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

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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 13. Staff training 10. Palliative care and education 12. Moving to 11. Supporting different care carers 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 advance the benefits lasting decisions to of planning power of refuse ahead attorney treatment advance statement: preferences for place wishes, preferences, of care and place of beliefs and values death regarding future care

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

Diagnosis: Relevance to Primary Care Recommended Cognitive Tests Memory 6-item 10-point 6-item Impairment cognitive cognitive screener Screen impairment screener (MIS) test (6CIT) (10-CS) Test Your Mini-Cog Memory (TYM)

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

Relevance to primary care: Risks during Hospital Admissions Increased Longer length morbidity on of stay discharge Assessment that balances current medical needs with additional harms they may face in hospital Increased Disorientation mortality

Relevance to primary care: Risks during Hospital Admissions Any Advance Care and Support Plans Take into Account The Value of Keeping them in a Familiar Environment

4: Relevance to primary care: Medicines that may cause cognitive impairment Commonly prescribed medicines are associated Consider minimising use with increased of such medicines, in anticholinergic burden, patients with suspected and therefore cognitive dementia. impairment.

Implications of Guideline Changes

Key Points for Primary Care ? Implications of Guideline Changes Medication Neuroimaging

Implications of Guideline Changes: Anti-Dementia Medication However, once a Previous decision has been New guideline: guideline: made to start Still should only treatment, the first Only specialist start on the advice prescription may be should initiate of a specialist. made in primary treatment. care .

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

Implications of Guideline Changes: Anti-Dementia Medication Less Delay in Treatment Implication: More Patients on Anti- Medication Dementia Medication Improved Access to Memantine

Key Points for Primary Care Implications of Guideline Regarding Changes Medication Regarding Neuroimaging

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

Implications of Guideline Changes: Neuroimaging ? Neuroimaging may be Reduced Implications: Neuroimaging ? May not be Offered Routinely

Case for Changing Berkshire’s Dementia Care Pathway

Berkshire: Current 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

Audit: Memory Clinic Annual Appointments 30% where a change was advised, a significant 70% of patients proportion had their medication required no change 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 other health conditions”

Changing Berkshire’s Dementia Care Pathway Current: GPs are already prescribing Successfully and reviewing anti- Proposed: dementia medication for implemented in Staged approach to around 75% of the total neighbouring Trusts managing this change number receiving treatment under current arrangements.

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 other symptoms associated with clinical risk.

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