Joint guidelines for the general hospital on the diagnosis of dementia, placement decisions, capacity
assessment and the referral of patients with dementia to Adult Social Care / Adult Services and Older
People’s Mental Health
Reference Number
TBC
Version
2
Name of responsible (ratifying) committee
Medicine for Older People Divisional Policy Group
PHT Ratifying Committee
Date ratified
07/12/2011
Document Manager (job title)
William Cutter - Consultant OPMH, Southern Health
NHS Foundation Trust
Date issued
19/12/2011
Review date
December 2012
Electronic location
Clinical Guidelines
Related Procedural Documents
Key Words (to aid with searching)
Diagnosis, dementia, placement decisions, capacity
assessment, referral, patients, Adult Social Care,
Adult Services, Medicine for Older People, Older
People’s Mental Health
Diagnosis of dementia Draft 10.08.2009 (review date TBC)
Page 1 of 12
CONTENTS
QUICK REFERENCE GUIDE....................................................................................................... 3
1. Introduction ……………………………………………………………………………………………….4
2. Purpose ……………………………………………………………………………………………………..4
2.1. Diagnosing Dementia .......................................................................................................... 4
3. Placement Decisions / Continuing Healthcare assessments ........................................................ 5
4. Mental Capacity Act / Best Interests Decisions ............................................................................ 6
APPENDIX A …………………………………………………………………………………………8
Flowchart for the diagnosis of dementia…..……………………………………………………...........8
APPENDIX B …………………………………………………………………………………………………..9
Checklist for the Review and Ratification of Procedural Documents……………………………. 9
APPENDIX C…………………………………………………………………………………………………..11
Equality Impact Assessment………………………………………………………………………. ..11
Diagnosis of dementia Draft 03.07.2009 (review date TBC)
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QUICK REFERENCE GUIDE
This policy must be followed in full when developing or reviewing and amending Trust procedural
documents.
For quick reference the guide below is a summary of actions required. This does not negate the need
for the document author and others involved in the process to be aware of and follow the detail of this
policy.
1. Patients with cognitive impairment may be already known to an Older People’s Mental Health
(OPMH) team (or in the case of someone with a learning disability (LD) the LD team). A
phone call to the relevant OPMH or LD team will provide this information. The OPMH team
can then fax relevant documentation.
2. Before diagnosing dementia, delirium should be excluded.
3. Consultant geriatricians and consultant physicians can make diagnoses of dementia in
straightforward cases where they feel confident to do so. Adult Social Care Adult Services
(Hampshire County Council) and (Portsmouth City Council) ASC/AS have agreed to accept
these diagnoses.
4. If an OPMH assessment is required, this can occur either as an inpatient, or where the issues
are not urgent the OPMH team may assess the patient as an outpatient.
5. Where there are issues that require OPMH input, provided the OPMH assessment is unlikely
to substantially alter the outcome for the patient, then the ASC/AS assessment should
proceed while the OPMH assessment is awaited.
6.
In some situations, particularly where the OPMH assessment may substantially alter the
outcome for the patient (e.g. uncertain diagnosis, severe behavioural issues) and therefore
the nature of the package of care that will be suitable for the patient, the ASC/AS assessment
may need to occur after the OPMH assessment.
7. Where someone has LD and a suspected dementia, the LD team should always be involved
in the assessment.
8. OPMH assessment may sometimes be required to supplement the Healthcare Needs
Assessment, especially where there are significant mental healthcare needs or where the
outcome of the OPMH assessment may affect the type of placement sought. The OPMH
team are not able to say what kind of placement is required, they are only able to comment on
the mental health risks and needs that the person has.
9. The OPMH team will usually only contribute to Continuing Healthcare assessments where
they are actively involved already with the patient. Where there are significant mental health
needs, OPMH advice may be sought.
10. Where decisions are being made in someone’s best interests who lacks capacity, where
possible multiple decision makers should be involved. Ultimately a ‘decision maker’ needs to
take responsibility for the decision: in the case of healthcare decisions this is the consultant
responsible for the patient, for social care decisions, this is the ASC/AS care manager for the
patient.
