Select a Diagnosis
This section outlines the specialist assessment process followed when patients are referred to one of our memory services. There are three stages involved in the assessment of dementia.
Stage 1: Pre-diagnosis counselling and consent for assessment
Every person referred to our memory services (and their carers) should understand the implications of the assessment and diagnosis process and have their questions answered before proceeding with the assessment.
This is the process of giving the person and their carer the opportunity to have a discussion about their concerns or worries prior to the assessment and/or diagnosis, in line with best practice guidance.
For most people, this can take place immediately prior to the assessment itself, as a short (5-10 minute) discussion. In some cases, if particular issues of concern arise (for example, if the person does not wish to know the diagnosis but their carer is asking for them to be assessed), the assessment may need to be deferred whilst the issues are addressed through appropriate emotional support or psychological intervention.
Time and space should be provided in a quiet, confidential environment where the person being assessed and their carers are able to discuss what is of concern to them within a therapeutic relationship where there is warmth, empathy and respect.
The allocated worker will:
- Ensure that the person coming for assessment knows why he/she has been referred to the service.
- Ensure that the person understands the process of assessment and diagnosis and has had all her/his questions answered before proceeding with the assessment.
- Ensure the person being assessed has given their consent to proceed with the assessment.
- Establish that the person undergoing the assessment has given consent for the practitioner to obtain a verbal history from their informant (a family member or friend) and whether they would prefer to be interviewed separately for this purpose, or together.
- Establish whether the person undergoing the assessment wants to know their diagnosis.
- Establish whether the person would like to receive a copy of their assessment letter and whether they would be happy for their carer/informant to receive a copy too.
- Establish with whom the person undergoing the assessment would be willing to share information about their diagnosis.
- Inform the person undergoing the assessment of the information sharing procedure regarding the assessment and diagnosis (for example, a letter being sent to their GP, and clinical records being kept on an electronic system) and ensure the person consents to this. This will also involve ascertaining what information the person would like to receive themselves (for example, a copy of the assessment letter) and how much they would like to be shared with family members.
Stage 2: Assessment interview
The allocated worker will obtain a full background history with the aim of making a diagnosis.
This will include undertaking:
- A review of problems reported by the person with memory problems and assessment of their needs.
- A full psychiatric history.
- A full medical history for all medical problems.
- A record of potential communication difficulties (language, hearing and vision).
- A record of the pulse rate and rhythm.
- Reviewing the problems reported by carers and assessment of their needs using the Adult Carer Quality of Life Questionnaire (AC-QoL) and where appropriate, the General Health Questionnaire (GHQ).
- An assessment of other psychiatric problems (such as depression or anxiety) by carrying out a mental state examination assessment and by using the Hospital Anxiety and Depression Scale (HADS).
- An assessment of function in activities of daily living using the Bristol Activities of Daily Living Scale (BADLS).
- An evaluation of risks in key areas, such as living situation, fire, mobility/falls, nutrition, wandering, driving, carer stress, and vulnerability to abuse.
- Cognitive assessment using the Standardised Mini Mental State Examination (SMMSE) and the Addenbrooke’s Cognitive Examination-III (ACE-III) taking into account factors potentially affecting performance, such as sensory impairment
- A record of behavioural disturbance, using the Neuropsychiatric Inventory (NPI) as indicated.
Stage 3: Investigation and review following the assessment interview
Brain imaging techniques can provide important information about brain changes in dementia and other conditions. A Magnetic Resonance Imaging (MRI) scan is the investigation of choice. A discussion will take place with the patient and carer explaining what this will involve. Where it is not possible to carry out a MRI scan (due to medical contraindications such as metallic implants or pacemaker, claustrophobia, or the person declining the investigation), a Computerised Tomography (CT) scan will be offered. Where a person undergoing an assessment does not wish to have a brain scan or it is not indicated, a diagnosis will be made or excluded based on the clinical assessment alone.
A number of other investigations may take place in particular clinical circumstances:
- Specialist Neuro-imaging: SPECT scan may be requested if Fronto-temporal Dementia is suspected or if the MRI scan and clinical findings are uncertain. A DAT scan may be performed if clarity is required as to whether patient has Parkinson’s Disease Dementia or Dementia with Lewy Bodies.
- Chest X-ray: If the person undergoing assessment has a history of unexplained weight loss or significant respiratory symptoms.
- Electroencephalogram (EEG): This is indicated if the person has a history which is suggestive of seizures and also in the investigation of suspected Fronto-temporal dementias and unusual clinical presentations where rarer causes of dementia are suspected.
- Referral for a neuropsychological assessment: This involves a series of tests about thinking and actions that help to assess brain functioning. These tests assist with making a diagnosis and/or identify possible coping strategies for people with an unusual presentation where rarer causes of dementia are suspected, and for those with very mild problems of memory and thinking.
- Referral for an assessment by a geriatrician or physician: If advice needed on significant undiagnosed or untreated medical problems are picked up or suspected after the initial assessment.
- Referral for an occupational therapy assessment: If there is a lack of clarity as to what the underlying difficulties with activities of daily living may be, and to identify possible coping strategies.
- Electrocardiogram (ECG): Where primary care colleagues (General Practitioners) highlight pre-existing cardiovascular problems, or low pulse rate (less than 50 beats per minute or irregular pulse) is detected during assessment, an electrocardiogram (ECG) will be required before dementia medication can be prescribed. The allocated worker will ask the person’s General Practitioners to arrange this.
This stage also includes review of the memory blood screening tests which would have been arranged by General Practitioners. Further blood tests may also be required, in order that any reversible causes for memory impairment are identified and corrected.