Cognitive Impairment and Dementia
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If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or follow local emergency care protocols or seek emergent medical advice if in a remote region.
- Very rapid onset of cognitive +/- other neurological symptoms
- Suspected delirium deemed unsafe to manage in the community by the treating medical practitioner
- Imminent safety risk to self or others
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| Category 1 (appointment within 30 calendar days) |
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| Category 2 (appointment within 90 calendar days) |
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| Category 3 (appointment within 365 calendar days) |
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Please insert the below information and minimum referral criteria into referral
1. Reason for request Indicate on the referral
- 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
2. Essential referral information Referral will be returned without this
- Current list of medications
- Relevant medical, psycho-social history (psychological symptoms), co-morbidities, allergies, and assessment of medication adherence.
- Brief historyregarding the cognitive, behavioural and functional changes/decline and their timeline
- Safety concerns e.g. unsafe walking & driving, medication non-compliance, unintentional weight loss, living alone, compromised insight (if relevant) disorientation in public spaces; concerns re financial management &/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 brain) (if available)
- Care-giver or other informant contact details (if patient consenting)
- 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.
3. 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)
- Recent Health Assessment (HA)
If so, please attach or provide information.
- Enduring Power of Attorney & Advance Health Directive or 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
4. Request
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Patient's Demographic Details
- 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
Referring Practitioner Details
- Full name
- Full address
- Contact details – telephone, fax, email
- Provider number
- Date of referral
- Signature
Relevant clinical information about the condition
- 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
Reason for request
- 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
Clinical modifiers
- 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
Other relevant information
- 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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If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or follow local emergency care protocols or seek emergent medical advice if in a remote region.
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Please note that where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service. Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.
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A change in patient circumstance (such as condition deteriorating, or becoming pregnant) may affect the urgency categorisation and should be communicated as soon as possible.
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Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.
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Last updated: 24 January 2023
© State of Queensland (Queensland Health) 2023
Except as permitted under the Copyright Act 1968, no part of this work may be reproduced, communicated or adapted without permission from Queensland Health. To request permission email ip_officer@health.qld.gov.au1.