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Cognitive Impairment and Dementia referral

Does your patient wish to be referred?

Minimum referral criteria

Does your patient meet the minimum referral criteria?

Category 1

Appointment within 30 days is desirable

  • Presence of concerning features (may include but not limited to):
    • Behavioural and Psychological Symptoms of Dementia (BPSD) – moderate to severe stage include rapidly evolving (over weeks)
    • Unresolved safety concerns in current living situation (patient or care giver)
    • Suspected self-neglect or abuse
    • Rapidly evolving (over weeks)
    • Significant care-giver stress

Category 2

Appointment within 90 days is desirable

  • Patients with suspected dementia who do not meet category 1 criteria

Category 3

Appointment within 365 days is desirable

  • No category 3 criteria

If your patient does not meet the minimum referral criteria

Consider other treatment pathways or an alternative diagnosis.

If you still need to refer your patient:

  • Please explain why (e.g. warning signs or symptoms, clinical modifiers, uncertain about diagnosis, etc.)
  • Please note that your referral may not be accepted or may be redirected to another service

Other important information for referring practitioners

Not an exhaustive list

  • Refer to local Healthpathways or local guidelines
  • Referral to accredited pharmacist for Home Medical Review/Residential Medication Management review if evidence of polypharmacy
  • If malnourished, consider referral to a dietitian
  • Referral to occupational therapy driving assessment if locally available

Consider ongoing Allied Health support as appropriate, i.e. Dietitian, Social Worker, Occupational Therapist, Physiotherapist, Psychologist, Speech and Language Therapist.

Referral requirements

A referral may be rejected without the following information.

Essential referral information

  • Current list of medications
  • Relevant medical, psycho-social history (psychological symptoms), co-morbidities, allergies and assessment of medication adherence.
  • Brief information regarding the cognitive, behavioural and functional changes/decline and their timeline
  • Care-giver or other informant contact details (if patient consenting)
  • Safety concerns require to be listed e.g. unsafe walking & driving, medication non-compliance, unintentional weight loss, living alone, compromised insight (if relevant), disorientation in public spaces; concerns re financial mismanagement and/or abuse
  • Assessment of cognitive function with a validated instrument
  • Investigation blood test results – FBC, ELFT, Calcium, TSH, Vitamin B12 (if available)
  • Recent brain imaging reports (CT or MRI Head) within last 6 months (if available)
  • Social situation:  living alone: partner/family supports?

NB If a specific test result cannot be obtained due to access, financial, religious, cultural or consent reasons a clinical override may be requested. This reason must be clearly articulated in the body of the referral.

Additional Referral Information (Useful for processing the referral)

  • Risk factors for cognitive impairment including strong family history, diabetes, smoking and sleep study (if completed).
  • Rockwood Clinical Frailty Scale score (if available)
  • Is there currently any of the following in place:
    • GP Management Plan (GPMP)
    • Team Care Arrangement (TCA)
    • Mental Health Management Plan (MHMP)
    • Health Assessment (HA)
  • If so, please attach or provide information.
  • Enduring Power of Attorney & Advance Health Directive & Statement of Choices document (copy)
  • Availability of transport to appointment and willingness to attend appointment or is home visit required? (This may vary dependant on your local region service)
  • Willingness or suitability to participate in Telehealth/virtual clinic

Out of catchment

Metro North Health is responsible for providing public health services to the people who reside within its boundaries. Special consideration is made for patients requiring tertiary care or services that are not provided by their local Hospital and Health Service. If your patient lives outside the Metro North Health area and you wish to refer them to one of our services, inclusion of information regarding their particular medical and social factors will assist with the triaging of your referral.

  • Impact on employment
  • Impact on education
  • Impact on home
  • Impact on activities of daily living
  • Impact on ability to care for others
  • Impact on personal frailty or safety
  • Identifies as Aboriginal and/or Torres Strait Islander

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can’t order, or the patient can’t afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

  • Presenting symptoms (evolution and duration)
  • Physical findings
  • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
  • Body mass index (BMI)
  • Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
  • Current medications and dosages
  • Drug allergies
  • Alcohol, tobacco and other drugs use

  • Full name (including aliases)
  • Date of birth
  • Residential and postal address
  • Telephone contact number/s – home, mobile and alternative
  • Medicare number (where eligible)
  • Name of the parent or caregiver (if appropriate)
  • Preferred language and interpreter requirements
  • Identifies as Aboriginal and/or Torres Strait Islander

  • Full name
  • Full address
  • Contact details – telephone, fax, email
  • Provider number
  • Date of referral
  • Signature

  • Willingness to have surgery (where surgery is a likely intervention)
  • Choice to be treated as a public or private patient
  • Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)
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