THE SERVICES AVAILABLE FOR PERSONS WITH DEMENTIA AND HOW TO USE THEM: HOSPITAL SERVICES
A young person with suspected dementia will probably first be referred to a neurologist. This is a doctor who has been specially trained in the diagnosis and treatment of disorders of the nervous system, including the brain. Neurologists ensure that a thorough physical examination is undertaken, having carefully inquired into the history of the illness, and will arrange appropriate tests, including blood tests and special X-rays. However, after making a diagnosis, many will not be in a position to offer any regular help and will refer the continuing management of the patient back to the general practitioner.
An older person with dementia is more likely to be referred to a geriatrician or a psychiatrist with a special interest in the elderly, sometimes called a psychogeriatrician. Geriatricians are trained in all the disorders that are found more commonly in older people. They will perform a very similar assessment to that provided by the neurologist for younger people, but will also have access to many of the health service resources that are essential for the continuing care and support for people with dementia, and for their relatives and carers.
As well as hospital beds to provide intermittent relief or holiday admissions the geriatric department usually has a day hospital. This is not necessarily a facility for providing relief for families, but an environment in which further careful assessment can be undertaken. In most cases there has to be a ‘therapeutic’ need for a person to attend a day hospital. Day relief is provided elsewhere, for example at day centres run by the statutory and voluntary services.
Although there are no strict rules, elderly people with dementia who require screening are generally referred first to a geriatrician, but after this the care for those who are mobile as well as demented usually falls to the psychogeriatrician. There are good practical reasons for this; for instance, psychiatric day hospitals are more secure and a wandering demented person is less likely to escape and come to harm. On the other hand a demented person who is heavily dependent on physical nursing will more usually need the help of the geriatric service. There are of course many exceptions to this generalization.
Very often psychogeriatricians will visit patients in their own home, and take the opportunity to familiarize themselves with the problems that relatives and other carers are having to manage. In this way they can judge how best the resources that they have available can help. It also allows those looking after a person with dementia to demonstrate the difficulties they are facing and being able to talk about the problem in their home environment is often easier than trying to describe the situation in a busy out-patient clinic.
Once the matters of diagnosis and assessment have been completed, the specialist will plan the future with the family, the general practitioner, and often other members of his team. It is important that everybody knows about this ‘package’ so that they can see the way ahead. One must also remember that the package has to be regarded flexibly and its provisions may need to be changed as the situation alters.
In some parts of the country there are specialist clinics for people with dementia where a person with dementia isn’t just seen in a slot between people with other conditions, but is assessed in an environment in which all patients have similar problems and all staff are specially trained in this area of medicine. The pattern in different memory clinics varies, but in some every patient is seen by a geriatrician, a psychiatrist, and a psychologist, and great attention is paid to the problems and needs of the carers. (A psychiatrist is a doctor trained in the problems of mental illness; a psychologist, although not medically qualified, is trained in the skills of behaviour assessment, behaviour treatment, and other related activities; he is also able to give valuable advice.) A full appraisal of the medical problems is made, a diagnosis of the underlying disorder is established, and treatment is prescribed for the fortunate few with a treatable underlying condition. The way ahead is mapped out and the patients and their families seen regularly two or three times a year. The day to day management of patients’ care is returned to the general practitioner or to the local specialist if they have been referred from another area of the country. The clinic may also have a support group attached to it for the families of people with dementia who live in the district. The number of clinics like this is increasing and, if one is available locally, your general practitioner will probably seek from it a second opinion. One of the major strengths of such clinics is that they often have a representative of both the geriatric and the psychogeriatric services, allowing closer collaboration between the two in dealing with the needs of a particular person.
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