1. Dementia 3 rd. edition – August 2011 NICE clinical guideline 42 Implementing the NICE/SCIE guidance

2. NICE Pathway The NICE Dementia pathway covers supporting people with dementia and their carers in health and social care. It includes the quality standard statements. The pathway looks at: Dementia diagnosis and assessment Dementia interventions Click here to go to NICE Pathways website

4. What this presentation covers NICE and SCIE backgrounds Guideline audience Background and content of the guideline Key priorities and recommendations TA217 (published March 2011) Interventions Find out more NICE dementia quality standard

5. 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.

6. 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.

7. 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

8. Dementia Dementia is a progressive and largely irreversible syndrome that is characterised by a widespread impairment of mental function

9. Need for this guideline 700,000 people are affected in the UK (Alzheimer’s 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

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

11. Key priorities Non discrimination Valid consent Carers Coordination and integration of care Memory services

12. Key priorities: continued Structural imaging Behaviour that challenges Training Mental health needs in acute hospitals

13. 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

14. 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

15. 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

16. 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

17. 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

18. Structural imaging for diagnosis Structural imaging should be used to assist in the assessment of suspected 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

19. 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

20. Training Health and social care managers should ensure that all staff working with older people in the health, social care and voluntary sectors have access to dementia-care training (skill development) that is consistent with their role and responsibilities

21. 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

22. 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 Detailed guidance on the use of cholinesterase inhibitors and memantine is set out in TA217

23. TA217 Alzheimer’s disease Guidance on acetylcholinesterase inhibitors (donepezil, rivastigmine and galantamine ) and memantine for Alzheimer’s disease See www.nice.org.uk/guidance/TA217 for detailswww.nice.org.uk/guidance/TA217 Guidance updated March 2011

24. Acetylcholinesterase inhibitor: mild to moderate disease initiate under specialist care continue only if worthwhile effect regular review Memantine: moderate disease and intolerant of or contraindication to acetylcholinesterase inhibitors or severe disease Guidance updated March 2011 TA217 Alzheimer’s disease

25. Acetylcholinesterase inhibitor: Start with the drug with the lowest acquisition cost Alternative if appropriate Guidance updated March 2011

26. Consider factors that could affect assessment scales and adjust as needed Secure equality of access to treatment Guidance updated March 2011 TA217 Alzheimer’s disease

27. Do not rely solely on cognition scores if: the patient has learning, other disabilities or communication difficulties the tool cannot be applied in a suitable language there are other similar reasons why the score is not an appropriate measure Guidance updated March 2011

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

29. Cognitive symptoms Offer cognitive stimulation programmes for mild to moderate dementia of all types For people with vascular dementia, do not use acetylcholinesterase inhibitors or memantine for cognitive decline, except as part of properly constructed clinical studies (1.6.3.1) For people with mild cognitive impairment (MCI), do not use acetylcholinesterase inhibitors except as part of properly constructed clinical studies (1.6.3.2)

30. 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 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 www.nice.org.uk/guidance/CG42 for detailswww.nice.org.uk/guidance/CG42

31. Non-cognitive symptoms and behaviour that challenges People with Alzheimer’s, vascular dementia or mixed dementias with mild-to-moderate non-cognitive symptoms should not be prescribed antipsychotic drugs because of the possible increased risk of cerebrovascular adverse events and death People with DLB with mild-to-moderate non-cognitive symptoms, should not be prescribed antipsychotic drugs, because those with DLB are at particular risk of severe adverse reactions

32. 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

33. 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 Costs correct at Nov. 2006. Costs not updated for 3 nd edition

34. Find out more Visit www.nice.org.uk/guidance/CG42 for the following NICE dementia guideline products:www.nice.org.uk/guidance/CG42 the NICE guideline the quick reference guide ‘Understanding NICE guidance’ costing report and template clinical audit tool memory assessment service commissioning guide end of life care for people with dementia commissioning guide

35. 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/publicationswww.scie.org.uk/publications

36. Further resources from SCIE

37. NHS Evidence Visit NHS Evidence for the best available evidence on all aspects of Dementia Click here to go to the NHS Evidence website

38. NICE Quality Standard Dementia

39. Dementia quality standard In 2010 NICE published a quality standard on dementia. This quality standard provides clinicians, managers and service users with a description of what a high-quality dementia service should look like It describes markers of high-quality, cost effective care that, when delivered collectively, should contribute to improving the effectiveness, safety, experience and care for adults with dementia The quality standard consists of 10 quality statements and can be found at: http://www.nice.org.uk/guidance/qualitystandards /dementia/dementiaqualitystandard.jsp http://www.nice.org.uk/guidance/qualitystandards /dementia/dementiaqualitystandard.jsp

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