1.1 Involving people living with dementia in decisions about their careInvolving people in decision-making1.1.1 Encourage and enable people living with dementia to give their own views and opinions about their care. Show
1.1.2 If needed, use additional or modified ways of communicating (for example visual aids or simplified text). 1.1.3 Consider using a structured tool to assess the likes and dislikes, routines and personal history of a person living with dementia. Providing information1.1.4 Provide people living with dementia and their family members or carers (as appropriate) with information that is relevant to their circumstances and the stage of their condition. 1.1.5 Be aware of the obligation to provide accessible information as detailed in the NHS Accessible Information Standard. For more guidance on providing information and discussing people's preferences with them, see the NICE guidelines on patient experience in adult NHS services and people's experience in adult social care services. 1.1.6 At diagnosis, offer the person and their family members or carers (as appropriate) oral and written information that explains:
1.1.7 If it has not been documented earlier, ask the person at diagnosis:
1.1.8 After diagnosis, direct people and their family members or carers (as appropriate) to relevant services for information and support (see recommendations 1.3.1 and 1.3.2 on care coordination). 1.1.9 For people who do not want follow-up appointments and who are not using other services, ask if they would like to be contacted again at a specified future date. 1.1.10 Ensure that people living with dementia and their carers know how to get more information and who from if their needs change. 1.1.11 Tell people living with dementia (at all stages of the condition) about research studies they could participate in. Advance care planning1.1.12 Offer early and ongoing opportunities for people living with dementia and people involved in their care (see recommendation 1.1.7) to discuss:
1.1.13 At each care review, offer people the chance to review and change any advance statements and decisions they have made. 1.2 DiagnosisInitial assessment in non-specialist settings1.2.1 At the initial assessment take a history (including cognitive, behavioural and psychological symptoms, and the impact symptoms have on their daily life):
1.2.2 If dementia is still suspected after initial assessment:
1.2.3 When using cognitive testing, use a validated brief structured cognitive instrument such as:
1.2.4 Do not rule out dementia solely because the person has a normal score on a cognitive instrument. 1.2.5 When taking a history from someone who knows the person with suspected dementia, consider supplementing this with a structured instrument such as the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) or the Functional Activities Questionnaire (FAQ). 1.2.6 Refer the person to a specialist dementia diagnostic service (such as a memory clinic or community old age psychiatry service) if:
1.2.7 If the person has suspected rapidly-progressive dementia, refer them to a neurological service with access to tests (including cerebrospinal fluid examination) for Creutzfeldt–Jakob disease and similar conditions. 1.2.8 For more guidance on assessing for dementia in people with learning disabilities, see the NICE guideline on mental health problems in people with learning disabilities. Diagnosis in specialist dementia diagnostic services1.2.9 Diagnose a dementia subtype (if possible) if initial specialist assessment (including an appropriate neurological examination and cognitive testing) confirms cognitive decline and reversible causes have been ruled out. 1.2.10 If Alzheimer's disease is suspected, include a test of verbal episodic memory in the assessment. 1.2.11 Consider neuropsychological testing if it is unclear:
1.2.13 Offer structural imaging to rule out reversible causes of cognitive decline and to assist with subtype diagnosis, unless dementia is well established and the subtype is clear. 1.2.14 Only consider further tests (recommendations 1.2.15–28) if:
Further tests for Alzheimer's disease1.2.15 If the diagnosis is uncertain (see recommendation 1.2.14) and Alzheimer's disease is suspected, consider either:
If a diagnosis cannot be made after one of these tests, consider using the other one. 1.2.16 Be aware that the older a person is, the more likely they are to get a false positive with cerebrospinal fluid examination. 1.2.17 Do not rule out Alzheimer's disease based solely on the results of CT or MRI scans. 1.2.18 Do not use Apolipoprotein E genotyping or electroencephalography to diagnose Alzheimer's disease. 1.2.19 Be aware that young-onset Alzheimer's disease has a genetic cause in some people. Further tests for dementia with Lewy bodies1.2.20 If the diagnosis is uncertain (see recommendation 1.2.14) and dementia with Lewy bodies is suspected, use 123I‑FP‑CIT SPECT. 1.2.21 If 123I‑FP‑CIT SPECT is unavailable, consider 123I‑MIBG cardiac scintigraphy. 1.2.22 Do not rule out dementia with Lewy bodies based solely on normal results on 123I‑FP‑CIT SPECT or 123I‑MIBG cardiac scintigraphy. Further tests for frontotemporal dementia1.2.23 If the diagnosis is uncertain (see recommendation 1.2.14) and frontotemporal dementia is suspected, use either:
1.2.24 Do not rule out frontotemporal dementia based solely on the results of structural, perfusion or metabolic imaging tests. 1.2.25 Be aware that frontotemporal dementia has a genetic cause in some people. Further tests for vascular dementia1.2.26 If the dementia subtype is uncertain and vascular dementia is suspected, use MRI. If MRI is unavailable or contraindicated, use CT. 1.2.27 Do not diagnose vascular dementia based solely on vascular lesion burden. 1.2.28 Be aware that young-onset vascular dementia has a genetic cause in some people. Case finding1.2.29 Only conduct case finding for suspected dementia as part of a clinical trial that also provides an intervention to people diagnosed with dementia. Telling the difference between delirium and dementia in people without a diagnosis of either1.2.30 For people who are in hospital and have cognitive impairment with an unknown cause, consider using one of the following to find out whether they have delirium or delirium superimposed on dementia, compared with dementia alone:
1.2.31 Do not use standardised instruments (including cognitive instruments) alone to distinguish delirium from delirium superimposed on dementia. 1.2.32 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. Review after diagnosis1.2.33 After a person is diagnosed with dementia, ensure they and their family members or carers (as appropriate) have access to a memory service or equivalent hospital- or primary-care-based multidisciplinary dementia service. 1.2.34 Memory services and equivalent hospital- and primary-care-based multidisciplinary dementia services should offer a choice of flexible access or prescheduled monitoring appointments. 1.2.35 When people living with dementia or their carers have a primary care appointment, assess for any emerging dementia-related needs and ask them if they need any more support. 1.3 Care coordination1.3.1 Provide people living with dementia with a single named health or social care professional who is responsible for coordinating their care. 1.3.2 Named professionals should:
Transferring information between services and care settings1.3.3 When developing care and support plans and advance care and support plans, request consent to transfer these to different care settings as needed. 1.3.4 Service providers should ensure that information (such as care and support plans and advance care and support plans) can be easily transferred between different care settings (for example home, inpatient, community and residential care). 1.3.5 Staff delivering care and support should maximise continuity and consistency of care. Ensure that relevant information is shared and recorded in the person's care and support plan. Making services accessible1.3.6 Service providers should design services to be accessible to as many people living with dementia as possible, including:
1.5 Pharmacological interventions for dementiaManaging medicines for all dementia subtypesPharmacological management of Alzheimer's disease1.5.3 Memantine monotherapy is recommended as an option for managing Alzheimer's disease for people with:
1.5.4 For people with an established diagnosis of Alzheimer's disease who are already taking an AChE inhibitor:
1.5.5 Treatment should be under the following conditions:
1.5.6 If prescribing an AChE inhibitor (donepezil, galantamine or rivastigmine), treatment should normally be started with the drug with the lowest acquisition cost (taking into account required daily dose and the price per dose once shared care has started). However, an alternative AChE inhibitor could be prescribed if it is considered appropriate when taking into account adverse event profile, expectations about adherence, medical comorbidity, possibility of drug interactions and dosing profiles. This recommendation is from NICE technology appraisal guidance on donepezil, galantamine, rivastigmine and memantine for the treatment of Alzheimer's disease. 1.5.7 When using assessment scales to determine the severity of Alzheimer's disease, healthcare professionals should take into account any physical, sensory or learning disabilities, or communication difficulties that could affect the results and make any adjustments they consider appropriate. Healthcare professionals should also be mindful of the need to secure equality of access to treatment for patients from different ethnic groups, in particular those from different cultural backgrounds. This recommendation is from NICE technology appraisal guidance on donepezil, galantamine, rivastigmine and memantine for the treatment of Alzheimer's disease. 1.5.8 When assessing the severity of Alzheimer's disease and the need for treatment, healthcare professionals should not rely solely on cognition scores in circumstances in which it would be inappropriate to do so. These include:
1.5.9 Do not offer the following specifically to slow the progress of Alzheimer's disease, except as part of a randomised controlled trial:
Pharmacological management of non-Alzheimer's dementia1.5.10 Offer donepezil or rivastigmine to people with mild to moderate dementia with Lewy bodies. 1.5.11 Only consider galantamine for people with mild to moderate dementia with Lewy bodies if donepezil and rivastigmine are not tolerated. 1.5.12 Consider donepezil or rivastigmine for people with severe dementia with Lewy bodies. 1.5.13 Consider memantine for people with dementia with Lewy bodies if AChE inhibitors are not tolerated or are contraindicated. 1.5.14 Only consider AChE inhibitors or memantine for people with vascular dementia if they have suspected comorbid Alzheimer's disease, Parkinson's disease dementia or dementia with Lewy bodies. 1.5.15 Do not offer AChE inhibitors or memantine to people with frontotemporal dementia. Note that logopenic aphasia, which has previously been included in some diagnostic guidelines for frontotemporal dementia, has now been shown to most commonly be caused by Alzheimer's disease 1.5.16 Do not offer AChE inhibitors or memantine to people with cognitive impairment caused by multiple sclerosis. 1.5.17 For guidance on pharmacological management of Parkinson's disease dementia, see Parkinson's disease dementia in the NICE guideline on Parkinson's disease. 1.6 Medicines that may cause cognitive impairment1.6.1 Be aware that some commonly prescribed medicines are associated with increased anticholinergic burden, and therefore cognitive impairment. 1.6.2 Consider minimising the use of medicines associated with increased anticholinergic burden, and if possible look for alternatives:
1.6.3 Be aware that there are validated tools for assessing anticholinergic burden (for example, the Anticholinergic Cognitive Burden Scale), but there is insufficient evidence to recommend one over the others. 1.7 Managing non-cognitive symptomsAgitation, aggression, distress and psychosis1.7.1 Before starting non-pharmacological or pharmacological treatment for distress in people living with dementia, conduct a structured assessment to:
1.7.2 As initial and ongoing management, offer psychosocial and environmental interventions to reduce distress in people living with dementia. 1.7.3 Only offer antipsychotics for people living with dementia who are either:
1.7.4 Be aware that for people with dementia with Lewy bodies or Parkinson's disease dementia, antipsychotics can worsen the motor features of the condition, and in some cases cause severe antipsychotic sensitivity reactions. For more guidance, see the advice on managing delusions and hallucinations in the NICE guideline on Parkinson's disease. Be aware that interventions may need to be modified for people living with dementia. 1.7.5 Before starting antipsychotics, discuss the benefits and harms with the person and their family members or carers (as appropriate). Consider using a decision aid to support this discussion. NICE has produced a patient decision aid on antipsychotic medicines for treating agitation, aggression and distress in people living with dementia. 1.7.6 When using antipsychotics:
1.7.7 Stop treatment with antipsychotics:
1.7.8 Ensure that people living with dementia can continue to access psychosocial and environmental interventions for distress while they are taking antipsychotics and after they have stopped taking them. 1.7.9 For people living with dementia who experience agitation or aggression, offer personalised activities to promote engagement, pleasure and interest. 1.7.10 Do not offer valproate to manage agitation or aggression in people living with dementia, unless it is indicated for another condition. If relevant, follow MHRA advice that valproate medicines are contraindicated in women and girls of childbearing potential unless a Pregnancy Prevention Programme is in place. Depression and anxiety1.7.11 For people living with mild to moderate dementia who have mild to moderate depression and/or anxiety, consider psychological treatments. 1.7.12 Do not routinely offer antidepressants to manage mild to moderate depression in people living with mild to moderate dementia, unless they are indicated for a pre-existing severe mental health problem. Sleep problems1.7.13 Do not offer melatonin to manage insomnia in people living with Alzheimer's disease. 1.7.14 For people living with dementia who have sleep problems, consider a personalised multicomponent sleep management approach that includes sleep hygiene education, exposure to daylight, exercise and personalised activities. Parkinson's disease1.7.15 For guidance on managing Parkinson's disease symptoms in people with Parkinson's disease dementia or dementia with Lewy bodies, see the NICE guideline on Parkinson's disease. Be aware that interventions may need to be modified for people living with dementia. 1.8 Assessing and managing other long-term conditions in people living with dementia1.8.1 Ensure that people living with dementia have equivalent access to diagnosis, treatment and care services for comorbidities to people who do not have dementia. For more guidance on assessing and managing multimorbidity, see the NICE guidelines on multimorbidity and older people with social care needs and multiple long-term conditions. 1.8.2 For more guidance on providing support for older adults with learning disabilities, see the NICE guideline on care and support of people growing older with learning disabilities. Pain1.8.3 Consider using a structured observational pain assessment tool:
