Physical Health Monitoring in the Memory Service

Abstract

Aims

Local guidelines state that pulse rate, weight, ECG if indicated, and bloods (U&E, LFT) are monitored in patients prescribed an acetylcholinesterase inhibitor or memantine. This can affect management as the above parameters can affect medication selection and titration. Aberrant measurements can indicate drug related adverse events. Compliance to standards will optimise patient safety. This audit aims to assess compliance to these guidelines in one Memory Service in the Trust.

Methods

This is a single-centre, baseline, retrospective audit performed on 19/10/2022.

An internal database was used to identify all patients seen for a diagnostic assessment between September 2021 and October 2022. Patients who were prescribed an acetylcholinesterase inhibitor or memantine were eligible for selection. These were randomised to identify 30 cases.

Information was gathered through electronic patient notes, clinician diagnostic letters, referral forms, and pathology specimen result reporting software.

Results

Compliance were as follows:

• • Pulse rate recorded: 97%

• • Weight recorded: 0%

• • ECG requested when indicated: 20%

• • Blood samples taken and the results recorded: 100%

Pulse rate is part of the assessment proforma and blood sampling is a requirement prior to referral. This suggests that having guidelines incorporated to local protocols enhances compliance.

Weight was not routinely monitored: the rationale behind this being part of the guidelines is that rivastigmine can cause weight loss as per the BNF due to loss of appetite. However, on speaking to the Memory Team, this was not routinely done in the service as staff appear to rely on reports of appetite loss.

ECG was not routinely done when patients fall under the criteria for indications. Clinicians appear to judge the requesting on ECGs pragmatically based on their clinical judgment rather than guidelines alone.

Blood pressure is not a requirement in the guidelines for monitoring so cannot be audited. However, this is essential for decision making of treatment commencement, titration, switching, or titration.

Findings suggest that local guidelines may need to be reviewed.

Conclusion

This audit suggests some general learning points as well as service-specific ones.

The incorporation of guidelines into routine practice such as proformas or the pathway itself contributes to good compliance. This may be due to these standards being auditable as well as acting as prompts for staff members or even requirements for patients to proceed in the pathway.

This was also a reminder that clinical judgment may differ from guidelines; this may not necessarily be an indicator of poor practice but may result from pragmatic decision making for individual patients.

The findings were presented at a consultant meeting, the result of which was that the guidelines will be reviewed with likely inclusion of blood pressure monitoring. This is an illustration of the role of audits and quality improvement in improving standards of care.