1. Management of palliative care in dementia: a cross-specialty approach to education in primary care
Dr Daniel Anderson
Consultant psychiatrist
Honorary senior lecturer, Bangor University

2. Background Work started as SpR in Cheshire
Personally noted high admission rates for advanced PWD locally to acute medicine
Lack of awareness of support services
High use of antipsychotics
‘Last minute’ care home moves
Inappropriate investigations and treatments
Poor awareness and management of common conditions
Lack of confidence around MCA and advance care planning

3. Policy drivers NICE dementia guidance
NICE end of life care for people with dementia commissioning guide
National dementia vision for Wales
DoH end of life care strategy
Intelligent targets for mental health
1000 lives plus: dying well matters
Target 2: general hospital quality of care and length of stay
Target 3: antipsychotics

4. Numbers… 750,000 PWD in UK, 100,000 of whom die each yearly
15% die at home, 53% in hospital, 32% in care home
Common symptoms:
Confusion 83%
Urinary incontinence 72%
Pain 64%
Low mood 61%
Constipation 59%
Loss of appetite 57%
Other factors-insomnia, aggression, psychosis

5. More numbers…
50% rise in referral numbers to memory clinics since 2009
BCUHB 32% diagnosed-gap, but improving
6% reduction in care home admissions (even if offset by increased comm investment) at 10 years will save £75 million
750k PWD, 180k on antipsychotics, 18k receive benefit
….in 6 hours spent in social engagement
Effect size risperidone…
Effect size care home training…

6. Mortality rates Identifying palliative care needs on dementia wards
2011 data
Tawel fan 12 month mortality rate 10% (all planned expected deaths)
Glan traeth 12 month mortality rate 1%
Tawel fan mortality rate 12 months post-discharge 16%, of whom 33% die within 30 days
Glan Traeth mortality rate 12 months post-discharge 5%, of whom 40% die within 30 days
COTE ward-10% mortality rate

7. Membership Consultant psychiatrist Consultant in palliative care
GP, locality lead
Palliative care nurses
Inpatient mental health nurse manager
Consultant COTE
Dietician
Pharmacy
Consultant in liaison psychiatry for older people
Social services lead
Care home manager

8. Aims
The recognition that many people with dementia will also have a co-morbidity that involves a separate life limiting condition.
Access to community services for all those approaching the end of life so supporting people to die in their home or preferred place of death.
Advance care planning within primary care to reduce unplanned hospital admissions in the last days. This will include entering the patient onto the palliative care register and informing out of hours services.
Diagnosis of dying and a multidisciplinary team approach.
Use of the All Wales Integrated Care Priorities for dying patients.
Symptom control of physical and mental health needs.
Psychosocial and spiritual support including carer support.
Care in the last days of life of someone with dementia should have been planned once that person enters the severe stages of dementia through advance care planning processes.
Frequent and open communication with the family and/or friends of the person with dementia.

9. Main headings Communication issues DNAR
All Wales integrated care priorities
Identification of the patient entering the last year of life with dementia
Common physical and mental health symptom control:
Pain
Constipation
Agitation, aggression and hallucinations
Low mood and lability of mood

10. Main headings Access to support services
Use of the Mental Capacity Act
Use of covert medications
Hydration and nutrition
Telephone numbers-OPMHS and palliative care
Local versions

11. Distribution Primary care services Care homes-EMI only COTE wards
Taken to the End of Life Alliance, Palliative Care Implementation Board
Linking into local dementia care pathway for inpatients

12. Audit Location Acute Primary Care Community Hospital Care Home
Profession Doctor. RN CPN
Are you aware of the palliative care in advanced dementia leaflet ?
YES NO (if no please return audit form as below)
Have you referred to it?
Which elements proved useful to you ?
How confident would you rate yourself in recognising advanced dementia before reading this leaflet
How confident would you rate yourself in recognising advanced dementia after reading this leaflet
How confident would you rate yourself in managing advanced dementia before reading this leaflet
How confident would you rate yourself in managing advanced dementia after reading this leaflet
Is there anything you feel is unclear? Free text
Is there anything else you feel should be included ? Free Text
Have you made any referrals to Specialist Palliative Care Team ? Yes/ No

13. Thank you and questions