Assessment, Diagnosis, Early Intervention and Ongoing Support

Assessment, Diagnosis, Early Intervention and Ongoing Support

ASSESSMENT, DIAGNOSIS, EARLY INTERVENTION AND ONGOING SUPPORT

The aim is to empower anyone who recognises changes in their own or someone else’s memory to seek an assessment and have timely access to an assessment.

A timely assessment is important as it can lead to an earlier diagnosis of dementia, opening the door to information and support that maximises the person’s ability to live well with dementia. It provides the person with dementia and their family and whanau with better awareness and understanding of what they are living with, which can have a positive effect on the person’s wellbeing. An assessment is also important as it can rule out the possibility of delirium and other conditions that are potentially reversible.

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ASSESMENT

Good Practice Points-

Any person who has concerns about their memory or cognition, regardless of age, is respected and their concerns are investigated through and assessment process.

No NZ research available on ease of access for anyone

Person with risk factors (e.g. Down syndrome, history of delirium, alcohol or drug dependency, head injury, late onset depression or anxiety) is offered routine monitoring by their health team and is offered assessment if dementia is suspected

 Kahokehr, A., Siegert, R. J., & Weatherall, M. (2004). The frequency of executive cognitive impairment in elderly rehabilitation inpatients. Journal of Geriatric Psychiatry and Neurology, 17(2), 68-72.

 McKinley, A., Grace, R., Dalrymple,-Alford, J., & Roger, D. (2009). Cognitive characteristics associated with mild cognitive impairment in Parkinson's disease. Dementia Geriatric Cognitive Disorders, 28(2), 121-129. doi: 10.1159/000235247.

  • Knight, R., Godfrey, H., & Shelton, E. (1988). The psychological deficits associated with Parkinson's disease. Clinical Psychology Review, 8(4), 391-410.
  • McKinlay, A., Grace, R.C., Dalrymple-Alford, J.C. and Roger, D. (2010) Characteristics of executive function impairment in Parkinson's disease patients without dementia. Journal of the International Neuropsychological Society 16(2): 268-277.
  • Rodwell, J., Fletcher, V., & Hughes, R. (2010). How well is cognitive function documented by medical staff in the over-65 age group at the time of acute medical admission? New Zealand Medical Journal, 123(1317), 1-7.

Person being assessed for dementia: receives explanation of assessment process, is provided with all information they need as they await outcome of the assessment process.

No information available about this

The health services

Ensure that health practitioners and support workers in the community understand the point of access for a cognitive assessment

Could survey workers about this???

  • Cheung, G., & Strachan, J. (2008). A survey of memory clinics in New Zealand. Australasian Psychiatry: \Bulletin of Royal Australian and New Zealand College of Psychiatrists, 16(4), 244-247. doi:10.1080/10398560701852131. http://www.ncbi.nlm.nih.gov/pubmed/18608146

Ensure primary health care teams, health care practitioners and support workers understand the significance of early diagnosis and undertake/ refer for diagnosis opportunistically if there is a trigger.

  • Mitchell, T., Woodward, M., & Hirose, Y. (2008). A survey of attitudes of clinicians towards the diagnosis and treatment of mild cognitive impairment in Australia and New Zealand. International Psychogeriatrics, 20(1), 77-85. doi:10.1017/S1041610207005583 http://www.ncbi.nlm.nih.gov/pubmed/?term=A+survey+of+attitudes+of+clinicians+towards+the+diagnosis+and+treatment+of+mild+cognitive+impairment+in+Australia+and+New+Zealand
  • Rodwell, J., Fletcher, V., & Hughes, R. (2010). How well is cognitive function documented by medical staff in the over-65 age group at the time of acute medical admission? New Zealand Medical Journal, 123(1317), 1-7.
  • King, AI ; Boyd, M ; Carver, P ; Dagley, E (2011) Health Workforce New Zealand, Auckland, New Zealand. 1-62, Evaluation of a gerontology nurse specialist in primary health care: Case Finding, Care Coordination and Service Integration for At-Risk Older People

Ensure health practitioners undertaking assessment have skills knowledge, awareness of importance of early diagnosis

  • de Vries, K., Brooker, D., & Smith, P. (2013). Dementia skills and competencies for primary care liaison: a model for improving identification and timely diagnosis. Primary Health Care Research & Development, 14(3), 240-249. http://www.ncbi.nlm.nih.gov/pubmed/?term=Dementia+skills+and+competencies+for+primary+care+liaison%3A+a+model+for+improving+identification+and+timely+

