Dementia NICE Guideline Dr Umar Bedi Consultant-Old Age Psychiatry - - PowerPoint PPT Presentation

Dementia NICE Guideline

Dr Umar Bedi Consultant-Old Age Psychiatry

Topics for Discussion

❑ Dementia: Nice Guideline ❑ Primary Care: Key Points ❑ Changes and Implications ❑ Berkshire Dementia Pathway

Dementia News “Daily Mail”

“People taking antidepressants after the age of 60 are 'THREE TIMES more likely to get dementia because they may cause nerve damage”

Dementia News “Daily Mail”

“Fruit flies' brains studied to help crack dementia”

Dementia News “Daily Mail”

“Scientists discover a new type of dementia that affects thousands: ‘‘LATE disease' has exactly the same symptoms as Alzheimer's but affects the brain in a very different way”

Dementia News “Daily Mail”

“Dementia: Four foods to help prevent 'UK’s biggest killer' among the elderly”

ALL DRESSED UP WITHOUT THE SLIGHTEST IDEA WHY.

Topics for Discussion

❑ Dementia: Nice Guideline ❑ Key Points for Primary Care ❑ Changes and Implications ❑ Case for changing the Berkshire Dementia

Pathway

JOURNEY – SOME LIGHT READING

❑ 2006-CG42-NICE GUIDELINE FOR DEMENTIA ❑ 2011-NICE GUIDANCE 217 ❑ 2018-NG97-NICE GUIDELINE FOR DEMENTIA

NICE GUIDELINE JUNE 2018

NG97 Dementia: assessment, management and support for people living with dementia and their carers Fifteen Recommendations

Recommendations

• 1. Involving people

living with dementia in decisions about their care

• 2. Diagnosis
• 3. Care

coordination

Recommendations

• 4. Interventions to

promote cognition, independence and wellbeing

• 5. Pharmacological

interventions for dementia

• 6. Medicines that

cause cognitive impairment

Recommendations

• 7. Managing non-

cognitive symptoms

• 8. Managing other

long-term conditions in people with dementia

• 9. Risks during

hospital admission

Recommendations

• 10. Palliative care
• 11. Supporting

carers

• 13. Staff training

and education

• 12. Moving to

different care settings

Topics for Discussion

❑ Dementia: Nice Guidelines ❑ Key Points for Primary Care ❑ Changes and Consequences ❑ Case for changing the Berkshire Dementia

Pathway

Few key points- primary care

❑ Advance Care Planning ❑ Diagnosis ❑ Risks of Hospital Admission ❑ Medicines that may cause cognitive impairment

1: Involving people living with dementia in decisions about their care : Relevance to Primary Care

preferences for place

• f care and place of

death lasting power of attorney advance statement: wishes, preferences, beliefs and values regarding future care advance decisions to refuse treatment the benefits

• f planning

ahead

2:Diagnosis: Relevance to Primary Care

Initial assessment in primary care Refer to a specialist dementia diagnostic service (such as a memory clinic) If the person has rapidly-progressive dementia, refer to a neurological service

Diagnosis: Relevance to Primary Care Recommended Cognitive Tests

10-point cognitive screener (10-CS) 6-item cognitive impairment test (6CIT) Mini-Cog Memory Impairment Screen (MIS) 6-item screener Test Your Memory (TYM)

3: Relevance to primary care: Risks during Hospital Admissions Delirium

Assessment that balances current medical needs with additional harms they may face in hospital

Relevance to primary care: Risks during Hospital Admissions

Disorientation Longer length

• f stay

Increased morbidity on discharge Increased mortality

Any Advance Care and Support Plans The Value of Keeping them in a Familiar Environment

Relevance to primary care: Risks during Hospital Admissions Take into Account

4: Relevance to primary care: Medicines that may cause cognitive impairment

Consider minimising use

• f such medicines, in

patients with suspected dementia. Commonly prescribed medicines are associated with increased anticholinergic burden, and therefore cognitive impairment.

