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A cognitive impairment pathway for primary care

A cognitive impairment pathway for primary care

GOALS:
To develop a dementia care pathway for the initial diagnosis and management of persons with cognitive impairment in primary care that has individual patient needs at the centre and provides:

  • accessible, proactive and integrated services that are flexible to meet a variety of needs
  • standardised advice on dementia care and services available

S Iliffe quote

Why?

  • Many people with dementia currently receive a diagnosis from a secondary health service at a more advanced stage in their illness. A later diagnosis means that the person with dementia often misses the opportunity to identify and communicate what is important to them because they may be no longer able to communicate their wishes and preferences.
  • A late diagnosis can also increase stress on the person and their family and whānau because they have not had access to the education and support services that can help them minimise or avoid symptoms of dementia[1]. This can create challenges such as depression, anxiety, behavioural and psychological symptoms and carer stress
  • Currently, a specialist service usually diagnoses a person with dementia. However, the increasing number of people with dementia is likely to add pressure to these specialist services. Primary Health Care needs to be better able to provide earlier diagnosis and appropriate care and support for people with dementia and their families and whānau
  • Primary health care practitioners need better knowledge, support and tools to have the confidence to make earlier diagnoses in the community setting[1]
  • An earlier diagnosis by a primary health care practitioner will free up specialist services to respond to episodic events and provide support and advice to the primary health care services in complex cases[2]
  • There are coordination issues between primary care, secondary care and Alzheimer's Auckland
  • There is variable advice provided about dementia care and available services

Key requirements for effective chronic disease care in primary health care

What did we find?

  • A report on the prevalence of dementia showed that in 2011 there were 47,000 New Zealanders with dementia
  • This is predicted to increase to 63,000 by 2020 and 120,000 by 2040

Absolute numbers of people with dementia for Waitemata DHB
Absolute numbers of people with dementia for Waitemata DHB

What did we do?

We have developed, piloted and evaluated a pathway for the initial diagnosis and management of persons with cognitive impairment primary care.

Our premise for undertaking this project is that:

  • patients should get the right care from the right person, at the right place, at the right time
  • for patients with cognitive symptoms, that means that initial evaluation and management may best be done in primary care

Project achievements

  • Co-developed a pathway for primary care diagnosis and management of dementia, the Cognitive Impairment Pathway. This was done through a co-design approach with general practitioner (GP) teams
  • Developed a decision support tool using the 'Nexxt' platform base on the agreed pathway
  • Delivered education sessions to general practitioners and practice nurses
  • Provided backup advice and support with dementia specialists (secondary care specialists) available by telephone
  • Co-developed a formalised package of education and support interventions delivered by Alzheimers Auckland
  • Trialled the Cognitive Impairment Pathway with 60 patients across 12 primary care practices

The Cognitive Impairment Pathway includes:

  1. An algorithm to guide identification, diagnosis and management of people with cognitive impairment for use in GP practices
  2. An education programme for GP teams (GPs and practice nurses) to enhance earlier diagnosis and management of cognitive impairment
  3. Integration of an Alzheimer's Auckland Key Worker into GP practices to support people with cognitive impairment and their carers
  4. Distribution of cognitive impairment resources (eg driving assessment, etc.)
  5. Increasing GP direct telephone access to Waitemata DHB geriatricians and psychiatrists for older adults

Cognitive Impairment Pathway decision support tool - Initial consultationCognitive Impairment Pathway decision support tool - Dementia pathway
Cognitive Impairment Pathway decision support tool in 'Nexxt'
[Click on each image to view larger version]

Did we make a difference?

We evaluated the project to:

  • determine if the intervention, the Cognitive Impairment Pathway, is acceptable to general practice teams and if it influenced their practice
  • explore patients’ and caregivers’ experience
  • analyse costs, resources and healthcare utilisation[3]

Methodology

  1. General practitioner questionnaires pre and post introduction of the pathway (intervention and control groups)
  2. Qualitative interviews with general practice teams, Alzheimers Auckland, Primary Healthcare Organisation staff and DHB clinician and leaders
  3. Pilot participants (patients and caregivers) were assessed for Quality of Life, depression, anxiety and carer stress (pre and post pathway introduction)
  4. Data tracking using DHB statistics, general practice team data and Alzheimers Auckland key worker records of time spent

Results

Acceptability in primary care teams:

  • General Practitioner confidence in diagnosis and care for persons with dementia improved*
  • Practice Nurse confidence in providing care for people with dementia and carers improved
  • General Practitioner / Practice Nurse confidence in responding to behavioural and psychiatric symptoms, getting information, obtaining support, improved
  • Improved General Practitioner / Practice Nurse dementia knowledge (objective finding) by end of pilot
  • Participants were keen to continue

Patient and carer results:

  • With respect to diagnosis:
    • 41% patients were diagnosed with dementia
    • 34% patients were diagnosed with mild cognitive impairment
    • 20% patients were given other diagnosis
    • 5% did not complete the assessment
  • There was no change in Quality of Life, anxiety, or carer stress scores
  • Most participants had little memory of the process or diagnosis, but neither they nor carers had any negative feedback
  • Carers found advice and support from the primary care team and Alzheimers Auckland beneficial
  • Participants were grateful for a timely diagnosis to allow them to anticipate and adapt to future developments.

Cost analysis and utilisation:

  • Mean number of general practitioner visits: 2.8 / 1.3 hours
  • Practice Nurse contacts: 2.6 / 1.9 hours
  • Alzheimers Auckland Key Worker: 5.65 hours
  • Total costs (time only) for person with dementia: $556*
  • No differences in other healthcare service utilisation

* all figures are for a dementia diagnosis; mild cognitive impairment costs were slightly lower


Feedback

Cognitive Impairment Pathway feedback

Lessons Learned

  • The success of Cognitive Impairment Pathway within a GP practice is dependent on a well-informed and prepared champion (practice nurse)
  • Alzheimer's Auckland are key to Cognitive Impairment Pathway sustainability by providing GP teams with someone to refer to for ongoing care once the cognitive impairment diagnosis is made
  • The Cognitive Impairment Pathway algorithm provided useful clinical information and clinicians referred to it often. However GP team members noted it was too detailed and they would prefer a less complex and easier to use tool

Where to from here?

The Cognitive Improvement Pathway is ready to be rolled out to other GP practices in Auckland. A business case is being developed for a roll out across primary care.

  1. "A Review of the Barriers and Enablers to Diagnosis and Management of Persons with Dementia in Primary Care." Aminzadeh F, Molnar FJ, Dalziel WB, et al. 2012. Canadian Geriatrics Journal 15(3): 85–94.
  2. "New Zealand Framework for Dementia Care." Ministry of Health. 2013.
  3. This was not a randomised controlled trial. We cannot prove that patients are better off than they would have been, merely that our premise was reasonable and the intervention safe and appreciated.

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