Integrated Care Pathway for Dementia – 2012 Draft NHS Grampian Creator: Rozi Sweetin.
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Transcript of Integrated Care Pathway for Dementia – 2012 Draft NHS Grampian Creator: Rozi Sweetin.
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