This guidance document, published by the London Strategic Clinical Networks, has been created for professionals to support people with dementia and their carers immediately following diagnosis.
The guidance covers prognosis, mediations, assessing carers needs, signposting, post diagnosis support, information on services available and signposts to further information.
This document supports NICE guidance that all memory assessment services should provide a range of assessment, diagnostic, therapeutic and rehabilitation services. In addition to a diagnosing clinician, services should include professionals from other disciplines relevant to the needs of their patients. These might include a specialist nurse, occupational therapist and clinical psychologist. Services should also have access to a dementia advisor or equivalent. It should be acknowledged that the resource to provide the early follow up meetings and counselling can have implications for commissioning the service.
It is important for dementia advisors to work closely with the service and to be involved in the diagnostic process (for example sitting in with the patient and carer when the diagnosis is being given) to offer immediate post diagnosis support and signposting.
Once the diagnosis has taken place, a structured person-centred care plan should be written summarising the issues discussed and who to contact in the event of patient or carer needing further advice and support. Any follow up plans should also be written in this care plan. The care plan should be sent to the patient (and with the patient’s consent to the carer) and GP. In some cases (for example when the patient declines consent) it may be appropriate for the carer to have a separate plan.
Following the diagnostic review, correspondence should be send to the GP in a timely manner so that there is an early review in the primary care for the patient if necessary. This could focus on a review of medications to optimise medical management with a particular focus on vascular risk factors.