Dementia

Introduction

The Mental Capacity Act is designed to protect patients who may lack the mental capacity to make decisions about treatment. At the Nuffield Orthopedic Centre (NOC) in Oxford, nurses obtain a baseline AMTS during the pre-operative assessment clinic. Following on from this, any patient over 64 years old that is seen by the orthogeriatrics team will have a post-op AMTS done to assess for cognitive impairment. If the AMTS is less than 8, or the patient is clinically believed to be delirious, then an MCA form will be completed for the decision to accept treatment. The aim of this QI project was to widen this practice to all the junior doctors at the NOC.

Method

AMTS and MCA data were collected from one month of inpatients >64 years old at the NOC. The AMTS were analysed and the patients with post-op AMTS of <8 were identified and checked for MCA form completions. The data was presented to junior doctors at the NOC, and a repeat cycle was performed to assess if the practice was being implemented.

Results

Data collected from 10/01/23 – 10/02/23 (n=125) showed that out of 10 patients meeting the AMTS criteria, only 4 had MCA forms completed. Once the QI projected was presented on 25/05/23, data collected from 12/06/23 – 15/07/23 showed that out of 5 eligible patients, 4 of them had MCA forms completed.

Conclusion

Prior to this QI project, only 40% of eligible patients from the collected data were having MCA forms completed by junior doctors at the NOC. Following the presentation to raise awareness, the data collected shows that this figure had increased to 80%. In conclusion, this QI project has been a success and should be repeated every 4 months to account for each new rotation of junior doctors.

Background

Patients aged over 65 years old account for a significant proportion of the attendances to emergency departments (EDs). Cognitive impairment (CI), including delirium and dementia, can be a common finding in this population and when undiagnosed, can be a significant contributor to morbidity and mortality. Our aim is to audit, against clinical standards, the assessment of cognitive impairment in those aged over 65 in the Birmingham City Hospital ED.

Standard

1. All patients aged over 65 are assessed for CI in ED, using a validated tool.
2. Whenever CI has been identified, there is documented evidence that this information was included in the ED discharge letter.

Methods

A retrospective pre- and post-intervention audit method was used. Intervention included educational posters displayed amongst clinical areas within the ED and raising clinician awareness on the topic during clinical handovers and educational teaching sessions.

Results

In the pre-intervention period, 7 out of a total of 240 (2.9%) patients had written evidence of a cognitive assessment using a validated tool and this improved to 13 out of a total 100 patients (13%) in the post-intervention period. AMTS was found to be the most common tool used. Communication of any identified cognitive impairment to GP increased from 0 out of 4 identified patients (0%) in pre-intervention period to 3 out of 6 patients (50%) post-intervention.

Conclusion

Despite the potential significant impact of cognitive impairment in older people, there is very little documented evidence of cognitive assessment within our emergency department. We demonstrate an improvement in this following intervention. However, the proportion of cognitive assessments being done remains low.

Introduction: Anti-psychotics and benzodiazepines are commonly prescribed for older people. They are usually indicated in the short term for delirium and agitation. There are known risks associated with these drugs in the older population including functional decline, increased falls risk and overall mortality. Moreover, chemical sedation is a form of restraint and deprives patients of their liberty. Sedative prescribing should be protocol driven and preceded by non-pharmacological intervention. However, these prescriptions are often initiated prematurely and evade review, continuing in the long-term.

Method: Our QI team aimed to reduce prescribing of new sedating drugs by 60% in patients using an MDT approach. Our strategies focused on increasing awareness and utilisation of existing protocols, to improve non-pharmacological management of delirium. This was achieved through the strategic delivery of teaching sessions for nursing, pharmacy and medical staff. Further, we utilised force function techniques and management charts to encourage review of these prescriptions. We gathered our data on a weekly basis over a five-month period by reviewing all prescribed medicines for patients on an older people’s ward.

