Dr Karen Looney, Principal Clinical Neuropsychologist at St Patrick’s Mental Health Services (SPMHS) gives information about the SPMHS Memory Clinic.
About the SPMHS Memory Clinic
The Memory Clinic offers a comprehensive, multidisciplinary assessment service for adults and their families who have noticed changes in memory, or other aspects of cognitive functioning, and may be worried about developing dementia.
The assessment process aims to establish objectively the nature and extent of any such cognitive problems and their probable causes. A treatment plan and recommendations follow and are shared with the service user, their family and referrer.
The service aims to provide service users with the highest quality of service, and to provide a timely diagnosis and intervention plan in line with priorities set out in The Irish National Dementia Strategy (2014).
In Ireland, there is a lack of uniformity in the services that memory clinics provide, and in the specialisms of the health professionals involved, and, so, memory clinics can vary widely in both their composition and the type of services provided (Gibb & Begley, 2018). The Memory Clinic assessments at SPMHS are conducted by a multidisciplinary team (MDT) made up of a consultant psychiatrist, clinical nurse specialist, psychiatric registrar, clinical neuropsychologist, clinical psychologist and an administrator. There is also access to occupational therapy as necessary.
From referral to diagnosis
Service users are typically referred by their GP, with referrals discussed and allocated at regular planning meetings. The assessment protocol involves a number of steps:
- service users are contacted by the team administrator with a proposed date for the assessment, and this is an opportunity for them to ask any questions they may have in advance of the proper assessment
- they are asked to arrange blood screenings through their GP prior to the assessment as follows: FBC, biochemistry, thyroid function tests, VDRL, fasting glucose and lipids, vitamin B12, red cell folate and ESR
- arrangements are made for a brain MRI scan to be conducted, with the report forwarded to the Memory Clinic team.
The assessment is offered as a physical admission to St Patrick’s University Hospital, or if a service user has already availed of services in SPMHS previously, the assessment can be run virtually through the Homecare Service. Service users are generally admitted for a short stay, during which time they participate in a range of assessments and observations, including collateral information. They are then discharged with a plan in place for a feedback meeting, which takes place one week after discharge. This is attended by members of the MDT, the service user and the person the service user has chosen to accompany them, which can often be several family members.
A multidisciplinary consensus meeting takes place prior to the feedback meeting, where the team agrees on diagnosis, a treatment plan and other recommendations.
At the feedback meeting, the results of all investigations are discussed with the service user and their family. A diagnosis is given where possible.
A discussion of treatment and next steps
Mild cognitive impairment (Petersen et al, 1999) is the most common diagnostic outcome, accounting for approximately 60% of cases, according to a recent audit. These cases are usually scheduled for re-assessment annually to track change over time. Where a diagnosis of dementia is given, drug treatments, including cholinesterase inhibitors, are started or a treatment regime is recommended to a referrer as appropriate.
Regardless of diagnosis, advice is generally given about lifestyle changes, consistent with research pointing to the modifiability of certain risk factors for dementia (Yaffe, 2018) in the areas of nutrition, exercise, social connectedness and cognitive stimulation. Other treatments may be recommended to maximise cardiovascular health and treat other medical conditions which may play a role in compromised cognitive performance, such as sleep apnoea or hypothyroidism.
Advice for GPs
GPs are generally adept at diagnosing dementia in primary care and typically diagnose between one to six new cases per year (Dyer et al, 2018). At a recent GP webinar hosted by SPMHS, cognitive screening tools that may be best suited for use in primary care were explored. The Montreal Cognitive Assessment (MoCA; Nasreddine et al, 2005; mocatest.org), used in tandem with the Irish normative data set generated from The Irish Longitudinal Study on Ageing (TILDA; Kenny et al, 2013), was highlighted as particularly useful as a statistically robust tool providing data on multiple cognitive domains, including memory functioning, which is generally acceptable to both clinicians and service users. The Irish normative data set allows for a richer, more nuanced output taking age and education within the Irish education system into consideration, allowing for greater sophistication than a simple cut-off score.
However, in certain circumstances, a referral to a specialist memory clinic may be advantageous. For example, complex cases with medical, neurological and mental health co-morbidities in the history may be more suited for a specialist work-up, or where there is uncertainty about dementia sub-typing, which can have implications for treatment planning.
Some GPs may feel more confident referring to a specialist memory clinic service for younger onset dementia cases, particularly where the service user may not be as well known to them in their practice, or in cases where the query is around a less common form of dementia, such as one of the frontotemporal dementias.
- Department of Health (2014). The Irish National Dementia Strategy. Dublin: Department of Health.
- Dyer, A.H., Foley, T., O’Shea, B., Kennelly, S.P. (2018). Dementia diagnosis and referral in general practice: A representative survey of Irish general practitioners. Irish Journal of Medicine, 11(4), 735.
- Gibb, M., & Begley, E. (2018). A guide to memory clinics in Ireland. DSIDC.
- Kenny, R.A., Coen, R.F., Frewen, J., Donoghue, O.A., Cronin, H., Savva, G.M. (2013). Normative values of cognitive and physical function in older adults: findings from the Irish Longitudinal Study on Ageing. Journal of the American Geriatric Society, 61 (2), 279-290.
- Nasreddine, Z.S., Phillips, N.A., Bédirian, V., Charbonneau, S., Whitehead, V., Collin, I., Cummings, J.L., Chertkow, H. (2005). The Montreal cognitive assessment, MoCA: A brief screening tool for mild cognitive impairment. Journal of the American Geriatric Society, 53(4):695-699.
- Petersen, R.C., Smith, G.E., Waring, D.V.M., Ivnik, R.J., Tangalos, E.G., Kokmen, E. (1999). Mild cognitive impairment; clinical characterisation and outcome. Archives of Neurology, 56, 303-308.
- Yaffe, K. (2018). Modifiable risk factors and prevention of dementia; What is the latest evidence? JAMA Internal Medicine, 178(2), 281-282.
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