Dementia November 2006

This presentation covers: Background Key recommendations Interventions Implementation

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.

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

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.

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

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

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.

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.

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.

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.

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

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 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.

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 Alzheimer’s technology appraisal.

Alzheimer’s 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).

Alzheimer’s Technology Appraisal Consider the acetylcholinesterase inhibitors donepezil, galantamine and rivastigmine for moderate Alzheimer’s disease (a Mini Mental State Examination [MMSE] score of 10–20 points) only and under a number of conditions. Memantine is not recommended as a treatment option for people with moderately severe to severe Alzheimer’s disease except as part of well designed clinical studies. See for details.

The NICE-SCIE clinical guideline When not to rely on the MMSE score In those with an MMSE score >20, 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 <10 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)

Other interventions Cognitive symptoms of dementia and mild cognitive impairment (MCI). Non-cognitive symptoms and behaviour that challenges. 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 studies. Mild cognitive impairment (MCI): do not use acetylcholinesterase inhibitors except as part of properly constructed clinical studies.

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

Integration and co-ordination of services Follow the checklist in ‘Everybody’s business’ ( when developing services. 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 – costing report and local costing template. Available from

Access the guideline online 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 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