Ensure health practitioner gains consent to undertake assessment, inform person and include family / whanau

No research on this

Develop standardised process that is culturally sensitive, comprehensive and follows validated assessment tool

  • Cheung, G., Clugston, A., Croucher, M., Malone, D., Mau, E., Sims, A., & Gee, S. (2015). Performance of three cognitive screening tools in a sample of older New Zealanders. International Psychogeriatrics, 27(6), 981-989. doi: 10.1017/S1041610214002889
  • Burmester, B., Leathem, J., & Merrick, P. L. (2014). Assessing subjective memory complaints: a comparison of spontaneous reports and structured questionnaire methods. International Psychogeriatrics, 3, 1-17. doi: org/10.1017/S1041610214001161.

http://www.ncbi.nlm.nih.gov/pubmed/?term=Assessing+subjective+memory+complaints%3A+a+comparison+of+spontaneous+reports+and+structured+questionnaire+methods+.

 Strauss, H., Leathem, J., Humphries, S., & Podd, J. (2012). The Use of Brief Screening Instruments for Age-related Cognitive Impairment in New Zealand. New Zealand Journal of Psychology, 41(2), 11-20.

  • Li, F., Jia, X.-F., & Jia, J. (2012). The informant questionnaire on cognitive decline in the elderly individuals in screening mild cognitive impairment with or without functional impairment. Journal of Geriatric Psychiatry & Neurology, 25(4), 227-232. doi: 10.1177/0891988712464822
  • Barker-Collo, S. L., Thomas, K., Riddick, E., & de Jager, A. (2011). A New Zealand regression formula for premorbid estimation using the National Adult Reading Test. New Zealand Journal of Psychology, 40(2), 47-55 Collo.pdf&rct=j&frm=1&q=&esrc=s&sa=U&ei=C1ksVJnvOZTZoAS9
  • McKinlay, A., Grace, R.C., Kaller, C.P., Dalrymple-Alford, J.C., Anderson, T.J., Fink, J. and Roger, D. (2009) Assessing Cognitive Impairment in Parkinson's Disease: A Comparison of Two Tower Tasks. Applied Neuropsychology 16(3): 177-185.
  • Cheung, G., & Williams, G. (2009). Clinical utility of Health of the Nation Outcome Scales for older persons in a memory clinic. Australasian Psychiatry, 17(2), 149-155 doi:10.1080/10398560802482101
  • Silva, M. L., McLaughlin, M. T., Rodgrigues, E. J., Broadbent, J.C, Gray, A. R., & Hammond-Tooke, G. D. (2008). A mini mental status examination for the hearing impaired. Age and Aging, 37(5), 593 595. http://www.ncbi.nlm.nih.gov/pubmed/18687874
  • Bourke, J., Castleden, C. M., Stephen, R., & Dennis, M. (1995). A comparison of clock and pentagon drawing in Alzheimer's disease. International Journal of Geriatric Psychiatry, 10(8), 703-705.
  • Knight, R. & Moroney, B. (1985). An investigation of the validity of the Kendrick Battery for the detection of dementia in the elderly. International Journal of Clinical Neuropsychology, 7(3), 147-151.

Theses

  • Strauss, H. (2012). Brief cognitive screening instruments and the clinical utility of three screens in a New Zealand clinical geriatric setting. (PhD thesis, Clinical Psychology, Massey University, Wellington).
  • Vineetha, U. (2011). The MoCA and ADL Items Separate Mild Cognitive Impairment and Dementia in Parkinson's disease. (Master’s thesis, Psychology, University of Canterbury).
  • Glass, J. N. (1999). Measuring memory in older adults: the relevance of everyday memory and the Rivermead Behavioural Memory Test. (PhD thesis, Psychology, Massey University). RT

Differentiation from depression

  • Feehan, M., Knight, R. G., & Partridge, F. M. (1991). Cognitive complaint and test performance in elderly patients suffering depression or dementia. International Journal of Geriatric Psychiatry, 6(5), 287-293.

Theses

  • Kay, S.M. (1990). An analysis of memory loss in dementia and depression. (Master’s thesis, Arts. University of Cantebury).

