Quality outcomes in dementia

1. Quality outcomes in dementia Alistair Burns National Clinical Director for dementia

2. Early diagnosis and intervention in primary care Dementia in the General Hospital Dementia in Care homes Reduction of antipsychotics Support for carers DH template

3. National Audit of memory services 80% of PCTs responded 94% have a dedicated memory service for dementia Average spend increased from £486k in 2008/09 to £593k in 2010/11 (22%) Average number of people using a memory service increased from 605 in 2008/09 to 951 in 2010/11 (57%)

4. A renewed push on implementation of the national dementia strategy and increased support for carers. A third national goal on improving diagnosis of dementia in hospitals.

5. We will require the NHS to commission services in line with NICE-SCIE guidance on supporting people with dementia

6. Dementia – Commissioning Pack

7. National hip fracture database 2011 Abbreviated mental test score Available in 56.9% of patients <6 out of 10 in 17.8% (31% when it has been recorded) Unavailable in 44.1%

8. Changing practice to reduce admissions for people with dementia Dr Afifa QaziConsultant Old Age Psychiatrist Havering older people’s services afifa.qazi@nelft.nhs.uk

9. National Council for Palliative Care

10. Depression Anxiety Delusions Hallucinations Paranoid ideas Reduplications Misidentifications Agitation Aggression Wandering Sleep disturbances Inappropriate eating behaviour Inappropriate sexual behaviour Emotional changesNeuropsychiatric features Non Cognitive symptomsBehavioural and psychological symptoms (BPSD) Psychiatric symptoms Behavioural disturbances Psychosis

11. Drug Treatments for Alzheimer’s disease Donepezil Galantamine Rivastigmine Memantine Symptoms Treatment Cognition Anti- Alzheimer drugs Daily activities Anti- Alzheimer drugs Behavioural and Anti-depressants Psychological Anti-convulsants Symptoms Sedatives Anti-psychotics Alzheimer’s disease All dementias

12. Antipsychotics/Neuroleptics for Dementia Typical antipsychotics Atypical antipsychotics (First generation) (Second generation) Chlorpromazine Risperidone Haloperidol Olanzapine StelezineQuetiapine PromazineAripiprazole Thioridazine(Clozapine) Side effects: greater in older people - cardiac, Parkinsonian side effects Not licensed for the treatment of agitation (except risperidone) 20-30% of people in nursing homes with dementia are on an antipsychotic NHS survey 2007/8: 5.3% of people over 65 are prescribed an antipsychotic

13. Alternative Treatments for BPSD ABC assessment antecedents, behaviours, consequences Physical assessment, in particular pain Mental state assessment, in particular depression Person centred care Aromatherapy Bright light therapy Other therapies: eg doll therapy, pets

14. Dementia training should be mandatory Care homes must receive effective support Mental Capacity Act training Protocols must be introduced There should be compulsory regulation and audit DH template

15. Antipsychotics in dementia 180,000 people with dementia prescribed antipsychotics 36,000 will derive some benefit 1800 additional deaths 1620 additional CVAs Perhaps 2/3 of prescriptions are unnecessary, if appropriate support available High level of prescribing outweighs benefits DH template

16. Use of antipsychotics in dementia Use of the drugs is still an integral part of clinical practice Changing their use is a complex challenge Two thirds reduction of their use is a challenge but should not be seen in isolation - raising the standards of care for people with dementia is the key DH template

17. DH template

19. Person with dementia has no current anti-psychotics prescription PREVENTION No symptoms Severe symptoms Mild to moderate symptoms WATCHFUL WAITING Trial of drug treatment PREVENTION Continue Watchful Waiting SPECIALIST REFERRAL

20. Useful contacts Dementia Portal http://www.dementia.dh.gov.uk The commissioning Pack dementiacommissioningpack@dh.gsi.gov.uk

21. Quality outcomes in dementia