1. Dementia
September 2007
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DISCLAIMER
This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself.
This slide set was updated in September 2007 following the judicial review of TA111 and its content now includes the amended details of TA111.
Full details of the amended TA111 are available at

2. This presentation covers:
Background
Key recommendations
Interventions
Implementation
NOTES FOR PRESENTERS
This presentation covers the background to the guideline, the key priority recommendations, the pharmacological interventions included in the guideline and relevant implementation issues.
It refers to the practical support tools available from NICE to support the implementation process.
There are also slides which reflect the updated Technology Appraisal TA111 Alzheimer’s disease – donepezil, galantamine, rivastigmine (review) and memantine (amended September 2007).

3. 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.
NOTES FOR PRESENTERS
The Department of Health asked the National Institute for Health and Clinical Excellence to work in partnership with the Social Care Institute for Excellence to produce a joint guideline on dementia.
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.

4. 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.
NOTES FOR PRESENTERS
The Social Care Institute for Excellence (SCIE) was launched in 2001 by Government. SCIE develops and promotes knowledge about good practice in social care and draws on and analyses knowledge from a range of sources to produce recommendations and resources for practice and service delivery. It improves access to knowledge and information in social care through Social Care online, for example. SCIE works in partnership with others, the products and services that are developed are free.
SCIE was set up to
Draw together and spread evidence of what works best in social care
Help local councils and other service providers take decisions about changing the ways services are delivered, and help practitioners make better decisions “A Quality Strategy for Social Care 2000”
SCIE’s role
To find out what is known
To translate this into guides for policy, practice and service delivery
To encourage and enable knowledge-based practice in social care
To disseminate and promote

5. 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.
NOTES FOR PRESENTERS
This is the first joint guideline produced by NICE and SCIE.
It is aimed at professional groups who share in the treatment and care for people with a diagnosis of dementia, including psychiatrists, clinical psychologists, mental health nurses, social workers, counsellors and others
Also at professionals in other health and non-health sectors who may have direct contact with or are involved in the provision of health, social care and other public services for those diagnosed with dementia
In addition, those with responsibility for planning services for people with a diagnosis of dementia, and their carers, including directors of public health, NHS trust managers, managers in PCTs and councils with social services responsibilities

6. 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.
NOTES FOR PRESENTERS
NICE clinical guidelines aim to ensure that promotion of good health and patient care in the NHS are in line with the best available evidence of clinical effectiveness and cost effectiveness. Guidelines help healthcare professionals in their work, but they do not replace their knowledge and skills. NICE clinical guidelines recommend appropriate treatment and care of people with specific conditions or diseases in the NHS in England, Wales and Northern Ireland .
“Standards for better health”, issued in July 2004 by the Department of Heath, identifies core and developmental standards for NHS organisations. Core standard C5 states that healthcare organisations should take into account nationally agreed guidance when planning and delivering treatment and care. Implementation of clinical guidelines forms part of developmental standard D2 which states that patients should receive effective treatment and care that conforms to nationally agreed best practice, particularly as defined in NICE guidance.
In England, the Healthcare Commission is responsible for assessing and reporting on the performance of both NHS and independent healthcare organisations.
In Wales, the Healthcare Commission works closely with the Health Inspectorate Wales, who are responsible for the NHS in Wales, and the Care Standards Inspectorate Wales, who are responsible for independent healthcare in Wales.
The Commission for Social Care Inspection (CSCI) is the single, independent inspectorate for social care in England. It incorporates work formerly done by the Social Services Inspectorate (SSI), Audit Commission Joint Review Team and the National Care Standards Commission (NCSC).
The Commission brings together the inspection, regulation and review of all social care services into one organisation. It was created by the Health and Social Care (Community Health and Standards) Act 2003 and became fully operational on 1 April 2004.

