Dementia is a common finding in the elderly and referrals to memory clinics have grown since the introduction of medication for treatment. Existing memory clinic models have been built on a foundation of clinical research and are time and cost intensive.

The HKH memory clinic model incorporates the General Practitioner (GP), clinical nurse consultant (CNC) and the Staff Specialist. Pre-screening is completed by the GP, while the CNC develops a comprehensive clinical profile including cognitive testing. The Staff specialist confirms the diagnosis and develops recommendations.

The model is popular with the GPs who remain the primary case manager. Staff specialists showed clear support, and patient / carers found it thorough and informative.

The number of new patients assessed in the clinic has doubled since 2002 while the waiting list is maintained between five to eight weeks. There is a proposal to create a transitional nurse practitioner position within the clinic.

To provide a user friendly, standardised, efficient and reliable assessment process to cope with demand.

The incidence of Alzheimer's disease is growing at an alarming rate and it is projected that within Australia, 850,000 people will be diagnosed by the year 2030. In 2002, Cholinesterase inhibitors were listed on the Pharmaceutical Board Schedule (PBS) for the treatment of Alzheimer's disease. PBS guidelines require a formal diagnosis by a specialist, use of standardised cognitive tools and evidence of improvement within a six month period. This dramatically increased referral rates to the specialist clinics, time required for assessment and the waiting list. 

The Specialist's one hour appointment was insufficient to accommodate the use of the cognitive assessment tool known as the Alzheimer's disease Assessment Scale - Cognition (ADAS-Cog).

The introduction of cholinesterase inhibitors onto the PBS caused a sudden increase in demand beyond current capacity. The HKH memory clinic waiting list extended to five months and was likely to continue to grow.

The introduction of a nursing clinic preceding the specialist appointment distributed the workload within the clinic and facilitated the use of a standardised assessment process. The availability of an appropriately skilled nurse enabled rapid change.

This model has been in operation over the period of 2002 to 2006. The double appointment process was trialed initially with one specialist, but then expanded to all specialists involved in memory assessment within two months.

As the model developed, team meetings incorporating the staff specialists, clinical neuropsychologist, nurses and research team were held to discuss continued improvement.

A staff survey to the specialists regarding the nursing clinic indicated strong support. A number of medical students, general practice trainees and new staff specialists request attendance at the preliminary clinic, in an observational capacity, to develop a stronger understanding of the model.

A questionnaire to the patients and carers who have utilised the service indicated strong support, while yielding some important comments regarding how they preferred feedback from the assessment. The integration of the GP into the model is an important aspect of its success.  

Staff involved in the HKH memory clinic have already conducted clinical drug trails and were familiar with the time intensive and expensive research model. Research models can require between three to five staff and frequently take a full day per patient for assessment. The HKH model was developed to provide service to all, rather than a select group.

To assist with increasing demand the CNC who had prior experience in cognitive testing offered to complete the ADAS-Cog following the Specialist appointment. This enabled eligibility for prescription of the Cholinesterase inhibitors. This service was well received but still meant that the patient needed a second visit to the Specialist to receive a script. The obvious solution was to have the testing done prior to the Specialist appointment.

Patient Flow Chart

NB.  The service closes for a number of weeks over Christmas and New Year to accommodate staff leave.  

Waiting list times for the first appointment were calculated by randomly selecting eleven patient files. Waiting periods in had previously been 12-16 weeks.

NB. The second appointment with the specialist is always scheduled to occur within 2 weeks of the first appointment.

The Specialists were individually approached to extend the offer of the CNC taking a detailed patient history as well as the cognitive testing to facilitate discussion at the following appointment. All four Specialists conducting the clinic agreed that this would be useful. A follow up questionnaire in 2004 to the specialists showed excellent support for the model, who stated that it was very, very useful.

The Specialists are now able to spend more time with the patient and carer to plan care and discuss concerns, and are able to complete all referral details and reports within the one hour allocated.

Periodic team meetings were held to discuss feedback and changes such as incorporating the CNC report in the report returned by the specialist to the GP resulted. The specialist therefore does not need to repeat information already documented, reducing the size of their summary letter. The GP received a more detailed report outlining current status or changes in the patient’s activities of daily living, sleep, diet and behaviour to serve as a baseline for care planning.

• More than 50% growth in clinic activity between 2002 and 2005. A total of 186 new patients were seen in 2005 for cognitive assessment.
• An estimated thirty three dollars and twenty six cents is saved per patient utilising this model compared to the same amount of time if using only staff specialists. Over one year this is estimated as a $6,186.36 saving.
• Waiting list times have been maintained for the memory clinic at five to eight weeks
• Increased availability for rapid response cognitive assessment.
• A standardised assessment process is established while meeting the PBS requirements.
• High satisfaction was reported on a patient/carer questionnaire, whilst providing useful feedback regarding their expectation for outcomes.
• GP referral rate continues to increase which provides anecdotal evidence of satisfaction with the service.
• Staff Specialists continues to support the model and promote its value.
• Patients are easily referred to additional disciplines / services e.g.. Respite services and Alzheimer's Association.
• A Transitional Nurse Practitioner (Cognition) is proposed by the service.
• The model has been able to expand and link with other services for referral e.g.. acute or community based services.

The HKH model is cost efficient and easily transferred. With the ageing population and increased longevity, exponential growth of people with memory disorders is anticipated. Assessment models established need to be easily replicated within tight fiscal restraints without jeopardising service delivery. There is strong evidence to show that results can be achieved with a less burdensome model, requiring additional evaluation by other disciplines as indicated rather than by rule.

This model works well along side a research based model of assessment and follow-up. Patients or carers are referred to our established international clinical drug trials, if they indicate an interest.