Dementia - Assessment & referral

Overview

Please note that not all patients with cognitive impairment will have dementia so please also consider other causes - these are summarised on the Cognitive Disorders page.

Being given a diagnosis of dementia is usually life changing for the patient and their family.  It is important during this process that both patient and carer have good access to care and advice and are fully informed and supported.

The criteria for diagnosis of dementia are relatively straightforward. Alzheimer’s Disease accounts for approximately 60% of cases after the age of 65 years, followed by vascular cognitive impairment.

GP Practices in BNSSG which have signed up to the BNSSG GP LES should have a trained dementia lead.

All patients who are diagnosed with dementia should be referred for post diagnostic support which is provided differently in Bristol, North Somerset and South Gloucestershire (see Services section below). 

What to do before referral (Diagnostic Process)

Presentation

Patients or often their carer or family member (informant) will present with concerns about memory / cognitive decline.

 A face to face appointment with the patient and the informant for a full assessment and establishing rapport and continuity is often best. This takes about 30 minutes.

Three questions need to asked before a diagnosis of dementia is made

• What cognitive functions have been affected
• How is day to day functioning affected
• Is there evidence of progression of symptoms

Using assessment tools

It is recommended that you use the EMIS Dementia Diagnosis and Review Template (RTF version of template)

Use a validated assessment tool to assess your patient. Links to the various tests are given in the Resources section below.

Use Mini-ACE or GPcog as a quick screening tool.

If you want to do a more in depth assessment use ACEIII (this may not be appropriate if you want to refer to a memory service for diagnostic assessment).

Assess for causes of deleriium

During the assessment think about causes of delirium and exclude:

• P-Pain
• I-Infection
• N-Nutrition
• C-Constipation
• H-Hydration and any hypo/hyper state (Na, glucose, thyroid, oxygen)
• M-Medication
• E-Environment

Next steps

If cognitive impairment is confirmed on initial testing then to demonstrate dementia there should be a documented history of memory AND functional loss. 

Identifying the first cognitive symptom affected is important in establishing the subtype.

• Mild Alzheimer’s disease presents with impaired learning and memory and repetitive speech
• Moderate Alzheimer’s disease presents with ‘living in the past’, 30% illusions and delusions, 20% hallucinations, loss of emotional control: temper, wandering
• In vascular cognitive impairment, symptoms depend on where the damage is. Prompting can help people access information and may be a sign of vascular damage.
• Lewy Body disease is characterised by fluctuating cognition, early and persistent visual hallucinations, Parkinsonian features and autonomic dysfunction

After the intial assessment is completed there will need to be discussion with the patient and/or their family about further investigations i.e. bloods and brain imaging.

The implications for driving should also be addressed - see the Dementia and Driving section below.

Investigations

Bloods - there is a dementia profile on ICE which includes the bloods required to exclude other causes of cognitive impairment.

Imaging - a CT scan of the brain should be requested and should include clinical details. If a recent brain scan has been done for another reason then you can usually ask the radiologists to review the films in the context of a possible dementia diagnosis. For contact details please see the Radiology Advice & Queries page.

Making a diagnosis

Do not make a diagnosis of dementia in someone who is drinking excessively, has a delirium or is depressed. Also consider screening for obstructive sleep apnoea which can be associated with cognitive impairment, increases the risk of dementia and may accelerate the onset of Alzheimer’s in a reversible fashion. Treat conditions and test cognition after resolution. 

If a patient has a history of head injury (either recent of past) then consider other referral routes.

See the Cognitive Disorders page for further details.

If the assessment and investigation are otherwise consistent with dementia, then a diagnosis in primary care can be made in most cases. Alternatively, if a GP is still not sure then patients can be referred to dementia services to confirm the diagnosis.

Patients and their family / carers should be informed of the diagnosis sensitively and offered referral to dementia services as detailed below. If medication is indicated then this should be offered. Further signposting to support and resources should also be offered (see Resources section below).

Prescribing 

Consider appropriate treatment with the patient. Please see the Prescribing in Dementia page of Remedy.

Red Flags

Delirium

• CKS guidelines on Delirium

Rapid decline e.g. suggestive of encephalitis: contact the on-call neurologist or medic to discuss whether needs admission vs other referral route.

HIV positive: if the patient is not already under care of HIV services, refer to NBT HIV Specialist Nurses (email: Brecon.nurses@nhs.net) for CD4 count, Viral load and cerebral lymphoma screen in the first instance – may need referral to Cognitive Neurology after this.

Normal Pressure Hydrocephalus: rapid onset of cognitive decline which may be associated with gait abnormalities and/or urinary incontinence is suggestive of NPH. Urgent brain imaging (CT or MRI) may be suggestive of diagnosis but is not diagnostic so consider urgent referral to neurosurgeons via eRS RAS.