7. Dementia
Dementia is a progressive and largely irreversible syndrome that is characterised by a widespread impairment of mental function.
NOTES FOR PRESENTERS
It can be viewed as one of the ways in which an individual’s personal and social capacities change with age. Changes in such capacities are only experienced as disabilities when environmental supports are not adaptable to suit changing needs and capacities.
Diagnostic criteria for dementia:
Alzheimer’s disease: Preferred criteria: NINCDS/ADRDA. Alternatives include ICD-10 and DSM-IV
Vascular dementia: Preferred criteria: NINDS-AIREN. Alternatives include ICD-10 and DSM-IV
Dementia with Lewy bodies: International Consensus criteria for dementia with Lewy bodies
Frontotemporal dementia: Lund-Manchester criteria, NINDS criteria for frontotemporal dementia
(DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, fourth edition; ICD-10, International Classification of Diseases, 10th revision)
For more details, refer to the NICE guideline – pages 7-8 and page 60.

8. 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.
NOTES FOR PRESENTERS
Demographic changes in the next 30 years, with a substantial increase in the proportion of people in the “old old” age groups, mean that the prevalence of dementia is set to more than double in the next years.
In a typical general hospital of 500 beds, 330 of those beds will be occupied by older people, of whom 102 will have dementia. For inpatients, in a General Hospital, dementia is an independent predictor of poor outcome, including increased mortality, increased length of stay, loss of function and higher rates of institutionalisation.
Coexistent medical problems are very common in people with dementia.
For more details, refer to NICE guideline – page 8.

9. What the guideline covers
Diagnosis
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
Interventions
NOTES FOR PRESENTERS
This shows pictorially what the guideline covers.
It includes risk factors, screening and prevention, early identification and diagnosis and promoting independence. This is for people of all ages with all forms of dementia whether they be mild, moderate or severe.
In relation to promoting independence it covers interventions for cognitive symptoms and maintenance of function, non-cognitive systems and challenging behaviour and comorbid emotional disorders. It also covers palliative and end of life care.
In relation to the interventions, it covers psychosocial interventions, pharmacological treatment including the technology appraisal TA111 Alzheimer’s disease – donepezil, galantamine, rivastigmine (review) and memantine (amended September 2007); use of self management strategies and the role of family and carers.
It covers care across sectors.
Palliative Care
Palliative and end-of-life care

10. Key priorities Non discrimination Valid consent Carers
Coordination and integration of care
Memory services
The key priorities within the guideline cover:
Non discrimination
Valid consent
Carers
Coordination and integration of care
Memory services

11. Key priorities continued
Structural imaging
Behaviour that challenges
Training
Mental health needs in acute hospitals
And continued ……….
Structural imaging
Behaviour that challenges
Training
Mental health needs in acute hospitals
This presentation now takes each of the recommendations within these key priorities.

12. 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.
NOTES FOR PRESENTERS
‘People with dementia should not be excluded from any services because of their diagnosis, age (whether designated too young or too old), or coexisting learning disabilities’.
People who are suspected of having dementia because of evidence of functional and cognitive deterioration, but who do not have sufficient memory impairment to be diagnosed with the condition, should not be denied access to supporting services.
Younger people with dementia have special requirements, and specialist multidisciplinary services should be developed, allied to existing dementia services, to meet their needs for assessment, diagnosis and care.

13. 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.
NOTES FOR PRESENTERS
‘Health and social care professionals should always seek valid consent from people with dementia. This should entail informing the person of options, and checking that he or she understands, that there is no coercion and that he or she continues to consent over time. If the person lacks the capacity to make a decision, the provisions of the Mental Capacity Act 2005 must be followed’.
People with dementia should have the opportunity to make informed decisions by ensuring the provision of proper support to them in reaching decisions. For example support that minimises the effects of poor memory and other cognitive impairments that reduce understanding relevant information and risks.
Seeking consent should entail informing the person with dementia of options, and checking that he or she understands, that there is no coercion and that he or she continues to consent over time.
Health and social care practitioners should discuss with the person with dementia, while they still have capacity, the use of advance decisions to refuse treatment and lasting powers of attorney, which are made under the provisions of the Mental Capacity Act People with dementia and their carers should be informed about the availability and role of local and national advocacy services.
Where people with dementia do not have the capacity to make decisions, healthcare professionals should follow the “Department of Health guidelines–Reference guide to consent for examination or treatment” (2001) and “Seeking consent: working with older people” (2002). The Mental Capacity Act 2005 is due to be implemented into full practice in April 2007.

