The document outlines the establishment of a multidisciplinary memory assessment and support clinic at St. Mary’s Day Hospital, initiated in February 2016 to address the lack of comprehensive services for older adults with memory and cognitive problems. The clinic includes a structured assessment process over multiple visits, involving various healthcare professionals, and ends with a follow-up plan for ongoing support to patients and their families. The service aims to provide compassionate care and valuable resources for both patients and caregivers, ensuring they are connected and informed throughout the process.

1. Caroline Walshe
Clinical Nurse Manager
St Mary’s Day Hospital

2. Memory Assessment & Support
Clinic (MASC)
Recognition that no comprehensive service for older
adults with a memory or cognitive problems
Recognition no support service for families and carers
MASC will fill this void.
New Clinic commenced February 2016
Multidisciplinary team approach
Referral criteria
Adults over 65 years with memory/cognitive problems
Letter of referral from GP, A&E other Medic

3. Assessment Process
Appointment offered to attend for assessment which may
be over two to four visits
Visit One
Nursing
Comprehensive Geriatric Assessment (CGA) - Nursing
Assessment
Cambridge Behavioural Inventory-Revised CBI-R (For
Carer)
Routine Blood screen

4. Assessment Process
Medical
CGA- Medical Assessment
CBI-R reviewed
Cognitive subsection of CGA
Other aspects of CGA
Clinical Examination
Follow up
Refer to OT for formal cognitive and functional assessment
Referral for brain imaging- CT/MRI/Other
Refer to other disciplines- PT/CNS-incontinence, diabetes,
audiology, tissue viability

5. Assessment Process
Visit Two
Occupational therapy initial interview (+/-
cognitive assessments)
Other Assessments (as necessary)
Physiotherapy CNS-incontinence, diabetes,
audiology, tissue viability
Visit Three
Further Occupational Therapy assessment (as needed)

6. MDT Meeting
Discussion with all team members on findings as per MASC checklist
Findings from brain imaging, bloods and other tests:
Findings from CBI-R/subjective opinions from family/carers:
Findings from cognitive and functional assessment
Diagnosis determined with clarification of stage:
Brief outline of terminology used with patient/ family and who
information was given to:
Medication commenced (type and dosage)
Other disciplines involved:
Outline any discussion regarding legal issues/future planning
(EPOA, Care Rep, Nursing Home, Respite, HCP, day centre etc)
Follow up plan

7. Outcome of Assessment
Consultant meeting with patient and/or family.
Brief Summary of conversation and terminology used
(e.g. cognitive impairment or dementia specific
subtype) outlined in MASC and in medical notes
Medication commenced, dosage documented in
medical chart and prescribed:
Acetylcholinesterase inhibitor
Memantine
Antipsychotic
Antidepressant
 Medical Social worker referral made if appropriate.

8. Support Clinic
Telephone follow up by dedicated nurse Caroline
Walshe.
Refer for routine medical 4/12 where appropriate
and/or
Telephone support service for patients who do not
require ongoing medical review

9. Support Clinic
HCP/HH/Private Care
Agency
Alzheimer’s Society
Symptoms and
Diagnosis
Support Groups
Day Care Centre
• CarersAllowance
• Dementia Advisor
Service
• Social Club
• Elder Abuse
• PHN
• Alzheimer Society Café
• Respite public/private
• Fold Telecare
• Care Representative
• Fairdeal NHSS application
• Enduring Power of Attorney
• Fold Housing
Information on relevant support services

10. Outcomes
Through comprehensive assessment and support
older adults with memory and cognition issues are
guaranteed a seamless service at a difficult time
Through ongoing support from the dedicated named
nurse provides the patient, family and carers with a
link which is available to them to address any
concerns
Scope for additional information and education
sessions around differing aspects of memory
impairment, cognition, dementia and Alzheimer's
Disease

11. Compassionate Care
Feedback to date from service users
“My sister now understands
what I have been going
through with my dad”
“I know now what is wrong
with me……. I thought I was
going mad……. I am getting
the help I need….”
“I am glad to have a
name I can call it
means a lot”
“Only for
you I’d be
lost”
I didn’t
know You
did all this
up here…..
Time Empathy
Listen
Understanding

12. Thank you
Caroline Walshe
St Mary’s Day Hospital
Ph 01 6250544