11. The medical team looking after the patient needs to make an initial assessment of capacity.
OPMH can provide a second opinion about mental capacity where capacity assessment is
complex or capacity uncertain.
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1.
Introduction
There are often occasions when people with dementia will require an assessment by Adult
Social Care (Portsmouth City Council) or Adult Services (Hampshire County Council) ASC/AS,
whether with a view to a package of care at home, or to placement. An OPMH (older person’s
mental health) assessment may in some cases be required before ASC/AS can assess the
patient, but in many cases may either not be necessary at all, or the referral can be made at the
same time as a referral to ASC/AS, and often OPMH could see the patient after discharge.
Sometimes an outpatient or home assessment by OPMH can be more useful than one in
hospital, as a better picture of the functioning of the patient can be obtained. Some doctors in
Portsmouth Hospitals Trust have the expertise to make some diagnoses of dementia. ASC/AS
will accept these diagnoses of dementia, provided the diagnostic procedure follows the
guidelines below. These guidelines set out under what circumstances doctors in PHT can
make a diagnosis of dementia, when an OPMH assessment is necessary prior to referring to
ASC/AS, and when an OPMH referral can occur at the same time as a ASC/AS referral.
2.
Purpose
These guidelines have been developed jointly between Portsmouth Hospitals Trust, Southern
Health NHS Foundation Trust, Primary Care Trusts within SHIP, Solent NHS Trust, Hampshire
County Council, Portsmouth City Council. They are designed to guide hospital medical and
nursing teams in the diagnosis of dementia and the referral of people with dementia to OPMH
teams and to ASC/AS teams. They set down who can make a diagnosis of dementia that will
be acceptable to ASC/AS teams. They also provide guidance as to the process for assessing
mental capacity and when to refer people for a second opinion regarding mental capacity to
OPMH. They further provide guidance with regard to the role of OPMH in Continuing
Healthcare Assessments.
2.1
Diagnosing Dementia
2.2 In all cases of cognitive impairment, the doctor looking after the patient should ensure that
delirium has been excluded. If present, the underlying cause should have been treated and the
delirium has resolved as far as possible before referring either to ASC/AS and/or OPMH. The
delirium guidelines outline this process (HYPERLINK HERE).
2.3 Where there is cognitive impairment in the absence of delirium (established by collateral history,
patient observation by the ward team, and an approved cognitive test, e.g. MMSE), firstly the
ward doctors should ensure that the patient is not already known to OPMH services. This can be
done by the ward clerk or team member contacting the OPMH secretaries for the area. The back
of the OPMH referral form gives these telephone numbers. The teams are organised according
to which GP practice the patient is under. Where the patient is known, a diagnosis of dementia
may already have been made, and relevant letters and documentation can be faxed to the ward
team. A referral can then be made to ASC/AS
2.4 Where dementia is suspected in someone with a learning disability, a dementia diagnosis may
have already been made by the Learning Disability Consultant Psychiatrist. Whether the person
has had contact with the local Learning Disability team can be checked by contacting the
appropriate team. ASC/AS’ own specialist Learning Disability Teams may also be able to provide
some information. It is advisable to seek specialist learning disability advice due to the
complexities of the dual diagnosis of a LD and a dementia, along with the difficulty of assessing
and diagnosing dementia in someone who already has a long standing cognitive impairment.
2.5 If the patient does not already have a diagnosis of dementia from an OPMH team, the consultant
in charge of the patient’s care may make a diagnosis of dementia, (provided a collateral history
has been obtained where possible and an MMSE or similar test has been performed, and
delirium excluded) under the following circumstances:
Diagnosis of dementia Draft 03.07.2009 (review date TBC)
Page 4 of 12
a)
b)
In straightforward cases of Alzheimer’s disease, vascular dementia and Lewy Body
dementia, a consultant geriatrician or neurologist may make the diagnosis
In straightforward cases of Alzheimer’s disease and vascular
dementia, a consultant physician may make the diagnosis.