Obstructive Sleep Apnoea: OSA can be a reversible cause of cognitive decline so should be investigated if concerns.

Head injury: If recent head injury then consider urgent imaging of brain or if more rapid decline in context of head injury then admit to ED for assessment. For patients with historical head injury then see section below.

Factors Suggesting Referral to Memory Services (Bristol Dementia Wellbeing Service, AWP Memory Services in North Somerset & South Glos) for Assessment:

• Co-morbid mental health diagnosis
• Early onset (less than 65 years)
• English not first language / cultural considerations
• Prominent Behaviour Change
• History Doesn’t Fit with Typical presentation
• Persistent and early visual hallucination consistent with possible Lewy Body Disease

Factors Suggesting Referral for Cognitive Disorders Clinic (NBT) Assessment :

• Patients with Movement Disorder and cognitive decline (also consider referral to the Movement disorder Clinic (geriatrics)
• History of recent seizures (see other considerations)
• Patients with new cognitive symptoms following a previous history of head injury. See cognitive disorders page for other scenarios. 
• Very rapid decline (significant cognitive decline with a les than 6 months history) - if encephalitis excluded - see above.

Other considerations

Mild Cognitive Impairment

If patients do not meet the threshold for a diagnosis of dementia and other causes of cognitive decline have been excluded then consider a diagnosis of Mild Cognitive Impairment.

Share Dementia: Helping your brain to stay healthy leaflet aimed at patients, focusing on what dementia is and the importance of a healthy lifestyle. Discuss lifestyle considerations.

Review in 6 months to assess any worsening of symptoms.

History of stroke

Patients presenting with new progressing cognitive decline who has previously had a stroke (recent or past) can be referred to a Dementia Wellbeing Service following initial assessment and investigation in primary care.

History of Seizures / Epilepsy

Patients with a history of epilepsy or seizures with cognitive decline consistent with dementia can be referred to a Dementia Wellbeing Service for triage if the seizures are well controlled. Where there have been recent changes to medication or any suspicion of new seizures, these patients should be referred to the general neurology epilepsy clinic. Patients with new onset seizures and cognitive decline should not be referred to DWS.

Delirium in COVID 19

Managing Delirium in confirmed and suspected cases: https://www.bgs.org.uk/resources/coronavirus-managing-delirium-in-confirmed-and-suspected-cases

Please also see the attached information on Atypical COVID 19 presentations in Older People produced by Sussex Partnership NHS Foundation Trust.

Wernicke - Korsakoff Syndrome

Alcohol-use disorder is often associated with a thiamine deficiency which, if severe, may lead to Wernicke's encephalopathy. This is characterised by ocular motility disorders, ataxia, and confusion. When people with Wernicke's encephalopathy are inappropriately treated with low doses of thiamine, mortality rates average about 20%, and Korsakoff's psychosis develops in about 85% of survivors. Korsakoff's psychosis is characterised by anterograde and retrograde amnesia, disorientation, and confabulation (1).

See Alcohol Misuse page for advice on treatment of Wernicke Encephalopathy.

Patients with suspected Korsakoff's syndrome can be discussed with the dementia wellbeing team and referral may be appropriate if they have stopped drinking and been abstinent from alcohol for a minimum of 3 months without improvement in cognition.

Dementia and Driving

Driving Guidance

For any patient assessed in primary care in whom there is a concern about cognitive impairment or dementia, it is the responsibility of the assessing clinician to give advice in line with DVLA guidance. This should be addressed prior to referral to secondary services.Please see link to DVLA guidance below:

Psychiatric disorders: assessing fitness to drive - GOV.UK (www.gov.uk)

The British Geriatrics Society provide further practical information to assist in assessment if required.

Driving with Dementia or Mild Cognitive Impairment - Consensus Guidelines for Clinicians

Other resources

DVLA Guidelines: a guide for medical professionals 

GMC guidance - patients' fitness to drive and reporting concerns to the DVLA

Referral and Reviews

Referral

If diagnosis is not clear then please review the information on the Cognitive Disorders page  which has further information on causes of cognitive decline and options for referral. 

Refer to your local Memory Service (see services section below) if you have made a diangosis of dementia  or are not sure of the diagnosis or if there are other complicating factors. You can also refer for help with prescribing and for post diagnostic support.

Review

• Review every 6 months if dementia medication has been prescribed.
• Review annually for all other patients.

Complete the Dementia Diagnosis and Annual review template** provided in EMIS 

(**RTF version of template)

Resources

(1) Complications |Alcohol - problem drinking | CKS

Services

• Bristol - Dementia Wellbeing Service

• North Somerset - Memory Service & Alzheimer's Society

• NBT - Cognitive Disorders Clinic

• South Glos - Memory Service & Dementia Support

• Assistive Technology Service

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.