Memory Monitoring (Kirklees) Care Pathway

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.


This guidance refers to:

  • Adults ≥65 resident in Kirklees where dementia is suspected

This guidance does not cover:

  • Adults <65 where dementia is suspected
  • Patients living outside Kirklees


A timely diagnosis of dementia is important. It gives patients the opportunity to plan for their future, and to access support and treatment earlier.

History and Examination

Differential Diagnoses

  • Rule out reversible causes of cognitive impairment:
  • Non-organic mental health problem, e.g. depression
  • Drugs: consider reviewing dose or stopping drugs that may impact on cognition e.g. tricyclic anti-depressants , opiates, benzodiazepines, anti-convulsants
  • Delirium e.g. infection, CVA, constipation, pain

Care Home Residents with advanced dementia

  • Some care home residents with advanced dementia have never received a formal diagnosis. In these cases a referral to memory services is not usually desirable, and could be distressing for the individual.
  • People with advanced dementia, their families and staff caring from them can still benefit from a formal diagnosis which:
    • Enables access to appropriate care to meet individual needs
    • Prompts staff to consider MCA and DoLS issues where appropriate
  • Use of the DiADeM Tool can help primary care clinicians make diagnosis in these cases with a high degree of certainty

Red Flags

Where reversible causes of cognitive impairment are identified, these should be treated. Seek urgent/acute advice from the Ambulatory Care consultant on-call if necessary via the GP Line 0845 304 4567 (North Kirklees only)


Undertake the following to aid diagnosis, inform management or prior to referral:

  • Bloods - HbA1C,RBS,FBC,U&E,Bone profile,B12, folate, TFT's, LFT's, CRP
  • MSU if UTI suspected
  • Rarely HIV/syphilis

Consider ECG (needed prior to commencing cholinesterase inhibitors)

CT/MRI scan

  • Arranging a scan at the point of referral will help speed up the diagnostic process

Choose CT scan where:

  • onset insidious, >12/12
  • >65 years
  • no history of stroke
  • No sudden change in personality

Choose MRI where:

  • rapid onset <6 months
  • younger patients
  • history of stroke
  • sudden change in personality
  • atypical history

If in doubt, please refer to the memory service where the scan request can be completed following further assessment.


Providing Quality Care and Follow Up

  • High-quality care, including regular monitoring and appropriate symptomatic treatment, is essential to maintain quality of life for individuals with dementia.
  • What are the requirements for practices for QOF?
    • Practice to establish and maintain a register of patients diagnosed with dementia
    • Provide a face-to-face review of the patient's care plan within the last 12 months
    • Newly diagnosed patients to have a record of 'dementia bloods' in the 12 months before or 6 months after entering the register

The Advanced Care Plan (ACP)

  • For the purposes of the Enhanced Service, newly diagnosed patients should have been offered an advanced care planning discussion ideally within 6 months. This remains good practice and should include:
    • Establishment of their physical, mental health and social needs
    • Identification of the patient's carer, and seeking permission to speak directly to the carer if appropriate
    • A record of the patient's wishes for the future
    • Referral/signposting to appropriate support services
    • The offer of a health check to the carer if registered with the practice

The Annual Face-to-Face Review of the ACP

  • This should focus on the support needs of the patient and their carer, reviewing the above plan or putting one in place. It should cover the following key issues:
    • Assessment of:
      • Physical health, including mobility, falls risk, nutrition, swallowing, continence, and co- morbidities.
      • Mental health, including cognition, behavioural issues and mood.
      • Medication, including response to cognitive enhancers and neuroleptics, side-effects and interactions.
      • Social needs, including capacity, safeguarding and need to consider Power of Attorney
  • A record of the patient's wishes for the future.
  • Co-ordination and communication arrangements with secondary care and social services
  • Review of the carer's needs

For further guidance see: NHS England Dementia: Good Care Planning

Management of patients with Mild Cognitive Impairment

  • In Mild Cognitive Impairment (MCI) there is minimal memory loss above what can be attributed to normal aging, but it is not severe enough to significantly impact on daily functioning.
  • MCI is a known risk factor for the development of Alzheimer's disease, but not all patients with MCI get worse, and some may improve. Evidence would suggest that patients with MCI go on to develop dementia at a rate of about 10 – 15% per year.
  • It would be advisable to review these patients as appropriate, at least annually.
  • There is currently no licensed drug treatment and management is supportive:
    • Healthy lifestyle advice
    • Regular exercise
    • Management of vascular risk factors
    • Enabling mental wellbeing – through mental and socially stimulating activities
  • Refer to memory service if cognitive decline/ADL's affected