Results: We exceeded our initial aim achieving a reduction of 82% in the prescribing of new lorazepam and haloperidol. We also attained a significant and sustained uptake of over 95% in the use of the delirium protocol. Where a review sticker was used, 80% led to discontinuation of the target prescription. Although these improvements were focused on one ward, the wider changes and improvements were observed throughout the hospital.

Conclusion: The significant reduction in sedative prescribing demonstrates the need and potential for improving the quality and safety of this aspect of patient care. The wider success of this project highlights the importance of addressing human factors to drive and sustain change. Improving the understanding of MDT members is integral to changing behaviours and improving patient safety.

During the pandemic, diagnosing Dementia has declined significantly by over 35%. A Collateral history refers to information obtained from individuals other than the patient, such as family members, friends, or caregivers. This information is often crucial and can provide valuable insights into a patient's medical history, symptoms, behaviours, and social circumstances. Studies have proven a collateral history can enhance medical assessment, improve treatment planning, aids safety concerns and act as a diagnostic aid. By obtaining information from multiple sources, Doctors can compare the patient's account with the observations and experiences of others. This can help in corroborating or identifying discrepancies, leading to a more accurate diagnosis. 

A convenient sample of 20 patients investigating the benefit of a collateral history using it as enhanced information to aid diagnosis of dementia earlier, and in turn, commencing treatment earlier.  

Results showed the collateral history provided more information enabling diagnosis of a delirium or a diagnosis of dementia. If it appeared the diagnosis was dementia, the information was relayed in a multiple disciplinary approach and with multidisciplinary agreement, treatment commenced. 

Early diagnosis of dementia is crucial as it allows for timely intervention, better disease management, and improved quality of life for both patients and their families. Collateral history aids in this process by capturing subtle changes in cognition and behaviour that may not be evident during routine clinical assessments. It provides a broader perspective on the patient's functioning over time and helps differentiate between normal aging and pathological cognitive decline. 

It is important to consider the collateral history limitations as a tool and use it in conjunction with other diagnostic tools to ensure an accurate and comprehensive evaluation.  

Introduction:

A scoping exercise in a residential dementia care home identified high numbers of falls occurring in residents’ bedrooms at night. Assessment and reduction of risk was often difficult since many falls were unwitnessed, and residents had poor recall. Collaborative working between Lewisham Community Falls Service (CFS); and Lewisham Linkline Service; involved the use of the ‘Just Checking’ monitoring system to enhance multifactorial falls assessment.

Method:

The Occupational Therapist (OT) in the CFS completed an initial multifactorial falls assessment. This helped to determine if data on night-time activity would be beneficial. This was discussed with care home staff and patient’s family prior to installation by the Telecare Specialist. The system was left insitu for four weeks with regular analysis of data by the OT and Telecare Specialist.

Results:

Resident A was a new admission with a recent dementia diagnosis and an injurious fall at home. 'Just Checking' was installed to monitor night time orientation and if he used his walking aid. He was refusing to keep a light on and was resistant to staff entering his room for checks. 'Just Checking' data guided intervention which included installation of motion centred lights. The resident started to use his walking aid at night without staff involvement. Resident B who had moderate to severe dementia, had demonstrated some challenging behaviours at night which increased his falls risk. 'Just Checking' data showed that he was restless throughout the night. This lack of quality sleep was identified as a key falls risk factor. Further exploration of his life story found that he had been a night worker for many years. Care home staff changed his day/sleep patterns. He experienced no further falls.

Conclusion:

Used as an adjunct to multifactorial falls assessment; ‘Just Checking’ can provide valuable data to understand falls risk and improve resident safety.

Introduction

People living with dementia and MCI progressively lose abilities, through increasing cognitive impairment, co-morbidities, inactivity, acute illnesses and injuries. Rehabilitation therapy may reduce disability and falls and increase resilience.