Discussion

  • Porter, R. J., Bourke, C., & Gallagher, P. (2007). Neuropsychological impairment in major depression: its nature, origin and clinical significance. Australian and New Zealand Journal of Psychiatry, 41(2), 115-128. http://www.ncbi.nlm.nih.gov/pubmed/?term=Neuropsychological+impairment+in+major+depression%3A+its+nature%2C+origin+and+clinical+significance. (From Ageing research: this does not talk about dementia, but discusses the different neurocognitive deficits in depression- knowing this might assist diagnosis).

Differentiation from delirium

  • Seymour, S., Henske, P., Cape, R., & Campbell, A. (1990). Acute confusional states and dementia in elderly: the role of volume dehydration/volume depletion, physical illness and age. Age and Ageing, 9(3), 137-146. doi:10.1093/ageing/9.3.137. http://www.ncbi.nlm.nih.gov/pubmed/?term=Acute+confusional+states+and+dementia+in+elderly%3A+the+role+of+volume+dehydration%2Fvolume+depletion%2C+physical+illness+and+age

Discussion

Neville, S., & Gilmour, J. (2007). Differentiating between delirium and dementia. Nursing New Zealand, 13(9), 22-24. http://www.ncbi.nlm.nih.gov/pubmed/18019822

Other conditions

Glass, J., & Baker, N. (2003). Relapsing polychondritis- an unusual but potentially treatable cause of cognitive impairment. New Zealand Medical Journal, 116(1175), 76-79. PR / CR

Chung, KK ; Anderson, NE ; Hutchinson, D ; Synek, B ; Barber, PA (2011) Cerebral amyloid angiopathy-related inflammation (CAA-I): three case reports and a review Neurol Neurosurg Psychiatry 82(1):20-26

This is a potentially reversible cause of cognitive impairment.

Discussion

Perkins, C. (2004). Other conditions can affect cognition. New Zealand Doctor, 25

DIAGNOSIS

Services aim to provide earlier diagnosis for people with dementia. An early diagnosis will allow the person and their family and whanau to plan for the future and to access health and social support services that will provide them with information that will promote self-management and rehabilitation thus ensuring that they will be able to live with a sense of wellbeing for as long as possible.

Good practice points

Person

Found to have MCI – receive education and information about healthy living / signs and symptoms to look out for /coping strategies / can ask for reassessment if changes / have CV risk assessed and treated

  • Mitchell, T., Woodward, M., & Hirose, Y. (2008). A survey of attitudes of clinicians towards the diagnosis and treatment of mild cognitive impairment in Australia and New Zealand. International Psychogeriatrics, 20(1), 77-85. doi:10.1017/S1041610207005583 http://www.ncbi.nlm.nih.gov/pubmed/?term=A+survey+of+attitudes+of+clinicians+towards+the+diagnosis+and+treatment+of+mild+cognitive+impairment+in+Australia+and+New+Zealand
  • Wood, K., Myall, D., Livingston, L., Melzer, Toni, T., Pitcher, L., MacAskill, M., Geurtsen, G., Anderson, T. & Dalrymple-Alford, J. (2016) Different PD-MCI criteria and risk of dementia in Parkinson’s disease: 4-year longitudinal study. npj Parkinson's Disease 2: 15027 (2016).
  • Dalrymple-Alford, J.C., Livingston, L., MacAskill, M.R., Graham, C., Melzer, T.R., Porter, R.J., Watts, R. and Anderson, T.J. (2011) Characterizing mild cognitive impairment in Parkinson's disease. Movement Disorders 26(4): 629-636.
  • McKinlay, A., Grace, R.C., Dalrymple-Alford, J.C. and Roger, D. (2009) Cognitive Characteristics Associated with Mild Cognitive Impairment in Parkinson's Disease. Dementia and Geriatric Cognitive Disorders 28(2): 121-129.

Has underlying depression or anxiety: receive treatment /then reassess

Has underlying alcohol or drug dependency: / receive treatment then are reassessed/ ongoing care and support- dementia and addiction services cooperate

Receives a diagnosis of dementia: family /whanau support is encouraged/follow up sessions after diagnosis/ discussions about what it means to person etc.

No information about these above though part of most pathways.

