The Stockport Memory Assessment Service

1. The Stockport Memory Assessment Service Dr Carol-Ann McArdle (Associate Specialist) Carol Rushton (Clinical Lead) Alison Hargreaves (CPN)

2. Aims of session • The dementias and their diagnosis • What makes a ‘good’ referral • MAS - pathway • Medications • Post diagnostic groups • Shared care re referrals • Q and A

3. “I forget things, doctor…” What to do next?

4. “Just old age” or The beginnings of a dementia?

5. Dementia is an umbrella term There are different types of dementia:

6. Alzheimer’s Disease: memoryloss, lack of vascular risk factors (patient generally well) Dementia with Lewy Bodies: parkinsonism, fluctuations, visual hallucinations, REM sleep disorder (physically acting out dreams) Dementia in Parkinson’s Disease: Parkinson’s disease diagnosed first, dementia develops later Frontotemporal Dementia:behavioural difficulties, disinhibition, personality change, (memory not bad) Alcohol related dementia: Global impairment in setting of high alcohol intake

7. Vascular dementia?

8. Please - if you are happy to diagnose vascular dementia, you do not need to refer in for a diagnosis Look for: • Vascular risk factors • A more physically ill patient – obese, poor mobility, breathless • Subcortical picture: slowness, lack of initiative and motivation, apathy (may present as depression “They don’t want to do anything doctor, just sit in that chair all day”)

9. Vascular dementia If you make a diagnosis of a vascular dementia, your patient can still access post diagnostic support from the Memory Assessment Service Vascular Dementia Conference Edgeley Park 31/1/19

10. Possible presentations of a dementia. • Memory problems (? Alzheimer’s) • Behavioural difficulties (? Frontotemporal dementia) • Apathy / lack of motivation (? Vascular dementia) • Hallucinations (? Dementia with Lewy bodies) • Delirium (? Not dementia)

11. Is it just “old age”… The assessing clinician needs a good history to understand when and what changes have been seen in the patient. An observer history is extremely valuable so… …a good referral will include carer contact details. A mental state examination picks up level of insight, any language problems, repetitiveness, mood disturbance or psychosis A cognitive assessment gives the extent and pattern of difficulties

12. …or the start of a dementia? A dementia screen of bloods and ECG will pick up (non cerebral) potentially reversible causes of memory loss and confusion so… …a good referral will include a dementia screen A brain scan will pick up (cerebral)potentially reversible causes of memory loss and confusion, and may give more information about the cause of the memory problems.

13. An ideal referral Clinical info: • Carer contact details • Good history (symptoms, time scale, functioning, associated physical illness?) • Past medical history • Drug history • Dementia screen Demographic info: • Ethnicity, marital status and religion

14. Can’t remember all that? Referral form available (on EMIS) ‘Old Age Psychiatry Referral Form’

15. GP Referral Form for Old Age Psychiatry

17. Referral arrives in SPOE Referral triaged by SPOE. Once complete, KPI start date recorded. Referral passed on to MAS for allocation Referral allocated to nurse (2/3) Referral allocated to doctor (1/3) If concern, patient allocated to a doctor for a follow up visit If no concern, patient discussed in MAS MDM with doctor and discharged back to GP Assessment and diagnosis at one appointment Doctor does further assessment and makes a diagnosis if appropriate

18. Medication follow up clinic • For patients with Alzheimer’s disease, dementia with Lewy bodies, and dementia in Parkinson’s disease. • Follow up will increasingly be by our support workers. • We are aiming to discharge patients within 3 months

19. NICE Guidelines 2018 The NICE guidelines allow for: • Anticholinesterases to be prescribed in combination with memantine. • GPs prescribing and titrating memantine without specialist involvement • Anticholinesterases and memantine’s use in BPSD

20. Post diagnostic groups • Alzheimer’s information session • Vascular information session • Dementia with Lewy Bodies information session • Frontotemporal dementia support group • In Two Minds (for patients)

21. Post diagnostic groups (cont.) • Living Well With Dementia Session(for carers) Followed by: Living Well With Dementia Drop In (carers) *New for 2019* • MAS Monthly Drop In Clinic (carers known to MAS) • As Dementia Progresses (course) • End of Life information session

22. New driving assessment centre RDAC Manchester AJ Bell Stadium 1 Stadium Way Barton-upon-Irwell Salford M30 7EY Phone: 0300 300 2240 Fax: 0121 333 4568 Email: info@rdac.co.uk Can make referrals on website: www.rdac.co.uk (Health professional referral costs £40, self referral, £80)

23. MAS re-referrals • We get approximately 25 re-referrals a month • MAS staff can: • Review of anti-Alzheimer medication including considering whether memantine would be appropriate • Manage BPSD • Give carer support (MAS does not have a S/W so referrals to do with the package of care at home will be redirected by SPOE to social services.) We are changing our approach to this part of the service by starting a monthly drop in clinic for re referred patients.

25. Key Messages We are hoping that today will encourage (more) good referrals and in particular referrals that include carer contact details and adementia screen Empower GPs to make their own vascular dementia diagnoses And raise awareness of our post diagnostic groups

26. Any Questions?