‘Cardiff and Vale DGH Cognitive
Impairment Pathway – Sharing
best practice and learning’
Dr Simon O’Donovan,
Clinical Director MHSOP/Younger Onset Dementia
Clinical Lead, Cardiff and Vale UHB
September 2011
National Dementia
Vision for Wales (2011)
Work started in 2008, to prepare
a National Dementia Action Plan
for Wales.
4 Action Plans published 2010:
1. Develop better joint working
across health, social care, the third
sector and other agencies;
2. Improve early diagnosis and
timely interventions;
3. Provide better information and
support for people with the illness
and their carers/families;
4. Offer additional training for
those delivering care.
“Our long term vision is to create
‘Dementia Supportive Communities’. To
do this requires a change in attitudes
and behaviours towards dementia at all
levels of society, which reflect the
challenge of demographic change and
the impact of dementia.”
Focus now on ‘on operational
delivery and genuine meaningful
service improvements’.
Implementation directed by
Dementia Sub Group of Mental
Health Programme Board.
Ministerial Letter
Sept 2010
Announced £1.5m funding for:
Increased clinical capacity within Older
Peoples Mental Health Teams
– LHBs submitted proposals for new
Dementia Care Advisor posts
Development of new Young Onset
dementia community services
– LHBs submitted proposals
Wales Dementia Helpline
– New bilingual helpline available 24/7
The Minister also called on UHBs to
publish their plans for developing Crisis
and Out of Hours community services.
Ministerial Letter
Dec 2010
Announced:
UHB Proposals for posts
approved
- appointments imminent
New Dementia Book Service
launched
- 4 books added to prescription
service
Alzheimer’s Society campaign
and information packs launch
Funding for Training Strategy
commissioned from DSDC Wales
– 2 Training Officer appointments
imminent
Cardiff and Vale Proposal
• DCA 1 - Follow service users and carers up post-diagnosis and identify
when further support from CMHTs OP may be required. Provide a
regular point of contact, appropriate emotional support, timely referral
and signposting to services. Support provision of psycho-educational
support for carers and cognitive stimulation for service users.
• DCA 2 - Follow service users who have been open to the CMHTs
OP when they are admitted to DGHs for acute medical care.
Support DGH staff in delivery of person-centred care, support
carers, facilitate discharge planning. Support delivery of training.
• DCA 3 - Work as part of Specialist Liaison Old Age Psychiatry Service
for Care Homes. Provide regular liaison visits (including urgent) to care
homes, advising on person-centred management of behaviour and
psychiatric symptoms. Support carers. Support delivery of training.
• DCA 4 - Support service users and carers in their own home during
crises, with the aim of preventing admissions to acute or permanent
care. Support carers with understanding and managing behaviour and
psychiatric symptoms of dementia. Support longer-term development of
Crisis and Out of Hours services.
C&V Proposal – younger onset dementia
• DCA 5 - Work alongside existing Alzheimer’s Society Information and
Support Officer, the existing and to be appointed Family (Respite)
Support Workers, the Clinical Lead for Younger Onset Dementia
(highly specialist nurse) and a Consultant in Old Age Psychiatry, to
form a virtual Younger Onset Dementia Clinical Team.
• Provide support to service users, carers and families post-diagnosis
and ensure regular follow-up review. Provide a point of regular contact
for clients and carers, which will out of necessity be more frequent
given the more rapid decline in this group of service users.
• With the Clinical Lead, supporting clients with more complex and
challenging presentations and their carers, especially when admission
to acute care or placement in longer-term care is necessary.
• Health Care Support Workers – Work as part of the Younger Onset
Dementia Service, providing respite support and socialisation for
clients with established younger onset dementia, both at home and in
the community.
Dementia
Intelligent Targets
5 Driver Diagrams:
1) Making and sharing the diagnosis
- reduce time between onset of symptoms
& diagnosis being communicated
2) Dementia in the general hospital
- improved quality of general hospital care
for people with dementia and reduced
length of stay
3) Use of anti-psychotics
- reduce inappropriate use of antipsychotic medications in accordance with
NICE/SCIE guidelines
4) Support for care-givers
- improved support for care givers
5) NHS in-patient care (mental health units)
- improved quality of care
Included in the 2011-12 AQF as part of the
1000 Lives Plus campaign to improve patient
safety and quality of care in NHS Wales.
Older People
Commissioner Wales
Report 2011
• Stronger ward leadership is needed to
foster a culture of dignity and respect.
• Better knowledge of the needs of PWD
is needed, together with improved
communication, training, support and
standards of care.
• Lack of response to continence needs is
unacceptable.
• Staffing levels have to reflect the needs
of older people both now and in the
future.
• Simple and responsive changes to ward
environment can make a big difference.
“I consider that my Review has
highlighted that the treatment of some
older people in Welsh hospitals is
shamefully inadequate. Organisations
must do more to learn from those who
are doing things well.”
• The experience of older patients and
carers should be effectively captured and
used to drive improvements in care.
• Good practice should be better
identified, evaluated and learnt from to
bring about improvements in care.
National Audit of
Dementia 2011
- 30% of hospitals have a formal system
in place for gathering information
pertinent to caring for the PWD.
- 73.8% of hospital assessments for
PWD include mental state assessment.
- 84.3% hospitals said that all staff
working with PWD have training in
POVA.
- 19% hospitals have a system in place
to ensure that staff are aware that a
person had dementia and how it affected
them.
