DOI: 10.1093/ageing/afad246.034 ISSN: 0002-0729

1896 Community geriatrician led memory service improving access to dementia diagnosis with focus on admission avoidance

M McCarthy, C O'Donnell
  • Geriatrics and Gerontology
  • Aging
  • General Medicine



The Community Geriatrician team based at the Countess of Chester Hospital is a multidisciplinary team offering comprehensive assessments at home to older patients with frailty. The team review frail patients identified as being at risk of hospital admission. Cognitive impairment and dementia are increasingly common concerns in our patient group and significant risk factors for admission. Frail patients often struggle to access traditional memory clinics for a variety of reasons and can therefore remain undiagnosed. They often require a more holistic approach in their home environment. We therefore identified a need to offer a dedicated frailty memory pathway within our community geriatrician team enabling better access to dementia assessment and diagnosis in complex frail patients.


A frailty memory assessment pathway was proposed and commenced in 2022. Following identification of a cognitive concern during the initial comprehensive geriatric assessment a further home visit is arranged to assess memory in more depth. Patients are then discussed, and a diagnosis reached via a monthly Frailty memory MDT attended by a consultant psychiatrist, consultant geriatrician, and specialist occupational therapist. Following delivery of a diagnosis our AGE UK well-being coordinator within the team provides post diagnostic support and sign posting to patient and family. A retrospective audit was undertaken reviewing the 44 patients diagnosed since pathway commenced. The number of hospital admissions and number of inpatient bed days was compared in the 3 months pre and post initial assessment.


In the 3 months following assessment, 82% of patients had a reduction or unchanged number of admissions, there was a total reduction of 71 inpatient bed days.


We believe our pathway offers a unique multidisciplinary approach to dementia diagnosis in the frail population, improving frail patients access to dementia assessment with a reduction in hospital admissions.

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