Art & science The acute synthesis care of art and science is lived by the nurse in the nursing act JOSEPHINE G PATERSON NURSE-LED OLDER ADULT MENTAL HEALTH CLINICS IN RURAL GP PRACTICES Bernie McInally describes how collaborative working between a community psychiatric nurse and staff in general practice resulted in the delivery of an improved clinical service Correspondence bernie.mcinally@btinternet.com Bernie McInally is a community psychiatric nurse/clinical studies officer, NHS Borders Dementia Clinical Research Network, Melrose Date of submission April 10 2014 Date of acceptance May 7 2014 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines journals.rcni.com/r/ mhp-author-guidelines Abstract Dedicated memory services have been recommended as a single point of referral for people with cognitive impairment for many years. This may, however, discourage them from visiting a GP or specialist services to seek early diagnosis, through fear of what might happen, or of stigma. GPs have limited skills in dementia diagnosis, in particular at the early stages of the illness, which is where the current need exists. One model that is known to be effective in healthcare delivery is that of the nurse-led mental health clinics for older adults. This concept was investigated using the specialist skills of a community psychiatric nurse in older adult mental health and trialled in three GP practices in the Scottish Borders. After one year the project was evaluated. This showed it to be cost-effective, to equal medical-led clinics in sensitivity and accuracy of diagnosis, and often to be preferred by service users. Non-medical prescribing by the nurse is central to its success. Keywords Alzheimer s disease, cognitive enhancers, dementia, nurse-led clinics, nurse prescribing A SIGNIFICANT amount of attention has been paid to memory clinics in the literature, but the same cannot be said for nurse-led clinics for older adult mental health assessment. This article reviews and evaluates the effectiveness of such a service in the UK one year in, with a focus on the nurse as a prescriber of the acetylcholinesterase inhibitors (AChEIs) or memory drugs. In addition, the author reflects on how such a service fits in with political thinking and also on its cost-effectiveness in relation to more traditional models. Studies show that GPs acknowledge the valuable contribution that mental health nurses make to patient care, but that this is dependent on the knowledge and skills of the individual nurses involved as well as their ability to engage with GPs (Meehan and Robertson 2012). I have almost 20 years experience working as a community psychiatric nurse (CPN) in older adult mental health. For several years I have worked in a rural area in the UK where there are four GP practices, and during this time have gained a great deal of academic learning as well as experiential knowledge and skills in the assessment, care and treatment of the dementias. It is through this close working with GPs that mutual trust and respect for each other s roles have developed, and this was further enhanced when I completed a non-medical prescribing course. The benefits of nurse prescribing are well documented in the literature and in most professional forums (O Connell et al 2009). From the service user s perspective, patient convenience and improvements to care are noteworthy, and increased autonomy and career progression are attractive to nurses. Unfortunately the mental health nurse, as a prescriber, appears to attract less recognition in the 12
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Art & science acute dementia care 14 literature than other types of nurse, and concern has been expressed about the take-up of this training in this specialty (Ross 2009). The service described in this article developed as a direct result of my undergoing non-medical prescriber training and becoming aware of barriers in the referral process while spending time in GP surgeries. It became apparent that a more open-access approach to mental health assessment for older adults, complementing the current referral pathway, would benefit clients. Nurse-led clinics It is well documented that the nurse-led clinic model has a positive effect on patient care (Shui et al 2011). There is evidence to demonstrate that this model provides a more flexible and holistic service to clients (Happell et al 2010) and is often preferred to the more traditional physician-led model (Laurant et al 2005). Studies show that nurse-led services are also associated with significant reductions in health costs (Chenoweth et al 2008, Bauer 2010), and comparative evaluations between medical and nurse-led diagnosis and treatment have proven to be at least equitable (Bauer 2010). To date, review of these services has tended to concentrate on the more physiological disciplines, such as urology, rheumatology, diabetes, cardiology and wound care (Lane and Minns 2010, Bala et al 2012, Farmer et al 2012). The development of the cognitive enhancer medications in the late 1990s to alleviate some of the symptoms of Alzheimer s disease was followed by the need for early diagnosis and the appearance of the memory clinic. This, in all its guises, resulted in the further development of the specialist dementia nurse role, which often meant taking on the role of clinical lead in these services (Boyd 2013). Research into nurse-led clinics specific to mental health revealed significant