Dementia Key slides

1. DementiaKey slides

2. IntroductionMeReC Bulletin 2007;18 (1) • Dementia is a distressing and disabling condition affecting about 700,000 people in the UK. The most common form of dementia is Alzheimer’s disease. • At present there are no proven ways to prevent dementia, although there are a number of potential preventable risk factors. • Accurate diagnosis requires specialist referral to eliminate other causes and to identify the sub-type. • Memory assessment services should be the single point of referral for all people with a possible or suspected diagnosis of dementia. • The NICE-SCIE clinical guideline 42 provides comprehensive recommendations for the care of people with all types of dementia and their carers. • Included are recommendations for the use of interventions (drug and non-drug) for cognitive, and non-cognitive symptoms, and comorbid emotional disorders. • Included are NICE Technology Appraisal Guideline 111 recommendations for use of AChIs and memantine in Alzheimer’s disease.

3. Non-drug treatments for cognitive symptomsNCCMH. NICE Full Guideline 42. 2006 Non-drug treatments • Wide range of psychological or psychosocial social interventions provided, but availability varies greatly. • e.g. CBT, life review, cognitive stimulation, reminiscence therapy, music, recreational activity (arts and crafts), sensory stimulation • NICE guidance • People with mild-to-moderate dementia of all types should be given the opportunity to participate in a structured group cognitive stimulation programme (irrespective of any drug prescribed for the treatment of cognitive symptoms)

4. A NICE summary of the evidence for clinical effectiveness of antidementia drugs NICE TAG 111, 2007 (Amended); NICE Full guideline 2006 AChIs • Compared with placebo, AChIs provide small but consistent gains in scores on cognitive and global scales for people with mild to moderately severe Alzheimer’s disease. • The evidence available on long-term effectiveness of AChIs on outcomes of importance to patients and carers, e.g. quality of life and delayed time to nursing home placement is limited and largely inconclusive. Memantine • The evidence to determine the clinical effectiveness of memantine in either the whole population of moderately severe to severe Alzheimer’s disease, …. was currently insufficient. Other situations • Insufficient evidence to recommend use in other forms of dementia or for mild cognitive impairment outside of RCTs.

5. Cost-effectiveness of AChIs and memantine in Alzheimer’s diseaseNICE TAG 111, 2007 (Amended) • AChIs: • Moderate dementia: £23,000 to £35,000 per quality adjusted life year (QALY) gained depending on the choice of drug, and by including carer benefits • Mild dementia, £56,000 to £72,000 per QALY gained. • Memantine • Moderately severe to severe dementia: £70,000 to £90,000 per QALY gained, depending on patient group/subgroup. “Having considered all the evidence and the comments of the consultees, the Committee concluded that the resulting estimates of cost-effectiveness could be sufficiently acceptable to suggest that the prescribing of AChIs for people with Alzheimer’s disease and moderate cognitive impairment (MMSE scores 10–20) is cost effective”

6. NICE TA111 Alzheimer’s disease www.nice.org.uk/TA111 (amended September 2007) • Consider an acetylcholinesterase inhibitor (donepezil, galantamine or rivastigmine) for Alzheimer’s disease of moderate severity only and under specific conditions. • Do not use Memantine except as part of well designed clinical studies • Treatment to be initiated by specialists only, review every 6 months, seek carer’s views at each stage Initiate therapy with a drug with the lowest acquisition cost (taking into account required daily dose and price per dose)

7. Non-cognitive symptomsMeReC Bulletin 2007;18 (1) • Behaviours that challenge are a major cause of distress to patients and their carers, and a frequent reason for transfer to nursing home care • Evidence for interventions for behaviours that challenge and comorbid emotional disorders in dementia is weak • People with dementia who develop non-cognitive symptoms or behaviours that challenge should be offered drug treatment ahead of non-drug interventions only if they are severely distressed or there is immediate risk to themselves or others • Benefits of antipsychotics are small and offset by an increased risk of cerebrovascular events and death, but can be used after full discussion of the risks/benefits with the person with dementia and/or their carers, and with frequent reviews

8. What about using AChIs for non-cognitive symptoms?NICE Clinical guideline 42. 2006 • Consider AChIs for patients with mild, moderate or severe AD who have non-cognitive symptoms and/or challenging behaviour causing significant distress or potential harm to the individual if: • Non-pharmacological ineffective / inappropriate • Antipsychotics ineffective / inappropriate • Consider AChIs in patients with DLB who have non-cognitive symptoms causing significant distress or leading to behaviour that challenges

9. Summary NICE-SCIE clinical guideline 42 • Provides wide-ranging recommendations for the care and support of people with dementia Diagnosis and assessment • Refer people with symptoms of cognitive impairment to a memory assessment service for assessment and diagnosis Cognitive symptoms • Group cognitive stimulation for all with mild-to-moderate dementia • AChIs and memantine have modest effects on cognition, but are associated with significant adverse effects • NICE restricts AChIs to use in moderate AD (usually MMSE 20-10) • Memantine and AChIs in other types of dementia in clinical trials only Non-cognitive symptoms • Drug treatment ahead of non-drug interventions only if patient is severely distressed or there is immediate risk to patient or others • Antipsychotic benefits are offset by an increased risk of stroke/TIA • AChIs in AD if significant distress and non-drug treatments or antipsychotics are inappropriate or ineffective, and in DLB