Methods

We co-produced a therapy intervention, comprising strength, balance and dual-task exercises, functional activity training and promoting community access, providing up to 50 therapy sessions, delivered over 12 months and underpinned by a behaviour change strategy. We evaluated the intervention in a 5-site multi-centred Randomised Controlled Trial, against a brief assessment control. Participants had a diagnosis of dementia or MCI, Montreal Cognitive Assessment (MoCA) between 13 and 25. Primary outcome was the Disability Assessment in Dementia (DAD), an ADL score, after 12 months, alongside a battery of other health status measures. The COVID-19 pandemic necessitated modifications.

Results

We recruited 365 participants, 42% female. Median age was 81 years (range 65-95), MoCA 20 (13-26), DAD 82 (5-100). Baseline balance between groups was good. Participants were predominantly white and socioeconomically advantaged. Intervention group participants received a median of 31 (IQR 22-40) session and undertook and additional mean 121 minutes of exercise per week. Assessed fidelity was good. 290 (79%) were followed up. There were no significant differences in DAD score (adjusted mean difference -1.3/100, 95% CI -5.2 to +2.6; effect size (d) -0.06; -0.26 to 0.15; p=0.5), physical activity, balance, quality of life, cognition or a range of other measures. Upper 95% confidence intervals excluded even small benefits. Rate of falling reduced by 22% (Rate Ratio=0.78; 0.46 to 1.3; p=0.3), but this was not statistically significant.

Conclusions

The intensive PrAISED intervention did not improve measured outcomes. It may be impossible to reduce the rate of functional decline in dementia. Alternatively, the pandemic may have distorted outcomes or participants may have been too advantaged to benefit. There may have been unmeasured psycho-social benefits.

Introduction: Scotland's National Dementia strategy (2017) highlights the need to improve identification and management of dementia. Hospital at Home (H@H) teams often identify undiagnosed cognitive decline as part of comprehensive geriatric assessment. A trainee ANP in dementia services was appointed in 2019 in West Lothian; before this, the average waiting time to memory clinic assessment was 6 months for a home visit, and 12 months for outpatient clinic review. Affiliated with REACT H@H, the ANP identified a significant unmet need for assessment of cognitive decline in a patient cohort referred to H@H.

Method: Baseline data from patients reviewed by the dementia ANP was collected between Sept 2021 – Feb 2022, including referrals from H@H. A new pathway was then introduced to streamline referrals including education and upskilling of the H@H team. Further data was collected between Sept 2022 – February 2023.

Results: In the first cohort, 161 patients were assessed by the Dementia ANP, of which 39 (24%) had been referred from H@H. 60 patients (37%) were seen as a home visit, and 101 (63%) in clinic. 2 (1%) of referrals were managed with advice only. 125 patients (78%) were given a diagnosis of dementia; other diagnoses included delirium, low mood and anxiety. In the second cohort, 168 patients were assessed by the Dementia ANP, 39 (23%) being referred from H@H. 94 (56%) were seen in clinic and 74 (44%) as home visits. 10 (6%) of referrals were managed with advice only. 138 (82%) were given a diagnosis of dementia. Time to diagnosis assessment of dementia was reduced to 1 month for home assessment, and to 4 months for outpatient clinic assessment.

Conclusion Appointment of a Dementia ANP and integration with H@H  services improves time to assessment and diagnosis of dementia. 

Introduction:

Cognitive impairment and dementia are prevalent in Parkinson’s disease (PD) and significantly impact patients’ quality of life. Accurate prognostic indicators of cognitive decline in this population are needed. Electroencephalography (EEG), a non-invasive measure of brain activity, is one such measure. The current study aimed to systematically review which EEG indices are associated with mild cognitive impairment (PD-MCI) and dementia in PD (PDD).

Method:

A systematic literature search was conducted in Embase, MEDLINE, PsycINFO and Web of Science in November 2022 to identify studies using EEG to assess cognition in PD-MCI and PDD.

