Dementia

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Dementia
November 2006
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This presentation covers

• Background
• Key recommendations
• Interventions
• Implementation

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National Institute for Health and Clinical
Excellence

• NICE is the independent organisation in the NHS,
  responsible for producing guidance based on the
  best available evidence of effectiveness and cost
  effectiveness to promote health and to prevent or
  treat ill health.

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Social Care Institute for Excellence

• SCIE develops and promotes knowledge-based
  practice in social care. It produces
  recommendations and resources for practice and
  service delivery and improves access to knowledge
  and information in social care by working in
  partnership with others.

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Who is this NICE-SCIE guideline aimed at?

• This is the first joint guideline produced by
  NICE and SCIE.It covers the care provided by
  social care practitioners, primary care,
  secondary care and other healthcare professionals
  who have direct contact with, and make decisions
  concerning the care of, people with dementia.

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What the guideline covers
Risk factors, screening and prevention
Diagnosis and assessment
Diagnosis
Promoting independence
Promoting independence
Cognitive symptoms and maintenance of function
Non-cognitive symptoms and challenging behaviour
Comorbid emotional Disorders
Interventions
Palliative Care
Palliative and end-of-life care
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Non-discrimination

• People with dementia should not be excluded from
  any services because of their diagnosis, age
  (whether designated too young or too old) or a
  coexisting learning disabilities.

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Valid consent

• Health and social care practitioners should
  always seek valid consent from people with
  dementia.
• If the person lacks the capacity to make a
  decision, the provisions of the Mental Capacity
  Act 2005 must be followed.

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Carers

• The rights of carers to an assessment of needs as
  set out in the Carers (Equal Opportunities) Act
  2004 should be upheld.
• Carers of people with dementia who experience
  psychological distress and negative psychological
  impact should be offered psychological therapy,
  including cognitive behavioural therapy, by a
  specialist practitioner.

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Coordination and integration of health and social
care

• Health and social care managers should coordinate
  and integrate working across all agencies
  involved in the treatment and care of people with
  dementia and their carers.
• Care managers/coordinators should ensure the
  coordinated delivery of health and social care
  services for people with dementia.

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Memory services

• Memory assessment services should be the single
  point of referral for all people with a possible
  or suspected diagnosis of dementia.
• Services may be provided by a memory assessment
  clinic or by community mental health teams.

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Structural imaging for diagnosis

• Structural imaging should be used to assist in
  the diagnosis of dementia, to aid in the
  differentiation of type of dementia and to
  exclude other cerebral pathology.

Magnetic resonance imaging (MRI) is the
preferred modality to assist with early diagnosis
and detect subcortical vascular changes, although
computed tomography (CT) scanning could be used.
(Neuropsychological assessment for mild or
questionable dementia)
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Behaviour that challenges

• People with dementia who develop behaviour that
  challenges should be assessed at an early
  opportunity to establish the likely factors that
  may generate, aggravate or improve such
  behaviour.
• Common causes include depression, undetected pain
  or discomfort, side effects of medication and
  psychosocial factors.

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Training

• Health and social care managers should ensure
  that all staff working with older people in the
  health, social care and voluntary sectors
  haveaccess to dementia-care training that is
  consistent with their role and responsibilities.

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Mental health needs in acute hospitals

• Acute and general hospital trusts should plan and
  provide services that address the specific
  personal and social care needs and the mental and
  physical health of people with dementia who use
  acute hospital facilities for any reason.

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Interventions

• The guideline recommends a range of
  non-pharmacological and pharmacological
  interventions for cognitive symptoms,
  non-cognitive symptoms and behaviour that
  challenges, and for comorbid emotional disorders.
• It incorporates the recommendations of the
  Alzheimers technology appraisal.

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Alzheimers technology appraisal

• NICE was asked to review the evidence on
  donepezil, rivastigmine, galantamine and
  memantine.
• Drugs are appraised within their licensed
  indications (acetylcholinesterase inhibitors for
  mild to moderate disease, memantine for
  moderately severe to severe disease).

