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Specifying a memory assessment service for the early identification and care of people with dementia

Service components

The key components of a memory assessment service for the early identification and care of people with dementia are:

Early identification and referral of people with a possible diagnosis of dementia

Early diagnosis and intervention in dementia is cost-effective yet only between a third and a half of people with dementia ever receive a formal diagnosis[1].

People with symptoms associated with the possible onset of dementia often do not present to their GP because of fear and the stigma associated with a diagnosis of dementia. The attitudes of GPs to the disease can also hamper diagnosis, with many holding the view that little can be done[2].

The National Audit Office report on improving services and support for people with dementia[1] suggests that memory assessment services can help to break down barriers and reduce stigma by:

  • being called ‘memory’ services rather than ‘mental health’ or ‘old age psychiatry’ services
  • improving communication
  • moving away from intimidating psychiatric or other hospital settings to a primary care environment.

Currently, people with suspected dementia can be referred to a variety of places for confirmation of the diagnosis, including memory clinics, community mental health teams, and neurologists or old age psychiatrists in secondary care. Commissioners should consider reviewing local practice and referral processes and protocols if these are not in line with the recommendations of the NICE–SCIE clinical guideline CG42 on dementia.

The NICE–SCIE clinical guideline CG42 on dementia contains the following recommendations.

  • ‘Memory assessment services (which may be provided by a memory assessment clinic or by community mental health teams) should be the single point of referral for all people with a possible diagnosis of dementia.’
  • ‘Primary healthcare staff should consider referring people who show signs of mild cognitive impairment (MCI) for an assessment by memory assessment services to aid early identification of dementia, because more than 50% of people with MCI later develop dementia.’
  • ‘Those undertaking health checks as part of health facilitation for people with learning disabilities should be aware of the increased risk of dementia in this group. Those undertaking health checks for other high-risk groups, for example those who have had a stroke and those with neurological conditions such as Parkinson’s disease, should also be aware of the possibility of dementia.’

Developing a high-quality service for dementia assessment, diagnosis and management

The diagnosis and general management of dementia is described in detail in NICE–SCIE clinical guideline CG42 on dementia, which recommends that memory assessment services should:

  • offer a responsive service to aid early identification and include a full range of assessment, diagnostic, therapeutic and rehabilitation services to accommodate the needs of people with different types and all severities of dementia, and the needs of their carers and family (see the clinical guideline for further detail on the recommendations made for each service component)
  • ensure an integrated approach to the care of people with dementia and the support of their carers, in partnership with local healthcare, social care and voluntary organisations
  • offer follow-up to people identified with MCI (including those with memory impairment, which may be absent in the earlier stages of non-Alzheimer’s dementias) to monitor cognitive decline and other signs of possible dementia in order to plan care at an early stage.

Memory assessment services are typically provided in psychiatric hospitals, by community mental health teams and in general hospitals. Commissioners may wish to consider the potential for locating such services (or aspects of such services) in primary care, where they may be provided by practitioners with a special interest in dementia.

Commissioners may wish to consider delivering a memory assessment service in a number of different ways, and mixed models of provision may be appropriate across a local health economy.

Local stakeholders, including service users, their carers and the voluntary sector should be involved in determining what is needed from a memory assessment service in order to meet local needs. The service should be patient-centred and integrated with other elements of care for people with cognitive impairment/dementia. Commissioners should consider joint local planning, together with the use of pooled budgets or joint funding of services where appropriate, in order to achieve a whole-systems approach to the consultation, planning, commissioning, delivery and monitoring of such services.

The NICE–SCIE clinical guideline on dementia recommends that the publication ‘Everybody’s business. Integrated mental health services for older adults: a service development guide’ is used as a framework for the planning, implementation and delivery of specialist mental health services for older adults, including memory assessment services. When developing integrated mental health services, commissioners should be aware that younger adults can also be diagnosed with dementia and that their needs will also have to be met.

The service specification needs to consider:

  • the required competencies of, and training for, staff responsible for providing the service
  • the expected number of patients (this should take into account how quickly any changes in service provision are likely to take place)
  • ease of access and service location; commissioners should engage with service users and other relevant individuals and organisations locally
  • care and referral pathways
  • information and audit requirements, including IT support and infrastructure
  • planned service improvement, including redesign, quality, equitable access, and referral-to-treatment times according to the 18 week patient pathway, or equitable waiting times locally for those services currently outside 18 weeks
  • service monitoring criteria.

Useful sources of information may include:

References

1. National Audit Office (2007) Improving services and support for people with dementia. London: The Stationery Office.

2. Audit Commission (2002) Forget me not 2002: developing mental health services for older people in England. London: Audit Commission.