1.8.4 For people living with dementia who are in pain, consider using a stepwise treatment protocol that balances pain management and potential adverse events. 1.8.5 Repeat pain assessments for people living with dementia:
Falls1.8.6 For guidance on managing the risk of falling for people living with dementia (in community and inpatient settings), see the NICE guideline on falls in older people. When using this guideline:
Incontinence1.9 Risks during hospital admission1.9.1 Be aware of the increased risk of delirium in people living with dementia who are admitted to hospital. See the NICE guideline on delirium for interventions to prevent and treat delirium. 1.9.2 When thinking about admission to hospital for a person living with severe dementia, carry out an assessment that balances their current medical needs with the additional harms they may face in hospital, for example:
1.9.3 When thinking about admission to hospital for a person living with dementia, take into account:
1.10 Palliative care1.10.1 From diagnosis, offer people living with dementia flexible, needs-based palliative care that takes into account how unpredictable dementia progression can be. 1.10.2 For people living with dementia who are approaching the end of life, use an anticipatory healthcare planning process (see recommendation 1.1.12 on advance care planning). Involve the person and their family members or carers (as appropriate) as far as possible, and use the principles of best-interest decision-making if the person does not have capacity to make decisions about their care. 1.10.3 For standards and measures on palliative care, see the NICE quality standard on end of life care for adults. 1.10.4 For guidance on care for people in the last days of life, see the NICE guideline on care of dying adults. 1.10.5 For guidance on best interests decision-making, see the NICE guideline on decision-making and mental capacity. 1.10.6 Encourage and support people living with dementia to eat and drink, taking into account their nutritional needs. 1.10.7 Consider involving a speech and language therapist if there are concerns about a person's safety when eating and drinking. 1.10.8 Do not routinely use enteral feeding in people living with severe dementia, unless indicated for a potentially reversible comorbidity. NICE has produced a patient decision aid on enteral (tube) feeding for people living with severe dementia. 1.11 Supporting carers1.11.1 Offer carers of people living with dementia a psychoeducation and skills training intervention that includes:
1.11.2 Ensure that the support provided to carers is:
1.11.3 Be aware that carer interventions are likely to be most effective when provided as group sessions. 1.11.4 Advise carers about their right to carer assessment, and assessment for respite care and other support (see the NICE guideline on supporting adult carers for recommendations on identifying, assessing and meeting the caring, physical and mental health needs of families and carers). 1.11.5 Be aware that carers of people living with dementia are at an increased risk of depression. For guidance on identifying and managing depression, see the NICE guideline on depression in adults. 1.12 Moving to different care settings1.12.2 Review the person's needs and wishes (including any care and support plans and advance care and support plans) after every transition. 1.13 Staff training and education1.13.1 Care and support providers should provide all staff with training in person-centred and outcome-focused care for people living with dementia, which should include:
1.13.2 Care providers should provide additional face-to-face training and mentoring to staff who deliver care and support to people living with dementia. This should include:
1.13.3 Consider giving carers and/or family members the opportunity to attend and take part in staff dementia training sessions. 1.13.4 Consider training staff to provide multi-sensory stimulation for people with moderate to severe dementia and communication difficulties. 1.13.5 Ensure that all health and social care staff are aware of:
1.13.6 Health and social care professionals advising people living with dementia (including professionals involved in diagnosis) should be trained in starting and holding difficult and emotionally challenging conversations. Terms used in this guidelineCase findingA strategy of actively assessing people who are at risk for a particular disease, before they present with symptoms and before there is clinical suspicion of the condition. It does not refer to situations such as assessing people for dementia after an acute episode of delirium, where clinical suspicion of dementia is likely to already be raised. Cognitive rehabilitationIdentifying functional goals that are relevant to the person living with dementia, and working with them and their family members or carers to achieve these. The emphasis is on improving or maintaining functioning in everyday life, building on the person's strengths and finding ways to compensate for impairments, and supporting independence. Cognitive rehabilitation does not aim to improve cognition, but addresses the disability resulting from the impact of cognitive impairment on everyday functioning and activity. Rehabilitation is sometimes referred to as 'reablement'. Cognitive stimulationEngaging in a range of activities and discussions (usually in a group) that are aimed at general improvement of cognitive and social functioning. Cognitive trainingGuided practice on a set of standard tasks that are designed to reflect particular cognitive functions. There may be a range of difficulty levels, to fit the tasks to each person's level of ability. Interpersonal therapyBrief structured attachment-focused therapies for people with mild to moderate depression. These therapies are based on the idea that difficulties interacting with other people can cause psychological symptoms such as depressed mood, which then make the difficulties with interaction worse, causing a cycle. Interpersonal therapies aim to help people interact more effectively with others, and through this improve the psychological symptoms. Therapy typically focuses on relationship issues such as conflict, difficulty starting or maintaining relationships, grief and loss, and life changes. Prescribing risperidone and haloperidolThe marketing authorisation for risperidone only covers short-term treatment (up to 6 weeks) of persistent aggression in people with moderate to severe Alzheimer's disease unresponsive to non-pharmacological approaches and when there is a risk of harm to self or others. The marketing authorisation for haloperidol only covers treatment of persistent aggression and psychotic symptoms in people with moderate to severe Alzheimer's dementia and vascular dementia when non-pharmacological treatments have failed and when there is a risk of harm to self or others. ReferA referral to a diagnostic service does not have to involve a clinic appointment. People can be seen in community settings (such as their home or a care home), or advice can be provided to the referrer without a formal appointment being made. The key issue is to ensure that dementia specialists are involved, both for advice on diagnosis and to ensure appropriate access to post-diagnostic support and treatment. Specialists are those with the appropriate knowledge and skills and include secondary care medical specialists (for example psychiatrists, geriatricians and neurologists) and other healthcare professionals (for example GPs, nurse consultants and advanced nurse practitioners) with specialist expertise in assessing and diagnosing dementia. Specialist clinicianSpecialist clinicians (for the purpose of starting and monitoring treatment with cholinesterase inhibitors and memantine) are those with the appropriate knowledge and skills and include secondary care medical specialists (for example psychiatrists, geriatricians and neurologists) and other healthcare professionals (for example GPs, nurse consultants and advanced nurse practitioners) with specialist expertise in diagnosing and treating Alzheimer's disease. Verbal episodic memoryEpisodic memories include information about recent or past events and experiences (rather than factual knowledge, or habits and skills). They may be recent, or from the distant past (remote or long-term episodic memory). Tests to assess episodic memory may use either verbal or visual material. Examples of verbal episodic memory tests include reading the person a list of words or a short story and asking them to recall this information, both immediately and after a delay. How do you communicate with someone who is cognitively impaired?Tips for Communicating with a Confused Patient. Try to address the patient directly, even if his or her cognitive capacity is diminished.. Gain the person's attention. ... . Speak distinctly and at a natural rate of speed. ... . Help orient the patient. ... . If possible, meet in surroundings familiar to the patient.. Which nontherapeutic technique would the nurse avoid while communicating with a patient?Which nontherapeutic techniques should the nurse avoid while communicating with the patient? . Giving false reassurance to the patient about the situation is unethical and may cause the patient to lose trust in the nurse.
How should the nurse communicate with a patient who has impaired hearing quizlet?To facilitate communication with a hearing-impaired person, face the patient when speaking, speak slower and in a normal tone, talk toward the patient's best or normal ear, articulate clearly, and demonstrate ideas you wish to convey. You should also position yourself so the light is on your face when you speak.
Which important action would the nurse perform when communicating with a hearing impaired patient?Avoid facing the patient while speaking. Speak clearly and slowly. Check for the patient's hearing aids. Make the patient aware while talking.
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