Memory clinics have produced proven results in early diagnosis and intervention for patients suffering memory loss symptoms - but many face a battle to continue improving quality without funding. Seraphim Patel and colleagues from Central and North West London Foundation Trust report.
Memory clinics provide assessment, information, diagnosis, support and if indicated, treatment to patients suffering from memory loss symptoms. The National Dementia Strategy has placed a great deal of emphasis on the role of such clinics to provide early and accurate diagnosis with early intervention.
However funding has always remained a concern and here we describe the challenges faced by an unfunded memory clinic service in a large greater London mental health foundation trust.
A retrospective survey of case notes was carried out for a 15-week period in 2010. The aim of this survey was to increase understanding of a patient’s journey from complaint of memory loss symptom to the point of receiving a confirmed diagnosis of dementia.
All patients seen in the memory clinic service who were newly diagnosed with dementia were identified and data was collected from their notes. 29 such patients were identified and their characteristics were looked in further detail.
The care pathway that led to a referral to memory clinic was as follows. A community mental health team member first saw the referral to old age psychiatry service for an initial assessment. If dementia was a provisional diagnosis, patients would be referred to the memory clinic for detailed assessment and treatment if indicated.
The memory clinic was consultant led and also offered follow-up to patients who went on to be prescribed cholinesterase inhibitors. There was input from occupational therapy and clinical psychology to in measuring neuro-psychiatric symptoms and repeating psychometric testing.
A significant majority (72 per cent) of these patients were females. A vast majority of patients, around 85 per cent, were white Caucasian followed by Asian (11 per cent) and other ethnic groups (4 per cent). Of these patients 31 per cent were noted to be suffering from some form of disability.
Nearly all referrals, 28 out of 29, referred to memory clinic were from primary care. Nearly 37 per cent of patients had not undergone any screening memory test in the primary care and 48 per cent had not had any blood investigations reported at the time of referral.
The initial consultation by CMHT was carried out on an average of 18.5 days (range 8-40 days) after the referral was received and the majority (66 per cent) of these consultations took place in patient’s own home.
Patients then waited for an average of 110 (22 patients, range 47-189 days) additional days to receive a confirmed diagnosis of dementia after undergoing further investigations like blood tests and neuro-imaging. This duration was significantly longer (232 days, seven patients) if patients had to wait for detailed psychometric testing.
The Memory Service National Accreditation Programme by the Royal College of Psychiatrists has set standards for such services. It is quite difficult (if not impossible) to adhere to such standards in a largely unfunded service. However, this survey highlighted some good practice examples of what can be realistically achieved in such a setting.
The increased rate of referral for female patients observed in this survey (nearly three times) is quite significantly more than the difference in incidence of dementia in both sexes. This study was not equipped to look at reasons behind this and given small sample size it was not possible to ascertain any group differences.
However, one explanation can be that females are more likely than men to report memory loss as a symptom to their GP. The ethnic breakdown of referrals was in line with the composition of the population in the borough.
Primary care remains an important place of initial contact for patients/family members when concerned about deterioration in memory. This survey highlighted differences in practices of GPs. Traditionally GPs have seen memory assessments as a role for secondary care via a memory clinic setting. However much can be gained by getting the ball rolling in form of blood tests and a screening cognitive examination.
For example, prompt treatment of treatable causes of memory impairment can be offered in primary care. Various bodies have identified the pressing need for further education on dementia in primary care settings and it will ensure a streamlined referral process to secondary care.
A prompt initial response by the community mental health team (assessment within three weeks of referral) offers a point of contact for future and reassurance that further investigations are being carried out. One cannot underestimate the importance of a provisional diagnosis at this stage and sign posting to voluntary services and social services.
However, there is an anxious wait to confirm what specific diagnosis of dementia is made and whether one would be eligible for treatment with cholinesterase inhibitor medication. This is anticipated to be a bigger concern in near future when proposed changes to NICE guidance come in to effect, recommending treatment for mild Alzheimer’s disease as well.
The CMHT has adopted a lean working model to arrange more assessments at the hospital to avoid time spent in travel during domiciliary visits while having option of home visits as and when necessary.
The drive and focus in national dementia strategy has been towards early accurate diagnosis and treatment of dementia. This approach has to be person-centred and there are often reasons why some patients have to wait longer for a confirmed diagnosis (189 days vs. 47 days). However, some small changes in approach can go a long way in streamlining existing care pathways.
For example, local training in use of Addenbroke’s cognitive examination-revised has lead to increased sensitivity and specificity at the time of assessment by CMHT and avoided extra time patients had to wait for detailed psychometric testing.
However, one has to question how much can be achieved and should be achieved when running an unfunded service. It is possible that ongoing quality improvement can make you “too good for your own good” and fall off the radar of commissioning agencies.