The Health Services

Provide a diagnosis including subtype (per NICE guidelines - )

Discussion

 Dalrymple-Alford, J. (2001). Comparative neuropsychology of Lewy body and Alzheimer's dementia. Journal of Neurology, Neurosurgery & Psychiatry, 70(2), 148.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1737200/pdf/v070p00148.pdf Discussion

  • Casey, G. (2012). Alzheimer’s and other dementias. Kai Tiaki Nursing. New Zealand Discussion

 Perkins, C. (2004). Several forms of dementia exist. New Zealand Doctor, 22 Discussion]

In giving diagnosis ensure person at centre and included in decision-making

  • McKinlay, A., Leathem, J., & Merrick, P. (2014). Diagnostic Processes and Disclosure: A survey of Practitioners Diagnosing Cognitive Impairment. New Zealand Journal of Psychology. 43(2). 1-12.

Discussion

  • Perkins, C. (2004). Giving the news is a delicate art. New Zealand Doctor, 26 (p, 73)-

Sessions at a pace to suit the person and their family/whanau

No information about this

Prescribe treatments for dementia if appropriate and monitor

  • Ndukwe, H., & Nishtala, P. S. (2015). Temporal trends for donepezil utilization among older people. International Clinical Psychopharmacology. Advance online publication. doi: 10.1097/yic.0000000000000112
  • Ndukwe, H. C., & Nishtala, P. S. (2015). Donepezil adherence, persistence and time to first discontinuation in a three-year follow-up of older people. Dementia & Geriatric Cognitive Disorders Extra, 5(3), 482-491. doi: 10.1159/000441894
  • Suh, Guk., Hee., Wimo, A., Gauthier, S., O'Connor, D., Ikeda, M., Homma, A., Dominguez, J., & Yang, B. M. (2009). International price comparisons of Alzheimer's drugs: A way to close the affordability gap. International Psychogeriatrics, 21(6):1116-26. doi: 10.1017/S104161020999086X.
  • Perry, N. S. L., Bollen, C., Perry, E. K., & Ballard, C. (2003). Salvia for dementia therapy: Review of pharmacological activity and pilot tolerability clinical trial. Pharmacology, Biochemistry and Behavior, 75(3), 651-659.http://www.ncbi.nlm.nih.gov/pubmed/12895683

Ensure CVD factors assessed and treated

Should be part of assessment (via Pathways) but do CVD factors get treatment?

Review prescribed medicines

  • Salahudeen, M. S., Duffull, S. B., & Nishtala, P. S. (2014). Impact of anticholinergic discontinuation on cognitive outcomes in older people: A systematic review. Drugs & Aging, 31(3), 185-192.

http://www.ncbi.nlm.nih.gov/pubmed/?term=Impact+of+anticholinergic+discontinuation+on+cognitive+outcomes+in+older+people%3A+A+systematic+review

  • Bloomfield, K ; John, N ; McGrogan, A ; Jones, R ; de-Vries, C. (2010) Co-Prescribing of Medications with Anticholinergic Properties to Those Using Cholinesterase Inhibitors for Dementia 26th International Conference on Pharmacoepidemiology and Therapeutic Risk Management. Aug 2010. Identifier:

Ensure medicines organised so easy to take

Could be a dissertation topic for a pharmacy student?

Encourage person to maintain usual lifestyle and social activities

  • Aldrich R (2009) Appraising DSM against recovery philosophies Appraising the Diagnostic and Statistical Manual against Recovery philosophies in elderly dementia Aotearoa, New Zealand Social Work Review; Spring Vol. 21 Issue 1/2, p22 (looking at psychosocial modes of rehabilitation)

Give information about living healthy lifestyle

Ensure person with dementia and family / whanau receive a resource pack

Research on how people receive the diagnosis, what they are told and what information and early follow-up they are given would be interesting.

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EARLY INTERVENTION AND ONGOING SUPPORT

Aim: The aim is to encourage people with a recent diagnosis of dementia to participate in ongoing culturally appropriate support that is tailored to meet their needs and maximise their abilities and independence. When and how a person wants to engage with health and social support services is their decision, but the aim is to make the opportunity to engage always available to them and give them and their families and whanau enough information and education to enable them to make appropriate decisions for as long as possible.

The aim is to help the person with dementia and their family and whanau navigate through the health and social system. Each person will have someone within their care team allocated the role of navigator. The person undertaking the navigator role will be responsible for providing advice, encouraging self-management, explaining the pathway, coordinating referrals and providing appoint of continuity, In most cases the role will be undertaken by a member of the person’s primary health care team where most of the population are enrolled for healthcare.

