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NICE guidance NG97 Dementia: assessment, management and support for people living with dementia and their carers (issued June 2018) includes sections on pharmacological interventions for Alzheimer’s disease and non-Alzheimer’s dementia, medicines which may cause cognitive impairment and managing non-cognitive symptoms.
For further details, see the Devon Partnership Trust’s Prescribing Guideline PG15- Pharmacological Management of Dementia. This guideline covers the treatment of Alzheimer’s dementia and other common forms of dementia.
For the management of behavioural and psychological symptoms of dementia (BPSD), see here
Only specialists in the care of patients with dementia should make the diagnosis of Alzheimer's disease, assess whether the individual is suitable for treatment and initiate treatment where appropriate.
Assessing the severity of Alzheimer's disease and the need for treatment should not rely solely on cognition scores in circumstances in which it would be inappropriate, for example with patients with learning disabilities or language differences.
The specialist should seek the carer’s views on the patient’s condition at baseline and at any follow-up.
The Mini Mental State Examination (MMSE) which has been used to define dementia severity is no longer freely available for inclusion in the formulary. NICE guidance NG97 and TA217 do not recommend specific tools for measuring the severity of Alzheimer’s disease. It is recognised that clinicians are more likely to consider global functioning, quality of life, and the impacts on people’s daily activities in the review of patients with an established diagnosis.
The Neuropsychiatric Inventory has been suggested as a means of assessing a patient’s dementia and the impact on others through a questionnaire administered to a caregiver who knows the patient well. The Inventory is not freely available for inclusion in the formulary.
NICE guidance NG97 includes the current treatment recommendations for acetylcholinesterase inhibitors and memantine (see below). This guidance includes a partial update to NICE TA217 Donepezil, rivastigmine, galantamine and memantine for the treatment of Alzheimer’s disease.
See section 4.11 Drugs for dementia
Do not offer the following specifically to slow the progression of Alzheimer’s disease except as part of a randomised controlled trial: diabetes medicines, hypertension medicines, statins, NSAIDs including aspirin.
The specialist should discuss with the patient and their carer(s) the benefits, side effects, frequency of dosing and monitoring requirements of their treatment.
There should be a suitable person identified to ensure concordance with treatment (e.g. relative or other carer), either by the specialist or GP. They should also make the carer aware of the nature of the effect of treatment and that it can be stopped if there are overly burdensome side effects.
AChE inhibitors are recommended for patients with mild or moderate Alzheimer’s disease unless there is a contraindication to their use. Memantine may be an appropriate initial treatment for some patients (see Indications above).
The specialist should choose the most appropriate drug, initiate treatment, prescribe and monitor the patient until the dose is stabilised. Treatment should be prescribed by the GP after communication with the specialist and once the maintenance dose has been established.
Primary care prescribers will be asked to initiate treatment with memantine in patients receiving AChE inhibitors. The specialist will provide advice on when to initiate treatment.
Patients diagnosed with mild Alzheimer’s disease by specialist and AChE inhibitor prescribed:
Patients diagnosed with moderate Alzheimer’s disease by specialist and AChE inhibitor prescribed:
The specialist should specify any necessary monitoring and review dates at clinically relevant time intervals for both the GP and specialist team and any other patient specific information.
Specialist services will provide advice and, if appropriate, undertake a treatment review in response to the following situations:
Whilst the three AChE inhibitors (donepezil, galantamnine and rivastigmine) are only licensed in the UK for the treatment of mild or moderate dementia, research evidence has shown that they can also have a beneficial effect in patients with a severe dementia as well (see NICE guidance NG97). Therefore, they are usually not stopped until either:
These decisions should be discussed with the family / carers and it is good practice to wean the medication off, e.g. reducing the dose by 50% for a month and then stopping. The patient then can be monitored over the next couple of weeks for signs of deterioration and the drug restarted if needed, although return to the previous level of functioning may not be achieved.
Contact details for the Specialist Teams
Devon Partnerships Trust
Contact details for the Older People’s Community Mental Health Teams and the Devon Memory Service can be found here
Mental Health Specialist Pharmacists 01752 434723 or 01752 439006