2.6 Once such a diagnosis has been made, a referral can be made to ASC/AS. These diagnoses will
be accepted by ASC/AS. On the form, it is very important to give details to ASC/AS about why an
OPMH assessment is not needed or why not essential to the ASC/AS assessment and can wait
(and, if thought more suitable for an outpatient assessment, why).
2.7 When a physician makes the diagnosis of dementia – it is very important that they discuss the
diagnosis with the patient (where appropriate) and / or with the carers, and document that this
discussion has taken place. Although people are often reluctant to discuss a diagnosis of
dementia with patients / carers, there is good evidence to suggest that the diagnosis, sensitively
given, is not badly received. In many respects it is no different from breaking the news regarding
other serious illnesses.
2.8 A new diagnosis of dementia must always be communicated to the patient’s GP.
2.9 Where a diagnosis of dementia has been made, there is likely to be a need for ongoing follow up
from OPMH services (or Learning Disability services depending on the individual). It is important
to identify new cases of dementia opportunistically while patients are being treated for other
conditions, and where appropriate, the OPMH service is keen to provide assessment and follow
up after discharge. For example in a new case of mild dementia, it may be appropriate for the
medical team to refer for an outpatient assessment by the OPMH team (there is a box on the
referral form to tick for this).
2.10 However there will also be occasions when no OPMH referral is necessary – for example in a
case of severe dementia where physical needs predominate, there are no behavioural problems
and where nursing home placement is proposed. In such cases, where a physician has made the
diagnosis of dementia and no OPMH referral is being made, the GP should be informed and may
refer to OPMH in the future if the need arises. The relevant consultant or their colleague in
OPMH will be happy to discuss cases on the telephone where there is uncertainty.
2.11 If there are also low level mental health needs (e.g. co-morbid mild behavioural problems,
mild psychiatric problems, issues over whether the patient needs a CPN once discharged or
whether they may benefit from acetylcholinesterase inhibitors) that require an inpatient
assessment by OPMH, then the referral to and assessment by ASC/AS can proceed while the
OPMH team is awaited, as these needs are unlikely to substantially alter the assessment of
ASC/AS. Where needs that will impact on care provision are likely to change, an OPMH
assessment may be required first (see 4 below).
2.11 Under certain circumstances, there will be a need for an OPMH assessment before the ASC/AS
referral / assessment can go ahead. These are:
i)
ii)
2.12
The diagnosis remains uncertain (e.g. still uncertain whether there is a sub-acute
delirium despite efforts to rule this out, uncertain type of dementia, possible rarer type
of dementia e.g. fronto-temporal, ?depressive pseudo-dementia).
Co-morbid significant behavioural problems or mental illness (e.g. depression /
psychosis) – these may respond to treatment by OPMH and therefore could affect the
outcome of an ASC/AS assessment.
Where the patient has a learning disability and dementia is suspected,
LD services should always be involved in making the diagnosis.
2.13 In the unusual situation where a person under the age of 65 is suspected of having a
dementia, the referral should be made as usual to the OPMH team rather than the adult mental
health team.
Diagnosis of dementia Draft 03.07.2009 (review date TBC)
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3.
Discharge Decisions (see PHT Discharge Policy – INSERT HYPERLINK HERE)
3.1
The presently used PHT Healthcare Needs Assessment is a useful tool to help ASC/AS and
the family to make placement decisions, as well as a useful part of the handover to care
homes, and supplement to the ASC/AS panel form.
3.2
Straightforward decisions requiring a very small package of care do not need the PHT
Healthcare Needs Assessment to be filled out – the Social Worker/Care Manager can make the
decision with the family.
3.3
In more complex cases, where a more significant package of care or placement is required, the
Healthcare Needs Assessment may be filled out and a Continuing Healthcare Checklist may be
needed (discuss with ASC/AS).
