Do memory problems matter?

1. "High Quality Care for All, Now and for Future Generations" Do memory problems matter?

2. Dementia Diagnosis- Why is it important Dr Sara Humphrey GP Westcliffe Medical Practice GP with a Special Interest in Older People-BTHFT Clinical Specialty Lead Older People & Stroke Bradford District & City CCGs GP Advisor Yorkshire & Humber Dementia SCN 16/9/15

3. "High Quality Care for All, Now and for Future Generations" Content of the Session What is Dementia What is the The National Picture? What are the National Drivers? Where are we now in Bradford? Why is diagnosis important? How to make a diagnosis in Established Dementia Patient Centered Care and Care Planning Advance Care Planning End of Life Care Carer Support Research

4. What is Dementia ?

5. What is Dementia ? It is the gradual loss of nerve cells in the brain and as they can not be replaced it is progressive and incurable The word Dementia just describes the collection of symptoms and is an umbrella term to cover all brain diseases that affect the brain in this way i.e. Alzheimer's and Vascular Dementia Dementia is not a normal, natural part of growing older

6. What is Dementia ? • For a person to be diagnosed with dementia, they need to have a problem with more than one of the following: Memory Communication The ability to see the world as others do The ability to carry out practical everyday tasks The ability to plan a course of action Problems with the control of some behaviours • These problems need to be sufficiently severe to have an impact on the person’s life.

7. What is Mild Cognitive Impairment? The term Mild Cognitive Impairment (MCI) is used when an individual has difficulty remembering things or thinking clearly but the symptoms are not severe enough to warrant the diagnosis of dementia. Only some individuals with MCI will go on to develop dementia.

8. What is the National Picture?

9. Dementia is under diagnosed • 850,000 people in the UK have dementia (Alzheimer’s Society, 2014) • We know that a third of patients remain undiagnosed!

10. We are slowly improving! • 2009 (England) • 31% of people with dementia registered on GP dementia lists Nat Dementia Strategy 2009 • 2012 (UK) • 41% of people who are living with dementia have a diagnosis • Increase of 2% since 2011 • Considerable nationwide variation AlzSoc2012 • Jan 2015 (UK) • HSCIC data shows we are now at 59% • Increase of 18% in 2 years

12. What are the National Drivers?

13. National Dementia Strategy 2009 • 5 year plan • 17 interlinked objectives • £150million extra funding Key themes • Improving awareness • Early and better diagnosis • Improved quality of care • Delivering the Strategy

14. Prime Minister’s challenge on dementia 2012

15. Awareness • Key role of GPs • Post diagnostic support • Information, advice, carers • Access to diagnosis • Staff training • Dementia Institute • Dementia Friends/ businesses • Research I million dementia friends Highest diagnosis rate

16. Where are we now in Bradford?

21. Why is a diagnosis important?

22. Patients and their Carers want it! “It was a huge relief…right thank goodness now we’ve got a diagnosis, now I know what I’m dealing with and I’ll cope with it” “It’s an illness, it’s a terminal illness as well you know, nobody gets better from it, and it isn’t treated like that with the NHS is it, unfortunately…if it was cancer it would be different, you know” “Absolutely instead of being really really aggravated you become empathic on diagnosis” Source: Dementia in Leeds Evaluation Project, 2013

23. Why is it important for the NHS and LA We spend £23 Billion a year as a society and we can spend this money more effectively rather than on expensive crisis interventions Crisis presentations Care Home Admission ( or delay them) Reduce Emergency Admissions and readmissions to Hospital Reduce hospital Length of Stay Spend the money saved on more meaningful support

24. Does it matter in Care Homes? YES even at a late stage it has Value Allows Advance Care Planning between you ,the patient and families Allows good Patient Centered Care & Care Planning esp around Prevention of Delirium Reduces Unplanned Emergency Admissions Helps plan for good Palliative Care and End of Life Prompts us to consider the MCA and DoLs Helps you to support Carers

