Background: A significant ‘diagnostic gap’ for dementia, of more than a 50%exists between predicted prevalence and the actual GP registers across many regions in England, with only 46% of estimated dementia patients having a formal diagnosis locally(Mapping the Dementia Gap 2012, Alzheimer's Society).This is due to a combination of factors like late patient recognition and presentation to the GPs, delayed referrals from the GPs to specialists and long waiting times to memory services. The delay in the diagnosis causes a delay in the treatment as well as forward planning, leading to unnecessary referrals and escalation to specialist clinics and acute care settings with resultant burden on Healthcare resources (Alzheimer'sSociety2013).
Innovation: Having observed the existing local ‘diagnostic gap’ of dementia and the long waits for cognitive and mental health assessments at memory clinic, an existing general medical clinic was converted into a collaborative clinic to be mutually run by a consultant geriatrician from WWL and an Advanced Nurse Practitioner (ANP) from 5 Boroughs Mental Health NHS Trust to address medical and cognitive health issues in one attendance.
The patients identified to have early signs of cognitive decline either by GPs or other consultant colleagues in the hospital l( wards or clinics) were referred.
The patients after being consented received:
1. A detailed memory related history, cognitive assessment and depression screening, performed by ANP, using standard assessment tools( MOCA, GDS)
2. A comprehensive geriatric assessment, resultant indicated interventions and a battery of investigations including bloods, ECG, structural Brain imaging (MRI) etc. to rule out medical causes of cognitive decline.
3. A referral to ‘Later Life and Memory Services’(LLAMS), for patients identified to have cognitive impairment, for commencing treatment and forward planning after discussing the findings with the patient and family.
Evaluation: Out of 65 new patients seen in 19 clinics, 33 (50.7%) showed cognitive impairment and were referred to LLAMS. 16 (24.6%) of these were confirmed to have dementia diagnosis and 10 (15.3%) planned for further investigations and follow up. 3 did not attend, 2 passed away and 2 were diagnosed with other intracranial pathologies.
Conclusion: A Collaborative Cognitive Assessment Clinic, such as above, aids the early diagnosis of dementia and rules out medical causes of cognitive decline in addition to addressing physical health problems in patients prior to being seen by the memory services, hence bridging the gap towards diagnosis of dementia. Early diagnosis helps to initiate prompt treatment, forward planning and prevent unnecessary escalation to acute settings thus saving time and resources. Following the successful running of pilot clinic (Jan-June2012), it was commissioned to carry on once a week by WWL NHS Health Trust. The feedback received from patients and relatives was 100% positive and encouraging.