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Alistair Burns, NHS England’s National Clinical Director, has teamed up with two Dementia Ambassadors, Dan Harwood and Paul Twomey, to give their views on improving diagnosis in care homes – why, and how to do it:
Around three-quarters of people living in residential and nursing homes have dementia.
Some residents will have been assessed in the past and have a recorded diagnosis of dementia. However, many will have bypassed pathways to formal diagnosis if they were admitted from direct from hospital, placed as an emergency because of severe risks or a breakdown in home support or were admitted from outside the locality with limited background information coming with them.
In most areas of the country, diagnosing dementia is something often carried out by specialist memory services or Community Mental Health Teams (CMHTs). However, residents of care homes with suspected dementia may find travel to specialist clinics difficult and do not always need the specialist interventions offered by these services.
It might be argued that there is limited benefit in diagnosing people with significant physical illness and high care needs as having dementia, as it will have little impact on their care. However, diagnosis, even in the presence of established disease, can have important practical benefits:
- Some care home residents have mild or moderate dementia and symptoms which may be helped by cholinesterase inhibitor drugs or memantine. These diagnoses may be “missed” as they may appear to care home staff as relatively cognitively intact compared with other residents with more severe dementia and present no challenges to care – labels such as “pleasantly confused” are often attributed to them.
- A diagnosis of dementia may trigger a general review of a resident’s medication – and the stopping of drugs which may affect cognition adversely.
- The diagnosis can be recorded in the care home records which are useful for health and social care professionals who may be assessing the resident.
A diagnosis can help care home staff understand behaviours which may emerge – people with dementia are at significantly increased risk of developing a confused state in the presence of an intercurrent physical illness – and can alert clinicians to the risks of prescribing neuroleptic drugs.
- Care staff may need to alter their care plans if a resident has cognitive impairment, for example to manage distress due to disorientation.
- In some areas of country appropriate levels of Local Authority funding for the residents care may be assisted by a “formal” diagnosis of dementia – although strictly speaking funding should be on basis of needs rather than diagnosis.
- Schemes to improve level of diagnosis rate in care homes may be an opportunity to link these to educational/training/organisational development within the homes, to ensure diagnosis is a trigger to improved care. An example is the Focused Intervention Training and Support (FITS) project.
- A diagnosis of dementia in a care home resident can act as a trigger for a discussion about advance care planning, addressing such important areas like how to manage physical illness and when and when not to admit to hospital.
- Relatives and friends may find a formal diagnosis of dementia helpful as it helps them to understand some of the changes they have seen in their loved one and helps them to contribute in an informed way to their relatives care.
- Good data on prevalence of dementia in different settings can assist planning of services by CCGs and local authorities. For example, discussion at Health and Wellbeing Boards regarding the appropriate utilisation of the Better Care Fund which has a focus on minimising avoidable emergency admissions, and supporting better community care.
So how can we support the improved diagnosis and care planning of dementia in the residents of care homes?
Remember this as “GEMS”:
- General Practitioners key role
- Enhanced services linkage
- Memory services involvement
- Support for care homes
General Practitioners key role
Some care homes will have dedicated sessions from a specific GP. It might be possible to encourage these GPs to double check that all the residents that the GP knows has dementia are on the QOF Register.
An extra hour or two going discussing all residents briefly with the care home manager may identify people who obviously have dementia but haven’t been formally diagnosed. Most of these will probably not need referral to specialist services to confirm the diagnosis, but of course those with unusual symptoms do need secondary care assessment (see the dementia primer for more details).
Care homes and GPs covering the homes could work together to set up a process whereby all new residents being admitted to care homes have a review to establish whether they have a diagnosis of dementia, carry out anticipatory planning review of medication, arrange baseline blood tests etc. If a diagnosis of dementia is made this is recorded in the care home records and GP QOF Register.
Enhanced Services linkage
These actions could be linked to the local and National Enhanced Services for dementia. Also, the over 75s now have a named GP, and the top two per cent of the population at greatest risk of avoidable admission have a care plan. So initiatives to improve diagnosis in care homes can support the existing focus of aligning GP practices to specific homes.
Memory services involvement
Staff from Memory Services could be seconded for short-term pieces of work in care homes, identifying people with dementia, communicating with GPs to ensure they are placed on the QOF Register, and advising and managing the assessment and diagnosis in more complex clinical situations. Such secondments have the advantage that the practitioner can lead the necessary communication with care home staff and relatives, and provides excellent opportunities for training of care home staff on aspects of dementia care.
Support for care homes
The voluntary sector, in particular the Alzheimer’s Society, can help carry out awareness raising training in care homes, often combined with training on other aspects of dementia care. This can encourage care home staff to be vigilant to the symptoms of dementia and ask GPs to review the diagnosis in people, who have these symptoms.
So, in summary, ensuring everyone in care homes with dementia has a formal recorded diagnosis can help improve the current and anticipatory care of this most vulnerable group of individuals.
Dan Harwood is a Consultant Old Age Psychiatrist, Maudsley Hospital, and Dementia Ambassador, NHS England.
Paul Twomey is a General Practitioner and Area Team Medical Director, North Yorkshire and Humber AT NHS England, and Dementia Ambassador, NHS England.
Alistair Burns is National Clinical Director for Dementia, NHS England.