14. 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.
NOTES FOR PRESENTERS
‘Health and social care managers should ensure that the rights of carers to receive an assessment of needs, as set out in the Carers and Disabled Children Act 2000 and the Carers (Equal Opportunities) Act 2004, are upheld’.
‘Carers of people with dementia who experience psychological distress and negative psychological impact should be offered psychological therapy, including cognitive behavioural therapy, conducted by a specialist practitioner’.

15. 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.
NOTES FOR PRESENTERS
‘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, including jointly agreeing written policies and procedures. Joint planning should include local service users and carers in order to highlight and address problems specific to each locality.
Care managers and care coordinators should ensure the coordinated delivery of health and social care services for people with dementia. This should involve:
a combined care plan agreed by health and social services that takes into account the changing needs of the person with dementia and his or her carers
assignment of named health and/or social care staff to operate the care plan
endorsement of the care plan by the person with dementia and/or his or her carers
formal reviews of the care plan, at a frequency agreed between professionals involved and the person with dementia and/or their carers and recorded in the notes’.
Time periods for review of care plans are stipulated by Care Programme Approach guidance and ‘Fair access to care services – guidance on eligibility criteria for adult social care’ (see

16. 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.
NOTES FOR PRESENTERS
‘Memory assessment services (which may be provided by a memory assessment clinic or by community mental health teams) should be the single point of referral for all people with a possible diagnosis of dementia’.
Memory assessment services that identify people with mild cognitive impairments should offer follow-up to monitor cognitive decline and other signs of possible dementia in order to plan care at an early stage.
Memory assessment services should include a full range of assessment, diagnostic, and therapeutic services to accommodate the different needs of people with different types and severities (from mild to severe) of dementia and the needs of their carers and families
Memory assessment services should also ensure a properly integrated approach to service provision for health and social care of people with dementia and their carers, and should do so in partnership with local health, social care and voluntary organisations
Clinicians who regularly diagnose dementia and discuss this with patients and carers may wish to consider mentoring, coaching or clinical supervision to support less experienced clinicians in undertaking this difficult and challenging work

17. 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.
NOTES FOR PRESENTERS
‘Structural imaging should be used in the assessment of those with suspected dementia to exclude other cerebral pathologies and to help establish the subtype diagnosis. 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. Specialist advice should be taken when interpreting scans in people with learning disabilities’.
Formal neuropsychological testing should form part of the assessment in cases of mild or questionable dementia.

18. 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.
NOTES FOR PRESENTERS
‘People with dementia who develop non-cognitive symptoms that cause them significant distress or who develop behaviour that challenges, including agitation, should be offered an assessment at an early opportunity to establish the likely factors that may generate, aggravate or improve such behaviour. The assessment should be comprehensive and include:
the person’s physical health
Depression
possible undetected pain or discomfort
side effects of medication
individual biography, including religious beliefs and spiritual and cultural identity
psychosocial factors
physical environmental factors
behavioural and functional analysis conducted by professionals with specific skills , in conjunction with family carers and care workers.
 Individually tailored care plans that help carers and staff address the behaviour that challenges should be developed, recorded in the notes and reviewed regularly. The frequency of the review should be agreed by the carers and staff involved and written in the notes’.
Challenging problems of dementia are: aggressive behaviour, restlessness and wandering, eating problems, incontinence, delusions and hallucinations and mobility difficulties.

19. 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.
NOTES FOR PRESENTERS
‘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’.

20. 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.
NOTES FOR PRESENTERS
‘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’.