25. How to make a diagnosis in Established Dementia ?

28. How can we make a difference in Care Homes?

29. What is patient Centered Care? Person-centred care focuses on the individual's personal needs, wants, desires and goals so that they become central to the care process. This can mean putting the person's needs and life style choices, as they define them, above those identified as priorities by health and social care professionals. Person-centred care promotes the importance of relationships that are important to the person

30. The ‘I’ Statements • I have personal choice and control over the decisions that affect me. • I know that services are designed around me, my needs and my carer’s needs. • I have support that helps me live my life. • I have the knowledge to get what I need. • I live in an enabling and supportive environment where I feel valued and understood. • I have a sense of belonging and of being a valued part of family, community and civic life. • I am confident my end of life wishes will be respected. I can expect a good death. • I know that there is research going on which will deliver a better life for people with dementia, and I know how I can contribute to it. • http://www.dementiaaction.org.uk/

31. What is Care Planning? An agreement between a patient & Health Care profession on how to manage the patient’s day to day health care It can be a written document or something recorded in your patient notes. It is about the patients personal needs, wants, desires and goals It should cover what we know makes a difference to people’s lives

32. Dementia QOF 2015/16

33. What do you need to consider during care planning? Physical and Emotional Health Medication Reducing Falls and Delirium Risks and Behaviours that challenge Advance Care Planning-DNA CPR etc Gold Standard Framework Carer support

34. Medication

35. What are the common antipsychotics? What’s the problem? -Sedation -masks Pain and Delirium -increased Strokes -increased Deaths Haloperidol Olanzapine Queltiapine Risperidone Clozapine

36. What are the Anticholinesterase Inhibitors? What are the side effects? -Diarrhoea -Headaches -Tiredness Check BP and Pulse-if low may need to consider stopping Donepezil (Aricept) Galantamine Rivastigmine

37. What else may be prescribed? What are the side effects? -Headaches -Dizziness -Drowsiness -Constipation -Depression Memantidine (antagonist NMDA receptor)

38. Delirium

39. Delirium and Behaviors that challenge? Training available through Care Home Liaison Service delivered as three x one hour sessions Training Booklet Get support from your local Care Home Liaison Service and CMHT

40. Advance Care Planning A discussion in which you maychoose to express some views, preferences and wishes about your future care. •Explore your options •Identify your wishes and preferences •Refusing specific treatment, if you wish to •Ask someone to speak for you •Appoint someone to make decisions for you using a Lasting Power of Attorney •Let people know your wishes

41. Advance Care Planning Advance care planning is a process of discussion between you and those who provide care for you, for example your nurses, doctors, care home manager or family members. Where patients have severe Dementia and may lack the capacity to make decisions on their own and then it is about ‘Best Interest ‘discussions

42. Advance Care Planning A guided discussion Can be undertaken by any qualified person Discussions about refusal of treatment or DNA CPR need to be had with a suitably qualified practitioner and you may need to consider the Mental Capacity of the patient in the discussions It needs updating if the patient has a significant change of circumstance , new illness or is palliative. Patients hold the ACP and the summary goes on System One Patient can change their minds!

43. Access to the Y&H Advanced Care Plan document • http://www.palliativecare.bradford.nhs.uk/Documents/Advance%20care%20plan%20booklet%20v.2%20Nov%202014.pdf • Also on System One

44. Dementia: A long and unpredictable condition

45. Dementia: A long and unpredictable condition People with Alzheimer’s have been known to live for up to 10 years after the initial diagnosis, although this depends on the age when the diagnosis is received. People diagnosed with fronto-temporal dementia can expect to live between six and eight years While people with dementia with Lewy bodies can live between six and 12 years Those diagnosed with vascular dementia can expect to live a shorter length of time after diagnosis – approximately five years

47. How do stage the disease?

49. How do we know when people are reaching the end of their life?

50. Dying and Dementia There are three ways in which people with dementia die (Cox and Cook, 2002). People may die from the complications arising from end-stage dementia. People may be in the early stages of dementia and die from another illness (eg cancer). People may die with a mix of problems. Dementia may not be the main cause of death, but it interacts with other conditions and can complicate and worsen them.