Dementia
NICE guideline [NG97] Dementia: assessment, management and support for people living with dementia and their carers. Published: Jun 2018.
Guidelines
Investigation and Diagnosis
To distinguish between delirium and dementia, NICE recommends using the:
- Confusion assessment method (CAM)
- Observational Scale of Level of Arousal (OSLA)
If not possible to tell between delirium and dementia, or delirium superimposed on dementia → treat delirium first
Primary Care
- Take a focused history, and
- Cognitive testing
- 10-point cognitive screener (10-CS)
- 6-item cognitive impairment test (6CIT)
- 6-item screener
- Memory Impairment Screen (MIS)
- Mini-Cog
- Test Your Memory (TYM)
If dementia is suspected → refer to secondary care
NICE did not specifically recommend the use of MoCA and MMSE which are still often used in practice. Expert summaries and reviews commented that:
- Longer or more complex tests may not be better than shorter simpler tools in primary care.
- MoCA is reported as not well tolerated by people with suspected dementia (ACNR Journal review)
Secondary Care
Dementia and its subtypes can be diagnosed clinically by a specialist
Also include a test of verbal episodic memory if Alzheimer’s disease is suspected
Imaging
Offer structural imaging (usually MRI brain, alternatively CT) to rule out reversible causes of cognitive decline and assist with subtype diagnosis
- Unless dementia is well established and the subtype is clear
Consider further imaging if there is diagnostic uncertainty for the dementia subtype (and would change management):
| Suspected dementia subtype | Test of choice | Findings |
|---|---|---|
| Alzheimer’s disease | Either of the following:
|
Functional brain imaging:
CSF analysis:
|
| Lewy body dementia |
Do not rule out Lewy body dementia based on normal results |
DaT scan
Cardiac scintigraphy:
|
| Frontotemporal dementia | Functional brain imaging:
|
Reduced function in frontal and/or anterior temporal lobes:
|
| Vascular dementia |
|
Ischaemic white matter changes:
|
Clarification of some confusing terms – different types of SPECT imaging.
- SPECT is a general imaging technique
- 123I‑FP‑CIT SPECT is a specific type of SPECT where 123I‑FP‑CIT binds to dopamine transporters thus is also called DaT scan. This is used to assess dopaminergic activity thus for Lewy body dementia and Parkinsonian syndromes
- When NICE just mentions SPECT, they are referring to brain perfusion SPECT that uses tracers like technetium-99m which measures regional cerebral blood flow
Therefore, the SPECT mentioned in Lewy body dementia, Alzheimer’s disease and frontotemporal dementia are NOT interchangeable.
On the other note, PET scans assess glucose uptake and metabolism in tissue using 18F-FDG tracer.
Management
General / Conservative Management
Offer:
- Range of activities to promote wellbeing tailored to the patient’s preferences
- Group cognitive stimulation therapy (for mild to moderate dementia)
Consider the following for mild to moderate dementia:
- Group reminiscence therapy
- Cognitive rehabilitation or occupational therapy
Behavioral and Psychological Symptoms of Dementia (BPSD)
1st line: non-pharmacological interventions (psychosocial interventions, environmental adaptations, verbal/non-verbal de-escalation)
- Ensure reversible triggers have been ruled out / managed (e.g., pain, infection, delirium, A/E of medications)
2nd line: pharmacological interventions
- Short-term antipsychotic therapy
- Indication
- Unresponsive to non-pharmacological interventions AND
- At risk of harming themselves, OR
- Experiencing agitation, hallucinations, or delusions that are causing severe distress
- Indication
- Licensed options (AD/VD): haloperidol & risperidone (started under specialist supervision)
Pharmacological Management
Alzheimer’s Disease
For mild to moderate disease:
- Step 1: AChE inhibitor (donepezil / galantamine / rivastigmine)
- Step 2: add memantine
Consider memantine monotherapy in:
- Severe Alzheimer’s disease on presentation, or
- Acetylcholinesterase inhibitors not appropriate
Lewy Body Dementia
NICE guideline focuses only on general dementia management and does not elaborate on a symptom-based management approach, which is particularly relevant for Lewy body dementia:
| Symptom | Pharmacological management |
| Neurocognitive (i.e. dementia) | Similar to Alzheimer’s management:
|
| Psychiatric |
|
| Motor (i.e. Parkinsonism) |
|
Vascular Dementia
Do NOT offer AChE inhibitor or memantine
- Only consider if the patient has suspected comorbid:
- Alzheimer’s disease
- Lewy body dementia
- Parkinson’s disease dementia
The mainstay of management of vascular dementia is identification and control of vascular risk factors (including hypertension, hyperlipidaemia, and diabetes)
Frontotemporal Dementia
Do not offer AChE inhibitor or memantine
The mainstay of management for frontotemporal dementia (FTD) is symptomatic and supportive care (focused on non-pharmacological interventions and caregiver support)