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Spotting signs of dementia

Care home staff are well placed to notice if an older person living in the home may be developing dementia. A tool developed for their use – DeAR GP (Dementia Assessment Referral to GP) – empowers care home staff, makes more efficient use of GPs’ and specialist memory nurses’ time, and improves diagnosis of dementia.

For most older people living in a UK care home, it is the staff who are their most constant contact.

Whiteoak Court Nursing Home clinical lead Prateebah Eburne (left) discusses the DeAR GP tool with healthcare assistant Maulene Chikerema

Picture credit: Nathan Clarke

It’s the care worker who will help residents dress in the morning, get ready for bed at night, bring them food, look after their personal needs and share the ups and downs of the day.

So perhaps that is why there is a growing understanding that care home staff are often best placed to notice if someone’s memory is going, or if they might be experiencing dementia.

This is the premise of DeAR GP (Dementia Assessment Referral to GP), a tool that has been developed for use by care workers to identify people who are showing signs of dementia.

Designed and tested with the help of care homes in south London, DeAR GP is now being rolled out in other areas.

‘There’s a recognition that between 70% and 80% of people in care homes have dementia, but not all of these will have a formal diagnosis,’ explains Aileen Jackson, senior project manager for the dementia clinical team at the Health Innovation Network (the Academic Health Science Network for south London), which developed the tool.

On-site expertise

Ms Jackson says: ‘Some people ask what’s the purpose of diagnosing people who are already being looked after in a care home setting? But they have the same rights as anyone else. They have the right to have treatment, and to have a proper care plan that takes account of their dementia.

‘If you look at the people who have the best opportunity to detect when someone might have dementia, it’s the care workers or the nursing staff. They know them best. GPs won’t see patients every week or every day, but care home staff will.’

DeAR GP is designed to tap into this on-site expertise. Following consultation with care workers and care homes, a simple tool was developed for use with residents whom they believed showed signs of possible dementia, but did not have a diagnosis (see box). The completed case-finding documents were then assessed by a GP or specialist memory nurse so they could confirm or rule out a diagnosis, or decide if further assessment was needed.

How DeAR GP works

Using the DeAR GP tool involves a mix of observation and simple memory tests for residents who have shown signs of confusion or memory problems. Care home workers are asked to fill out a simple form that is then passed to the memory nurse or GP for assessment.

After observing the resident for three months, the worker is asked to rate how frequently the resident showed the following:

Forgetting things.

Repeating themselves.

Appearing disoriented.

Being restless.

Walking about.

Needing prompting with basic tasks, such as dressing and hygiene.

Having speech and language problems.

Appearing withdrawn.

Staff are also asked to note any other potential signs of memory problems or confusion. Residents are asked for permission but if a resident can not give informed consent, the care home worker will complete the observation chart alone.

Residents considered to have capacity are then asked to answer four simple questions – how old they are, their date of birth, where they were now, and what year it is (the Abbreviated Mental Test-4 or AMT-4).

For more information go to www.tinyurl.com/dearGPreport

The tool was tested in four care homes. Of the 23 residents reviewed in the short pilot period, 20 (87%) were either diagnosed with dementia, or referred for further assessment.

Care workers reported that they felt empowered because it gave them the opportunity to identify residents they suspected of having dementia, and communicating this in a formalised way.

Ms Jackson thinks this kind of tool is essential for mobilising the specialist knowledge of care home staff, while equipping them to make best use of their opportunities. ‘In care homes, people’s jobs are becoming more challenging as people’s needs become more complex,’ she says. ‘The feedback we had is that when staff noticed a potential problem, they liked to be able to do something about it. It was empowering them to say something and to be heard.

‘The GPs and memory nurses also reported that they felt they could trust the tool.’

Indeed, the tool chimes with national policy to improve diagnosis of dementia in care homes. In 2014, NHS England national clinical director for dementia Alistair Burns warned that people in care homes with dementia might have avoided formal diagnosis if they were admitted directly from hospital, were placed as an emergency, or admitted with limited background information, possibly from another locality.

He said the advantages of diagnosis included helping care home staff understand behaviours that might emerge and trigger moves such as a medication review, possibly stopping drugs that adversely affect cognition.

In his bulletin to clinical commissioning groups in January, Professor Burns said DeAR GP acts as a communication between care workers and health professionals. He said diagnosis would aid the understanding of care workers and family members, leading to better support for the person with dementia.

Care home jobs are becoming more challenging as people’s needs become more complex

Whiteoak Court Nursing Home in Chislehurst was one of the four care homes involved in the pilot project. Prateebah Eburne, clinical lead at the home (previously a senior nurse and team leader for people with learning disabilities), says the process has led to greater awareness among staff.

‘It has broadened minds,’ she says. ‘In care homes, we have the opportunity to get to know our residents over a period of time. That means our staff are in a good position to observe residents for signs of dementia.

‘The training has been positive, and we are now trying to ensure that all our staff go through wider training about dementia. Yes, it’s important that people are diagnosed, but it’s also important that our staff develop a broader understanding about what a dementia diagnosis means.

‘For example, sometimes a resident will be tearful or aggressive, so we ought to think about what we can do to make them feel better.’

Staff who undertook the training felt they were doing something that potentially made life better for residents, as well as improving their own knowledge and skills. ‘You feel good about yourself if you are helping someone else to feel better,’ says Ms Eburne. ‘This helps us to meet people’s needs’.

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