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P2. Memory clinics and centres

Detailed programme, abstracts and poster presentations

P2.1. Setting standards for UK memory services: 10 years of the Memory Services National Accreditation Programme

CARTWRIGHT Vicky, BLANCHARD Eve

The Royal College of Psychiatrists’ Centre for Quality Improvement, London, United Kingdom

The Memory Services National Accreditation Programme (MSNAP) is a quality improvement and accreditation network for services that assess, diagnose and treat dementia. MSNAP is an initiative of the Royal College of Psychiatrists’ Centre for Quality Improvement and was established in 2009. There are currently 92-member services across England, Wales and Northern Ireland.

The standards set by MSNAP for memory services cover assessment and diagnosis; care management and follow-up; pharmacological intervention; psychosocial interventions and service management.

For the past 10 years MSNAP has gathered, via self-assessment and peer review visits, about how services operate to meet these standards as well as staffing levels, service size, caseload and time from referral to assessment.

This presentation will cover:

  • How standards for UK memory services were developed and how these have changed over the 10 years the project has been running
  • Variation in caseload numbers, diagnostic rates and service staffing geographically and over time
  • Successful examples of quality improvement in memory services as a result of working towards the MSNAP standards

This presentation will be of interest to professionals that assess, diagnose and treat dementia and will share practical examples of how the MSNAP standards can be applied to memory services across Europe.

P2.2. ABIDE Delphi study: information provision in memory clinics

FRUIJTIER Agnetha1, VISSER Leonie1, BOUWMAN Femke1, VAN DER FLIER Wiesje1, SMETS Ellen2

1Alzheimer Center Amsterdam, Amsterdam UMC, location VU medical center, Amsterdam, Netherlands, 2Medical Psychology, Amsterdam UMC, location AMC, Amsterdam, Netherlands

Introduction:Information given to patients and care partners during the clinician-patient consultations varies considerably between memory clinic professionals [1,2]. Patients and caregivers express a clear desire for more information [2,3]. In the ABIDE Delphi study we first identified informational topics on which health care professionals, patients and caregivers agreed that these should be discussed during diagnostic consultations in memory clinics. Next, we aimed to establish; 1) to what degree these informational topics are actually discussed in clinician-patient consultations, 2) if these are discussed during the pre- and/or post-diagnostic testing consultations, and 3) who initiated the discussion of the topic, the professional, the patient or the caregiver.

Methods: We performed a three-round Delphi consensus study. Professionals (N=80), patients (N=66) and caregivers (N=76) rated the importance of 44 informative topics through an online questionnaire. Audio-recordings of pre- and post-test clinician-patient consultations of 71 patients, seen by 32 clinicians, were collected in eight memory clinics and content-coded by two coders. The coding scheme encompassed the core informational topics that resulted from the Delphi consensus procedure.

Results: In the ABIDE Delphi study we identified 17 topics on which health care professionals, patients and caregivers agreed that these should be discussed during diagnostic consultations in memory clinics. In addition, eight topics were identified on which the three groups significantly disagreed. We are currently analyzing the audio-recorded consultations.

Conclusion: Expected results will provide insight into which relevant informational topics are (not) routinely discussed, when they are discussed and who initiates the discussion. The core list of topics, supplemented with these insights, can support professionals in their communication with patients and caregivers. In addition, the topic list can empower patients and caregivers in their preparation for and communication during diagnostic clinician-patient consultations.  

P2.3. A regional approach to reducing variation in memory services

COOK Laura, ISAACS Jeremy

NHS England, London, United Kingdom

In the UK, dementia is predominantly diagnosed in memory services operated by mental health providers.  There is limited data comparing diagnostic and care practices between memory services.  In 2016, memory services in London were invited to participate in a comparative audit of consecutive patient referrals. 10 out of 30 services in London took part, contributing to data on 590 patients in total (mean number of patients audited per service 50, range 43-92). Results demonstrated significant variation in; referral rejection rates, location of initial assessment (i.e. home versus clinic), referral for imaging (and choice of imaging modality) and neuropsychology, rates of diagnosis of mild cognitive impairment and dementia sub-types, access to pharmacological treatment and cognitive stimulation therapy and provision of information about research.  Average time from referral to diagnosis varied from 5 to 23 weeks. The proportion of patients deemed not to require brain imaging ranged from 6% to 43%.  We deemed much of this variation to be unwarranted. Notably, 85% of people under the age of 65 referred to memory services were found not to have dementia.

