This project will establish a primary care based model of memory assessment to increase the recognition, diagnosis and targeted case management of people living with dementia in Kent and Medway.

This will build upon the best practice within the exisitng memory clinics provided by Kent and Medway Partnerhips Trust (KMPT) by aligning KMPT staff to GP practices. This will support GPs to carry out pre-diagnositic tests and memory screening in accordance with an agreed diagnostic pathway. This project will support an education and training programme for both primary care and KMPT staff to underpin this transformation programme. Access to specialist memory clinics in secondary care will remain for people with complex needs and will provide specialist advice to GPs when required.

Kent and Medway collectively have a population of 1,727,600 and according to 2011 census figures the population is predicted that it will grow to 1843,100 based on ONS projections for 2010; with the number of people over the age of sixty five predicted to increase to 375, 200. The impact of this growth will see our predicted number of people with dementia rise to 27,395.

Primary Care professionals will undertake specialist training to learn how to assess, diagnose and prescribe for dementia. The training will provide the skills and confidence required to:

• Identify people with cognitive impairment or symptoms of dementia at an early stage
• To differentiate dementia, delirium and depression
• Safely prescribe pharmacological treatments for people with dementia, specifically cognitive enhancers under a shared care protocol with Consultant Psychiatrists.
• Carry out the full range of pre-diagnostic tests required to inform diagnosis
• Identify those at greater risk of developing dementia
• Identify common co-morbidity factors and to assess risk factors accurately
• When a diagnosis is made learning how to break a diagnosis well
• To increase their overall understanding and subsequent management of the condition
• Review medications in order to identify and minimise the use of drugs that can contribute to cognitive impairment and the rationalisation of anti-psychotic medications.
• Learn when and to whom to refer for structural imaging to rule out other pathologies

Objectives

• Achieve a significant increase in the number of people receiving a formal diagnosis of dementia across Kent and Medway.
• Establish appropriate baseline tests consistent across the county to exclude the causes of other cognitive impairment including medication reviews
• Establish a shared understanding of what these tests are and who will undertake them
• Improve education and understanding and there will be recognition of the difference between dementia and delirium
• Establish agreed protocols of who makes the diagnosis and when
• Establish a diagnostic pathway with an agreed timely process for assessment and review
• Ensure all people with dementia and their carers receive post diagnostic support and information. This includes:
  • Psychological support
  • Advance and end of life care planning
  • Information on support services
  • A carers assessment to identify their personal need while maintaining their caring role
• An increase in GP Dementia registers and a system to generate regular reviews
• Develop a skilled workforce within Primary Care to identify, diagnose and manage dementia safely at a practice level.
• Improve the ability of this patient group to remain at home for as long as possible
• Promote the use of assistive technology and the benefits for people with dementia
• Develop a greater understanding of dementia within multi-disciplinary teams with a specific focus on end of life care planning.

Anticipated outcomes

• All people with dementia will have access to a pathway of care that delivers a rapid and competent specialist assessment.
• People with Alzheimer’s disease benefit from early initiation of cholinesterase inhibitors where appropriate to delay the disease progression.
• People with dementia and their carers are supported and able to continue doing the things they enjoy for as long as possible through improved and targeted management of dementia care
• People with dementia and their families across Kent & Medway are able to make decisions and plan for their future. They make an informed decision and have an advance care plan so that there ends of life wishes are respected.
• Carers are well informed about dementia and the progression of the condition and have access to local support groups and services to enable individuals to share worries and develop coping strategies with support from health professionals.
• All people with dementia receive an early diagnosis that enables them to make informed choices.
• People with dementia and their carers are confident of the care and diagnosis received in the new primary care memory pathway.