The National Board of Health and Welfare adjudges that the recommendations below are central preconditions to enable these guidelines, in overall terms, to deliver the desired result. Recommendations may be resource-intensive and entail for example the need for investments in staff and competence.
Firstly basal – then widened
There is no simple assessment method that can ascertain whether a person has a dementia-type illness. In the first place, Health and Medical Care should carry out a basic investigation of dementia that is based on a balancing of
- structural amnesia, interviews with those close to the person, assessment of physical and psychological condition, assessment of cognition through cognitive test (MMT together with clock test)
- structured assessment of function and activity capacity
- taking of samples to exclude other conditions that may cause cognitive impairment
- structural brain imaging with computer tomography that can contribute to identifying cognitive impairment and exclude other conditions in the brain that may cause cognitive impairment.
A basal investigation is not always sufficient to ascertain whether a person has a dementia-type illness. Health and Medical Services should then carry out an extended dementia examination that includes one or several of the following elements:
- neuropsychological tests
- structural brain imaging with magnetic camera
- lumbar punction for analysis of biomarkers
- functional brain imaging with SPECT.
The National Board of Health and Welfare adjudges that the effect of the recommendations on basal and extended examinations will be that the number of examinations will increase by about 7,000 investigations annually at a cost of around SEK 41–59 million (about one promille of the total costs for dementia-type illnesses). A higher quality in respect of dementia examinations may be expected to contribute to a more adequate care and a reduced requirement for emergency measures, e.g. hospitalisations, which does not lead to increased total costs.
Person-centred car – multiprofessional teamwork and training
The National Board of Health and Welfare considers that all nursing care for persons with dementia should be based on a person-centered approach and multiprofessional team-based work.
The National Board of Health and Welfare also considers that Health and Medical Care and Social Services should offer staff the possibility of long-term training, combined with practical training, instruction and feedback.
The National Board of Health and Welfare estimates that the effect of the recommendations on
- person-centred care initially does not affect, but in the longer term reduces, the costs of health and medical care and social services
- multiprofessional work initially increases, but in the longer term reduces, the costs of health and medical care and social services
- training initially increases, but in the longer term reduces, the costs of municipal health and medical care and social services.
Follow-up at least once a year
The National Board of Health and Welfare considers that Health and Medical Care and Social Services should follow up, at least once a year, medication treatment, cognition, functional capacity, general state of health, behavioural changes and support those inputs agreed upon.
The National Board of Health and Welfare considers that the recommendation reduces the costs of health and medical care and social services in the longer term.
Medicinal treatment for cognitive impairment in case of Alzheimer’s disease and evaluation of medicines
Health and Medical Care should offer treatment with cholinesterase inhibitors (donezepil, galantamine and rivastigmine) to combat cognitive impairment symptoms for persons with mild to moderate Alzheimer’s disease.
Health and Medical Care should also offer treatment with memantine for cognitive impairment symptoms in those persons with moderate to severe Alzheimer’s disease. Health and Medical Care should also follow up the treatment when the dose is adjusted and subsequently, at regular intervals of at least once a year in combination with possible discontinuation of treatment.
The National Board of Health and Welfare considers that the effect of the recommendations on treatment with cholinesterase inhibitors and memantine entails an increase of medication costs by a maximum of SEK 170 million. The total costs for society as a whole, however, are expected to be unchanged or to decline.
Investigation of behavioural and psychological symptoms in case of dementia
Health and Medical Care and Social Services should always investigate the underlying reasons for behavioural and psychological symptoms in the case of persons with dementia. (BPSD).
For persons with dementia and simultaneous depression, Health and Medical Care should offer treatment with SSRI medication.
The National Board of Health and Welfare considers, furthermore, that the medical care services in exceptional cases (where person-centred nursing care inputs and the adaptation of the care environment have been shown to be insufficient and the condition causes substantial suffering for the dementia patient) can try medication treatment with
- Memantine for persons with Alzheimer’s and behavioural and psychological symptoms
- fast-working bensodiazepines in case of nervousness and anxiety
- antipsychotic agents in case of psychosis symptoms or agitation
- Clomethiazole at night in case of dementia and behavioural and psychological symptoms or confusion.
A prerequisite when a person is treated with bensodiazepines or antipsychotic agents is that Health and Medical Care plan for a short treatment time and evaluate effects and side-effects within two weeks.
There are also drugs that are not suitable to use in the treatment of BPSD. The National Board of Health and Welfare considers that Health and Medical Care should not treat the condition with antiepileptic drugs (Carbamazepine, Valproate and Topiramate).
The National Board of Health and Welfare considers that the effect of the recommendations on the treatment of behavioural and psychological symptoms may lead to an increased demand for resources within municipal operations in order to look after persons with these symptoms.
Adult day care adapted to the group in question
The National Board of Health and Welfare considers that Social Services should offer persons with dementia daily activities that are specifically adapted to group needs. Younger persons should be offered a place in adult day care specifically adapted to their needs.
The National Board of Health and Welfare adjudges that adult day care specifically tailored to persons with dementia as well as for younger persons with dementia-type illnesses is indeed cost-effective in comparison with other daily activities. The cost for one day in adult day care is estimated to be equivalent to the cost for 1-2 hours home help services.
Sheltered housing specifically adapted for persons with dementia
The National Board of Health and Welfare considers that Social Services should offer persons with dementia a place in small-scale sheltered housing schemes specifically adapted to persons with dementia. Social Services should also act to ensure that the residential environment is designed with the person in mind, is homelike and that the persons who need to be outside for periods are enabled to do this.
The National Board of Health and Welfare also considers that Social Services should work to achieve a psychosocial living environment characterised by security and accessibility and where the daily lives of those persons with dementia are meaningful in terms of content.
The National Board of Health and Welfare adjudges that small-scale sheltered housing specifically adapted for persons with dementia is cost-effective in comparison with mixed housing. The National Board of Health and Welfare also assesses that the effects of the recommendations will mean increased costs for the municipalities. County council (landsting) costs are expected to decline in the longer term
Support for close relatives
Health and Medical Care and Social Services should offer close family members opportunities for education and psychosocial support programmes, combination programmes and relief (stand-in).
It is thought that the positive effects of this support could be reinforced where it is offered at an early stage in the course of the illness, lasts over time, is flexible, situation-adapted, individualised and developed in dialogue with family members. The National Board of Health and Welfare adjudges that the effects of the recommendations will initially increase the costs for the municipalities. County council (landsting) costs are expected to decline in the longer term.
Lack of data sources complicates follow-up
The National Board of Health and Welfare has drawn up 14 different indicators for the follow-up of medical care, long-term care and welfare of persons with dementia illnesses. Of these, it is possible to monitor six through existing records at the National Board of Health and Welfare.
A major problem within this area is that there is a lack of data sources, e.g. for those inputs by Social Services on behalf of persons suffering from dementia and within primary care. Furthermore, the existing data sources are not used in a correct manner. This means that it has still not been possible to continuously monitor eight of the quality indicators, whether at the national, regional or local level. It is therefore urgent that Health and Medical Care and Social Services develop individually based data that enable the follow-up and evaluation of quality in medical care and the longer term care of persons with dementia.