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Monday 22 October 2018
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What do NICE’s updated dementia guidelines mean for hospital pharmacy?

The guidance recommends co-prescribing cholinesterase inhibitors and memantine in moderate to severe Alzheimer’s disease, building on broader prescribing advice from the 2006 guidelines. A spokesperson from NICE said that the change was in response to new trials, including the DOMINO-AD trial in the UK.

The UK’s National Institute for health and Care and Excellence (NICE) has updated dementia guidelines to  include revised prescribing advice, new measures for patients suffering from dementia with lewy bodies (DLB) and a move to primary care treatment.
 
The guidance recommends co-prescribing cholinesterase inhibitors and memantine in moderate to severe Alzheimer’s disease, building on broader prescribing advice from the 2006 guidelines. A spokesperson from NICE said that the change was in response to new trials, including the DOMINO-AD trial in the UK.
 
It also recommends offering cholinesterase inhibitors for people living with DLB. This medication was previously only recommended to treat the behavioural symptoms of Alzheimer’s disease, but new research has shown it also has a positive impact on cognition.
 
NICE has put greater emphasis on pharmaceutical treatment being carried out in primary care, as opposed to specialists. The spokesperson added that once prescribing and monitoring has been approved in primary care people would be able to switch over to co-prescription with specialist support. NICE said the change reflected new evidence but was also reflection of how practice is changing in the UK, as greater familiarity with these medicines means they are becoming part of a standard GPs toolkit”.
 
Julia Blagburn, a clinical pharmacist working in geriatric medicine in Newcastle, England, explained the impact for hospital pharmacists: “NICE are allowing a more holistic approach to assessing the benefits of drug therapy in dementia, which a lot of clinicians have already been doing. It’s person-centred approach and I think the correct one for many people living with dementia and all of their carers.”
 
Ms Blagburn said these changes are likely to result in longer-term use of of AChE (Acetylcholinesterase) therapies in combination with memantine. She said availability of these memory drugs within primary care should enable “rapid access” but will shift work to overloaded GPs or practice pharmacists, who would become responsible for monitoring patients.
 
More generally, the new NICE guidelines put emphasis on staff face-to-face training and mentoring, doctor evaluation of patient history with ‘someone who knows the patient well’ and greater patient involvement.
 
Sally Copley, director of policy, campaigns and partnerships at Alzheimer’s Society, called the guideline “just a starting point” and said greater support and investment is needed to make these recommendations possible.
 
Ms Copley said: “What we need now is support to implement these recommendations. Take training as an example - a third of homecare workers currently have no dementia training, resulting in inadequate care for many people with dementia. The guideline alone can’t change this, we’ll need to see significant investment to improve care quality, when the [UK] Government announces its plans for social care reform in the autumn.
 
“With diagnoses on the rise, and one million due to have dementia by 2021, all health and social care professionals must be properly equipped to support people with dementia at every stage.”
 
Professor Gillian Leng, deputy chief executive at NICE, said: “Dementia is a highly complex and challenging condition. It can present differently from person to person, having a huge impact on the patient, their family and their carers.”
 
Ms Leng highlighted the “person-centred” focus in new recommendations, and the value of patient involvement in their care. She added: “Everyone diagnosed with dementia should have an individual care plan that is reviewed at least once a year.”


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