Memory clinics can make a difference

Mental Health Nursing,  May 2004  by White, Ellie

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Memory clinics were first seen in the UK in the 1980s, mainly in academic research centres. There are now approximately 246 memory clinics but there are no official NHS figures and no specific standards or set models relating to them. The National Service Framework (NSF) for Older People stipulates that every specialist mental health service for older people should have a memory clinic but it gives no specific guidelines for establishing one. Ellie White visited one in Manchester and spoke to service users and practitioners about their experiences

Graham Fraser had 'always had a bad memory' but when he was told he was suffering from a vascular cognitive impairment after several spells in hospital with 'heart problems', he admits he had finally received a diagnosis that felt right.

When he first collapsed on Christmas Day in 1998, his GP diagnosed 61-year-old Graham with flu, then a viral infection. 'I had so many tests and scans and ended up losing my job because of the time it all took,' he says. 'But I kept collapsing. They said I had heart problems and fitted me with a pacemaker.'

It was only when Graham visited his GP surgery for a second opinion on the depression he had been experiencing as a result of losing his job that the GP he saw guessed he might be suffering from a vascular cognitive impairment and referred him to the Manchester memory clinic.

Memory clinics

Graham be lucky. The establishment of memory is certainly something of a 'postcode lottery' and acetylcholinesterase inhibitor drugs (treatments available since 1997) have certainly been victims of postcode prescribing. 'Acetylcholinesterase inhibitors have been shown to delay the path to institutional care for many patients, therefore saving social and health care budgets in the long term,' says Sean Page, clinical nurse specialist at the Manchester memory clinic. 'But the fact remains that if you don't live near a service like a memory clinic that provides access to the drugs, then you don't get them.'

Every clinic works from NICE's 2001 guidelines, which set a minimum national standard to apply to memory clinics. Within this standard are local variations, which rely on resources and funding for their make up.

The Manchester memory clinic was set up in 1994 to address the reluctance of many GPs to give a diagnosis of dementia to people like Graham who are young when they present symptoms of dementia or whose dementia is in its early stages.

'We are looking for cases where the GP is not sure if there is a problem or not,' says Sean. 'We want to catch the disease in its early stages and get people on the drug treatments, not wait until the dementia is obvious and advanced.'

The availability of drug treatments for dementia was a major driving force in the establishment of memory clinics. The licensing of the acetylcholinesterase inhibitor drug genepozone (Aricept) in 1997 led to the establishment of Manchester's (memory) treatment clinic. This was set up to manage the introduction of Aricept and was paid for out of the research funds of the drug's trials at the University of Manchester.

When other acetylcholinesterase inhibitors like Rivastigmene and then Exelon came along later, the clinic was able to provide more treatment and services. Research money was used to develop services for people with early dementia over and above taking part in research.

Memory clinics vary in size, scope and the number of staff working in them. Most are based in hospitals but they can be in primary care or day hospitals or, like the Manchester clinic, operate on a domiciliary basis, seeing patients at home.

Team composition varies but frequently contains one or more from a psychiatrist, nurse, psychologist, geriatrician, occupational therapist and social worker. The Manchester team comprises two nurses, a consultant clinical psychologist and two assistant psychologists who work on a rotational basis, as well as senior house officers who come to the memory clinic for experience and training. This multi-disciplinary team works together, meeting once weekly to discuss cases, concerns, test results and courses of action. Joined-up working with other agencies can be patchy, says memory clinic community psychiatric nurse Sarah, despite weekly meetings with social services and joint visits to try and effectively meet patients' needs.

The role of the nurse assessment and diagnosis

Nurses have a huge role to play in both the pre and post-diagnostic phases of dementia.

The Manchester clinic is a nurse-led service that operates a model of nursing triage and a social model of intervention care. The nurse is responsible for establishing first contact with the patient establishing a potentially therapeutic relationship. At initial assessment, patients are invited to share their experiences of memory loss and their expectations for treatment.

There is also medical screening, which involves the nurse taking a full drug and medical history, cognitive assessment, which comprises a range of neuropsychological tests, including a mini-mental state examination (MMSE), and mood assessment, which determines whether the patient has a depressive rather than a dementing illness.