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Dementia

NICE guideline [NG97] Dementia: assessment, management and support for people living with dementia and their carers. Published: Jun 2018.

Guidelines

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
 

  • 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)

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
 

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 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: FDG-PETFluorodeoxyglucose-positron emission tomography-CT or perfusion SPECTSingle‑photon emission CT scan
  • CSF analysis for tau protein and amyloid beta 
 Functional brain imaging:
  • Hypometabolism in temporoparietal cortex and posterior cingulate

CSF analysis:
  • ↑ Total tau protein and phosphorylated tau
  • ↓ Amyloid beta 1-42 and 1-40
Lewy body dementia
  • 1st line: DaT scanDopamine transporter scan (123I‑FP‑CIT SPECT)Single‑photon emission CT
  • 2nd line: 123I‑MIBG cardiac scintigraphy

Do not rule out Lewy body dementia based on normal results		 DaT scanDopamine transporter scan
  • ↓ Dopamine transporter uptake in the basal ganglia (esp. in putamen and caudate nuclei)

Cardiac scintigraphy:
  • ↓ Uptake in myocardium (reflects reduced cardiac sympathetic innervation)
Frontotemporal dementia Functional brain imaging:
  • FDG-PETFluorodeoxyglucose-positron emission tomography-CT or
  • Perfusion SPECTSingle‑photon emission CT scan
 Reduced function in frontal and/or anterior temporal lobes:
  • FDG-PET: reduced glucose metabolism
  • SPECT: reduced blood flow
Vascular dementia
  • 1st line: MRI
  • 2nd line: CT
 Ischaemic white matter changes:
  • Diffuse white matter hyperintensities on T2/FLAIR
  • Cortical and subcortical infarcts, lacunar infarcts
  • Cerebral atrophy (patchy)
 
 

 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.

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

For mild to moderate disease:
  • 1st line: acetylcholinesterase inhibitors (donepezil / galantamine / rivastigmine)
  • 2nd line: add memantine

Consider memantine monotherapy in:
  • Severe Alzheimer's disease on presentation, or
  • Acetylcholinesterase inhibitors not appropriate

Treat with acetylcholinesterase inhibitors
  • 1st line: donepezil / rivastigmine
  • 2nd line: galantamine

Do NOT offer acetylcholinesterase inhibitors 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, diabetes)

Do not offer acetylcholinesterase inhibitors or memantine

 

The mainstay of management for frontotemporal dementia (FTD) is symptomatic and supportive care (focused on non-pharmacological interventions and caregiver support)

References

Author: Adams Lau
Reviewer:
Last edited: 26/07/25