Mind Reading

Doncaster’s health and wellbeing board (HWB) is working closely with its partner organisations to prioritise the diagnosis of dementia and to support service users and their carers in getting the right help at the right time and by the right people in the right place. The aim is to increase the region’s dementia diagnosis rate from 55% in 2013 to meet the national ambition of 67% by March 2015 but encouraging GPs to assess more ‘at risk’ patients is only one part of the solution. Wayne Goddard, Doncaster CCG head of strategy and delivery (vulnerable people) has suggested more accurate cognitive assessment technology could help “the early identification of possible problems and provide the catalyst for GPs to instigate further investigations and assessments, in line with National Institute for Health and Care Excellence (NICE) clinical guidance, before referral to the memory services as necessary.”

To evaluate this proposition, the CCG conducted a two-week pilot study using an assessment tool app within two practices before applying for NHS England funding to support ‘embedding research and evaluation in general practice.” Having successfully secured the funding, 23 practices are now using the new touchscreen assessments for a more extensive 12 month study, while the CCG’s 20 other practices continue with tools such as the six-item cognitive impairment test (6CIT), the mini mental state self-evaluation (MMSE) or in some cases the general practitioner assessment of cognition (GPCOG). The budget is also part funding the author to support practices in carrying out these new assessments and in offering more person-centred and sensitive care to patients diagnosed with dementia.

The assessment app, called Cantab Mobile and developed by Cambridge Cognition, is an easy-to-use iPad app that provides a quick and accurate cognitive assessment for patients aged 50 to 90 to help differentiate between memory loss due to early Alzheimer’s disease (AD) or other dementias and normal forgetfulness. The tool includes optional screens to assess depression and activities of daily living (ADL). With training, anyone can administer the test and results are automatically scored and compared with expected performance for age, sex and education in line with NICE recommendations. To date, over 10,000 NHS patients have been assessed with Cantab Mobile across 30 CCGs.

 

Improving the quality of referrals

One of the main concerns raised by most GP practices is that more assessments mean more memory service referrals with longer waiting times, but RDaSH argues this is not an inevitable consequence.

Patients are already being screened but the new assessment tool is more sensitive and specific than existing paper-based approaches so GPs can make higher quality, more informed referrals. Also several studies have shown around 50% of patients with subjective memory complaints are the ‘worried well’ so a more specific and objectively-scored test can help GPs focus on patients who are potentially showing clinically-relevant signs of memory loss.

Secondly, practices are not always sure which blood tests to request or what other factors to consider as possible explanations for the patient’s memory loss leading to incomplete or inappropriate referrals. The service is working closely with practices to address this and in turn minimising delays for patients awaiting a diagnosis. 

RDaSH has streamlined its internal processes to maintain waiting lists at around two weeks, whereas patients in some regions typically wait four months or more for an initial appointment.  As soon as a memory-related referral arrives, the service requests a computed tomography (CT) head scan, which currently has an eight week waiting list, and ensures the consultant has everything they need as quickly as possible to diagnose the type of dementia.

Patients diagnosed with early AD are normally offered drug treatments, monitored and reviewed every six to 12 months. However, there is little the service can do for anyone diagnosed with early vascular dementia (VD) beyond social support so those patients are normally discharged.

 

Training to administer new tests

All 23 practices involved in the evaluation study were signed up for a one-hour training session in central Doncaster with some GPs attending, although generally it was practice managers and nurses. 

The session was designed to help participants administer Cantab Mobile assessments, as well as raising awareness of essential blood tests pre-referral, treatment options and highlighting what support is available from the memory service and within the wider Doncaster community for patients living with dementia and their carers. Trainees were given detailed briefing notes with tips and suggestions on administering tests, based on feedback from the pilot study; for example ensuring the patient does not already have a dementia diagnosis, or reminding patients to concentrate on the screen to prevent them from getting distracted. Most practice staff say patients find the iPad assessments easy to use and less stressful than traditional tests, where they might be expected to recall the names of prime ministers or a specific address. The tool’s audio soundtrack is available in 20 languages to talk patients through each step with no reading or writing required. Patients failing the memory component of the three-part assessment are automatically questioned about their activities of daily living (ADL) and a mood assessment to differentiate signs of dementia from symptoms of depression. Some GPs and practice staff have queried the importance of the ADL component of the assessment because a memory issue has already been identified for the patient. However, the memory service always recommends this test is carried out as the answers can provide additional insights into where patients see themselves within the disease process. When the test sequence completes, the results are presented with a traffic light score: red for further investigation, amber for ‘watch and wait’ and green if no further action is needed.

 

Eliminating common causes of memory loss

Practices using Cantab Mobile have been supplied with a detailed flowchart from the memory service setting out what further steps or tests are necessary for any patient, regardless of their assessment result and to ensure a more consistent approach for patients across the region. For example, patients scored as red need blood tests to rule out urinary tract infection (UTI), delirium or alcohol-related factors; whereas green need reassurance their memory function is normal. The flowchart also stresses the importance of summarising the patient’s medical and psychiatric history on the referral form, along with an up to date list of medications.

The memory service aims to resolve any initial teething problems with the new assessments within the first few weeks, before then focusing on on-going support and new initiatives to help practices and any of their patients diagnosed with dementia. For example, setting up patient and carer workshops or ensuring every patient who is diagnosed by the memory service is correctly captured by their practice on the quality and outcomes framework (QOF) register as having dementia. Differences between the two systems have been identified for some regions resulting in patients not receiving regular and ongoing reviews.

 

Dementia diagnosis remains a national priority

Doncaster expects to report fully on the outcomes of its evaluation study in 2015 but hopes the approaches and improvements discussed here could benefit other CCGs in their drive to raise dementia diagnosis rates. Early diagnosis can make a marked difference to quality of life for a person with dementia, allowing them to make important lifestyle choices, remaining independent for longer and to access the essential health and social care support they need. GPs are also likely to continue facing sustained pressure to raise their dementia diagnosis rates, beyond the current 2015 target of 66% as part of an evolving healthcare policy to manage the disease. In its revised Dementia UK report, The Alzheimer’s Society is recommending every region should aspire to a diagnosis rate of 75% by 2017, no patient should wait longer than 12 weeks from GP referral to receiving their diagnosis, and there should be a guaranteed minimum standard of post-diagnosis support available to everyone affected by the disease.