?


• IDEAL - Improving the experience of dementia and enhancing active life. Investigation of those factors which influence personal outcomes in dementia.

• Pride – Development of an intervention for people with early stage dementia with aim of encouraging participants to maintain a healthy lifestyle.

• Journeying through Dementia – Evaluation of the effectiveness and cost-effectiveness of a self-management group intervention for people in the early stages of dementia.

• Alzheimer’s Disease genetics- To build a better understanding of the causes of AD and provide a platform for the development of targeted treatments and preventions.

Its not all drug studies…far from it.


• DECIDE – Psychometric evaluation of Dementia Carers Instrument to measure quality of life in carers of people with dementia to better support carers, help evaluate services and inform policy.

• Caregiving Hope - To find out how obligated, prepared and willing people feel about providing support to family members living with dementia. Findings will aid the development of future services and support programmes for people supporting relatives living with Dementia.

Its not all drug studies…far from it (2).


But we do drug studies to….

Academic

• RADAR - Reducing pathology in Alzheimer’s Disease through Angiotensin taRgeting. A phase II, two arm, double-blind, placebo-controlled, randomised trial to evaluate the effect of losartan on brain tissue changes in patients diagnosed with Alzheimer’s disease.

• MADE - Minocycline in Alzheimer’s Disease Efficacy. Multi-centre, double-blind, placebo-controlled, randomised trial to determine whether minocycline is superior to placebo in reducing the disease course in AD over 2 years.

Pharma

• Various in Y&H. Participants typically happy to travel for the right study.


www.joindementiaresearch.nihr.ac.uk


JDR

• Nationally >27,000

• Y+H recruitment

–Dementia – 390

–Diagnosis unknown – 112

–Healthy volunteer – 1827

• Local strategies:

–Post diagnostic support pack

–Discharge appointment

–Any point in between


Thank You

www.england.nhs.uk

Time for a break?

20 minutes only please!

www.england.nhs.uk

Triage – a lean approach

Dr Tolu Olusoga, Joint clinical Advisor (Dementia Diagnosis &

Treatment Services), Y&H Dementia & OPMH Clinical Network

Triaging – A Lean Approach

By

Dr Tolu Olusoga

Clinical Advisor –Dementia Diagnosis and

Treatment Yorkshire and Humber Clinical Network

Historic Context

Prior to a year ago, referrals came from GPs to

memory service all via faxes, post, phone calls and to

multiple points/routes –different clinicians, different

services.

Multiple triages

Disagreement between teams about who was best to

see patient

Challenges

GPs sent the same referral to multiple service areas (in

hope that one will see asap)

Uncertainty from GPs about which service really needs

to see

Lack of awareness from stakeholders about referral

criteria and what services are able to offer

Delays in actioning referrals

What did we actually do?

Kaizen event focussed on access

Liaised with CCG to gain agreement

CCG agreed to a trial period of 3 months

Other services –CMHT, RRICE (Crisis team for older

people) excluded in this phase, liaison excluded at this

point

Triage Process

All memory referrals from GPs are sent to a central

RSS point via(choose and Book system) and these

referrals are received via a single email address for

harrogate mhsop.

Buy in was high as it streamlined referrals

GPs were told no wrong door so if referrals were

inadvertently sent through and was for a different

mental health service, we forwarded to the right service

and notified GP.

Admin staff

accepts electronic referral if right team or forward to

appropriate team if not

Opens a patient electronic record

copies and paste referral onto electronic patient record

Notifies the duty worker (clinician)

Duty Worker(Clinician)

Checks detail of referral to ensure all pre-referral

investigations have been done

Rings patient/carer to gain consent for CT head

request and arrange appointment with patient/carer

Appointment letter sent out

Arrangements made for medic to do CT head request

Results

Referrals were received on same day they were sent

Referrals were actioned daily hence no batching

Improved ability to meet service standards

Been working now for over eight months

System Changes

At end of pilot, access to RSS was discontinued due to

contract changes within CCG.

All GP practices now simply use same template and

refer by email to single email address manned daily.

Next Steps

Gain agreement to have all referrals to harrogate

mhsop received via email without exception

Pseudodementia

Dr Sophia Bennett Consultant Old Age Psychiatrist

PSEUDODEMENTIA’

Objectives

Depression in older adults

PREVALENCE OF LATE-LIFE DEPRESSION

OUTCOMES OF UNTREATED DEPRESSION

DEPRESSION SYMPTOMS:

DIFFERENCE IN LATE-LIFE DEPRESSION

DEPRESSION: HIGHER RISK

DEPRESSION SCREENING

TWO QUESTION SCREENING TEST:

DELIRIUM IN OLDER ADULTS

DELIRIUM: EPIDEMIOLOGY

SIGNIFICANCE

DELIRIUM: DEFINITION

DELIRIUM: PREDISPOSING FACTORS

DELIRIUM PRECIPITATING FACTORS

DELIRIUM: SCREENING

Feature 1 Acute

Onset/Fluctuating Course

Feature 2 Inattention

Feature 3 Disorganized Thinking (speech)

