Dr Alan Cohen and his colleagues at the Care Services Improvement Partnership (CSIP) discuss the implications of the dementia clinical indicators in primary care
The 2006 amendment to the quality and outcomes framework (QOF2) of the GMS contract for primary care services introduced several new clinical domains, as well as amending some of the pre-existing clinical domains. With regards to the mental health domains, the mental health clinical indicators were updated, and two new domains — depression and dementia — were added.
The Care Services Improvement Partnership (CSIP) has produced best practice guidance for primary care staff related to the mental health domains. This has been serialised in Guidelines in Practice, and concludes this month with the dementia clinical domain. The mental health domain was featured in the November 2006 issue of the journal, and the depression domain appeared in December 2006.
Although designed for primary care clinicians so that they provide high-quality, evidence-based, essential services, this guidance will also be of interest to specialist mental health trust clinicians; a greater understanding of the level of care being provided in primary care should lead to improvements in the primary–secondary care interface. Dementia is a new domain, which consists of two indicators (Table 1). The first indicator creates a register of people with dementia, and the second incentivises the regular review of people with dementia. Together, the two indicators represent 20 points.
Table 1: Clinical indicators for dementia
|Disease indicator||Clinical indicator||
|DEM 1||The practice can produce a register of patients diagnosed with dementia||
|DEM 2||The percentage of patients diagnosed with dementia whose care has been reviewed in the previous 15 months||
The key roles for primary care are:1
- health promotion, and helping people to care for themselves and their condition more effectively
- recognising early signs of dementia
- formulating a care plan and providing ongoing support for the majority of patients, including support for family and carers
- referral to specialist services, as appropriate.
Primary healthcare staff should consider referring people who show signs of mild cognitive impairment (for example impairments in memory, language, planning, visuospatial, or other cognitive tasks) for assessment at memory assessment clinics to aid in early identification of dementia. This is important because more than 50% of people with mild cognitive impairment later develop dementia.2
A diagnosis of dementia should only be made after a comprehensive assessment consisting of history-taking, cognitive and mental state examination, physical examination, and appropriate investigations as discussed below.2
Clinical cognitive assessment in those suspected of having dementia should include examination of attention and concentration, orientation, short- and long-term memory, praxis, language, and executive function.
As part of this assessment, formal cognitive testing should be undertaken using a standardised instrument.
The Mini-Mental State Examination (MMSE) has been frequently used, but a number of alternatives are now available, such as the 6-Item Cognitive Impairment Test (6-CIT);3 the General Practitioner Assessment of Cognition (GPCOG);4 and the 7-minute screen.2,5
A basic dementia screen should be performed at the time of presentation, usually within primary care, and should include:2
- routine haematology tests
- erythrocyte sedimentation rate (ESR)/viscosity or C-reactive protein (CRP) measurement
- biochemistry (including electrolytes, calcium, glucose, renal and liver function tests)
- thyroid function tests
- serum vitamin B12 and folate levels.
Healthcare and social care practitioners should always seek valid consent from people with dementia. People with dementia should be given the opportunity to convey information to professionals involved in their care in a confidential manner. The practitioner should discuss the use of advance decisions to refuse treatment and lasting powers of attorney with the person with dementia while they still have capacity.2
Dementia may occur in younger people, i.e. under the age of 65 years. The risk of people with Down's syndrome developing Alzheimer's disease is high; and although this risk increases with age, the average age of onset is lower than for the general population.
Primary care staff should be aware of the specialist needs of younger people and people with learning disabilities who develop dementia. These groups of people need to be seen by a specialist who has experience of younger or disabled patients. Special equipment, for example aids to daily living, may also be required.
Indicator DEM 1
As with other registers in QOF2, the dementia register is much more akin to an 'electronic list', and requires the correct diagnosis (and diagnostic code) to be entered for the patient to be included in the register.
The Read codes recognised by QMAS and used to create a register of people with dementia are: Eu02.%, E00..%, Eu01.%, E02y1, E012.%, Eu00.%, E041., Eu041, F110. – F112., F116.
If there are individuals who should be excluded from the register the exclusion codes are 9hD0. and 9hD1. Exclusions are decided on an individual basis and relate to specific clinical concerns. If a patient asks to be excluded from the dementia register it is not necessary to withhold care, and sensitive discussion of the issues will usually resolve the problem.
Indicator DEM 2
A useful way to consider the content of a review is to consider a practice-based patient centred audit (PCA), which will address the needs of the individual, and determine who will deliver these needs.
People in contact with specialist mental health trusts (for example those who have been referred for investigation and treatment for a specific type of dementia, or those who have an underlying mental health condition, which needs specialist treatment) will have a care programme approach (CPA) document; many people have their care coordinated through the single assessment process. For those people not in contact with specialist services, the PCA allows the same principles to be reviewed.
The CPA documentation always includes the name and contact details of the key worker who is the first point of contact for patients who are in the care of specialist mental health teams.
For individuals who elect to remain under the care of their GP, and with whom a PCA plan is agreed, the GP is the equivalent of the key worker. It should be made clear that this does not mean that the GP is the key worker, or has the training to become a key worker, or is taking on the responsibility of a key worker. It means that the GP and the practice is the first point of contact for that patient as and when it is necessary.
The principles of either the CPA or PCA are exactly the same: an assessment of need, an agreement as to who can fulfil that need, and a review date (to complete the audit cycle). The CPA or PCA documents need the agreement of the patient (and/or their carer when appropriate) and should cover the following areas:
- physical health needs
- see screening tests above
- further review of long-term conditions as appropriate
- social care needs
- employment/meaningful daytime activity
- carers needs
- are there carers?
- are they registered with the same practice as the person suffering from dementia?
- contact details
- how to consider the needs of the carer(s)
Care plans need to be reviewed at least annually, when both the physical health needs, and broader psychological and social needs can be assessed.
The Read codes for having carried out a dementia review are: 6A6.., 8CM2., 8BM0., 8CR7., 3A... – these are recognised by QMAS.
Professor Jane Gilliard, Social Care Lead, Older People's Mental Health Programme, CSIP.
Ian McPherson, Director, CSIP West Midlands Development Centre.
Ruth Eley, National Programme Lead – Older People, CSIP.
Nadine Schofield, National Lead – Older People's Mental Health, CSIP.
Kate Hardy, Project Manager – Older People & Disability, Directorate of Care Services, Department of Health.
Debbie Nixon, National Programme Lead – Primary Care and Commissioning, CSIP.
- Health promotion, recognition of early dementia, care plan formulation, and ongoing support for patients and carers can be undertaken in primary care
- Patients with possible or suspected dementia should be referred to memory assessment clinics or community mental health teams
- Some areas may need to increase the number of memory assessment clinics to meet need
- Department of Health. Everybody's Business – integrating mental health services for older adults: a service development guide. London: DH, 2005. www.everybodysbusiness.org.uk
- National Institute for Health and Care Excellence and Social Care Institute for Excellence. NICE clinical guideline CG42. Dementia: supporting people with dementia and their carers in health and social care. London: NICE, 2006.
- Brooke P and Bullock R. Validation of a 6 item cognitive impairment test with a view to primary care usage. Int J Geriatr Psychiatry 1999; 14 (11): 936–940.
- Brodaty H, Pond D, Kemp N et al. The GPCOG: a new screening test for dementia designed for general practice. J Am Geriatr Soc 2002; 50 (3): 530–534.
- Meulen E, Schmand B, van Campen J et al. The seven minute screen: a neurocognitive screening test highly sensitive to various types of dementia. J Neurol Neurosurg Psychiatry 2004; 75 (5): 700–705G