4 Research recommendations

In 2006, the guideline committee made the following recommendations for research on the basis of its review of the evidence, to improve NICE and SCIE guidance and the care of people with dementia in the future. The effective care of people with dementia (included in standard 7 of the National Service Framework for older people) is of great importance, especially because the proportion of people with dementia will rise in line with the aging population. Therefore, further research is urgently needed to generate a better evidence base for the update of this guideline.

4.1 Acetylcholinesterase inhibitors and memantine for the treatment of psychotic symptoms in dementia

For people with dementia who develop severe non‑cognitive symptoms (psychosis and/or agitated behaviour causing significant distress), is an acetylcholinesterase inhibitor (donepezil, galantamine or rivastigmine) and/or memantine effective in improving quality of life and reducing non‑cognitive symptoms/behaviour that challenges when compared with placebo over 6 months, and is treatment cost effective in dementia and/or its subtypes?

Why this is important

Up to 75% of people with dementia may be affected by non‑cognitive symptoms/behaviour that challenges. They are a leading cause of distress to carers and often lead to the institutionalisation of the person with dementia. Several studies have shown that acetylcholinesterase inhibitors may improve non‑cognitive symptoms of dementia; however, the cost‑effectiveness of these drugs in the treatment of people with dementia with severe non‑cognitive symptoms has not been established.

4.2 Cognitive stimulation and/or acetylcholinesterase inhibitors in Alzheimer's disease

For people with Alzheimer's disease, are cognitive stimulation (activities involving cognitive processing; usually in a social context and often group‑based, with an emphasis on enjoyment of activities), acetylcholinesterase inhibitors (donepezil, galantamine or rivastigmine) or combined treatment clinically and cost effective in terms of cognition, global functioning, ADLs and quality of life when compared with placebo over 6 months?

Why this is important

No randomised studies have directly compared cognitive stimulation with an acetylcholinesterase inhibitor, and few randomised studies have compared the combination with an acetylcholinesterase inhibitor alone in people with mild‑to‑moderate Alzheimer's disease. Evidence suggests that cognitive stimulation is effective in people with dementia, but it is difficult to compare the magnitude of the effect with that of acetylcholinesterase inhibitors.

4.3 Psychological interventions for carers of people with dementia

For carers of people with dementia, is a psychological intervention cost effective when compared with usual care?

Why this is important

Those providing care for people with dementia are one of the most vulnerable groups of carers and often have high levels of stress, feelings of guilt, depression and other psychological problems. They often ignore their own health needs in favour of those of the person for whom they care. They may become exhausted, have poor physical health and feel isolated. Current research suggests that psychological interventions may be effective, but there is insufficient evidence to establish cost effectiveness. The promotion of good mental health in older people (many carers are the spouses of people with dementia) – included in standard 7 of the National Service Framework for older people – is vital, especially because the proportion of people with dementia will rise in line with our aging population. Support for carers in general has been given priority in England and Wales through Carers' Strategy documents. Further research is urgently needed to generate a better evidence base for the update of this guideline.

4.4 The effect of staff training on behaviour that challenges

Does training of care staff in dementia‑specific person‑centred care lead to improvement in behaviour that challenges and reduced prescription of medication to control such behaviour in people with dementia requiring 24‑hour care when compared with current practice?

Why this is important

According to prescribing advice published by the Royal College of Psychiatrists, there is a history of inappropriate use of antipsychotic drugs in people with dementia. The proportion of people with dementia with behaviour that challenges tends to rise as the dementia progresses; therefore this issue is of particular importance for people requiring 24‑hour care.