Managing Behavioural and Psychological Symptoms of Dementia (BPSD)

  • More than 90 per cent of patients with dementia will experience BPSD difficulties during the course of their illness. These include sleeplessness, wandering, agitation, pacing, aggression (including spitting), and disinhibition (including sexual disinhibition).
  • Challenging behaviour needs to be seen as a manifestation of unmet need, which the patient may not be able to express. It can also be a manifestation of underlying pain and physical illness.
  • They can often be managed by providing training and support to relatives and carers, but the expectation is often put on GPs that they should provide a quick drug fix for patients with troublesome symptoms. This can lead to inappropriate prescribing.
  • If drugs have to be used, you should use the safest drugs you can, at the lowest doses that work, and set a review date for reducing or stopping them.
  • Most BPSD symptoms settle within a few weeks. Please see the excellent section on the most appropriate drug treatments in Dementia Revealed What Primary Care Needs to Know: A Primer for General Practice

When and how to stop treatment:

  • When they no longer appear to be working:
  • In the early years of use, AChEIs were stopped when the MMSE reached 10/30 but evidence has emerged that supports their continued usage in severe dementia. The effectiveness of an AChEI becomes more difficult to assess the longer a patient is on it because the baseline will have changed and sometimes the only way to know if it is still helping is to stop the drug and be prepared to re-start it if there is a sudden significant deterioration. It is therefore reasonable to continue these drugs indefinitely.
  • When they are not tolerated:
  • AChEIs should be stopped if they are thought to be causing problems – such as nausea, weight loss or bradycardia. Anxiety or agitation might prompt a trial without AChEIs as they are stimulant drugs. The result might be more apathy but less agitation.
  • On deciding to stop medication:
    • Donepezil, Galantamine and Memantine: reduce the dose gradually every two months to the minimum dose, then discontinue for a trial period of 4 weeks
    • Rivastigmine: reduce the dose by 1.5mg every 4 weeks, then discontinue for a trial period of 4 weeks
    • If using a patch, reduce to the lower dose patch for 2 months then discontinue.
    • A discussion needs to be had about the potential emergence of discontinuation syndrome (agitation, sleeplessness, delusions etc.). The clinician needs to be particularly careful in patients with Lewy Body Dementia.


Referral Criteria

  • Refer patients with suspected dementia to the SWYPFT memory service
  • Prior to referral to memory services, there is an expectation that:
    • patients will have had all potential physical causes for memory problems investigated and ruled out
    • anxiety and/or depression, which may impact on cognitive function, has been excluded as a cause
  • The post-referral memory monitoring pathway can be viewed here
  • Patients who have deteriorated after discharge can be referred back for to the SWYPFT via SPA for speedy assessment/advice
  • Adults under the age of 65 where dementia is suspected should be referred to The Crowlees Team via the SWYPFT Single Point of Access
  • Following diagnosis patients can be referred to Kirklees Dementia Hub for a structured education programme
  • General Information & Advice is available for anyone from Kirklees Dementia Hub

Referral Instructions

  • Routine referrals to SWYPFT memory service can be made via Locala website eRS or by telephone on 0300 304 5555
  • Urgent referrals to SWYPFT memory services can be made via SPA on 01924 284555
  • Urgent referrals or referrals for patients who have deteriorated after discharge can be made via SPA on 01484 434630
  • Adults under the age of 65 can be made via SWYPTs SPA on 01924 284555
  • For referrals and general advice contact Kirklees Dementia Hub on: 01484 503908

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation. Please see Making-decisions-and-managing difficult-situations or Dementia-Making-Decisions

Patient Information/Public Health/Self Care

Evidence/Additional Information

Assurance & Governance

  • This guidance was developed on: 05.2017
  • This guidance was ratified by: OSCAR Assurance Group
  • Date ratified: 05.2017
  • Publication Date: 05.2017
  • Updated: 03.2018
  • Review Date: 05.2019
  • Ref No: MH3 – 05.2017
Any feedback or suggestions to improve this guidance should be sent to:
Only the electronic version is maintained, once printed this is no longer a controlled document


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