Following the audit, three pan-London projects were initiated to reduce variation in care. Firstly, memory service clinical pathways were mapped, which revealed several areas where efficiencies could be introduced to reduce time to diagnosis without impacting on quality of care. Guidance on streamlining pathways was published, and local implementation supported. Secondly, recommendations for several non-dementia conditions were published to support memory services and general practitioners in managing patients with cognitive symptoms who do not have dementia. Thirdly, neuroimaging guidance was published to advise practitioners on the most appropriate use of brain scans in the investigation of suspected dementia.

Services are currently being re-audited to establish the impact of these improvement projects. Data from the re-audit will be presented. 

P2.4. Clinicians’ communication with patients receiving an MCI diagnosis: the ABIDE project

VISSER Leonie1, VAN MAURIK Ingrid1, BOUWMAN Femke1, STAEKENBORG Salka2, VREESWIJK Ralph3, HEMPENIUS Liesbeth4, DE BEER Marlijn5, ROKS Gerwin6, BOELAARTS Leo7, KLEIJER Mariska8, VAN DER FLIER Wiesje1, SMETS Ellen9

1Alzheimer Center Amsterdam, Department of Neurology, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, Netherlands, 2Department of Neurology, Tergooi Hospital, Blaricum, Netherlands, 3Department of Clinical Geriatrics, Spaarne Gasthuis, Haarlem, Netherlands, 4Geriatric Center, Medical Center Leeuwarden, Leeuwarden, Netherlands, 5Department of Neurology, Reinier de Graaf Gasthuis, Delft, Netherlands, 6Department of Neurology, ETZ Hospital, Tilburg, Netherlands, 7Geriatric Department, NoordWest Ziekenhuis Groep, Alkmaar, Netherlands, 8Department of Neurology, LangeLand Ziekenhuis, Zoetermeer, Netherlands, 9Department of Medical Psychology, Amsterdam Public Health research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands

Objective:The use of the label mild cognitive impairment (MCI) in clinical practice is challenging for clinicians, since it describes the individual’s current situation, but does not imply the cause of symptoms or prognosis in terms of dementia or symptom development. Despite these challenges, guidelines recommend accurate communication about the MCI diagnosis, cause, prognosis and long-term (care) planning. We aimed to explore clinicians’ communication about these issues in post-diagnostic testing consultations with MCI patients.

Methods:Thematic content analysis was used to qualitatively analyze clinicians’ communication during audiotaped consultations in which clinicians (n=10) disclosed diagnostic test results to 13 MCI patients and their care partners. All audio-recordings were independently coded by two coders, using a self-developed coding scheme. The coded communication combined with transcripts of the consultations were further analyzed to extract core findings.

Results:The analyses yielded six core findings: clinicians  1) differed in the way they informed about the MCI diagnosis; 2) often addressed the cause of patients’ symptoms in a tentative manner; 3) (implicitly) steered against additional biomarker testing by an unbalanced presentation of arguments; 4) rarely specifically informed about the risk of developing dementia; 5) often informed about the expected course of symptoms by particularly emphasizing potential symptom stabilization/improvement in addition to progression, and; 6) did not engage in a conversation on long-term (care) planning.

Conclusion:Clinicians often did not provide MCI patients with specific information about the underlying cause, risk to develop dementia and implications for long-term (care) planning. Since most patients and care partners have a strong need to explain the patient’s symptoms, and for information on prognosis and implications for the future, clinicians’ approach may not match with those needs. We should develop recommendations on how to optimally communicate about these issues, and develop tools to support clinicians in their adherence to MCI guidelines.

P2.5. Dementia diagnostic orocesses and practices in Ireland: a national survey of clinicians who assess people with suspected dementia

TIMMONS Suzanne, DESIUN Anna, BEGLEY Emer, MANNING Mary

National Dementia Office, Tullamore, Ireland

Background: The Irish National Dementia Strategy (2014) identified timely diagnosis and intervention as a priority area. The National Dementia Office established a Dementia Diagnostic Project to develop a framework for diagnostic services nationally. As part of preparatory work, a national survey explored baseline peri-diagnostic practice in geriatric medicine, neurology and psychiatry of old age services.

