ClinicalPracticeGuidelinesforDementiainAustralia

BrisbaneMarch21st 2016

sydney.edu.au/medicine/cdpc/

SusanKurrle

Geriatrician,HornsbyKu-ring-gaiandEurobodallaHealthServicesDirector,NHMRCCognitiveDeclinePartnershipCentre

CurranProfessorinHealthCareofOlderPeopleFacultyofMedicine,UniversityofSydney

WhoistheNHMRCCDPC?• PartnershipbetweenNHMRC,DepartmentofHealth,Alzheimer’sAustralia,and3agedcareproviders(BrightwaterCareWA,HammondCareNSWandVic,andHelpingHandSA)

• Partnersdriveresearchagendawhichiscarriedoutbyateamofresearchandsystembasedinvestigators(cliniciansandagedcareproviders)

• Stronginputfromconsumersfrominitiationtocompletionofprojects

• $25millionfundingover5years• FundingbeganinFeb2014

WhoistheCDPC?• Investigatorteamisamixtureofclinicians,researchers,consumers,andagedcareprovidersandpractitioners

• Investigatorsinclude:– Medicine,nursing,physiotherapy,psychology,occupationaltherapy,pharmacy,socialwork

– Law,sociology,healtheconomics,changemanagement• Consumersincludepeoplewithdementiaandcarers ofpeoplewithdementia,whoaremembersofAlzheimer’sAustraliaConsumerDementiaResearchNetwork

• Theteamcovers5states,10universities,otherinstitutions(eg RDNS,SouthernNSWLHD,NSWACI)and15professions,andincludesurbanandruralsites

NHMRCCDPC• ObjectivesofPartnershipCentre:– Implementationofcurrentknowledge– Synthesisanddisseminationofcurrentresearch– Collaborativeresearch– Capacitybuilding

• MajorfocusofPartnershipCentreisonknowledgetranslationie knowingtodoing

• ProjectsforCentrearedevelopedtogether byPartnersandInvestigatorteammembers

• End-user/Consumerinvolvementseenasessentialfromthebeginningoftheprocess

CognitiveDeclinePartnershipCentre(CDPC)

• Aimistoimprovethelivesofpeoplelivingwithdementia,andtodevelopandcommunicateresearchtoimprovethecareofpeoplewithdementia

• Focusisparticularlyonthe“care”areaofcognitiveandassociatedfunctionaldecline

• Onewaytoachievethatisthroughthedevelopmentanddisseminationofbestpracticeguidelinesforthemanagementofpeoplewithdementia

Whydoguidelines?

• Therewerenone• Dementiaiscommon(9%overage65,25%overage80)

• DementiaisaNationalHealthPriority• Dementiaisthe2nd highestcauseofdeath• ClinicalPracticeGuidelineshavebeenshowntoimprovequalityandconsistencyofcareforarangeofconditions

Whyaretheseguidelinesimportant?

• DementiaisnotmanagedconsistentlywellinAustralia,thereislotsofroomforimprovement,andtheseguidelinesoutlinehowthatcanbedone.

• Consumershavehadextensiveinvolvementintheirdevelopmentandtheircontributionhasbeenincrediblyvaluable

• HavingGuidelinesgivesdementia“clinicallegitimacy”

Howdidwedoit?• Wetookexistinginternationalguidelines(fromNICEintheUK)andusedtheADAPTEprocesstomodifyandadaptthemtoAustralianconditions

WhatistheADAPTEprocess?• Systematicapproachtotheadaptingofguidelinesdevelopedinonesettingforuseinadifferentsetting

• ToolkitdevelopedbyagroupofcollaboratorsinCanadaandEuropetopromotetheuseofclinicalpracticeguidelinesthroughtheadaptationofexistingguidelines

Howdidwedoit?• AspartoftheADAPTEprocess,weconductedaseriesofmini-systematicreviewsaroundeachrecommendationtoensureevidencewasuptodate(wheretherewasevidenceavailable)

• UsedtheGRADEapproach(GradingofRecommendations,Assessment,DevelopmentandEvaluation)whichprovidesasystemforrating thequalityofevidence,andstrengthofrecommendation,foreachindividualoutcome(asusedbyCochraneCollaboration)

Howdidwedoit?• FormedaconsultativeGuidelineAdaptationCommitteeof21people:consumers,representativesfromATSI andCALDcommunities,clinicians,andresearchersinthedementiafield

• providedregularconsultationandcommentsviaemailoneachrecommendation,with3facetofacemeetingsforfinalconsensus

• ClassifiedeachrecommendationaccordingtoNHMRCStandardsasEBR,CBRorPP

• ClassifiedeachEBRaccordingtoGRADE

Definitionoftypesofrecommendations

NHMRCStandards2011

DefinitionofGRADEratings

GRADEWorkingGroup2013

Howdidwedoit?• Guidelineswereputoutforpublicconsultationandreviewfor45daysin2015,andreceived70submissions.Somemodificationsweremadeasaresult

• FinalversionwasapprovedinFebruary2016bytheNHMRCCouncil

• Finalversioncontains109 recommendationswith29 evidencebasedrecommendations

Howdidwedoit?

• TheGuidelineswereofficiallylaunchedbytheMinisterofHealthLeyonMarch16th 2016

WebaddressforGuidelines

Examplesofrecommendations:Barriers,screening

ExamplesofrecommendationsDiagnosis

Examplesofrecommendations:Treatment

Examplesofrecommendations:Behavioural andpsychological

symptomsofdementia

Examplesofrecommendations:Care

HowwilltheGuidelinesimprovecare?

• Timelydiagnosis– Memorylossisnotanormalpartofageing– Peopleleavethediagnosistoolate– Providesasystematicapproachonhowtomakethediagnosisandwhattreatmentsareavailable

• Addressinglegalissues– Organise affairs– POAetc

• ManagementofBPSD– Morethan20recommendations– Avoiduseofantipsychotics

Prioritiesforfurtherresearch• Earlyidentification– doesitresultinimprovedoutcomes?

• Memoryassessmentservices– aretherebenefits,whatisoptimalconfiguration?

• Cognitiveassessmenttools– whatisbeingusedandaretheyappropriate?

• Communicatingthediagnosis– isthereanoptimalwaytodothis?

• Organisation ofservices– whatismosteffectiveandefficientway?

Prioritiesforfurtherresearch• Respitecare– flexibleandinnovativeformsofrespiteandtheireffectonthepersonwithdementiaandtheircarer

• RoleofGPandhowtheyinteractwithotherservices

• Physicalandcognitiverehabilitation– when,whatandhowmuch?

• Driving– howtosupportpeoplewithdementiatokeepdrivingifable,andhowtoencouragecessation

• Consentandcapacityassessmentfornondementiaspecialists

Prioritiesforimplementation• Referraltomemoryservices• Communicatingthediagnosis• Organisation ofcare• Trainingforstaffandstudents• Promotingfunctionalindependence• BPSD• Reducingoverprescriptionofantipsychotics• Supportforcarers

Reflectionsondevelopingaguideline• Howdoyousynthesise evidencewhenthereoftenisn’tany?– Manypracticepoints,fewevidencebasedrecommendations

• Howdoyouincluderepresentativesfromeveryprofessionalandcaregroup?– Youcan’t,beasinclusiveaspossible

• Howdoyoucounterentrenchedviewsfromprofessionals?– Muchconsultationanddiscussion,majorityrules

• Howdoyoucounterconflictsofinterest?– Excludethemfromdiscussiononthatrecommendation

QUESTIONS?