REFERRAL PROCESS

Referring someone to the Dementia Prevention Research Clinics

BRNZ’s Dementia Prevention Research Clinics (DPRCs) are seeking to enrol individuals reporting early, mild difficulties with memory and / or other thinking abilities (such as planning, organising, problem-solving). Individuals may meet the criteria for Mild Cognitive Impairment.  These include mild difficulties with memory / cognitive functioning and intact functional abilities, such as completing usual activities of daily living (e.g. driving, managing home and work-related tasks).

Who should you refer for assessment?

We accept referrals from healthcare professionals that meet the entrance criteria below. Our team will inform the healthcare professional of the outcome of the referral. Please note, our clinics are for research purposes only, we do not provide ongoing care and treatment.

Eligiblity Criteria

  • Aged over 55 (unless strong family history of dementia)
  • Reported / suspected memory and / or other cognitive difficulties
  • Fluent in English
  • Not living in a long-term care facility

**If an individual meets each of the above criteria, they are eligible to attend the DPRCs**

Exclusion Criteria

  • Dementia
  • Montreal Cognitive Assessment (MoCA) score below 19
  • Moderate to severe traumatic brain injury
  • Psychiatric history (e.g. schizophrenia, bipolar affective disorder)
  • Alcohol / substance abuse / dependence
  • Intellectual disability
  • Known cerebral infarct
  • Pacemaker insertion
  • Significant neurological condition (e.g. Parkinson’s disease, epilepsy, intracerebral tumour)
  • Significant medical co-morbidities

**Individuals will NOT be eligible to attend the DPRCs if ANY of the exclusion criteria are met **

How to make a referral to the Dementia Prevention Research Clinics (DRPC)

There are two ways to refer a patient to the DPRCs. You will need your patient’s consent before providing information on their behalf.

1. Online

  • Use the DEMENTIA PREVENTION RESEARCH CLINIC online form - this is the quickest and easiest way to make a referral.
  • If all relevant information is included in the referral, it will be sent directly to our clinic team.
  • You can attach documents to the referral form e.g. GP letters, specialist advice.
  • Information entered in the form populates a client record. This is then used to support the patient’s assessment.
  • All sections of the form must be completed. This is to ensure efficient triage of referrals.

2. Email or Post Us a Referral form

Remember:

  • Providing your contact details is important as our team may contact you if additional information is needed about your patient.
  • Your patient cannot be referred for an assessment unless the correct information is provided.
  • Personal information and documents are retained securely by our clinical team.

DEMENTIA PREVENTION RESEARCH CLINIC REFERRAL FORM

Thank you for your referral. Please fill out this form, along with any relevant supporting documentation, and click on the submit button when all details are complete.

ABOUT THE PATIENT
PATIENT ADDRESS
PATIENT ELIGIBILITY CRITERIA
Yes    No    Don't Know
Yes    No    Don't Know
Yes    No    Don't Know
Yes    No    Don't Know
PATIENT EXCLUSION CRITERIA
Yes    No    Don't Know
Yes    No    Don't Know
Yes    No    Don't Know
Yes    No    Don't Know
Yes    No    Don't Know
Yes    No    Don't Know
Yes    No    Don't Know
Yes    No    Don't Know
Yes    No    Don't Know
Yes    No    Don't Know

**If you have ticked “Yes” to ANY of these boxes, the person is unfortunately NOT eligible to attend the DPRC**

INVESTIGATIONS

1. Lab blood results
Please upload current (within 3 months) lab blood results for: TSH, Lipids, LFT, Ca/P04, B12/Folate, FBC, U&E, CRP, HbA1c

 

2. Cognitive screening results

MMSE (Mini-Mental State Examination)
MoCA (Montreal Cognitive Assessment)
MRI Brain
CT Brain
IQCODE (Informant Questionnaire on Cognitive Decline in the Elderly)
Any other cognitive screen
MEDICAL DETAILS
REFERRER DETAILS
PATIENT CONSENT
Yes
No