21. 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 TA111.
NOTES FOR PRESENTERS
The next section covers interventions. Firstly we cover TA111 Alzheimer’s disease – donepezil, galantamine, rivastigmine (review) and memantine (amended September 2007) and then we move on to look at what the clinical guideline says about other interventions – pharmacological and non-pharmacological.
These interventions are presented under the following categories:
Cognitive symptoms of dementias and mild cognitive impairment (MCI).
Non-cognitive symptoms and behaviour that challenges.
People with comorbid emotional disorders.

22. TA111 Alzheimer’s disease (amended September 2007)
NICE was asked to review the evidence on donepezil, rivastigmine, galantamine and memantine.
Drugs are appraised within their licensed indications at the time of the appraisal (acetylcholinesterase inhibitors for mild to moderately severe disease, memantine for moderately severe to severe disease).
NOTES FOR PRESENTERS
NICE Technology appraisal (TA) 111 provides guidance on the use of the acetylcholinesterase inhibitors donepezil, rivastigmine and galantamine and another drug, memantine, for the treatment of Alzheimer’s disease.
The appraisal was first issued in November Following the outcome of a judicial review in August 2007, NICE amended and reissued TA111.  The amended guidance clarifies the steps healthcare professionals should take when assessing whether Alzheimer’s disease is of moderate severity and highlights that clinicians should be mindful of the need to secure equality of access to treatment.
The benefits of these drugs for patients with other forms of dementia (for example, vascular dementia or dementia with Lewy bodies) were not assessed in this guidance.
Full details of the judicial review and the amended technology appraisal are available at

23. TA111 Alzheimer’s disease (amended September 2007)
Consider an acetylcholinesterase inhibitor (donepezil, galantamine or rivastigmine) for Alzheimer’s disease of moderate severity only and under specific conditions.
Moderate severity: a Mini Mental State Examination [MMSE] score of 10–20 points
Do not use Memantine except as part of well designed clinical studies.
See for details.
NOTES FOR PRESENTERS
This information is taken from the technology appraisal:
‘The three acetylcholinesterase inhibitors donepezil, galantamine and rivastigmine are recommended as options in the management of people with Alzheimer’s disease of moderate severity only (that is, subject to circumstances where it is inappropriate to do so [see next slide], those with a Mini Mental State Examination [MMSE] score of between 10 and 20 points), and under the following conditions:
• Only specialists in the care of people with dementia (that is, psychiatrists including those specialising in learning disability, neurologists, and physicians specialising in the care of the elderly) should initiate treatment. Carers’ views on the patient’s condition at baseline should be sought.
• Patients who continue on the drug should be reviewed every 6 months by MMSE score and global, functional and behavioural assessment. Carers’ views on the patient’s condition at follow-up should be sought. The drug should only be continued while the patient’s MMSE score remains at or above 10 points, subject to circumstances where it is inappropriate to do so, (see next slide), and their global, functional and behavioural condition remains at a level where the drug is considered to be having a worthwhile effect. Any review involving MMSE assessment should be undertaken by an appropriate specialist team, unless there are locally agreed protocols for shared care.
When the decision has been made to prescribe an acetylcholinesterase inhibitor, it is recommended that therapy should be initiated with a drug with the lowest acquisition cost (taking into account required daily dose and the price per dose once shared care has started). However, an alternative acetylcholinesterase inhibitor could be prescribed where it is considered appropriate having regard to adverse event profile, expectations around concordance, medical co-morbidity, possibility of drug interactions, and dosing profiles.
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.
People with mild Alzheimer’s disease who are currently receiving donepezil, galantamine or rivastigmine, and people with moderately severe to severe Alzheimer’s disease currently receiving memantine, whether as routine therapy or as part of a clinical trial, may be continued on therapy (including after the conclusion of a clinical trial) until they, their carers and/or specialist consider it appropriate to stop’.
See for details.

