The London memory service audit and quality improvement programme

Cook, Laura D.; Nichol, Katie E; Isaacs, Jeremy D.

doi:10.1192/bjb.2019.18

Cited by 19 publications

(29 citation statements)

References 4 publications

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“…This heterogeneity of aetiologies between and within individuals with cognitive impairment creates wide variation in diagnosis, prognosis and therapeutic approach. Without tissue-based diagnosis, clinico-pathological correlation is exceptionally poor, both in leading centres and routine practice [ 21 ], also in UK routine practice [9].…”

Section: Diagnostic Criteriamentioning

confidence: 99%

Mild Cognitive Impairment: the Manchester consensus

et al. 2020

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Given considerable variation in diagnostic and therapeutic practice, there is a need for national guidance on the use of neuroimaging, fluid biomarkers, cognitive testing, follow-up and diagnostic terminology in mild cognitive impairment (MCI). MCI is a heterogenous clinical syndrome reflecting a change in cognitive function and deficits on neuropsychological testing but relatively intact activities of daily living. MCI is a risk state for further cognitive and functional decline with 5–15% of people developing dementia per year. However, ~50% remain stable at 5 years and in a minority, symptoms resolve over time. There is considerable debate about whether MCI is a useful clinical diagnosis, or whether the use of the term prevents proper inquiry (by history, examination and investigations) into underlying causes of cognitive symptoms, which can include prodromal neurodegenerative disease, other physical or psychiatric illness, or combinations thereof. Cognitive testing, neuroimaging and fluid biomarkers can improve the sensitivity and specificity of aetiological diagnosis, with growing evidence that these may also help guide prognosis. Diagnostic criteria allow for a diagnosis of Alzheimer’s disease to be made where MCI is accompanied by appropriate biomarker changes, but in practice, such biomarkers are not available in routine clinical practice in the UK. This would change if disease-modifying therapies became available and required a definitive diagnosis but would present major challenges to the National Health Service and similar health systems. Significantly increased investment would be required in training, infrastructure and provision of fluid biomarkers and neuroimaging. Statistical techniques combining markers may provide greater sensitivity and specificity than any single disease marker but their practical usefulness will depend on large-scale studies to ensure ecological validity and that multiple measures, e.g. both cognitive tests and biomarkers, are widely available for clinical use. To perform such large studies, we must increase research participation amongst those with MCI.

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Section: Diagnostic Criteriamentioning

confidence: 99%

Mild Cognitive Impairment: the Manchester consensus

et al. 2020

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“… 11 However, this supports previous data from the London memory audit services, where only 15% of those referred under 65 received a dementia diagnosis. 12 Instead, the majority in this group were diagnosed with mild cognitive impairment or other psychiatric disorders. Our analysis of HoNOS scores of patients on entry to the service did not broadly support the idea that YoD patients, at least at presentation, suffer from more neuropsychiatric disturbance.…”

Section: Discussionmentioning

confidence: 94%

Patients with young-onset dementia in an older people's mental health service

et al. 2020

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Aims and method Currently, no separate service exists for patients with young-onset dementia in Cambridgeshire. These patients are managed together with late-onset dementia patients within old age psychiatry services. To inform service design, we sought to characterise young-onset dementia patients in our population. We first analysed service-level data and supplemented this with a detailed case review of 90 patients. Results Young-onset dementia remains a relatively rare condition. Only a small proportion of those referred for assessment receive a diagnosis of dementia. Data collected on presenting complaints, comorbidities, medication and Health of the Nation Outcome Scales scores associated young-onset dementia with a greater incidence of depression than late-onset dementia. Outcomes in the two groups did not appear to differ. Clinical implications The data presented here do not suggest a need to create a separate service. Practitioners should be aware of the increased incidence of depression observed in this group.

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“…Evidence from UK services suggests considerable variation in the use of imaging in the investigation of cognitive impairment. The 2019 London memory service audit 77 reported that the percentage of patients deemed not to require a scan for dementia diagnosis varied from 6% to 46%. Of those patients who did have a scan, the percentage who received computerised tomography (CT) (rather than MRI) varied from 2% to 58%.…”

Section: Imagingmentioning

confidence: 99%

Assessment and management pathways of older adults with mild cognitive impairment: descriptive review and critical interpretive synthesis

Chambers

Cantrell

Sworn

2022

Health Soc Care Deliv Res

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Background Mild cognitive impairment in older adults is a risk factor for dementia. Mild cognitive impairment is a result of a diverse range of underlying causes and may progress to dementia, remain stable or improve over time. Objectives We aimed to assess the evidence base around the assessment and management pathway of older adults with mild cognitive impairment in community/primary care, hospital and residential settings. Data sources In January 2021, we searched MEDLINE, EMBASE, PsycInfo®, Scopus, Cumulative Index to Nursing and Allied Health Literature, The Cochrane Library (i.e. Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials), Science Citation Index and Social Science Citation Index. The search was limited to studies published in English between 2010 and 2020. Grey literature and citation searches were also performed. Methods We performed two separate evidence reviews: (1) a descriptive review with narrative synthesis focusing on diagnosis, service provision and patient experience; and (2) a critical interpretive synthesis of evidence on the advantages and disadvantages of ‘mild cognitive impairment’ as a diagnostic label. Results A total of 122 studies were included in the descriptive review, of which 29 were also included in the critical interpretive synthesis. Study participants were most commonly recruited from populations of community-living older adults or those who had sought medical help from their general practitioner for memory problems. Follow-up searching identified a further 11 studies for the critical interpretive synthesis. The descriptive review identified multiple barriers to efficient diagnosis, starting with patient reluctance to seek help. General practitioners have a variety of cognitive tests available, but substantial numbers of patients meeting criteria for dementia do not have a diagnosis recorded. Patients may be referred to a memory clinic, but these clinics are mainly intended to identify and support people with dementia, and people with mild cognitive impairment may be discharged back to their general practitioner until symptoms worsen. Availability of scanning and biomarker tests is patchy. Qualitative studies show that patients with mild cognitive impairment and their carers find the process of investigation and diagnosis difficult and frustrating to negotiate. The key finding from the critical interpretive synthesis was that the need for a ‘timely’ diagnosis outweighs the ongoing debate about the value, or otherwise, of early investigation and labelling of memory problems. Determining what is a timely diagnosis involves balancing the perspectives of the patient, the health system and the clinician. Conclusions The two reviews reported here have applied different ‘lenses’ to the same body of evidence. Taken together, the reviews highlight the importance of a timely diagnosis for memory problems and identify barriers to obtaining such a diagnosis, from reluctance to seek help through to patchy availability of advanced diagnostic tests. Limitations The review was primarily descriptive, reflecting the prespecified review questions. Study selection was complicated by lack of a consistent definition of mild cognitive impairment and its overlap with other memory disorders. It was not possible to employ double study selection, data extraction or quality assessment, although processes of checking and verification were used throughout the review. Future work Priorities include evaluating remote methods of memory assessment and preparing for the likely future availability of disease-modifying treatments for early dementia. Research is needed on the investigation of memory problems in hospital and social care settings. Study registration This study is registered as PROSPERO CRD42021232535. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 10, No. 10. See the NIHR Journals Library website for further project information.

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The London memory service audit and quality improvement programme

Cited by 19 publications

References 4 publications

Mild Cognitive Impairment: the Manchester consensus

Mild Cognitive Impairment: the Manchester consensus

Patients with young-onset dementia in an older people's mental health service

Assessment and management pathways of older adults with mild cognitive impairment: descriptive review and critical interpretive synthesis

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