“The majority of hospitals have yet to
implement the Dementia Intelligent
Target 2 and Older Persons NSF
Standard 4 which would address the
impact of the hospital experience on
people with dementia.”
- 52.4% of hospitals said that their
guidelines included asking the carer
about their wishes and ability to provide
care and support to the PWD after
discharge.
- In 16.3% of cases less than 24 hours
notice of discharge had been given. In
6% no notice at all provided.
• The NHS needs to recognise that dementia
is a significant, growing and costly problem for
them, which lies at the heart of the agenda to
drive efficiency and quality improvement.
• Reduce the number of people with dementia
being cared for in hospitals.
• Hospitals to identify a senior clinician to take
the lead for quality improvement in dementia
and for defining the care pathway.
• Commission specialist liaison older people’s
mental health teams to facilitate the
management and care of people with
dementia in hospitals.
• Ensure that there is an informed and
effective acute care workforce in hospitals for
people with dementia.
• Reduce the use of antipsychotics to treat
people with dementia on a general ward.
• Involve people with dementia, carers, family
“A quarter of hospital beds are
and friends in the care of people with
occupied by people with dementia and dementia to improve person-centred care.
although good care does exist, some
• Make sure that people with dementia have
hospitals remain a challenging
enough to eat and drink.
environment. The majority of people
• Begin to change the approach to care for
with dementia leave hospital worse
people with dementia to one of dignity and
than when they arrived.”
respect.
Counting the cost,
Alzheimer’s
Society, 2009
DGH Cognitive
Impairment Pathway
• Designed to support the treatment
and care management for people
with cognitive impairment and
dementia who enter the emergency
and acute medicine stream.
• 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.
• Specifically developed to support
the UHB’s response to the Dementia
Intelligent Target for General
Hospital Care.
• 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.
DAY OF ADMISSION
Ward/Unit where Pathway initiated: Note admission ward and
subsequent wards where care is provided. There is an aim to reduce
internal transfers as they can be disorientating and exacerbate confusion.
Is there a Lasting Power of Attorney or Court Appointed Deputy (for
Health and Welfare)? Identify whether an LPA or CAD is in place, as there
will be a legal requirement to consult with the LPA or CAD and to seek their
consent for treatment and care decisions.
Is there an established dementia diagnosis? 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? If it appears to be acute
confusion, the NICE Delirium guideline will need to be followed. If it
appears to be longstanding cognitive impairment but no dementia
diagnosis, refer to specialist on discharge.
Is the patient known to specialist services? If the person has a history of
contact with CMHT Older People or other specialist service, inform those
services of their admission.
REQUIRED WITHIN FIRST WEEK OF ADMISSION
Getting To Know You Form: Gathers information about life history, likes and
dislikes and normal habits and routines. Informs the development of person-centred
care plans and provides a basis for positive communication.
AD8 Dementia Screening Interview: Not to be used if there is an established
dementia diagnosis. Informs the implementation of the NICE Delirium guideline.
Montreal Cognitive Assessment: Replaces the MMSE (withdrawn due to
copyright restrictions). Seeks to identify the degree of cognitive impairment and is
useful in identifying improvements in functioning after treatment/as a measure of
progression of dementia.
PHQ9: Aims to identify key features and degree of concurrent depression. If there is
a high score, i.e. above 20, refer to the Hospital Old Age Liaison Psychiatry Service.
Butterfly Scheme: Aims to identify to staff which patients have a cognitive
impairment or established dementia and may need more assistance and
observation, e.g. in respect of fluid and nutritional intake.
Review anti-psychotics: If the patient is on anti-psychotics when they are
admitted, review appropriateness of the prescription and reduce where possible. If
there is a complex prescription or advice on withdrawing anti-psychotics is required,
refer to the Liaison Service.
ONGOING - AS REQUIRED
Formal Test of Capacity/Best Interest Assessment: Required to support decisionmaking regarding major decisions such as serious medical treatment or change of
accommodation.
Bristol Activities of Daily Living: To be completed by the carer, based on previous
level of functioning before the person became acutely medically unwell. Thus helpful
in highlighting rehabilitation potential.
24 Hour Behaviour Monitoring Forms: Helpful in establishing the frequency and
severity of behavioural and psychiatric symptoms of dementia. Detailed analysis of
behaviour can help identify triggers and successful methods of avoidance/
management. Required to support referrals to Liaison Service.
Abbey Pain Scale and Wong Faces: Designed to identify pain in patients with
cognitive impairment/dementia who are unable to easily communicate their pain
experience. Patients with dementia often express pain experience in behavioural
ways. Trialling analgesia and noting effects may be helpful.
Care Plan Templates and Top Tips for Care: Guidelines for staff involved in
providing direct care to support them in delivering person-centred care. Aimed at
supporting staff to manage common areas of difficulty, e.g. resistiveness to care,
wandering, reduced nutritional intake and aggression. There is a requirement to
involve carers in care planning.
DISHCARGE PLANNING
Carers Assessment (UA): Requirement to engage carers in discharge
planning. Critical in supporting decision making. Key questions to ask are
their ability and willingness to provide care and service needs.
Discharge destination: 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: 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 SW.CPN
or other Case Manager must be informed of the discharge.
Signpost to specialist services: Refer to Cardiff Memory Team if there is
cognitive impairment but not an established dementia diagnosis. If
established dementia diagnosis and behavioural or psychiatric symptoms,
refer to CMHT OP.
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
Training sessions are provided to
support implementation, especially in
care planning.