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Occupation Therapist Chrissy Bishop gives her perspective of early detection of dementia from within an intermediate Care Team.

Occupational Therapists (OTs) play a pivotal role within the multidisciplinary teams working in intermediate care services within the NHS, assessing the needs of older people and supporting them to remain in their own homes, thereby reducing costly hospital admissions.

However, a marked variation in knowledge and practice is likely to be undermining the diagnosis, referral, and treatment of dementia by OTs working in intermediate care.

Researchers have cautioned healthcare professionals that they need to be aware that the assessment of dementia requires differentiation of the specific type. This is due to the variety of medical managements, specific patient presentation, differing rates of decline, and the overall prognosis (Sharon and Inouye 2006). It is this differentiation that is often overlooked.

At risk of delirium

Older people and people with dementia, severe illness, hip fracture, or altering doses of anticholinergic medications, benzodiazepines, as well as narcotics in high doses, are more at risk of delirium.

The development of delirium in certain persons may therefore help to identify those who are vulnerable to cognitive decline, whether through a genetic predisposition or the presence of early dementia or MCI that may otherwise remain unidentified.

Assessing these early stages is critical for services which have contact with patients at risk of delirium, as some acute dementia-related disorders may be reversible if detected and treated promptly.

Better access to development

A recent survey I conducted as part of MSc research in intermediate care, has suggested that OTs want and need better access to continuing professional development to improve their ability to conduct cognitive assessments.

These improvements can, and should, go some way towards tackling the growing challenge of dementia while we await the uncertain impact of any additional research funding on innovations in prevention, treatment and cure.

Of particular concern in this survey findings was the infrequent use of cognitive testing (which is likely to result in the even lower frequency of cognitive impairment diagnosis reported), and the inappropriate or inadequate next steps reported by respondents (which was also evident in their lack of awareness about what other local services might be available for people with cognitive impairments).

The survey was of 22 Occupational Therapists working in ICT, where they play a crucial role assessing the needs of older people and supporting them to remain in their own homes.

Despite the relevance of cognitive assessment to the primary clinical needs of their patients, these OTs reported substantial variation in knowledge, practice and confidence. Indeed, fewer than a third (7; 31.8%) felt that patients with cognitive impairment received appropriate and adequate intervention from their multidisciplinary team.

More training required

In part, this may reflect the paucity of effective interventions and the need for additional research on such interventions – as highlighted recently by Doug Brown, director of R&D at the Alzheimer’s Society. But it is also likely to reflect deficiencies in knowledge, practice, and confidence that might be remedied by improvements in training and clinical governance.

It should be promoted across older people services that the results of cognitive assessments are used as one element in a series of integrated health and social care interventions to support older people, perhaps including training on effective interventions available after diagnosis, and communication approaches for professionals.

Scientists’ calls for increased funding for dementia research described in Ingrid Torjesen’s recent report in the BMJ received a muted response from countries represented at the recent G8 Summit. Nonetheless, the additional research funds committed are to be welcomed, not least given the scale of the disease and its projected growth by the middle of this century.

However, there is much that is already known, and much that can already be done, in terms of dementia diagnosis and care.

It is therefore crucial that we do everything we can to implement current best practice if we are to support the needs of those who develop the disease – particularly given the uncertain impact that even a quadrupling of research funding may have on the development of successful therapies over the next ten years.

And while delivering current best practice may itself require an increase in funding, substantial improvements in training, practice and clinical governance are likely to be possible at a fraction of the cost.

Cause for concern

Our survey’s findings are therefore a serious cause for concern, albeit one that Occupational Therapists themselves seem likely to share given their reported lack of confidence in this survey, and the fact that all but one of the 22 respondents were interested in further training in cognitive assessment.

These findings also indicate substantial scope for immediate improvements in cognitive assessment practices and in subsequent referral to available local support services.

These improvements can, and should, go some way towards tackling the growing challenge of dementia while we await the uncertain impact of any additional research funding on innovations in prevention, treatment and cure.

Chrissy Bishop is a registered Occupational Therapist, and studying epidemiology and biostatistics at Leeds University.

Download the full report, 'Timely Diagnosis of Dementia in Intermediate Care: Strengthening the Knowledge and Practice of Occupational Therapists' (PDF, 176KB)

For more information: Call Age UK Advice: 0800 169 2081

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