Implications of Guideline Changes

Medication Neuroimaging

Key Points for Primary Care

? Implications

• f Guideline

Changes

Previous guideline: Only specialist should initiate treatment. New guideline: Still should only start on the advice

• f a specialist.

However, once a decision has been made to start treatment, the first prescription may be made in primary care.

Implications of Guideline Changes: Anti-Dementia Medication

Combine Medication: Co-prescription of cholinesterase inhibitors and memantine (Donepezil plus Memantine) GP’s can commence Memantine: May be added for people already taking cholinesterase inhibitors without taking advice from specialist clinician Don’t Stop Donepezil: A cholinesterase inhibitor should not be stopped on the basis of disease severity alone.

Implications of Guideline Changes: Anti-Dementia Medication

Implication: Medication

Less Delay in Treatment Improved Access to Memantine More Patients on Anti- Dementia Medication

Implications of Guideline Changes: Anti-Dementia Medication

Regarding Medication

Regarding Neuroimaging

Key Points for Primary Care

Implications of Guideline Changes

Previous guideline: Structural imaging ‘Should’ be used for the assessment of people with suspected dementia. MRI is the preferred modality. CT could be used. New guideline: ‘Offer’ structural imaging to rule out reversible causes of cognitive decline and to assist with subtype diagnosis, unless dementia is well established and the subtype is clear.

Implications of Change: Neuroimaging

Implications: Neuroimaging

? Neuroimaging may be Reduced ? May not be Offered Routinely

Implications of Guideline Changes: Neuroimaging

Case for Changing Berkshire’s Dementia Care Pathway

Initiation of anti-dementia medication in Memory Clinic Followed by an annual review by the Memory Clinic. This happens in parallel with an alternate annual review in Primary Care

Berkshire: Current Dementia Care Pathway

Audit: Memory Clinic Annual Appointments

70% of patients

required no change 30% where a change was advised, a significant proportion had their medication dose increased or decreased or medication ceased entirely.

The Challenges

3280 plus – Patients on Anti Dementia Medication 2,500 plus – New Referrals

The Challenges

❑ New NICE guidance recommends continuation of anti-dementia medication into the severe stage of dementia. ❑ Result in further growth in the Memory Clinic caseloads of largely stable patients. ❑ Increase the number of annual review appointments required.

“This is not Sustainable”

Proposed Changes: Berkshire’s Dementia Care Pathway

Changing Berkshire’s Dementia Care Pathway

“Proposing that all stable patients receiving anti- dementia medication are monitored by their GP during consultations attended for

• ther health conditions”

Current: GPs are already prescribing and reviewing anti- dementia medication for around 75% of the total number receiving treatment under current arrangements. Proposed: Staged approach to managing this change

Successfully implemented in neighbouring Trusts

Changing Berkshire’s Dementia Care Pathway

Changing Berkshire’s Dementia Care Pathway

“How will this benefit service users and stakeholders?”

Advantages of Proposed Changes

❑ The Memory Clinic resource released from the reduction in routine review appointments used to ensure: ❑ timely initial assessments ❑ timely provision of post-diagnostic support ❑ prompt response when there is a re-referral

Advantages of Proposed Changes

❑ Patients who require secondary mental health intervention would remain open to Older Peoples Mental Health Services such as ❑ those with significant behavioural problems or

• ther symptoms associated with clinical risk.

HOPE FOR THE FUTURE…Mail Online:

Cure for Alzheimer's closer. Experiments on mice indicated that a new vaccine not only halts the advance of the disease, but repairs damage already done.

Dementia News “Daily Mail”

Feb 2013: “Taking HRT may reduce the risk of Alzheimer’s disease”

More Dementia News “Daily Mail”

March 2019: “Millions of women who take HRT pills may face a greater risk

• f Alzheimer’s"

Dementia News “The SUN”

“DOPE’S ALZ HOPE: Smoking Cannabis could improve the memory of Alzheimer’s sufferers”

Dementia News “The SUN”

“HIGH HOPES: Dementia patients will be given cannabis drug to calm aggression”

Thank You