positive outcomes (Happell et al 2010) and this, together with the establishment of nurse prescribing training, provided the opportunity for nurses to take on more responsibility for diagnosis and prescribing, and therefore provide more timely intervention in care and treatment (Griffith 2013). Background UK government guidance shows that dedicated memory services have been recommended as a single point of referral for many years (National Institute for Health and Care Excellence (NICE)/Social Care Institute for Excellence 2006) and nurse-led memory clinics have been part of the dementia strategy since 2009 (Department of Health (DH) 2009). Following various attempts by the mental health for older adult team (MHOAT) to initiate memory clinic models in GP practices within the Scottish Borders region, three practices were approached to discuss what the GPs thought might be a useful addition to the service already offered. The standard provision in the MHOAT consisted of a GP referral followed by domiciliary visits by a consultant, senior registrar or experienced specialist CPN, on occasion accompanied by a junior medical/nursing colleague. Government programmes focusing on improving dementia awareness and care, such as the dementia strategy of the Scottish Government (SG) (2009) and the Prime Minister s Challenge (DH 2012), heavily influenced service change at the time. However, any connection with political initiatives was avoided while discussing the feasibility of nurse-led clinics with GPs, because I had seen that approaching referrers with target-driven changes tended to discourage participation. Usually, a good working relationship and mutual trust with the GPs are sufficient to enable this change. Setting up the clinics Initial meetings were positive and, although the shape and criteria of the service were open for discussion, I suggested a structure of a clinic of four hours one afternoon per month, with the practice holding the diary and populating the five 45-minute diary slots as required. This arrangement meant that I would not be aware of the client list beforehand, but agreed that a simple practice summary including name, address, date of birth, past medical history and current medication would be provided for each service user. This included entries of previous GP consultations and indicated why the person was being referred. Meetings with the practice managers were arranged because access to primary care IT systems was necessary, including the client s records and investigations/results; this was arranged with relative ease. All practices allowed me full access to their EMIS (patient information) and Docman (investigations/results) IT systems. A room and personal computer were provided and it was agreed that I would give initial clinic feedback via the EMIS system. This would involve entering an assessment summary of initial findings, further investigations and the treatment plan in the GP consultation section. This would be followed up at a later date with a letter when appropriate. Referral criteria The referral criteria needed to be as inclusive as possible, giving access to any person with concern about their memory, regardless of age, or anyone
over 70 years of age with a mental health problem. There was also an understanding between the practice and me that if inappropriate referrals became a feature of the clinics this would be discussed immediately with the referring GP and that seeing a person as a one-off in the clinic did not automatically label them as a client of the MHOAT. Working with the practices over a long period of time meant that the GPs and primary care clinicians were confident about my level of knowledge in older adult mental health, and were happy to accept all recommendations for further medical investigations and treatments. They were also comfortable with my ability as a registered non-medical prescriber. Initially, service users were seen by me and, depending on their presentation, a decision to carry out a formal or informal assessment was taken. Factors influencing how the interview was conducted included the person s anxiety levels and willingness to engage, and the presence of a carer. If it looked likely that the diagnosis would be dementia, the CPN would arrange to visit the service user at home where a more accurate baseline of cognitive state could be achieved the individual usually being more relaxed in familiar surroundings. Computerised tomography (CT) scans were requested, and an approximate four to five weeks turnaround from request to report gave ample time for follow up to take place. Most people who received a diagnosis of mild cognitive impairment (MCI) were then seen, assessed and given a diagnosis in one consultation. Referral/diagnosis rates Boxes 1, 2 and 3 show the figures of attendance and diagnostic rates for the first year, from June 2012 to June 2013. Clinic A, for example, began on June 27 2012, offering 12 sessions. The age range of the patients referred was 58 to 98 years and, of the two people who did not attend (DNA), one attended future clinics and one was visited at Box 1 Diagnostic rates for first year of clinic A Over-65 population 1,567 Number referred 38 Diagnosis of dementia 18 Diagnosis of mild cognitive impairment 12 Other diagnoses* 6 Did not attend 2 *Other diagnoses included: analgesia dependency, meningioma, hypnopompic hallucinations. home; this achieved 100% take-up of referrals (Box 