New guidelines from SIGN for Dementia

Dementia remains (and will continue to remain) a Hot Topic for us all in primary care. It will surprise no one that the numbers of patients we are seeing in General Practice continue to rise substantially; there are estimated to be 944,000 people living with dementia in the UK. 

The last guidance from NICE on dementia was back in 2018, so the new guideline on the assessment, diagnosis and care of people with dementia from SIGN in November 2023 is really welcome. 

Like most SIGN guidelines, it’s not overly complex and has some really useful key points, not to mention a few glorious infographics that we at the NB team always love! SIGN have made the interesting decision not to include any pharmacological interventions in their guidance, which instead contains thought-provoking sections on post-diagnostic support, grief and dementia and the changing needs of people with dementia. It focuses heavily on the support needed by patients and their families both around diagnosis and longer term coping. 

While we tend to focus on treatments, importantly the guideline stresses the importance of addressing the 40% of risk factors for dementia that are modifiable. It is estimated that 60% of the risk for Alzheimer's is genetic, but the remainder is where general practice can really add value and hopefully avoid some of the dementia diagnoses we might otherwise see. 

Knowing the increasing incidence of vascular dementia, it won’t surprise you that things that promote atherosclerosis are the ones to target. Smoking, alcohol consumption (> 21U per week), hypertension and diabetes all feature strongly and need to be avoided or well controlled to minimise risk. Alongside this is obesity with its multi-factorial causes that itself includes a large non-modifiable genetic component but the possible interventions from health and wellbeing coaches, dedicated tier 1-3 weight loss services and the improved understanding of obesity and overweight provide some hope that this can be addressed for patients. 

Physical inactivity is a risk factor on its own, whether linked to obesity or not. Explaining to patients that you can have a normal weight and still be unfit is important, and the beneficial effects of exercise regardless of weight or weight loss should be stressed.  

Depression and social isolation carry a risk of developing dementia and while some patients respond quickly and well to pharmaceutical treatments for symptomatic depression, not all do and social isolation cannot be managed with a tablet. The muti-factorial nature of isolation means that practices in England are increasingly using their ARRS workforce via PCNs to try and address this, and the voluntary sector often has a broad range of offers available at local level. MIND has helpful information on loneliness and its links to mental health and depression. Age UK provide The Silver Line alongside their other extensive work. This is a dedicated phoneline for friendship, conversation, and support for those over age 55yrs. It is particularly aimed at helping to tackle loneliness.   

But perhaps the two most interesting risk factors identified are hearing loss and air pollution. We’ve talked about air pollution in the context of respiratory disease on our courses before, but it’s links to dementia appear to be more related on the impact on the cardiovascular system and the resulting impaired circulation to the brain. Hearing loss on the other hand certainly raised questions in my mind. We see a lot of people with dementia who have hearing loss – are we now saying that preventing hearing loss can prevent dementia? Does this apply to everyone or just those with other risk factors for dementia? And surely given how non-invasive a hearing test is, would it meet the criteria for a potential screening test for future dementia? We will be exploring these risk factors and trying to answer these questions in our newest course in the Spring, sharing with you the evidence behind this guideline and what current research tell us so we can best advise our patients.