Diagnosis and management of dementia: a summary of recommendations

Takehome

• The latest NICE guidance aims to address how dementia should be assessed and diagnosed.
• The recommendations in this summarised version of the guideline have been mainly restricted to GPs.

Diagnosis

• Take a history (including cognitive, behavioural and psychological symptoms, and the impact of symptoms on daily life) from suspected patients and if possible from someone who knows the patient well.
• If it is not possible to tell whether a person has delirium, dementia, or delirium superimposed on dementia, treat for delirium first. For guidance on treating delirium, see treating delirium in the NICE guideline on delirium.
• Individuals with suspected dementia after an initial assessment should be subjected to a physical examination, cognitive testing, and lab tests to exclude reversible causes of cognitive decline.
• Cognitive testing should make use of structured cognitive instruments such as 10-point cognitive screener (10-CS), 6-item cognitive impairment test (6CIT), 6-item screener, Memory Impairment Screen (MIS), Mini-Cog, and Test Your Memory (TYM).
• A normal score on a cognitive instrument, however, does not rule out dementia.
• Individuals with suspected rapidly-progressive dementia need to be evaluated for Creutzfeldt–Jakob disease or similar conditions by referral to a neurological service.
• Individuals should still be referred to specialist dementia diagnostic service if reversible causes of cognitive decline have been identified and dementia is still suspected.

Management

Care coordination

• Provide people living with dementia with a single named health or social care professional who is responsible for coordinating their care.
  • Provide information about available services and how to access them.
  • Develop a care and support plan.

Non-pharmacological interventions for dementia

• Acceptable interventions for promoting cognition, independence and well-being in individuals with mild to moderate dementia include group cognitive stimulation, group reminiscence therapy, and cognitive rehabilitation or occupational therapy.

Pharmacological management of Alzheimer’s dementia

•  Apart from psychiatrists, geriatricians and neurologists, GPs with specialist expertise in diagnosing and treating Alzheimer's disease can prescribe pharmacotherapy.
• Acetylcholinesterase inhibitors should not be discontinued because of disease severity alone.
• Other classes such as antidiabetic and antihypertensive drugs, statins, and NSAIDs are not recommended to slow the progress of Alzheimer’s dementia.

Management of non-cognitive symptoms

• Agitation, aggression, distress and psychosis
  • Before starting non-pharmacological or pharmacological treatment for distress in people living with dementia, conduct a structured assessment to explore possible reasons for their distress and check for and address clinical or environmental causes (for example pain, delirium or inappropriate care).
  • Offer antipsychotics only if patients are at risk of harming themselves or agitation, hallucinations or delusions are causing severe distress.
  • They should be used at the lowest effective dose for the shortest possible time.
• Depression and anxiety
  • For people living with mild to moderate dementia who have mild to moderate depression and/or anxiety, consider psychological treatments.
  • Do not routinely offer antidepressants unless they are indicated for a pre-existing severe mental health problem.
•  Sleep problems
  • Personalised multicomponent sleep management including sleep hygiene education, exposure to daylight, exercise and personalised activities. Melatonin is not recommended for insomnia.

Comorbid conditions

• Individuals living with dementia should be assessed and managed for other long-term conditions which include pain, falls, diabetes, incontinence, and sensory impairment. The appropriate NICE guidelines should be referred for this purpose.
• Individuals with dementia who are hospitalised are at an increased risk for delirium, which can be prevented and treated as per the NICE guideline for delirium.           

Palliative care

• A flexible, needs-based palliative care approach is recommended which considers the unpredictable nature of dementia progression.

This summary is reviewed by Prof. Rishabh Prasad MBBS, MA, MSC, FRCGP FRSA