TA217 Alzheimer s disease

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        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
     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
                         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

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 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,
  Diagnosis                                        Diagnosis and assessment
                  screening and prevention

  Promoting                       Promoting independence

                  Cognitive symptoms      Non-cognitive          Comorbid emotional
Interventions     and maintenance of      symptoms and              Disorders
                        function       challenging behaviour

Palliative Care
                                   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

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
                                  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

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
          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

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

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

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
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

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
• 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

• 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 (

• For people with 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/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

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 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:
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