24. TA111 Alzheimer’s disease (amended September 2007)
When using the MMSE to diagnose moderate Alzheimer’s disease, clinicians should be mindful of the need to secure equality of access to treatment for patients from different ethnic groups (in particular those from different cultural backgrounds) and patients with disabilities.
NOTES FOR PRESENTERS
Usually, healthcare professionals should use the MMSE test to assess whether a person has moderate Alzheimer’s disease. However, the
test is not suitable for some people.
When using the MMSE test, healthcare professionals should make sure that people from different ethnic or cultural backgrounds and people with disabilities have equal access to treatment.
This reflects the details included in TA111 Alzheimer’s disease – donepezil, galantamine, rivastigmine (review) and memantine (amended September 2007) .

25. TA111 Alzheimer’s disease (amended September 2007)
Circumstances where the MMSE or the MMSE alone would not be appropriate to assess the severity of Alzheimer’s disease:
the patient has learning or other disabilities
the patient has linguistic or other communication difficulties
the MMSE cannot be applied in a language in which the patient is sufficiently fluent
Usually, healthcare professionals should use the MMSE test to assess whether a person has moderate Alzheimer’s disease. However, the test is not suitable for some people.
When using the MMSE test, healthcare professionals should make sure that people from different ethnic or cultural backgrounds and
people with disabilities have equal access to treatment.
In some cases, healthcare professionals should not rely on the MMSE test – or not rely on it alone – to assess whether someone has
moderate Alzheimer’s disease. This may be the case when assessing people who:
• have learning disabilities or other disabilities such as deafness or blindness, or
• have difficulty speaking (for example, after a stroke) or other difficulties with communicating, or
• are not fluent enough in a language in which the MMSE test can be given
if this means that the MMSE test will not fairly reflect the severity of the disease.
For these people, healthcare professionals should use a different method to judge whether the person has moderate Alzheimer’s disease when deciding about starting or stopping treatment.

26. TA111 Alzheimer’s disease (amended September 2007)
When it is inappropriate to use the MMSE score, healthcare professionals should determine whether the patient has Alzheimer’s disease of moderate severity by making use of another appropriate method of assessment.
The acetylcholinesterase inhibitors are recommended as options in the management of people assessed on this basis as having Alzheimer’s disease of moderate severity.
Full details are included in TA111 Alzheimer’s disease – donepezil, galantamine, rivastigmine (review) and memantine (amended September 2007) .
Section 1.2 states
1.2 In determining whether a patient has Alzheimer’s disease of moderate severity for the purposes of section 1.1 above, healthcare professionals should not rely, or rely solely, upon the patient’s MMSE score in circumstances where it would be inappropriate to do so. These are:
where the MMSE is not, or is not by itself, a clinically appropriate tool for assessing the severity of that patient’s dementia because of the patient's learning or other disabilities (for example, sensory impairments) or linguistic or other communication difficulties or
where it is not possible to apply the MMSE in a language in which the patient is sufficiently fluent for it to be an appropriate tool for assessing the severity of dementia, or there are similarly exceptional reasons why use of the MMSE, or use of the MMSE by itself, would be an inappropriate tool for assessing the severity of dementia in that individual patient’s case.
In such cases healthcare professionals should determine whether the patient has Alzheimer’s disease of moderate severity by making use of another appropriate method of assessment. For the avoidance of any doubt, the acetylcholinesterase inhibitors are recommended as options in the management of people assessed on this basis as having Alzheimer’s disease of moderate severity.
The same approach should apply in determining for the purposes of section 1.1 above, and in the context of a decision whether to continue the use of the drug, whether the severity of the patient’s dementia has increased to a level which in the general population of Alzheimer’s disease patients would be marked by an MMSE score below 10 points.