Methods: A survey was developed by the project steering group, piloted, and then distributed to all 86 geriatricians, 39 neurologists, and 34 psychiatrists of Old Age Psychiatrists in Ireland. Two reminder e-mails were sent.

Results: In total, 56 clinicians responded (response rate 35%). The majority (74%) saw 1-20 People with Suspected Dementia (PwSD) per month. Most referrals came from general practitioners or other physicians; but rarely from health and social care professionals. Most people were referred specifically for their memory complaint, rather than a co-morbidity. Waiting times for urgent review varied between 24 hours and 4 years; neurology services had the longest waiting times. Only 30% saw PwSD in a dedicated clinic; about the same proportion saw PwSD in their own home; or in residential care settings. About half reported assessing people with intellectual disability and suspected dementia, mainly the neurologists.

The Montreal Cognitive Assessment was the most commonly used cognitive tool (89%), followed by the Addenbrook’s Cognitive Examination (56%). Only 17% commonly used functional brain imaging in diagnosis, mainly neurologists; half of respondents ‘never’ or ‘rarely’ used cerebrospinal fluid analysis. Multidisciplinary input was mainly from occupational therapists (61%), psychology/neuropsychology (52%), and nursing disciplines (33%). When asked which discipline would most benefit their diagnostic service, neurologists all chose psychology input; geriatricians selected a range of disciplines.

Conclusion: The significant variability within current services who see PwSD, in terms of multidisciplinary involvement, waiting times, setting, and supporting investigations, supports the need for a national diagnostic framework.

P2.6. Implementing dementia memory clinic models in primary care: Experiences from Ontario, Canada

MCAINEY Carrie1, VEDEL Isabelle2, BERGMAN Howard2, COUTURIER Yves3, INGRAM Jennifer4, HAWKINS Stacey4, HUNTSBARGER Deana5, KAY Kelly4, TONG Catherine1, LEE Linda6, ARSENAULT-LAPIERRE Genevieve2, KAASALAINEN Sharon7

1University of Waterloo, Waterloo, Canada, 2McGill University, Montreal, Canada, 3University of Sherbrooke, Sherbrooke, Canada, 4Seniors Care Network, Coburg, Canada, 5Kawartha Centre, Peterborough, Canada, 6Centre for Family Medicine, Kitchener, Canada, 7McMaster University, Hamilton, Canada

The Canadian consensus guidelines on dementia recommend that the majority of cases of dementia are managed by general practitioners (GPs) in primary care. However, many GPs find it challenging to provide such care, as they may not feel they have the required dementia expertise. In addition, while some practices have moved towards team-based models, many practices are still organized to manage acute and simple chronic conditions, and not complex conditions like dementia. To address these issues, different models of dementia care in the primary care setting have been developed. The purpose of this presentation is to describe two models that have been developed in Ontario, Canada and to examine the factors influencing implementation of these models in 8 primary care practices.

In this qualitative descriptive study, semi-structured interviews were conducted with 30 health care professionals (e.g., physicians, nurses, occupational therapists, pharmacists, administrators). The interviews were transcribed and two authors (CM & CT) independently coded two transcripts and developed the initial coding structure. CT then engaged in line-by-line coding, using a priori and thematic coding.

Three practices described themselves as being in the ‘early’ stages of implementation of their model and five considered their models to be ‘established’. Barriers to implementation of the models included: physician recruitment, balancing roles, wait times, and physical space constraints. Ten participants reported that there were no implementation barriers faced. Implementation facilitators included: staff buy-in, training, use of an interdisciplinary approach, having leadership support and champions, and enjoying the work in dementia care.

Approaches to support GPs and other primary care providers in managing dementia are needed. Findings from this study provide insight into the implementation of novel models of dementia care in primary care settings.

 

 
 

Last Updated: Monday 21 October 2019

 

 
  • Acknowledgements

    The 29th AE Conference in The Hague received funding under an operating grant from the European Union’s Health Programme (2014-2020). Alzheimer Europe and Alzheimer Nederlands gratefully acknowledge the support of all conference sponsors.
  • European Union
  • Roche
 
 

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