Dementia NICE Guidelines Update Key points for primary care - NICE guideline (June 2018 update ) 26 September 2018
How NICE guidelines are reviewed Multidisciplinary guideline committee established Review of research evidence If a lack of evidence is found recommendations for future research NOTE: wording is key when reading guidelines OFFER means a strong recommendation usually with clear evidence CONSIDER means recommendation where evidence less clear 2
Emphasis on Person-centred care Not changed and emphasised Remember these principles underpin planning and care Human value of individual person with dementia Individuality of person with dementia Importance of patient perspective Importance of carer and relationships for person with dementia Include people in decisions about them Provide accessible information
Advance Care Planning Offer early and ongoing opportunities for people to discuss planning ahead Including lasting power of attorney Advance statement of wishes Advance decision to refuse treatment Preferences around place of care and place of death
Initial Assessment of possible dementia Take history including from person and collateral information History of cognitive, behavioural and psychological symptoms If suspected dementia following steps Physical examination Appropriate blood tests and urine test to exclude reversible causes Cognitive test using validated brief structured cognitive instrument- eg 10- CS, 6CIT, 6 item screener, Memory Impairment Screen (MIS), Mini-Cog, Test your memory (TYM) Collateral history consider IQCODE (informant Q on cog decline eld)
Diagnosis in Specific Dementia Diagnostic Service Not our focus today but a few points to notice Refer MAS or similar, although neurology may be more appropriate at times New advice on testing for Alzheimer's if diagnosis not clear FDG-PET or Perfusion SPECT Lumbar puncture examining CSF for Tau, or amyloid beta 1-42 BUT: Exception not the rule. Dementia is a clinical diagnosis ultimately
Delirium versus Dementia If no diagnosis of dementia and unsure if delirium or dementia, consider using the following tools CAM the long confusion assessment method OSLA the observational scale of level of arousal Cognitive test is unhelpful to distinguish If unsure if dementia or delirium treat delirium first
Care Coordination People living with dementia should be provided with a single named health or social care professional who is responsible for coordinating their care Initial assessment of needs Provide information re services and how to access them Involve carer and family Consider those without capacity, and also difficult to reach groups Develop care and support plan (agreed with person, specified when reviewed, covers other health issues, copy with person and family, shared appropriately with other services with consent)
Interventions to promote cognition, independence and wellbeing Commissioners need to consider this Offer range of activities to promote wellbeing suitable for people with dementia Offer group CST (Cognitive Stimulation Therapy) Consider group reminiscence therapy Consider cognitive rehabilitation or occupational therapy to support functional ability Do not offer acupuncture, supplements (vit E, ginseng etc), brain stimulation, cognitive training
Pharmacological Interventions in Alzheimer's 3 acetylcholinesterase (AChE) inhibitors are used as monotherapy for mild to moderate alzhiemer s Donepezil, galantamine, rivastigmine If AChE inhibitor contraindicated or not tolerated in mild to moderate Alzheimer s use memantine as monotherapy In moderate severe Alzheimer s disease use memantine as monotherapy Prescribers should only start on advice of clinician with necessary knowledge and skills. (secondary care- psych, geriat, neurol or other health care professionals if they have specialist expertise).
Pharmacological Interventions in Alzheimer s part 2 Then Consider Memantine in addition to AChE inhibitors for moderate Alzheimer s Offer Memantine in addition to AChE inibitors for Severe Alzheimer s Don t stop AChE inhibitors because of severity of Alzheimer's disease alone If person is taking AChE inhib, primary care prescribers may start treatment with memantine without taking advice from specialist
Memantine NMDA receptor antagonist Blocks glutamate effects Glutamate released in increased amounts in Alzheimer s Can slow progression of symptoms disorientation May help with delusions, aggression, agitation Usually well tolerated (better tolerated than AChE inhibs) SE: dizziness, headaches, tiredness, elevated BP, constipation
Assessing Severity of Alzheimer's Don t rely on cognitive test score alone Consider physical, sensory or learning disabilities or communication difficulties can affect score results ICD 10 Research Definitions Moderate decline in cognitive abilities make the individual unable to function without assistance of another for daily living including shopping and handling money. Within the home, only simple chores can be performed. Activities are increasingly restricted Severe needs assistance with nearly all activities of daily living. People will need a significant package of care due to their level of cognitive impairment.
Non Alzheimer s dementia - pharmacological Dementia with lewy bodies donepezil or rivastigmine Vascular dementia only consider AChE inhib or memantine if comorbid Alzheimer s, Parkinson's disease dementia or dementia with lewy bodies Frontotemporal Dementia don t use AChE inhib or memantine
Medications causing cognitive impairment Consider anticholinergic burden Various tools available to review Medication reviews important Consider de-prescribing in elderly
Managing non Cognitive Symptoms Explore reasons for person s distress Try non pharmacological interventions Only antipsychotics if risk of harming self or others, or severe distress Use lowest dose for shortest possible time Reassess at 6 weeks and stop if no benefit Parkinson s disease dementia and dementia with lewy bodies antipsychotics may worsen motor features Consider sleep and pain Sensory impairments
Supporting Carers Offer psychoeducation and skills training Education about dementia and changes to expect in person with dementia Training to adapt communication styles for person with dementia Information of services available Advice on planning enjoyable and meaningful activities for the person with dementia Ensure support for carers if provided likely most effective in groups Advice on right to formal assessment of needs and assessment for respite