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Alzheimers Technology Appraisal

• Consider the acetylcholinesterase inhibitors
  donepezil, galantamine and rivastigmine for
  moderate Alzheimers disease (a Mini Mental State
  Examination MMSE score of 1020 points) only
  and under a number of conditions.
• Memantine is not recommended as a treatment
  option for people with moderately severe to
  severe Alzheimers disease except as part of well
  designed clinical studies.
• See www.nice.org.uk/TA111 for details.

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The NICE-SCIE clinical guidelineWhen not to rely
on the MMSE score
In those with an MMSE score gt20, who have
moderate dementia as judged by significant
impairments in functional ability and personal
and social function compared with premorbid
ability
In those with an MMSE score lt10 because of a low
premorbid attainment or ability or linguistic
difficulties, who have moderate dementia as
judged by an assessment tool sensitive to their
level of competence
In people with learning disabilities
In people who are not fluent in spoken English
or in the language in which the MMSE is applied
Tools used to assess the severity of dementia in
people with learning disabilities should be
sensitive to their level of competence
Cambridge Cognitive Examination Modified
Cambridge Examination for Mental Disorders of the
Elderly DMR Dementia Scale for Down Syndrome
(DSDS)
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Other interventions

• Cognitive symptoms of dementia and mild cognitive
  impairment (MCI).
• Non-cognitive symptoms and behaviour that
  challenges.
• People with comorbid emotional disorders.

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Cognitive symptoms

• Offer cognitive stimulation programmes for mild
  to moderate dementia of all types.
• Vascular dementia do not use acetylcholinesterase
  inhibitors or memantine for cognitive decline
  except as part of properly constructed clinical
  studies.
• Mild cognitive impairment (MCI) do not use
  acetylcholinesterase inhibitors except as part of
  properly constructed clinical studies.

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Non-cognitive symptoms and behaviour that
challenges

• Consider medication for non-cognitive symptoms or
  behaviour that challenges in the first instance
  only if there is severe distress or an immediate
  risk of harm to the person or others (can use
  AchEI for DLB or AD)
• Use the assessment and care-planning approach as
  soon as possible.
• For less severe distress and/or agitation,
  initially use a non-drug option e.g.
  aromatherapy, music
• See www.nice.org.uk/CG042 for details.

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People with comorbid emotional disorders

• Assess and monitor people with dementia for
  depression and/or anxiety.
• Consider cognitive behavioural therapy.
• A range of tailored interventions such as
  reminiscence therapy, multisensory stimulation
  etc should be available.
• Offer antidepressant medication.

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Integration and co-ordination of services

• Follow the checklist in Everybodys business
  (www.everybodysbusiness.org.uk) when developing
  services.
• Promote incentives to improve implementation
  using the Quality and Outcomes Framework (QoF)
  and relevant targets such as the 18 week wait.

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Service provision

• Provide a single assessment process.
• Ensure health and social care managers jointly
  agree written policies and procedures.
• Combine care plans between health and social
  services and ensure the person with dementia
  and/or carers endorse it.

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Communication, education and training

• Review communication and training arrangements
  within and across partner organisations.

Work with mental capacity act networks. Use best
practice tool from Department of Health.
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Communication, education and training

• Collaborate with your local workforce development
  directorate, local dementia specialists, social
  services, higher education institutions and
  voluntary agencies to consider training in
  dementia as part of CPD for health and social
  care staff.
• Consider using Skills for Care Knowledge Set
  (www.skillsforcare.org.uk).
• Ensure approved social workers training contains
  relevant material.

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Access tools online

• This slide set.
• Implementation advice.
• Audit criteria.
• Costing tools costingreport and local costing
  template.
• Available from www.nice.org.uk/CG042

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Access the guidelineonline

• The quick reference guide a summary of the
  recommendations for health and social care staff.
• Understanding NICE-SCIE guidance information
  for people with dementia and their carers.
• The NICE-SCIE guideline all the
  recommendations.
• The full guideline the recommendations, how
  they were developed and summaries of the
  evidence.
• Available from www.nice.org.uk/CG042 and
  www.scie.org.uk/publications

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Access further information from SCIE

• Practice guides summaries of information on a
  particular topic to update practice at the health
  and social care interface.
• Research briefings information, research and
  current good practice about particular areas of
  social care.
• Available from www.scie.org.uk/publications