1). Clinic B started on September 12 2012, offering ten sessions (Box 2). Clinic C has a more flexible approach, with service users having the option of either attending the health centre or being seen at home. Box 3 shows the diagnostic rates of clinic C during the first year. Figures 1 and 2 (page 16) and Box 4 (page 17) show the total numbers and diagnoses of those who consulted. Nurse prescribing As stated in the introduction, the advantages to the service user, clinician and services in general of nurse prescribing are well documented (Laurant et al 2005, Happell et al 2010, Shui et al 2011). In the present situation the clinics helped significantly in identifying and making up for shortfalls in access to assessment and treatment, and they strengthened the existing trust between primary care staff and the CPN. Because of the close proximity, ease of access and shared documents, people requiring medication were provided with a prescription either by me (often at a follow-up visit, once further investigations have been carried out, to confirm diagnosis with the patient), or by the GP following a direct request from me. Therefore, for the purposes of this article, any prescription written by me or requested Box 2 Diagnostic rates for first year of clinic B Over-65 population 1,466 Number referred 35 Diagnosis of dementia 15 Diagnosis of mild cognitive impairment 13 Other diagnoses* 6 Did not attend 1 *Other diagnoses included: over-concern re memory, depression/grief. Box 3 Diagnostic rates for first year of clinic C Over-65 population 433 Number referred 8 Diagnosis of dementia 6 Diagnosis of mild cognitive impairment 1 Other diagnosis* 1 Did not attend 0 *The other diagnosis was a review of a person seen previously. 15
Art & science acute dementia care Figure 1 Number of clients 40-35 - 30-25 - 20-15 - 10-5 - 0 Figure 2 Referrals per clinic and diagnosis 26 Clinic ic A Clinic B Clinic ic C Total referrals per diagnosis 13 3 39 Referrals Dementia Mild cognitive impairment Other Did not attend Dementia Mild cognitive impairment Other Did not attend by me from the GP practice constitutes a nurse prescribing decision. Following assessment, prescription of cognitive enhancers is only a small part of care, treatment and support; people with dementia require follow up and referral to other agencies, as well as monitoring of the appropriateness of these and other drugs. Thus regular review and ongoing support were further outcomes of the clinic contact. Of the 39 people who received a dementia diagnosis, 27 were diagnosed with Alzheimer s or Alzheimer s mixed dementia and, as per guidelines, were appropriate for consideration of a trial of a cognitive enhancer (NICE 2011 ). Two individuals had a diagnosis of Lewy body disease and also underwent a trial of a cognitive enhancer that has been found to be effective in this condition (Anda 2011 ). Although not relevant to the prescribing element of this clinic, nine of the ten remaining people were found to have vascular dementia and one had frontotemporal dementia. The proportions of the different diagnoses made in the clinic reflected accurately the prevalences accepted by the Alzheimer s Society (Figure 3 ). Figure 4 shows the resulting levels of medication. A total of 24 service users started with an AChEI, 23 receiving donepezil and one a rivastigmine patch. Of the remaining five, four were not prescribed medication on account of either their choice not to have it, high risk or bradycardia. One person died of an unrelated illness before the trial could begin. Follow up was as per guidelines (NICE 2011 ), with a review within 28 days and a recommendation to increase dosage if appropriate. At the end of three months of treatment, 19 people continued with the higher dose of 10mg donepezil or 9.5mg rivastigmine patches. One person went back to a lower dose of 5mg donepezil due to adverse effects caused by the higher dose, and four discontinued treatment during the trial period for similar reasons. Of the 20 patients who received a cognitive enhancer, 18 were found to have sufficient benefits to continue with treatment at end of their trial. Improvements included increase in confidence/ motivation, improvement in functioning and/or positive family/carer feedback. As well as the AChEl prescriptions, one individual who had a diagnosis of anxiety and depression, received an antidepressant (sertraline). Feedback on service In addition to looking at the statistics, qualitative feedback was requested from GPs on the effectiveness and functionality of the clinics. GPs provided the feedback individually or as a practice. The only negative feedback related to administration issues, such as the time taken for assessment letters to reach the practice. Below is a summary of the comments by GPs: A successful and productive clinical service. Unanimous it has worked well as we are confident in your clinical expertise. Aware of four patients previously referred all refused but you have engaged and built up a rapport. Patients diagnosed with dementia... dealt with between ourselves and you, directly reducing the referral burden on consultant colleagues. This genuine collaborative working is one of the few examples where we in general practice feel supported in delivering a better clinical service. The system in its informality works particularly well because we know and trust you. It might be difficult to reproduce more widely without your degree of expertise and the relationship you have with us. built on a firm foundation of solid lines of communication and the fact that we are well aware of the depth of your knowledge, years of 16
