Vascular Dementia

See related articles Dementia and Alzheimer's Disease.

NICE have produced several guidelines on the management of dementia (including non-Alzheimer's Disease), the most recent guideline released in 2006.¹ Whilst further consultation needs to take place on the drug management of dementia, the document lays down certain which are unlikely to change further.

Principles of good practice

Priorities for Implementation:

• Patients with dementia should not be discriminated against when considering treatment options for other conditions.
• Their valid consent should be sought for treatment wherever possible. This may mean making information available to them in an appropriate form. The use by patients and carers of advocacy services and voluntary organisations should be encouraged. If patients are not competent to make a decision, the requirements of the requirements of the Mental Capacity Act 2005 (which received Royal Assent on 7 April 2005 and was fully implemented on 1 October 2007) should be followed.
• Carers should receive an assessment of needs as required by the Carers and Disabled Children Act 2000² and the Carers (Equal Opportunities) Act 2004.³ Carers should be offered individual or group psychoeducation and psychological therapy, peer-support groups, information in a variety of media, and training courses. Issues such as transport, night-sitting, and respite care should also be considered.
• Health and social care managers should take a joint approach to management, and this should include joint written policies and procedures, and joint planning of services which take on board the views of local service users and carers.
• Care managers and co-ordinators should ensure that a combined care plan takes account of the changing needs of the patient and the carers, is reviewed regularly, and receives the endorsement of the patient and carers.
• Named health and/or social care staff should be assigned to operate the plan.
• A memory assessment service should act as the single point of referral for all patients with a suspected diagnosis of dementia.

People with challenging behaviour

This patient group is given a specific mention. They should be offered early assessment which includes:

• Physical health
• Depression and any psychosocial issues
• Possible undetected pain or discomfort
• Adverse effects of medication
• Life history, including spiritual, cultural and religious identity
• Physical environment
• Behavioural and functional analysis by a skilled professional

Comorbid emotional disorders

Non-drug options for the management of agitation, anxiety or depression might include aromatherapy, multisensory stimulation, music therapy, animal-assisted therapy, massage, cognitive behaviour therapy (sometimes involving carers), reminiscence therapy, and exercise.

Principles of care

Person-centred care

This means tailoring services to the individual needs of the person as far as possible. If the patient does not have capacity to make decisions, the Department of Health guidance - 'Reference guide to consent for examination or treatment' (2001),⁴ 'Seeking consent: working with older people'(2001)⁵ and 'Seeking consent: working with people with learning disabilities' (2001) should all be followed.

Whilst the patient is in a relatively early stage of the condition, opportunity should be taken to discuss such issues as advanced statements (which outline how they would like decisions taken on their behalf, should they lose capacity), advance decisions about refusing treatment, Power of Attorney, and preferred place of care.

The Mental Capacity Act 2005 has the following principles:

• Adults must be assumed to have capacity to make decisions about their care unless proved otherwise.
• Individuals should be given all available support to help them come to a decision.
• Individuals should retain the right to make what others might consider eccentric or unwise decisions.
• Anything done on behalf of an individual without capacity must be in that person's best interests.
• The rights and basic freedoms of an individual without capacity should be restricted as little as possible.

With the patient's consent, relatives and carers should be involved, in management decisions. Relatives and carers should also have their own needs assessed.

Diversity and equality

This section in the NICE guidance is a reminder about the importance of respecting individuality. Patients and carers should be given support appropriate to their needs and should not be discriminated against in terms of race, language, religion or sexuality. Focussed support should be available for younger people with dementia, and those with learning disabilities.

Social, sexual and financial support

The effects of the condition on existing personal and sexual relationships should be discussed and patients and carers given information about local support services if appropriate.

Information should be provided about financial issues, including direct payments, individual budgets, and possible eligibility for NHS continuing care.

Promoting independence

A care plan should be instituted that addresses activities of daily living (ADL), and considers such issues as the person's environment, toileting skills, and physical exercise.
For people who also have learning disability, consider using the Assessment of Motor and Process Skills (AMPS) at the time of diagnosis,⁶ and the Dementia Questionnaire for Mentally Retarded Persons (DMR) and Dalton's Brief Praxis Test (BPT) for monitoring change in function.⁷

Improving cognitive skills

People with mild to moderate dementia may improve if they participate in a structured group stimulation programme.

Community and hospital care

Patients should be cared for in the community as much as possible. However, if they become severely disturbed and need to be contained for their own safety or the safety of others, inpatient care should be considered (this might include those liable to be detained under the Mental Health Act 1983). Inpatient admission would also be justified for patients with complex physical and psychiatric problems who could not be properly assessed in the community.

Palliative and end of life care

Physical, psychological, social and spiritual support should be offered, and dementia patients should have the same access to palliative care services as any other patient. Oral nutrition should be encouraged for as long as possible. Tube feeding may be appropriate in patients with transient dysphagia but should be used as a last resort in patients with severe dementia. Decisions to withhold nutritional support should be taken within a legal and ethical framework.

Fever may be managed with antipyretics and mechanical cooling. Palliative antibiotics should be given after an individual assessment of the patient.

Resuscitation is unlikely to succeed in patients with severe dementia. If no advanced decision has been taken by the patient, the decision to resuscitate should take into account the views of the carers and the multidisciplinary team, the Resuscitation Council UK 's guidance, and the Mental Capacity Act 2005.⁸ The decisions should be recorded in the notes and care plan.

Drugs currently play a small part in the management of non-Alzheimer's dementia. NICE do not recommend the use of acetylcholinesterase inhibitors or memantine for cognitive decline in vascular dementia or acetylcholinesterase inhibitors in mild cognitive impairment, unless this is part of a properly constructed clinical study

Medication for non-cognitive symptoms (e.g. emotional symptoms) and challenging behaviour

This should only be used if there is severe distress or immediate risk of harm to the patient or others. NICE do not recommend the use of antipsychotics for mild-to-moderate non-cognitive symptoms in dementia with Lewy bodies, vascular dementia or mixed dementia because of the increased risk of cerebrovascular adverse events and death. For severe symptoms (e.g. psychosis and/or agitated behaviour causing significant distress), antipsychotics should only be prescribed once the risks and benefits have fully been considered and discussed with carers, risk factors have been assessed and a regular assessment is made of changes in cognition. Comorbid conditions such as depression should be considered and treated, and treatment should be time-limited.

Acetylcholinesterase inhibitors have a place in the management of non-cognitive symptoms in patients with dementia with Lewy bodies, but only if symptoms cause significant distress or lead to challenging behaviour.

Urgent treatment of challenging behaviour

If intramuscular agents are required for behavioural control, NICE recommend lorazepam, haloperidol or olanzapine. If possible, a single agent should be used, unless rapid tranquilisation is required, in which case lorazepam and haloperidol should be used in combination. Diazepam or chlorpromazine should be avoided. The patient should be monitored for dystonia and other extrapyramidal effects. Anticholinergic drugs may be used if side effects become distressing, but monitor for deteriorating cognitive function.