Good practice points

The person with dementia

Has a member of care team allocated as navigator

Receives education/ info. at their pace in their format

  • Byrd, M. (1990). The use of visual imagery as a mnemonic device for healthy elderly and Alzheimer's disease patients. American Journal Alzheimer’s Disease & Other Dementias, 5, 210-215.
  • Mullen, R., Howard, R., David, A., & Levy, R. (1996). Insight in Alzheimer's disease. International Journal of Geriatric Psychiatry, 11(7), 645-651.

1166(199607)11:7%3C645::AID-GPS366%3E3.0.CO;2-P/abstract

Palliative approach recognising dementia = life-limiting

Is this information given? Do people take this in at the time of diagnosis?

Assisted to engage with appropriate services

  • Melding, P. (2005) New Zealand’s psychiatry of old age services. Revisiting ‘the view from the bottom of the cliff’—have we made any progress since 1998? New Zealand Medical Journal 118 (1214) Page 1 URL: © NZMA
  • O'Connor, D., & Melding, P. (2006). A survey of publicly funded aged psychiatry services in Australia and New Zealand. Australian & New Zealand Journal of Psychiatry, 40(4), 368-373.

Thesis

 King, A. (2010) Creating sustainable home care services for older people

Identifier:
PhD Thesis. The University of Auckland.

Has their support needs assessed

  • Parsons, M., Senior, H., Mei-Hu Chen, X., Jacobs, S., Parsons, J., Sheridan, N., et al. (2013). Assessment without action; a randomised evaluation of the interRAI home care compared to a national assessment tool on identification of needs and service provision for older people in New Zealand. Health & Social Care in the Community, 21(5), 536-544. doi:10.1111/hsc.12045 http://www.ncbi.nlm.nih.gov/pubmed/?term=Assessment+without+action%3B+a+randomised+evaluation+of+the+interRAI+home+care+compared+to+a+national+assessment+tool+on+identification+of+needs+and+service+provision+for+older+people+in+New+Zealand.

Has functional ability assessed

Don’t know about this. Probably part of pathway.

The family and whanau

Receive education / info. at their own pace

Offered info. about broader concepts that could help manage over time

  • Wall, J. (2014). Being and being lost: Personal identity and dementia. In C. Foster, J. Herring, & I. Doron (Eds.), Law and ethics of dementia. (pp. 327-337). Oxford: Hart
  • Astell, H., Lee, H., & Sankaran, S. (2013). Review of capacity assessments and recommendations for examining capacity. New Zealand Medical Journal, 126(1383), 38-48.
  • Gallrach, F., Kirk, R., Hornblow, A., & Croucher, M. (2009). Quality of life in dementia: Money matters. Alzheimer's & Dementia: The Journal of the Alzheimer's Association, 5(Supplement), 91-92. doi:10.1016/j.jalz.2009.05.239

Assisted to connect with dementia support organisations

Made aware dementia = chronic, life limiting condition but there are positive aspects.

  • Pollock, M., & Hornbrook, R.W. (1966).The prevalence, natural history and dementia of Parkinson’s Disease. Brain, 89(3), 429-448.

The navigator

Member of person with dementia’s care team

Works closely with primary health

Qualities of navigator listed

Maintains contact with PWD and family / whanau after diagnosis

Continues to discuss, educate ad encourage PWD re future plans, healthy lifestyle, continuing daily activities

  • Van Dijkhuizen, M., Clare, L., & Pearce, A. (2006). Striving for connection: Appraisal and coping among women with early-stage Alzheimer's disease. Dementia: The International Journal of Social Research and Practice, 5(1), 73-94.
  • Clare, L., Rowlands, J. M., & Quin, R. (2008). Collective strength: The impact of developing a shared social identity in early-stage dementia. Dementia, 7(1), 9-30. doi: 10.1177/1471301207085365.

Supported by other health practitioners and social support sectors

Recognises when specialist knowledge needed

  • O'Connor, D., & Melding, P. (2006). A survey of publicly funded aged psychiatry services in Australia and New Zealand. Australian & New Zealand Journal of Psychiatry, 40(4), 368-373.

Transfer info. to any new navigator.

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