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

28. 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.
NOTES FOR PRESENTERS
‘Mild cognitive impairment (MCI) is not a type of dementia, it is a syndrome defined as cognitive decline greater than expected for an individual’s age and education level but that does not interfere notably with activities of daily life’.
The treatment of cognitive and non-cognitive symptoms of dementia in people with Parkinson’s disease is covered by the NICE clinical guideline ‘Parkinson’s disease: diagnosis and management in primary and secondary care’ (available from

29. 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.
NOTES FOR PRESENTERS
Do not use antipsychotic drugs for mild-to-moderate non-cognitive symptoms in:
DLB, because of the risk of severe adverse reactions.
Alzheimer’s disease, vascular dementia or mixed dementias, because of the increased risk of cerebrovascular adverse events and death.
Consider antipsychotics for severe non-cognitive symptoms (psychosis and/or agitated behaviour causing significant distress) only if:
Risks and benefits have been fully discussed; assess cerebrovascular risk factors and discuss possible increased risk of stroke/transient ischaemic attack and possible adverse effects on cognition.
Changes in cognition are regularly assessed and recorded; consider alternative medication if necessary.
Target symptoms have been identified, quantified and documented and changes are regularly assessed and recorded.
Comorbid conditions, such as depression, have been considered.
The drug is chosen after an individual risk-benefit analysis.
The dose is started low and titrated upwards.
Treatment is time limited and regularly reviewed (every 3 months or according to clinical need).
In DLB, monitor for severe untoward reactions, particularly neuroleptic sensitivity reactions (development or worsening of extrapyramidal features or acute, severe physical deterioration).
Consider an acetylcholinesterase inhibitors for:
People with DLB who have non-cognitive symptoms causing significant distress or leading to behaviour that challenges.
People with mild, moderate or severe Alzheimer’s disease who have non-cognitive symptoms and/or behaviour that challenges causing significant distress or potential harm to the individual if:
• a non-pharmacological approach is inappropriate or has been ineffective, and
• antipsychotic drugs are inappropriate or have been ineffective.
Do not use acetylcholinesterase inhibitors for non-cognitive symptoms or behaviour that challenges in vascular dementia except as part of properly constructed clinical studies.
People with Alzheimer’s disease, vascular dementia, mixed dementia or DLB with severe non-cognitive symptoms (psychosis and/or agitated behaviour causing significant distress) may be offered treatment with an antipsychotic drug after the following conditions have been met.
There should be a full discussion with the person with dementia and/or carers about the possible benefits and risks of treatment. In particular, cerebrovascular risk factors should be assessed and the possible increased risk of stroke/transient ischaemic attack and possible adverse effects on cognition discussed.
Changes in cognition should be assessed and recorded at regular intervals. Alternative medication should be considered if necessary. Target symptoms should be identified, quantified and documented.
Changes in target symptoms should be assessed and recorded at regular intervals.
The effect of comorbid conditions, such as depression, should be considered.
The choice of antipsychotic should be made after an individual risk–benefit analysis.
The dose should be low initially and then titrated upwards.
Treatment should be time limited and regularly reviewed (every 3 months or according to clinical need).

30. 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.
NOTES FOR PRESENTERS
Assess and monitor people with dementia for depression and/or anxiety.
Consider psychosocial interventions:
Consider cognitive behavioural therapy (possibly involving carers).
A range of tailored interventions such as reminiscence therapy, multisensory stimulation, animal-assisted therapy and exercise, should be available.
Offer antidepressant medication:
Specialist staff should start treatment after risk–benefit analysis.
Treatment should follow the NICE guideline on depression.
Drugs with anticholinergic effects should be avoided because they may adversely affect cognition.
The need for adherence, time to onset of action and risk of withdrawal effects should be explained at the start of treatment
NICE clinical guideline on Depression: management of depression in primary and secondary care’ is available from

31. Suggested actions Integration and co-ordination of services.
Service provision.
Communication, education and training.
NOTES FOR PRESENTERS
Three key areas for implementation have been identified by NICE. These are integration and co-ordination of services, service provision and communication, education and training.

