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6AB.. Dementia annual review
The face to face review should focus on support needs of the patient and their carer. In particular the review should address four key issues:
i. an appropriate physical and mental health review for the patient
ii. if applicable, the carers needs for information commensurate with the stage of the illness and his or her and the patients health and social care needs
iii. if applicable, the impact of caring on the care-giver
iv. communication and co-ordination arrangements with secondary care (if applicable).
An ES for facilitating timely diagnosis and support for people with dementia has been introduced (which builds on the 2013/14 ES). The ES from 1 April 2014 requires practices to develop a care plan which includes an element of advanced care planning (ACP). Where appropriate this should include a record of the patient's wishes for the future, identification of the patients' carer(s) and provide appropriate permissions to authorise the practice to speak directly to the nominated carer(s) and provide details of support services available to the patient and their family.
Patients diagnosed with dementia are expected to be offered annual appointments specifically to review their diagnosis and care plan. The practice will agree with the patient and their carer, what is to be covered in the review and the duration of the consultation - where appropriate, extended consultations may take up to 30 minutes. Ideally the first such appointment would be within six months of diagnosis.
Where a patient with dementia has an advanced care plan, it is expected that this would be reviewed as part of the face-to-face review for this indicator and updated as appropriate.
A series of well-designed cohort and case control studies have demonstrated that patients with Alzheimer-type dementia do not complain of common physical symptoms, but experience them to the same degree as the general population. Patient assessments therefore include the assessment of any behavioural changes caused by:
Depression should also be considered since it is more common in people with dementia than those without (Burt et al. Psychol Bull 1995; 117: 285-305).
Patients and carers are to be given relevant information about the diagnosis and sources of help and support (bearing in mind issues of confidentiality). Evidence suggests that healthcare professionals can improve satisfaction for carers by acknowledging and dealing with their distress and providing more information on dementia. As the illness progresses, needs may change and the review may focus more on issues such as respite care.
There is good evidence from well-designed cohort studies and case control studies of the benefit of healthcare professionals asking about the impact of caring for a person with dementia and the effect this has on the caregiver. It is important to remember that male carers are less likely to complain spontaneously and that the impact of caring is dependent not on the severity of the cognitive impairment but on the presentation of the dementia, for example, on factors such as behaviour and affect. If the carer is not registered at the practice, but the GP is concerned about issues raised in the consultation, then with appropriate permissions they can contact the carer's own GP for further support and treatment.
As the illness progresses and more agencies are involved, the review could additionally focus on assessing the communication between health and social care and non-statutory sectors as appropriate, to ensure that potentially complex needs are addressed. Communication and referral issues highlighted in the review need to be followed up as part of the review process.
NICE clinical guideline CG42. Dementia. Supporting people with dementia and their carers in health and social care. 2006. http://guidance.nice.org.uk/CG42/NICEGuidance/pdf/English
Further information The Audit Commission Report (2002). Forget Me Not.
The NSF for Older People.
NICE public health guidance 16 (2008). Mental wellbeing in older people.
NICE clinical guideline 42 (2006). Dementia. Supporting people with dementia and their carers in health and social care. http://guidance.nice.org.uk/CG42/NICEGuidance/pdf/English
No decision has been taken on the endorsement of clinical guideline 42 in Northern
Ireland but the position is under review. Information on NICE guidance endorsed
in NI may be found at:
SIGN clinical guideline 86 (2006). Managing patients with dementia.
Coping with Dementia – a Handbook for Carers (2009).
See indicator wording for requirement criteria.
Verification – NHS England may require randomly selecting a number of patient records of patients in which the review has been recorded as taking place to confirm that the four key issues are recorded as having been addressed, if applicable.
Prepared By Jean Keenan