Dementia September 2007
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 impairmentof 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 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 Palliative Care Palliative and end-of-life care
Non discrimination Valid consent Carers Coordination and integration of care Memory services Key priorities
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 haveaccess 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. • Detailed guidance on the use of cholinesterase inhibitors and memantine is set out in TA111.
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).
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 www.nice.org.uk/TA111 for details.
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.
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
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.
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 www.nice.org.uk/CG042 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’ (www.everybodysbusiness.org.uk) 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 (www.skillsforcare.org.uk). • 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 – costingreport and local costing template. • Available from www.nice.org.uk/CG042
Access the guidelineonline • 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 www.nice.org.uk/CG042 and www.scie.org.uk/publications
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 www.scie.org.uk/publications