32. 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.
NOTES FOR PRESENTERS
‘Everybody's Business - integrating mental health services for older adults’ was launched in 2005 by Care Services Improvement Partnership to improve health and social care practice at the front line. The main message of the document is that older people’s mental health cuts across health and social care, physical and mental health and mainstream and specialist services. The service development guide is committed to:
    improving people’s quality of life
    meeting complex needs in a co-ordinated way
    providing a person-centred approach
    promoting age equality.
Policies and procedures should clearly specify the roles, responsibilities and methods of integrated working of all professionals, practitioners and other care workers across all agencies
Agreed multi-agency policy and practice guidance should be available at local level and all identify the approaches to be taken when abuse or neglect are suspected.
Use other incentives to help improve implementation such as the QoF and relevant targets such as the 18 week wait.

33. 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.
NOTES FOR PRESENTERS
The single assessment process (SAP) for older people was introduced in the National Service Framework for Older People. Detailed guidance was published in January ‘It aims to make sure older people's care needs are assessed thoroughly and accurately, but without procedures being needlessly duplicated by different agencies’.
The Department of Health produced a checklist intended to help local health and social care systems facing particular difficulties in implementing SAP to identify and address the key tasks necessary to implement the Single Assessment (go to
There should be formal reviews and evaluations of care plans

34. 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.
NOTES FOR PRESENTERS
As a result of your baseline assessment, review communication and training arrangements within and across partner organisations in line with the Everybody’s Business service development guide (
Use the NICE slide set to raise awareness of guideline recommendations and promote the key messages to health and social care staff, using local communication channels including lunchtime meetings and local protected time initiatives.
Work with Mental Capacity Act implementation networks ( and use the Department of Health best practice tool ( to assist with giving people with dementia the choice of treatments and information about practical support and entitlements.
Collaborate with your local workforce development directorate, local dementia specialists, higher education institutions and voluntary agencies to ensure that NICE-SCIE guideline recommendations are incorporated into existing training and continuing professional development programmes.
Ensure that approved social workers’ training and refresher training includes content on the assessment and provision of care for people with dementia.
Ensure local authority social services training departments provide courses on working with people with dementia for all relevant staff.
Use the Skills for Care knowledge set for dementia when designing training programmes.

35. 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.
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 (Knowledge set for dementia, published by Skills for Care 2005).
Ensure approved social workers’ training contains relevant material.

36. 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.
NOTES FOR PRESENTERS
Main elements of cost impact have been identified as:
Psychological therapies - 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. 
Structural imaging - should be used in the assessment of those with suspected dementia to exclude other cerebral pathologies and to help establish the subtype diagnosis.
EEG - should not be used as a routine investigation in people with dementia.
Joint working – start up costs, policies, procedures: will lead to savings once established – economies of scale, duplication of tasks.
Training – 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.

37. Access tools online This slide set. Implementation advice.
Audit criteria.
Costing tools – costing report and local costing template.
Available from
NOTES FOR PRESENTERS
This guideline is supported by a number of implementation tools, all of which are accessible via the NICE website. This includes this slide set, implementation advice which supports action planning, audit criteria and costing tools – both a national report which explains the cost impact assumptions and a local template which can be tailored to local populations to calculate the cost impact at a local level.

38. 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
NOTES FOR PRESENTERS
The guideline is available in a number of formats. You can download them from the NICE website or order hard copies of the quick reference guide or information for the public by calling the NHS Response Line on
Please refer to the accompanying implementation advice for the policy context and useful links.

39. 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
Practice guide 2: Assessing the mental health needs of older people -
Practice guide 5: Implementing the Carers (Equal Opportunities) Act
SCIE Research briefing 15: Helping older people to take prescribed medication in their own home: what works?
Report 15: Using digital media to access information and good practice for paid carers of older people
SCIE Research briefing 12: Involving individual older patients and their carers in the discharge process from acute to community care: implications for intermediate care A summary of the key knowledge.
SCIE Research briefing 03: Aiding communication with people with dementia A summary of the issues and knowledge.