Feature 4 Altered LOC OR

CAM

4A Test www.the4at.com

[1] ALERTNESS Normal (fully alert, but not agitated, throughout assessment) 0 Mild sleepiness for <10 seconds after waking, then normal 0 Clearly abnormal 4 [2] AMT4 Age, date of birth, place (name of the hospital or building), current year. No mistakes 0 1 mistake 1 2 or more mistakes/untestable 2 [3] ATTENTION “Please tell me the months of the year in backwards order, starting at

December.” To assist initial understanding one prompt of “what is the month before

December?” is permitted. Achieves 7 months or more correctly 0 Scores < 7 months / refuses to start 1 Untestable 2 [4] ACUTE CHANGE OR FLUCTUATING COURSE Evidence of significant change or fluctuation in: alertness, cognition, other

mental function (eg. paranoia, hallucinations) arising over the last 2 weeks and still evident in

last 24hrs No 0 Yes 4

Total: 0 = Probably normal, 1-3 = Probable cognitive impairment,

4 or more = Probable delirium

RELATIONSHIP BETWEEN 3DS…

DEPRESSION AND DEMENTIA

•Pseudodementia—“depression

with reversible dementia”

syndrome: dementia develops

during depressive episode but

subsides after remission of

depression.

•Mild cognitive impairment in

depression ranges from 25% to

50%, and cognitive impairment

often persists 1 year after

depression clears.

DELIRIUM AND DEMENTIA

Recovery from delirium (cole EDA 2008)

55% improved at 1 month

70% improved at 6 months (i.e. 30% not)

A substantial minority of patients don`t recover (~10%)

Full recovery associated with good outcomes (= no delirium)

Incomplete recovery may impair self management worse outcomes

DIFFERENTIATION

IT IS COMMON FOR OLDER ADULTS TO EXPERIENCE MORE THAN ONE OF THE THREE D’S AT THE SAME

TIME!

Final thoughts…

Thankyou

www.england.nhs.uk

Group Work Session:

Locality action planning – towards

2020

Focus on system flow, triage, managing inappropriate referrals

www.england.nhs.uk

Group Work Session:

Table feedback

www.england.nhs.uk

Time for some lunch?

See you in 40min!

www.england.nhs.uk

Welcome back and introduction to

afternoon session

Dr Tolu Olusoga (Afternoon Chair), Joint Clinical Advisor (Dementia


Network

Improving access to

Memory pathway & CT

scans in Kirklees

Dr Subha Thiyagesh

Consultant in Old Age Psychiatry & Deputy

Medical Director

What was the problem? What did we do? Kirklees Memory pathway Challenges Key points

Overview

national drive to increase diagnostic dementia rates

unclear local pathways for referral of patients, with gaps

long waits for initial assessment, advice in crisis

changing incentives for primary care: QoF, DES’s x2

guidance for GPs not readily accessible

patients and carers not able to access support

What was the problem?

increasing rate of referrals to memory clinic

patients attending without necessary investigations

high numbers of patients attending for follow-up

patients referred who could have been diagnosed safely in primary care

challenging to successfully bring clinicians from primary and secondary care together to produce genuinely clinically-led change.

What was the problem? - 2

To provide patients with suspected dementia access to timely diagnostic assessment

To empower primary care clinicians to diagnose patients confidently, without referral when appropriate

To ensure patients and their carers are able to access support throughout their care journey.

Aim

• Memory nurses, health care assistants, doctors

• Initial assessment

• Diagnostic clinics

• Post diagnosis support

Memory service

What did we do?

A joint programme of work – CCG mental health and SWYPT leads with management support

Regular meetings

Challenges affecting all parts of the system were openly discussed; objectives were agreed and worked through.

Workshops held with third sector that had the view of the service users and carers and were aware of the ongoing issues with access and support in the system.

What did we do?

A clear redefined care and service pathway was developed

Clear diagnostic and support guidance was put together for GP’s

engagement events with member practices

targeting of practices with low diagnostic rates

regular updates

Next…

Making a case to CCG

Demographic changes

Good practice assessment & diagnostic times

Lack of value of routine follow-ups

Discharge of over 1800 patients to primary care

Rule out reversible causes of Cognitive

Impairment

Depression

Delirium : infection, CVA, constipation,

Endocrine, Pain

Drugs – Reviewing dose or stopping that

impact on cognition ; E.g., Amitriptyline

(anticholinergic effects), Opiates,

Benzos

Bloods

Blood tests to consider - Blood glucose

(HBA1C), FBC, U&E, Bone profile, B12,

Folate, TFTs, LFTs, CRP, MSU if

urinary infection suspected, rarely

HIV/Syphilis

Primary care screening

Consider ECG / send results if already

done

Treat any potentially reversible causes

Referrals

Referral to Older Peoples service (routine)

