Question

case study :

Mr. Green, is 79 years of age and lives at home with his wife Ruby. Mr. Green has been finding daily living activities difficult; Mr. Greens’ General Practitioner has recently diagnosed him with Rheumatoid Arthritis and Sjorgren’s syndrome.

Mr. Green, in his working life was a carpenter and still tries to make his own home repairs around the family home for the last 50 years and at the local elderly citizens club which Ruby and he attend. Up until recently, he was making dolls houses for underprivileged girls; lifting the power tools has become hard on his hands and he cannot stand for long periods of time. Mr. Green states that most of the time he has some degree of pain in his hands, shoulders, hips and knees. He has noticed Ulnar deviation is observed in both hands. The joints of the hands, knees, and feet are oedemateous. Morning stiffness lasts about an hour. His doctor has prescribed him Osteo panadol which he takes 4 times a day which he now believes is not holding the pain to a level he can cope with. He is also taking other medications such as Caltrate 600mg daily and Vitamin D 25mcg daily, Indomethacin 50mg daily. Isopto Carpine 2 drops in both eyes BD. He has admitted to his community nurse who visits them both once a week that at times he cannot open his Webster pack of medications and squeezing the eye drops for his Sjorgens; due to the pain in his finger joints and often misses doses for himself and his wife’s medications as he manages her medications too.

Mr. Green cannot manage his showering or making the bed till at least 10.00am. He is finding as the months go on, the less he manages to do and the longer it takes.

Mr. Green is also concerned for his wife’s health as Mrs. Green is becoming more confused, leaving him to prepare and cook their meals, clean and vacuum and do the washing. Mr. Green, witnessed Ruby put their electric kettle onto the gas stove, where he had to intervene to avoid a fire. Mr. Green does not drive his beloved Commodore anymore and has relinquished his licence due to his slowness and pain. He cannot always get to his Doctor, Pharmacy or supermarket to get the necessary supplies they both need and thinks he could not carry anything anyway with his hands.

The Greens have two adult sons who have left home and established their own families, neither of whom lives within the area.

He wants to ask his sons, but they live too far away and the grandchildren keep the sons busy at the weekends with their sporting activities.

Ruby

Ruby will need to undergo a series of screening tests

The GP may ask you to complete the General Practitioner Assessment of Cognition (GPCOG) tool with either Mr. Green or Ruby or both of them. This test can be done online apart from the clock drawing test.

The results of this testing indicate that further tests are warranted before a diagnosis. The GP refers Ruby to the local Cognitive Dementia and Memory Service (CDAMS) clinic.

AT cognitive dementia and memory services ( CDAMS ) patient is introduced to dementia pathways tool .

As a part of the referral the CDAMS requires a range of tests and investigations to be completed and compiled. As practice nurse you are required to follow up and collate this information for the referral.

1. List the information requirement for the referral

1. Why has this pathway been developed?

2. How useful is this tool for you as a practice nurse?

3. Although this tool has been developed with the Grampians Region in mind how useful is it for guiding practice nurses in other regions of Victoria and Australia? Discuss how you could use this tool when working in Primary Health settings with people undergoing the process of being diagnosed with dementia?

Answer 1

ANSWERS:-

## The information required for the referral;-

* People with a possible diagnosis of dementia should be offered a referral to memory assessment specialist for a comprehensive assessment.For a typical presentation referral may not be necessary.

* Information regarding atypical signs and symptoms,psychotic or behavioural disturbances,multiple or complex co morbidities,,medications

## Why has the pathway been developed?

* Dementia care pathways is the term used to describe the process of care a person with dementia may receive from the time they consult their GP with concerns about symptoms such as short term memory loss and are diagnosed with dementia through to the end of their life.

* The dementia Pathways Tool is a publically-accessible resource providing primary health care professionals with access to a web based repository containing information ,tools and resources to guide and enhance current assessment,referrral and management practices for patients with dementia.

* Dementia is one of the fastest growing disease in Australia, with prevalence rates expected to rise steadily.

* At the forefront of dementia care is the primary health care work force ;i.e. general practitioners and practice nurses; who are providing essential support across the disease process from early diagnosis to ongoing managment . This disease is complex and often places significant demand on primary health care workers .

* Online dementia pathways tool offers a comprehensive yet intuitive web based repository of dementia -related information,tools, service directories and resources available publically.

*This enables community access to information about dementia that may be of relevance ,including family and carrier support ,financial and legal issues,,driving capabilities and power of attorney.

### How useful is this tool for you as a practice nurse?

* Useful to be aware and identify the first and early signs of dementia.

*It offers an informed approach to diagnosis, referral and ongoing management of people with the symotoms of dementia.

* Dementia pathways tool helps practice nurse to promote dementia prevention and risk reduction inhealth assessments.

* It is useful for practice nurse to provide health education and support from first till the end of dementia pathways.

* Useful in developing chronic disease management plans with the context of cognitive impairement.

* This provides with access to an intuitive .online web based repository of information irrespective of practice location.

* It is available publiclyand therefore accessible to all practioners and the general public.

## How useful it is for guiding practice nurse in other regions,

* It is useful for guiding practice nurse in other regions of Victoria because it has a provision of expert advice on the content of the tool including pathways for local referrals and supports,local resources,recommended assessments ,investigations and review of cognitive decline,contact details about local support services for patients and carers,information about advance care plans.

* Although the dementia pathways tool was designed and developed specifically for practitioners in the Grampians region and contains a host of local resources,the web site has much broader appeal .As a publically accessible resource it offers all GPs and health professionals a web- based repository to guide and enhance current assessment and referal practices.