3.4
An OPMH assessment may be needed to supplement the Healthcare Needs Assessment
under the following circumstances:
If the Healthcare Needs Assessment identifies a significant and challenging mental health
need
ii) The MDT feel there may be potential for improvement with treatment which may influence the
placement decision
i)
3.5 Discharge decisions will be informed by the multidisciplinary team in consultation with the patient
and their carers/family, however ultimately the decision lies with ASC/AS or the Continuing
Healthcare Team. Therefore clinical teams should not pre-empt the decision about the discharge
destination (e.g. by saying “your mother needs a nursing home”) as the final decision may be
different.
3.6 People with dementia or other mental health care needs do not necessarily require EMI (now
called: ‘care home with dementia’ or DE (dementia) placement etc) placement, non-dementia /
mental health. However, if the reason for placement results from the dementia, then the
placement must be DE or MD (mental disorder) registered. It is only if the physical needs
substantially outweigh the DE/MD needs that an OP (older person’s) placement should be
considered.
3.7 It is not acceptable for clients to be placed in OP homes that cannot fully meet their needs
because that is the only bed available.
3.8 The Healthcare Needs Assessment should be used as part of the handover to care homes.
4.
Continuing Healthcare assessments
3.9
For Continuing Healthcare assessments, the ward team will usually be best placed to fill in
the Mental Health Needs Nursing Assessment; an RMN background is not necessary to fill out this
document.
OPMH may contribute if they are currently actively involved. For example if a
community mental health nurse (CMHN) has a patient on their caseload, they may advise the ward
team on aspects of their mental health problems (and sometimes to attend a meeting to help fill in
the Decision Support Tool). There is an expectation in the Continuing Care process that where
there are needs in relation to cognition, that “active thought should be given to a referral to an
appropriate specialist”. If this is not considered necessary, there is an expectation that a “record” is
made regarding ”the reason for the decision not to refer.” Where there are significant mental health
needs, or where any member of the multi-disciplinary team feel they need advice about the
individual’s mental needs/management, the OPMH team may contribute to the assessment
process.
Diagnosis of dementia Draft 03.07.2009 (review date TBC)
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4
Mental Capacity Act / Best Interests Decisions
4.1
The official Portsmouth Hospitals Trust paperwork for recording MCA assessments / best
interests decisions is located at INSERT HYPERLINK HERE. Mental capacity assessments
and best interests decisions must be documented on the correct forms.
4.2
Multiple decision makers are allowed and encouraged to be involved in mental capacity
assessments, best interests decisions and particularly decisions about IMCA referrals (e.g. the
social worker and one or two members of the MDT).
4.3
The Social Worker or Continuing Healthcare Team should take the lead when placement and
funding decisions are required (the ‘decision maker’ in MCA terms).
Where decisions are about healthcare treatment, the decision maker is the consultant
responsible for the patient. If the decision maker is uncertain about capacity, verbal discussion
should be encouraged, and if required, verbal discussion with the OPMH team should be
sought.
4.4
An exception to the above is where a patient lacking capacity has a valid and applicable health
and welfare lasting power of attorney, in which case the attorney makes the decision on behalf
of the patient
4.5
Referral to OPMH for assessment of capacity and/or to contribute to the best interests decision
making process is only needed when the assessment is very complex and there are particular
mental health needs (for example depression, delusions etc). OPMH will not accept referrals
such as ‘? has capacity to decide on accommodation’ where no assessment of capacity has
been made by any member of the MDT. OPMH may provide a second opinion where there is
disagreement between parties about capacity.
4.6
In general, the Mental Capacity Act applies first in most situations, however where the condition
is not transient, then the Deprivation of Liberty Safeguards or Mental Health Act may be
required.
Definition: The term Adult Social Care (ASC) refers to the department formerly known as Social
Services Department for Portsmouth City Council. The term Adult Services (AS) similarly refers
to the former Social Services Department for Hampshire County Council. Throughout the
document the abbreviation ASC/AS will therefore be used.
Glossary of Terms:
Dementia – a group of disorders that are characterised by progressive cognitive decline (e.g.
memory loss) and functional impairment. Dementia includes disorders such as Alzheimer’s
disease, Vascular dementia and Lewy Body Dementia.
