Care Cluster 19: Cognitive Impairment (Moderate need)
Description: People who have problems with their memory, and or other aspects of cognitive functioning resulting in moderate problems looking after themselves and maintaining social relationships. Probable risk of selfneglect or harm to others and may be experiencing some anxiety or depression.
Diagnosis: : Likely to include: F00 – Dementia in Alzheimer’s disease, F01 – Vascular dementia, F02 – Dementia in other diseases classified elsewhere, F03 – Unspecified Dementia, F09 – unspecified organic or symptomatic
mental disorder, Dementia with levy bodies (DLB), Front temporal dementia (FTD)
Review period: 6 months
Cluster Duration: 3 years (review every 6 months).
Duration: Long Term
Aim of Intervention: Once diagnosed time to discuss diagnosis and its implications and written information about the signs and symptoms, the course and prognosis of the condition treatments, local care services and support
groups, sources of financial and legal advice and advocacy, medico-legal issues and including driving. There will also be a look at managing behaviour and psychological symptoms of Dementia. Maximise functioning.
Assessment: Comprehensive assessment by Psychiatrist with expertise in differential diagnosis including full history of behavioural and psychological symptoms of dementia, cognitive assessment and mental state
examination, physical examination , CT scan and other appropriate diagnostic interventions, a review of medication to identify and minimise use of drugs that may adversely affect cognitive functioning, assessment of carer
strain, assessment of risk due care given to safeguarding and vulnerability issues including deprivation of liberty, assessment of co morbidity including depression and psychosis, formal neuropsychological testing in mild or
questionable dementia Assessment to. There will also be an at home assessment by a CPN/OT who will assess the level of functioning and any also discuss any carer strains. Assessment process may last up to 6 weeks)
(This template should be read in conjunction with latest Mental Health Clustering booklet Version 3.0 2013/14)
Function
Resource
Time
Frequency
Outcome
1.Treatment
Planning
Core Interventions
 Assessment to include mental & physical health and
treatment
 Provision of CT scan and interpretation of results
 Diagnostic clarification
 Diagnostic disclosure and support
 Diagnosis of subtype of dementia and formation of treatment
plan
 Management of physical and mental health co-morbidity
 Consider medication in line with NICE guidance
 Monitoring mental health/side effects of medication
 Prescription medication
 Review of risk
 Psychoeducation
 Carers support
 Developing care plan
 Assessment to determine level of functioning and assess
need for additional support
 Treatment to address immediate needs and risks but also
support longer-term engagement

Monitoring mental capacity
1 – 2 hours
1-2 sessions
30-1hours
weekly
every 4-6
weeks
Psychiatrist
Psychiatrist
CMHN
Psychiatrist
OT
OT/CMHN/Memory
Service Nurse
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Function
Resource
Supplementary Interventions
CMHN

Lead memory nurse



Assessment of carer/family (including dependants) needs
and signposting where appropriate
Referral to social care for additional input around activities of
daily living and social interactions
Monitoring of following shared care protocol
Monitoring of physical health and vascular risk factors
Time
Frequency
Outcome
Social worker
(dementia care
worker)
Lead memory nurse
Primary care
2: Delivery













3: Review (in line
with CPA policy)








Personalised care plan formulated
Discussion of diagnosis & its implications, including written
information with patient and carers
Ensure up to date and accessible information on
medications for patient and carers/families
Monitoring enabling and treatment adherence
Prophylactic interventions
Rehabilitation
Consider accommodation in relation
ADL/OT assessments
Lifestyle considerations
Liaise with team members for review as appropriate
including social services to including services to ensure
assessment of accommodation needs
Carer support
Risk assessment
Psych education
Review patients’ strengths, achievements and goals
including medication efficacy and compliance
Cluster review
Risk review
Accommodation
Contingency planning
Carer review
3rd Sector on-going support
Residential care and support
Case manager
`
CPN/HCSW/
Psychiatrist
1 hour
Weekly &
fortnightly
Psychiatrist
Memory service
Lead Nurse
30mins
½ hour
6-12 weeks
6 monthly or
earlier as
required
Psychiatrist
½ hour
Completed cluster review
Updated care plan and risk
assessment
Satisfaction questionnaire
Sharing of care plan with service
user/carers
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Function
4: Next steps
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
Specialist placement
DOLS , advance decisions
Mental capacity
Social support/ benefit review
LPA/welfare review
Promote self-esteem, empowerment and autonomy

Consideration of transfer of care to primary care setting
under SCA
Transfer to different cluster pathway provider- including
advance planning/joint working as needed
Manage ending and transition
Signposting for extended support
Re engagement discussed
Sign posting for on-going carer support
In case of deterioration consider re-clustering
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Resource
Time
Frequency
Outcome
HONOS at each review
Symptom rating scales
Care Coordinator/
Lead professional
Psychiatrist
Memory Service
Lead Nurse
As per
clinical
need
As per
clinical need
GP
Other agency or
professional as
needed
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