Results:

Of the 1716 studies retrieved, 30 were eligible for inclusion. Spectral power in delta, theta, alpha, beta and gamma bands was most frequently investigated (n=13), followed by functional connectivity (n=9) and event related potentials (ERPs; n=6). Slowing of spectral power, characterised by global increases in delta and theta bands with a concomitant decrease in alpha and beta bands, was found in PD-MCI and PDD (n=11). Reduced functional connectivity between anterior and posterior regions was also associated with cognitive impairment in PD (n=2), together with decreased functional connectivity in the alpha band (n=9) in PD-MCI and PDD. However, two studies displayed normal functional connectivity of delta sources in PD-MCI and PDD respectively. ERP studies revealed deficits in attention and semantic processing associated with PD-MCI/PDD.

Conclusions:

This review demonstrates that slowing of EEG activity, reduced functional connectivity and aberrant ERPs are associated with PD-MCI and PDD. Study limitations include small sample sizes and discrepancies in the criteria used to define PD-MCI, together with the wide variety of EEG tasks, montages and analysis pipelines used between sites. Overall, this study highlights the potential application of EEG to predict and monitor cognition in PD. Further work should be undertaken to determine the sensitivity, specificity and prognostic value of these EEG indices.

Background:

Dementia with Lewy bodies (DLB) is one of the most common degenerative dementias, and it is associated not only with cognitive symptoms, but motor, neuropsychiatric, sleep and autonomic symptoms. There is increasing emphasis on the involvement of patients and their representatives in dementia research, but little is known about the extent and nature of surveys and qualitative research methods capturing the views of those affected by DLB. The objective of the scoping review is to determine the extent and nature of published literature that uses surveys and qualitative methods to elicit the views of people diagnosed with DLB and their care partners.

Methods:

The electronic databases MEDLINE ALL, EMBASE, CINAHL Plus, PsycINFO and Web of Science will be searched for relevant publications (from inception onwards). Papers using qualitative and survey-based research methods to investigate the view of patients and caregivers affected by DLB on any aspect of their healthcare or research will be included. Google Scholar and The Networked Digital Library of Theses and Dissertations will be searched for additional literature. The search strategy for published peer-reviewed articles will be limited to qualitative and survey-based study designs. Reviews, scoping reviews, narrative reviews, research reports, grey literature and editorial, reflection or perspective articles written by a person with DLB or their caregiver will be considered. An established methodological framework will guide the scoping review process. Two reviewers will independently screen all citations, full-text reports and abstract data. Data analysis will involve descriptive numerical analysis and qualitative content analysis.

Expected Outcomes:

It is anticipated that the extent of qualitative and survey-based research in this context is limited in quantity. It is expected that work will predominantly focus on the importance of post-diagnostic support and general information and support needs with relatively little work around individual symptoms, drug therapies or trials.

Introduction: With the anticipated rise in the annual number of dementia cases in Cardiff and the Vale of Glamorgan (C&V), improvements in dementia diagnosis rates are essential. However, barriers to accessing support still exist, precipitating delays in diagnosis and establishing appropriate interventions. This article aims to highlight potential barriers patients attending the C&V Memory Assessment Service (MAS) may face, as well as ascertain possible delays within diagnostic pathways of cognitively impaired patients.

Methodology: Demographic and primary data analysis was undertaken using a questionnaire. Data was collected in an outpatient setting at two hospitals in C&V. WCP supplemented additional information on patient referrals and memory appointments. Subsequent findings were reviewed.

Results: The C&V MAS received satisfactory feedback from 87.2% of patients, with negative comments surrounding the lack of awareness of support available in the community. 34.5% (n=19)of participants faced difficulties in accessing support. Barriers included stigma, the Covid-19 pandemic, language, delayed GP referrals to the MAS, transport, and parking. The survey discovered an underrepresentation of ethnic minority dementia patients attending the C&V MAS. 94.5% (n=52) of patients were of Caucasian ethnicity. The remaining patients (5.5%) who were from ethnic minority backgrounds reported facing language and/or stigma barriers in obtaining support. The average duration for patients to present to primary care where applicable was 6-12 months from cognitive symptom recognition.

Conclusion: It is evident that the data obtained is not an accurate representation of the overall C&V dementia population, due to sample bias. Educational and strategic interventions need to be implemented to target this issue as well as barriers identified to accessing care.