Delirium – a temporary state of impaired consciousness, characterised by a wide variety of
symptoms including confusion, fluctuating conscious level and hallucinations. Delirium is caused
by an underlying physical condition of some kind (commonly an infection or medication side
effects) and resolves once the underlying condition is successfully treated.
Cognitive impairment – an impairment of the processes of thought and memory. This can include
a wide variety of symptoms, but commonly manifests in impairment of short term memory,
concentration and ability to find one’s way around.
Learning disability – ‘a state of arrested or incomplete development of mind'. Somebody with a
learning disability is said also to have 'significant impairment of intellectual functioning' and
'significant impairment of adaptive/social functioning’.
Diagnosis of dementia Draft 03.07.2009 (review date TBC)
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APPENDIX A
Patient with
cognitive
impairment
Exclude delirium:
blood etc
investigations,
collateral history +/CT scan
Meets criteria for dementia?
Yes
Y
e
s
Y
e
known s
Consider other
causes e.g. Mild
N
o Cognitive
Impairment,
depression etc
Already
to
OPMH?
(phone
relevant secretary /
check if known)
No
Get copies of
letters/assessments
faxed
Consultant physician
reviews available
information
Consultant
physician able to
make diagnosis
Dementia subtype
uncertain or severe
behavioural / psychiatric
issues
Other issues e.g. ?AChE inhibitors, mild
behavioural / psychiatric disturbance, ?needs
CPN etc: ASC/AS assessment goes ahead
while waiting for OPMH assessment
OPMH assessment
ASC/AS referral for
assessment
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APPENDIX B
Checklist for the Review and Ratification of Procedural Documents and
Consultation and Proposed Implementation Plan
To be completed by the author of the document and attached when the document is submitted for ratification: a
blank template can be found on the Trust Intranet. Home page -> Policies -> Templates
CHECKLIST FOR REVIEW AND RATIFICATION
TITLE OF DOCUMENT BEING REVIEWED:
1
2
3
4
5
Title
Yes
Is the title clear and unambiguous?
Yes
Will it enable easy searching/access/retrieval??
Yes
Is it clear whether the document is a policy, guideline, procedure,
protocol or ICP?
Yes
Introduction
Yes
Are reasons for the development of the document clearly stated?
Yes
Content
Yes
Is there a standard front cover?
Yes
Is the document in the correct format?
Yes
Is the purpose of the document clear?
Yes
Is the scope clearly stated?
Yes
Does the scope include the paragraph relating to ability to comply,
in the event of a infection outbreak, flu pandemic or any major
incident?
No
Are the definitions clearly explained?
Yes
Are the roles and responsibilities clearly explained?
Yes
Does it fulfill the requirements of the relevant Risk Management
Standard? (see attached compliance statement)
N/A
Is it written in clear, unambiguous language?
Yes
Evidence Base
N/A
Is the type of evidence to support the document explicitly
identified?
N/A
Are key references cited?
N/A
Are the references cited in full?
N/A
Are associated documents referenced?
N/A
No
Yes
Dissemination and Implementation
Is a completed proposed implementation plan attached?
7
Yes
Review Date
Is the review date identified?
6
Not relevant
Process to Monitor Compliance and Effectiveness
Are there measurable standards or KPIs to support the monitoring
of compliance with the effectiveness of the document?
7
COMMENTS
Approval Route
Does the document identify which committee/group will approve it?
6
YES/NO
N/A
No
Equality and Diversity
Is a completed Equality Impact Assessment attached?
Diagnosis of dementia Draft 03.07.2009 (review date TBC)
Yes
Page 9 of 12
APPENDIX B
cont……
Checklist for the Review and Ratification of Procedural Documents and
Consultation and Proposed Implementation Plan
CONSULTATION AND PROPOSED IMPLEMENTATION PLAN
Date to ratification committee
Groups /committees / individuals involved in the
development and consultation process
Initial special committee of interested parties
to develop guidelines on 27/08/08, attended
by representatives from Portsmouth City
Adult Social Care, Hampshire County Council
Adult Services, Portsmouth Hospitals Trust,
Hampshire Partnership NHS Foundation
Trust, Portsmouth City Teaching Primary
Care Trust, Hampshire Primary Care Trust.
