A New Approach To Nursing Home Liaison: Lochaber Telemedicine Clinic NHS Highland Dr Fiona McGibbon Consultant Old Age Psychiatry

Future Challenges for Old Age Psychiatry  Ageing population  4029 people in the Highlands with dementia, predicted to double in 20 years  Costs of dementia care predicted to triple in 20 years.  Declining working age population – less younger people to care for the elderly.

Abbeyfield Ballachulish  At least 2 hours and 80 miles from Inverness.  No Old Age CPN’s in Lochaber  Previous input only 1 – 2 visits by a psychiatrist per year

Abbeyfield Ballachulish 24 care home beds 2 are intermediate care beds 2 are respite beds Very sheltered housing Day Care Lunch Club

Old Age Psychiatry Telemedicine Clinic  There is evidence to support using telemedicine in dementia.  Identifying undiagnosed dementia in residential care veterans: comparing telemedicine to in-person clinical examination. Shores, M et al Int. J. Geriat. Psychiatry, 19: 101–108. doi: /gps.1029  Cognitive intervention for community dwelling older persons with memory problems: telemedicine versus face to face treatment. Poon, P; Hui, E; Dai, D; Kwok, T; Woo, J, International Journal of Geriatric Psychiatry  Evidence mainly for early dementia, none for mid to later stages of dementia.

Old Age Psychiatry Telemedicine Clinic  Nurse led clinic.  Lead nurse – Richard O’Keeffe (Nurse Team Leader of acute dementia assessment ward)  Twice a week for 2 hours.  Patients can be referred by GP, Psychiatrist or Abbeyfield Staff.  Any psychiatric problem not just dementia.  Patients can be interviewed, meetings with family, discuss cases with staff and/or GP via VC.  Supervised by Consultant Psychiatrist.  6 monthly (ish) visits to Abbeyfield (nurse and consultant) allowing face to face reviews.

Old Age Psychiatry Telemedicine Clinic  Patients are asked if they agree to be reviewed via telemedicine.  Next of Kin/Power of attorney are also asked where appropriate.  No recordings are made.

Old Age Psychiatry Telemedicine Clinic  Focus areas  BPSD (use of Forth Valley BPSD guidelines)  Antipsychotic monitoring - using the 3 T’s approach (Royal College of Psychiatrist Guidelines)  Depression  In the first 3 months  10 patients involved in the clinic  All had a diagnosis of dementia  Most commonly referred with behavioural and psychiatric symptoms of dementia (BPSD)

Outcomes  2 patients successfully withdrawn from antipsychotic medication.  2 patients managed solely with behavioural plans.  No new prescriptions for antipsychotics  2 prevented admissions  Difficult to calculate a cost saving but average stay in our dementia assessment unit is 10 weeks and cost of admission to New Craigs is £290/day. Potential savings of £  One patient was admitted

Outcomes  3 patients were able to complete questionnaire  All were satisfied with the clinic, felt comfortable and listened to, all were happy to have further consultations in this manner and did not want to wait longer or travel further for a face to face appointment.  9 staff questionnaires  All very positive. All feel there knowledge and confidence has improved, all were comfortable with communicating via VC and felt residents managed VC as well.  “Communication flowed easily between client and VC Nurse”  “Very beneficial and informative”  “Great way to communicate”

Example case  86 yr old lady, severe dementia.  Two recent admissions to hospital with challenging behaviour that staff felt unable to manage.  Recurrence of same symptoms  Mainly during interventions (scratching, kicking, biting, shouting)  At times requiring 3 staff to assist  Poor compliance with medication  One occasion so agitated she refused interview via VC and attempted to push VC unit over.

Example case  However, discussing her with staff and putting in place various behavioural techniques (validation/distraction/minimising stimulation) staff confidence improved as did her behaviour and compliance with medication.  Contact information for staff to arrange violence and aggression training given.  No additional medication was prescribed.  Admission was avoided (similar symptoms resulted in admission previously).  Developed an infection in the setting of late stage dementia, reviewed by GP for palliative care and died peacefully in her local area close to her family instead of 80 miles away in a dementia ward.

Future Plans  Roll out to two other care homes in the Lochaber area in progress  MacIntosh Centre Mallaig  Invernevis House Fort William