This is a new guideline from NICE on the management of dementia. Most of this is not new, but there were a couple of things I wasn't fully aware of. I'll list the things that were new to me, then do a bit of a summary.
- Cognitive testing. NICE lists a few recommended tests we should use. None of them are MMSE or GPCOG 🙁
- Anticholinergic burden. If your patients are on drugs that affect this, especially if they are on several, then it may have a significant impact on their memory.
- If a patient is eligible for memantine as add on therapy, it can be started by the GP without discussion with a specialist.
How should we assess patients in primary care?
Take a history and examination and do some blood and urine tests. Interestingly NICE gives no advice on what bloods to do, nor on what urine tests to do. There is apparently no evidence. They are for ruling out other causes though.
What cognitive tests should we do?
I suspect that MMSE and GPCOG are the best known of these for us. Neither is on NICE's list. MMSE isn't because it takes too long to complete (and hence is more expensive) and is also under copyright and so theoretically we should pay every time we use it (oops - didn't know that one myself). GPCOG is not on the list because there isn't any research done on its use in dementia diagnosis. There is good evidence for its use in screening for dementia - just not in 'suspected dementia' patients.
The following are on the list. I haven't used any of these, but particularly like the idea of the 'Test your memory' score, which is self-administered by the patient (so frees up our time).
- the 10-point cognitive screener (10-CS) (I couldn't find a link for this test)
- the 6-item cognitive impairment test (6CIT)
- the 6-item screener
- the Memory Impairment Screen (MIS)
- the Mini-Cog
- Test Your Memory (TYM). There is a proviso on the website that this should not be used routinely in clinical practice (though NICE has recommended it...).
All of these tests are sensitive and specific and also don't take too long to administer.
What informant tests should we do?
NICE advises one of the following 2 tests should be done:
- Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE)
- Functional Activities Questionnaire (FAQ)
Refer patients if a reversible cause for the memory loss has been excluded (eg delirium, depression, sensory impairment or anticholinergic burden). Patients on anticholinergic medication may have their memory affected. The more of these medications they are on, the greater this effect may be. There are websites that help you calculate the anticholinergic burden of different drugs. It may be worth trying to stop such drugs in patients presenting with memory loss.
If a patient has a rapidly progressive dementia, then refer to a neurological service that can assess cerebrospinal fluid (eg looking for CJD).
Patients newly diagnosed with dementia should have a single named health or social care professional responsible for their care coordination (it doesn't say who this should be). They should:
- arrange an assessment of needs.
- provide information about local services.
- involve carers where appropriate.
- consider a patient’s needs if they do not have capacity (eg local advocacy services/IMCA)
- provide a care and support plan (specify how often it should be reviewed, record progress, cover management of any co-morbidities, provide copies to carers and the individual where appropriate).
For patients with mild to moderate dementia:
- offer group cognitive stimulation therapy.
- consider group reminiscence therapy.
- consider cognitive rehabilitation therapy or occupational therapy.
Medication in Alzheimer's dementia
Acetylcholinesterase (AChE) inhibitors (donepezil, galantamine and rivastigmine) are all recommended as monotherapies in mild to moderate Alzheimer’s disease.
Memantine monotherapy is recommended as an option for managing Alzheimer’s disease in people with:
- Moderate Alzheimer’s who are intolerant of or have a contraindication to AChE inhibitors.
- Severe Alzheimer’s disease.
Use the lowest cost drug, unless an alternative is more suitable.
If people already have a diagnosis of Alzheimer’s and are taking an AChE Inhibitor:
- Consider adding memantine if they have moderate disease.
- Offer memantine in addition if they have severe disease.
For people not taking any medications, the decision to start should be made by a specialist, though the first prescription may be done by a GP.
If patients already have a diagnosis of Alzheimer’s disease and are already taking an AChE inhibitor, then a GP may start memantine without taking specialist advice.
Medication in non-Alzheimer's dementia
Lewy Body dementia
- Offer donepezil or rivastigmine in mild to moderate disease. Consider them if there is severe disease.
- Consider galantamine in mild to moderate disease if the above 2 are not effective.
- Consider memantine for any severity if AChE inhibitors are not tolerated or are contraindicated.
Only consider AChE inhibitors or memantine if there is suspected co-morbid Alzheimer’s disease, Lewy Body dementia or Parkinson’s disease dementia.
Parkinson’s disease with dementia
- Offer an AChE inhibitor for mild to moderate disease and consider it for severe disease.
- Consider memantine if AChE inhibitors are not tolerated or are contraindicated.
Frontotemporal lobe dementia and MS associated cognitive impairment
Do not offer AChE inhibitors or memantine.