Title: Dementia
1Dementia
November 2006
2This presentation covers
- Background
- Key recommendations
- Interventions
- Implementation
3National 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.
4Social 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.
5Who 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.
6What 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
7Non-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.
8Valid 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.
9Carers
- 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.
10Coordination 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.
11Memory 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.
12Structural 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)
13Behaviour 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.
14Training
- 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.
15Mental 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.
16Interventions
- 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.
17Alzheimers 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).
18Alzheimers 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.
-
19The 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)
20Other interventions
- Cognitive symptoms of dementia and mild cognitive
impairment (MCI). - Non-cognitive symptoms and behaviour that
challenges. - People with comorbid emotional disorders.
21Cognitive 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.
22Non-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.
23People 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.
24Integration 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.
25Service 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.
26Communication, 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.
27Communication, 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.
28Access tools online
- This slide set.
- Implementation advice.
- Audit criteria.
- Costing tools costingreport and local costing
template. - Available from www.nice.org.uk/CG042
29Access 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
30Access 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