experience and believe these qualities have meant that you have been more than qualified to deal with the clients referred to this pilot service. It has been of great benefit that there is some flexibility around the referral criteria. Although no formal evaluation was sought from clients and carers, positive verbal feedback was received as follows: I didn t want someone coming to my house in case the neighbours asked who it was but it was fine at the health centre. Mum would never have agreed to let someone visit at home, but at the clinic it was just another appointment. Discussion It became apparent to me that, possibly due to the ease of access to the service or the importance of early diagnosis, people being referred were scoring in the high 20s out of a possible 30 in the Mini Mental State Examination (MMSE) (Folstein et al 1983 ), and in the high 80s into the 90s out of a possible 100 in the Addenbrooke s Cognitive Examination (ACE-r) (Mioshi et al 2006 ). This suggests MCI. However, in many cases the history, pre-morbid IQ, presentation and effect of cognitive decline on day-to-day functioning, were more indicative of dementia, and in particular of Alzheimer s disease. On these occasions a referral to a psychologist for neuropsychiatric testing and CT scanning was submitted to confirm the diagnosis. This may not be the most accurate and cost-effective method of diagnosing Alzheimer s disease in people presenting with MCI scores, but without advanced imaging techniques or cerebrospinal fluid analysis, these were the tools available. It is important to note that quantitative data in itself gives no indication about the quality of the service being provided in the nurse-led clinics, the level of knowledge required by a clinician to successfully run a similar service or, as yet, its effects on diagnostic rates in total. This review indicates that so far the evidence strongly supports the effectiveness and appreciation of a properly organised nurse-led clinic in older adult mental health. The model is reliable diagnostically, is often preferred by service users and is more cost effective than traditional models. The evidence also supports non-medical prescriber training as a skill that is valuable to practices and to healthcare managers (Vidall et al 2011). Further research In view of the ever-increasing size of this client group and the lack of outcome measures, there is clearly potential for more longitudinal studies in these older adult mental health clinics to look at areas such as cognitive enhancer prescribing rates or MCI follow up. There is evidence that service users want to be involved in research (Darling and Parra 2013, Law et al 2013 ), and these clinics have already provided a steady supply of people with a dementia or MCI diagnosis, and also carers, who are Box 4 Figure 3 Number of clients Number of clients 30-25 - 20-15 - 10-5 - 0 Figure 4 Alzheimer s/mixeded 30-25 - 20-15 - 10-5 - 0 Total diagnostic rates for the first year of clinic sessions Over-65 population 3,466 Number seen 81 Diagnosis of dementia 39 Diagnosis of mild cognitive impairment 26 Other diagnoses 13 Did not attend 3 Dementia types Lewy body diseasease Prescribed medication Donepezil tablets Rivastigmine patch Otherer Not prescribeded 17
Art & science dementia willing to be involved and have registered with the Scottish Dementia Clinical Research Network. This is a target in the Prime Minister s Challenge (DH 2012) and should be incorporated into the Dementia Care Pathway (SG 2009). With the announcement in 2013 of an extra 450,000 of funding for dementia research in Scotland jointly from the SG and Alzheimer s Research UK, research is now more achievable. Although there are no specific targets as yet in Scotland, these nurse-led clinics have helped towards reaching the UK target of people with dementia being involved in research, which is 10% by 2015 (DH 2012). The clinics have also supplied a steady stream of referrals to the dementia link workers service, which again is supportive of the goals of the National Dementia Strategy (SG 2009, 2013). Implications for practice Through close working between the community psychiatric nurse and the GP, a mutual trust and respect for each other s roles develops. Nurses should consider non-medical prescriber training as a valuable addition to their functions. Nurse-led clinics can be an efficient, cost-effective and valued alternative to the more traditional model and they are preferred by service users. Online archive For related information, visit our online archive and search using the keywords Conflict of interest None declared References Anda R (2011) Behavioural and Neurophysiological Characteristics of Lewy Body Dementia: Implications for Intervention. tinyurl. com/n5zld4z (Last accessed: 7 December 2014.) Bala S, Samuelson K, Hagell P et al (2012) Experience of care at nurse-led rheumatology clinics. Musculoskeletal Care. 10, 4, 202-211. Bauer J (2010) Nurse practitioners as an underutilised resource for health reform: evidence based demonstrations of cost-effectiveness. Journal of the American Academy of Nurse Practitioners. 22, 4, 228-231. Boyd R (2013) Early diagnosis and access to treatment for dementia patients. 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