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... diagnosis of dementia, to aid in the differentiation of type of dementia and to ... cognitive stimulation programmes for mild to moderate dementia of all types. ... – PowerPoint PPT presentation

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Title: Dementia

November 2006
This presentation covers
  • Background
  • Key recommendations
  • Interventions
  • Implementation

National Institute for Health and Clinical
  • 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.

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.

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.

Changing practice
  • Standards for better health issued in July 2004
    states that healthcare organisations should take
    into account nationally agreed guidance
    particularly as defined in NICE guidance.
  • The Healthcare Commission assesses implementation
    of NICE guidelines in its Annual Health check
    process. The Commission for Social Care
    Inspection use SCIE practice guides to underpin
    and develop inspection standards.

  • Dementia is a progressive and largely
    irreversible syndrome that is characterised by
    a widespread impairmentof mental function.

Need for this guideline
  • 700,000 people are affected in the UK
    (Alzheimers Society) with 5 over 65, rising to
    20 of the over 80s.
  • Dementia is associated with complex needs and
    high levels of dependency and morbidity.
  • Care needs often challenge the skills and
    capacity of carers and available services.

What the guideline covers
Risk factors, screening and prevention
Diagnosis and assessment
Promoting independence
Promoting independence
Cognitive symptoms and maintenance of function
Non-cognitive symptoms and challenging behaviour
Comorbid emotional Disorders
Palliative Care
Palliative and end-of-life care
Key priorities
  • Non discrimination
  • Valid consent
  • Carers
  • Coordination and integration of care
  • Memory services

Key priorities continued
  • Structural imaging
  • Behaviour that challenges
  • Training
  • Mental health needs in acute hospitals

  • 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.

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

  • 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.

Coordination and integration of health and social
  • 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.

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.

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.
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
  • Common causes include depression, undetected pain
    or discomfort, side effects of medication and
    psychosocial factors.

  • 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.

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.

  • 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.

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

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 for details.

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

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
  • Mild cognitive impairment (MCI) do not use
    acetylcholinesterase inhibitors except as part of
    properly constructed clinical studies.

Non-cognitive symptoms and behaviour that
  • 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.
  • Use the assessment and care-planning approach as
    soon as possible.
  • For less severe distress and/or agitation,
    initially use a non-drug option.
  • See for details.

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.

Suggested actions
Integration and co-ordination of services.
  • Service provision.
  • Communication, education and training.

Integration and co-ordination of services
  • Follow the checklist in Everybodys business
    ( when developing
  • Promote incentives to improve implementation
    using the Quality and Outcomes Framework (QoF)
    and relevant targets such as the 18 week wait.

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.

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.
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
  • Ensure approved social workers training contains
    relevant material.

Costs and savings
  • Psychological therapies 27.4 million.
  • Structural imaging 20.2 million.
  • EEG 6.9 million.
  • Joint working not quantified nationally.
  • Training not quantified nationally.

Access tools online
  • This slide set.
  • Implementation advice.
  • Audit criteria.
  • Costing tools costingreport and local costing
  • Available from

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
  • The full guideline the recommendations, how
    they were developed and summaries of the
  • Available from and

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