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Planning the way forward for dementia services

A recent review of dementia services in Ireland concluded that diagnostic pathways should be based on “adaptable models” and “not necessarily all provided in a single service”.

Last month, the National Dementia Office (NDO) launched its Dementia Diagnostic Services for Ireland: A Literature Review.

Using a scoping review methodology, the review looked at diagnostic pathways to dementia care, providing both Irish and international evidence.

According to the NDO, the “review examined three distinct areas: Dementia diagnostic service models (with a key focus on ‘memory clinics’), diagnosing dementia in primary care settings, and dementia diagnosis disclosure”.

The report was commissioned by the NDO “to inform the work of the Dementia Diagnostic Project Steering Group to support decisions with regard to recommendation or implementation of potential dementia diagnostic services/pathways for Ireland”.

Writing in the foreword to the review, Prof Brian Lawlor, Conolly Norman Professor of Old Age Psychiatry and Co-Director of the Global Brain Health Institute, Trinity College Dublin, said the review highlights that there is no “one size fits all” when it comes to creating the best approach and pathway.

‘Modern approach’

“However, it is clear that a modern approach to timely diagnosis must emphasise flexibility and fluidity between assessment at primary, secondary and tertiary levels, with regional specialist assessment readily accessible for atypical and hard-to-diagnose cases,” writes Prof Lawlor.

“The modern concept of diagnostic pathways for dementia should also take into consideration the importance of prevention, the imperative to address modifiable factors in at-risk populations and the importance of brain health education and advice.

“This literature review makes a significant and welcome contribution to the evidence needed to inform the creation of an equitable system of assessment and diagnosis of dementia as part of the advancement of the Irish national dementia strategy.”

The authors of the review note the general background to the services, where “the population over 65, and especially over 80, continues to rise year-on-year” the incidence and prevalence of dementia also rises year-on-year.

“We need to carefully consider the best model for dementia diagnostic services in Ireland to match current and future predicted demand,” the authors conclude.

“The literature review has shown the complexity of dementia diagnostic services and hence the likely complexity of a national diagnostic pathway. The very nature of dementia as an umbrella term for multiple diseases, and its varied initial manifestation from person-to-person, is a challenge in terms of early detection and diagnosis.

“In addition, it is apparent that lack of awareness, stigma, and lack of familiarity with, or trust in, existing post-diagnostic care also present significant challenges to timely diagnosis.”

Adaptable

The authors add in their conclusion that any models for dementia diagnosis pathways need to be “adaptable”.

“This report has described several models that could be used in dementia diagnosis pathways in Ireland,” write the authors. 

“The findings overall suggest that memory diagnostic models are still evolving and have considerable complexity and there is large variability, even with a model as provided in clinical practice. The key approach should be to create adaptable models which maximise the use of existing skills and resources and provide good integration between diagnosis, disclosure and post-diagnostic support, not necessarily all provided in a single service, and between the dementia assessment and management and the ongoing care of the person’s other morbidities or chronic conditions.”

Strategy

It is almost four years since the National Dementia Strategy was launched in December 2014.

Last month, the Minister with Special Responsibility for Mental Health and Older People, Jim Daly, told the Dáil that the Strategy’s implementation is “being led by the National Dementia Office in the HSE”.

“The office has made substantial progress towards developing evidence-based care pathways for people with dementia and progress to date.”

The mid-term review of the National Dementia Strategy was published in May. The Minister noted at the time of its publication that “good progress” had been made but there were also “challenges still to be overcome”.

“It is acknowledged that there are gaps in access to services and a large variance in what services are provided across the country,” Minister Daly told the Dáil last month.

“The National Dementia Office has met with senior HSE officials in each Community Healthcare Organisation region to highlight gaps in each area and to develop local action plans to improve service provision.

“The National Dementia Strategy calls for the HSE to consider the provision of dementia advisers, based on the experience of demonstrator sites. An evaluation of the Dementia Adviser Service was published on 26 September. It recommends the continuation and expansion of the service to ensure equity of access countrywide.”

Also in the Dáil last month, the Minister was asked whether the upcoming HSE National Service Plan for 2019 would provide for new and expanded services for people with dementia.

In reply, the Minister said “the Department of Health is working with the HSE to prepare the 2019 National Service Plan. Pending agreement of the National Service Plan, I am not in a position to comment either on the funding that will be made available for dementia care or the specific services that will be provided.”

The report can be accessed at https://www.lenus.ie/handle/10147/623887 or by contacting the National Dementia Office at dementia.office@hse.ie.

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