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Improving dementia care

Professor Clive Ballard and Samantha Sharp outline the implications of the NICE/SCIE recommendations for GPs

Professor Clive Ballard and Samantha Sharp outline the implications of the NICE/SCIE recommendations for GPs

GPs are at the centre of dementia management from the point of diagnosis through to the final stages of palliative care. This pivotal role is recognised by the new GP contracts and recent NICE guidelines on managing dementia, co-authored by the Social Care Institute for Excellence (SCIE).

The NICE/SCIE guidance covers a range of diverse but key issues such as:

• pharmacological treatment

• services for people with mild dementia

• training for residential care home staff

• brain imaging.

The guideline tackles the issues of recognising and treating Alzheimer's disease and other types of dementia with a combination of practical advice and detailed recommendations on the systems that should be in place to support GPs and other professionals.

It looks at a broad range of treatment and care that should be available and features key recommendations to support GPs. In particular, the report highlights the integration of both primary and secondary care, and health and social care as key to providing optimal treatment.

Pharmacological management

Recommendations from the recent controversial technology appraisal are incorporated into the clinical guideline, which considers the issue of drugs in the treatment of people with dementia.

• Only those in the moderate stages of Alzheimer's disease with a mini-mental state examination (MMSE) score of 10–20 should be prescribed acetylcholinesterase inhibitors (donepezil hydrochloride, galantamine and rivastigmine).

• Memantine should not be prescribed outside a well-designed clinical trial.

Although this falls short of what we consider best practise in the use of these drugs, the guideline does make it clear that the decision to offer acetylcholinesterase inhibitors should be based on an assessment that is much broader than the results of the MMSE. Some groups, for example those with learning disabilities or language difficulties, are likely to score outside 10 to 20 on the MMSE despite being in the moderate stages.

Early diagnosis and investigation

Early detection of dementia is important because it allows:

• quick access to appropriate agencies and support networks, which can reduce the disabling psychological distress commonly experienced by patients and carers

• people to plan for the future and make advance directives should they wish to

• treatable causes of dementia to be identified

• appropriate treatment of vascular risk factors, which has a substantial stabilising effect on the progression of cognitive impairment and functional disabilities in people with vascular dementia.

To boost early recognition rates, the report recommends the wider implementation of evidence-based educational interventions. These include decision-support software developed by Downs et al (2006) in research funded by the Alzheimer's Society.

Easy to use tools such as a CD-ROM with information about dementia should help GPs confidently identify the condition along with the most appropriate service and treatment pathway for patients. The advice on appropriate investigations to inform the 'basic dementia screen' reinforces best practice for GPs (see box).

For those with suspected dementia, the Memory Assessment Service should be the single point of referral. Structural brain imaging is also recommended in the assessment of people with suspected dementia to exclude other cerebral pathologies and establish the subtype diagnosis. This provides further impetus to refer to specialist centres.

Palliative care for people with dementia is an area that has been neglected in the past. Primary care teams are now advised to ensure the palliative care needs of people close to death are fully assessed, with their requests explained to both health and social care staff.

Care management and training

After diagnosis, the major focus is on providing optimal clinical and social treatment and care. The guideline emphasises the importance of co-ordinated care management and the continuing involvement of GPs to best meet this objective.

Patients with Alzheimer's disease and other types of dementia often miss out on assessments and a seamless package of care, because of the lack of a comprehensive system of care management. If no single health or social care specialist is responsible for leading on managing care, many people with dementia can fall between the cracks in professional care.

There is a strong case for a generic system of care management using locally available skills. GPs will have an important role to play and further changes to the GP contract have been recommended to support this.Recent research shows that more than 50 per cent of people with dementia are living in care homes.

The care of this group of patients places a considerable demand on GPs, not least because the physical and mental health problems of residents can be exacerbated by the lack of formal training of care home staff.

Consequently, NICE/SCIE recommend that all staff working with older people should have access to dementia care training consistent with their responsibilities.

Non-pharmacological management

• Structured group cognitive stimulation programmes are advised for people with mild to moderate dementia, irrespective of whether they are receiving drug treatments.

• Non-pharmacological interventions are recommended as the first-line management approach for non-cognitive symptoms of dementia and behaviour that challenges.

An early assessment should be made to identify factors that may influence behaviour, before an individual care plan is drawn up. Suggested interventions should be tailored to the person's preferences, skills and abilities. Medication for non-cognitive symptoms or behaviour that challenges should only be prescribed when there is severe distress or an immediate risk of harm to the individual or others.

Best practice

The NICE clinical guideline provides examples of best practice and illustrates how GPs can be enabled to offer the optimal treatment to patients using a range of available tools and utilising the expertise of health and social care colleagues.

Clive Ballard is professor of age-related disorders at King's College and the Institute of Psychiatry, London, and director of research at the Alzheimer's Society

Competing interests Professor Ballard has received researc hfunding from the pharmaceutical industry for clinical trials involving anti-dementia drugs

Samantha Sharp is senior policy officer at the Alzheimer's Society

Competing interests None declared



Alzheimer's disease and dementia Alzheimer's disease and dementia

• More than 750,000 people in the UK have a form of dementia and another 100,000 will develop the condition over the next 12 months. This is expected to double to 1.8 million people by 2050.
• Dementia affects more than 18,000 people under the age of 65 years.
• One in 20 people over 65 years of age develop dementia. This figure increases to one in five among people in their 80s.

GP investigations GP investigations

• Basic dementia screen, including:

– routine haematology
– biochemistry tests (electrolytes, calcium, glucose, and renal and liver function)
– thyroid function tests
– serum B12 and folate levels

• Midstream urine test, if delirium is a possibility
• Chest X-ray, ECG if appropriate clinically

Key points Key points

• Working with a multidisciplinary team helps to provide a seamless package of dementia care and treatment from diagnosis to palliative care
• GPs are encouraged to implement evidence-based interventions to boost early recognition rates
• Basic dementia screening is important to support early diagnosis and intervention
• All staff working with older people should receive formal training in dementia care

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