Present: Dr Bill Cutter (Co-chair and
Consultant Old Age Psychiatrist, HPT), Dr
Carol Trotter (Co-chair and Consultant Old
Age Psychiatrist, PCPCT), Gill Gould (), Dr
Claire Spice (Consultant Geriatrician, PHT),
Leslie Humphrey (Divisional Manager,
DMOP, PHT), Olive Brown (Hospital
Discharge Team), Michelle Ennis (HPCT),
Pauline Mundy (Team Leader, Hospital
Team, HCC), Liz Leray (Team Leader,
Hospital Team, PCC), Dr Ed Neville (DCD
Medicine), Dr Zoe Hemsley (Consultant
Geriatrician, PHT). Subsequently all parties
have agreed the present version of
guidelines.
Department of Medicine for Older People
Consultants’ Meeting approved the document
12/10/09
Vulnerable Adults and Older Persons’
Committee 06/11/2009
Version 2 – meeting of interested parties on
15/04/11 to revise guidelines: attended by: Dr
Cutter (Southern Health NHS Foundation
Trust), Diane Wilson (NHS Hampshire),
Gemma Rainger (NHS Portsmouth), Paula
Hardy (Portsmouth City Adult Social Care),
Julia Lake and Dr Zoe Hemsley (Portsmouth
Hospitals Trust), Liz Hierons-Leith (Solent
NHS Trust), Nadia Martin (Hampshire County
Council Adult Services Department).
Is training required to support implementation?
Yes
If yes, outline plan to deliver training
Dr Cutter to present document to relevant
physicians and social workers
Outline any additional activities to support
implementation
Diagnosis of dementia Draft 03.07.2009 (review date TBC)
Page 10 of 12
Individual Approval
If, as the author, you are happy that the document complies with Trust policy, please sign below and send the document,
with this paper, the Equality Impact Assessment and NHSLA checklist (if required) to the chair of the committee/group
where it will be ratified. To aid distribution all documentation should be sent electronically wherever possible.
Name
Dr William Cutter
Date
Signature
Committee / Group Approval
If the committee/group is happy to ratify this document, would the chair please sign below and send the policy together with
this document, the Equality Impact Assessment, and NHSLA checklist (if required) and the relevant section of the minutes
to the Trust Policies Officer. To aid distribution all documentation should be sent electronically wherever possible.
Name
Date
Signature
If answers to any of the above questions is ‘no’, then please do not send it for ratification.
Diagnosis of dementia Draft 03.07.2009 (review date TBC)
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APPENDIX C
EQUALITY IMPACT ASSESSMENT
To be completed by the author of the document and attached when the document is submitted for
ratification: a blank template can be found on the Trust Intranet. Home page -> Policies -> Templates
Title of document for assessment
Joint guidelines on the diagnosis of dementia,
placement decisions, capacity assessment and the
referral of patients with dementia to Adult Social
Care / Adult Services and Older People’s Mental
Health
Date of assessment
12/01/10
Job title of person responsible for assessment
Consultant Old Age Psychiatrist
Division/Service
Department of Older People’s Mental Health, Hampshire
Partnership NHS Foundation Trust
Yes/No
Comments
Does the document affect one group less or more favourably than another on the basis of:

Race

Gender (including transgender)

Religion or belief


Sexual orientation, including lesbian, gay and
bisexual people
Age (for HR policies only)
No
No
No
No
No
Disability – learning disabilities, physical
disabilities, sensory impairment and mental
health problems
No
Does this document affect an individual’s human
rights?
No

If you have identified potential discrimination,
are the exceptions valid, legal and/or justified?
If the answers to any of the above questions is ‘yes’ you will need to complete a full Equality Impact
Assessment (available from the Equality and Diversity website) or amend the policy such that only an
disadvantage than can be justified is included. If you require any general advice please contact staff
in the Equality and Diversity Department on 02392 288511
Diagnosis of dementia Draft 03.07.2009 (review date TBC)
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