Dementia
Implementing the NICE/SCIE guidance
3rd. edition – August 2011
NICE clinical guideline 42
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
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
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
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
Diagnosis
Promoting
independence
Interventions
Palliative Care
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
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 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
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 (skill development) 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
Detailed guidance on the use of cholinesterase inhibitors
and memantine is set out in TA217
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 details
Guidance updated March 2011
TA217 Alzheimer’s disease
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
Acetylcholinesterase inhibitor:
• Start with the drug with the lowest acquisition cost
• Alternative if appropriate
Guidance updated March 2011
TA217 Alzheimer’s disease
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
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
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
• 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)
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 details
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
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
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 3nd edition
Find out more
Visit www.nice.org.uk/guidance/CG42 for the following
NICE dementia guideline products:
•
•
•
•
•
•
•
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
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
Further resources from SCIE
NHS Evidence
Visit NHS Evidence for
the best available
evidence on all
aspects of Dementia
Click here to go
to the NHS
Evidence website
NICE Quality Standard
Dementia
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
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