Sysytm 1 link

E-referral

Telephone through Locala SPoC

All urgent referral that require a 4 hour response go through SPA

Improving access Duty worker role development

triages referral

look for other missing investigations

Development of Advanced Nurse Practitioner (ANP) role

Improved access for ANP and memory nurses to access ICE / PasWeb and refer for blood tests & CT scans

Improving Access

% Assessed within 42 days of referral – July 2016 – March 2017

% Treated within 84 days of assessment

Access to CT scans Last year – 1/3 of referrals sent with requests made for

CT scans

This year

30% = had referrals with CT requested by primary care in the month prior to the forum

Discussion with GP lead

Forum with GPs arranged in June 2017

Access to CT scans - 2 Forum with GPs

Joint presentation of the pathway with GP Lead

Online resource for primary care – OSCAR (Online Support and Clinical Advice Resource

55% of referrals with CT scans being requested = improvement noted since the GP forum

Benefits of early CT request Reduces the time of assessment to diagnosis =

diagnosing well pathway

Set up of Advanced Nurse Practitioner One Stop Shop

thorough review of their previous medical notes with access to PASWeb/ICE and SystmOne (read only)

Initial assessment and work closely with Consultant

Diagnosis made where appropriate and support and information given to patients

ANP One Stop shop Eddercliffe Health centre

good feedback from patients and families

a positive experience of attending the ANP clinic, closer to home

Reduced number of appointments

Complex cases still seen by Consultants / SAS

Can be seen in 4 weeks from referral if all investigations completed = 2020 target

reduction in clinic appointments may also enable reduced need for interpreters, transport needs and costs linked to these areas.

Diagnosis of Advanced Dementia in care homes

Key points Whole systems approach

Completed screening investigations reduces delay

ANPs in GP surgeries to familiarise the need for screening investigations

CT scan request can greatly reduce waiting times and improve patient care

Needs an ongoing programme of close working with primary care and presentations

Discussion

www.england.nhs.uk

New evidence in neuro imaging

Dr Daniel Blackburn, consultant Neurologist and Honorary Senior

Lecturer, Sheffield Institute for Translational Neuroscience

Slides available to download from:

https://drive.google.com/file/d/0Bz3yrkpWiupSQURqaUdTeWJjYjA/vie

w

https://drive.google.com/file/d/0Bz3yrkpWiupSQURqaUdTeWJjYjA/view



Mild Cognitive Impairment –Is

there more we need to do?

By Dr Tolu Olusoga

Consultant Psychiatrist and Clinical Advisor- Yorkshire and Humber Clinical Network

29/06/2017

Does a diagnosis of MCI

benefit patients?

• No cure so why worry people

unnecessarily?

• Can’t we just reassure and leave alone?

• There is evidence of significant clinical

variability in the use of the MCI diagnosis

Resnick et al.

• The grey zone is between healthy

cognitive ageing and dementia (mainly

AD)

–Neurology 2010;74:807–815

JAMA June 2017 Vol 317 no

22

• A number of studies have shown that

cognitively normal individuals with amyloid

pathology experience more rapid cognitive

decline compared to those without

Prevalence of MCI

• 7% in population based studies

• 18.9% in expanded Mayo Clinic criteria

(Major population based studies)

• Progression rate to dementia in many

referral clinics is 10-15% per year

• On the other hand, progression rates in

general population is 5-10% per year (from

prospective sampling)

Benefits of MCI Diagnosis

• Early diagnosis – Advance directives

– planning treatment and care

• Possibility of making an early (predementia) diagnosis is essential to ensure benefit from new treatment trials

Harm from Diagnosis

• Suicide on the whole is rare though it is 3x

higher in Late onset dementia and 10x

higher in early onset dementia compared

with healthy elderly individuals

Currently

• Most services diagnose MCI and

discharge with advice

• A few advice and review in 1 year (review

done in primary care)

• With repeat serial neuropsychology

• Much fewer do more scans –FDG PET;

amyloid PET

Is this the right thing to do?

• Is there anymore we should be doing?

– e.g Active recall, time frame -1year?

– What happens at recall appointment?

– Is there capacity to do this in current climate?

– Next steps?

www.england.nhs.uk

Questions and group discussion:

• What are the main indications for a CT scan

in the diagnosis of dementia?

• What are the risks in not completing a CT

scan?

• Which patients do not need a scan?

• MCI – what should we be offering to people

with MCI?

www.england.nhs.uk

Table feedback

www.england.nhs.uk

Next steps for CN work – membership

of consensus group on scanning

Dr Tolu Olusoga

Please note there is a joint meeting with Regional Dementia Leads on

12th September 2017

www.england.nhs.uk

Thank you for Attending!

Please remember to fill out your

evaluation survey!

yorkshire and the humber dementia & opmh network memory service slide pack... · 29 june 2017 ....

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