Prescribing Guideline
Pharmacological Management
of Dementia
PG15
PG 15 – Pharmacological Management of Dementia
Approved by Drug and Therapeutics Committee: September 2015
Review date: September 2017
Page 1 of 10
Document Control
Version
1.0
Date Issued
July 2011
2.0
February 2013
3.0
James Lee, Senior Clinical Pharmacist, [email protected]
Target Audience/staff groups
Ratifying group
Date Ratified
Implementation date
Review date
Document History
Version
Start
date
0.1
Feb 2011
0.2
Clinical staff responsible for the prescribing of pharmacological treatment for the
management of dementia
Drug and Therapeutics Committee
End date
Author
History
June 11
AG
First draft of new Prescribing Guideline (based on NICE TAG 217
issued March 2011)
Comments added following Prescribing Forum meeting June 7th
attended by members of wider health community including
geriatricians, and commissioners.
Document signed off after approval at the July Medicines
Management Governance Group.
Prescribing note ‘6’ added (page 5) to reflect recently published
evidence. Hyperlink added to note ‘1’ regarding comparative
treatment costs.
Version 2 signed off.
Review date extended from Feb 14 to Mar15 to allow for scheduled
DTC review
Review date extended from Mar 15 to Oct15 to allow for scheduled
DTC review
Agreed in March DTC to rename this from ‘Management of
Alzheimer’s Dementia’ to ‘Management of Dementia’
Expanded to include additional types of dementia. Updated with
latest guidance.
June
2011
1.0
1.1
Author Name / Job Title / Email
Amanda Gulbranson
Clinical Effectiveness Lead
[email protected]
CS
July 2011
Oct12
KS
AG
2.0
2.0
Feb 13
Apr 14
KS
KS
2.0
Jul15
KS
2.1
Mar15
KS
2.1
Mar15
JL
3.0
Sep15
JL
Contents:
General Advice
Anticholinergic Medicines
Dementia Treatment Summary
Alzheimer’s Dementia
Shared Care Guidelines
Vascular Dementia
Mixed Dementia
Lewy Body Dementia & Parkinson’s Dementia
Mild Cognitive Impairment
PG 15 – Pharmacological Management of Dementia
Approved by Drug and Therapeutics Committee: September 2015
Review date: September 2017
Page 2 of 10
Pharmacological Management of Dementia

The aim of these guidelines is to promote evidence based, cost effective prescribing and
support adherence to:
√ NICE CG42: Dementia (Nov 2006)
√ NICE TAG 217 (revision of TAG111, March 2011)

This guideline is for the treatment of the most common dementia sub-types including
Alzheimer’s dementia, vascular dementia, Dementia with Lewy Bodies and Parkinson’s
Dementia. For the treatment of less common dementias, contact your local pharmacist.

Clinicians using these guidelines should also be aware of PG14 for Pharmacological
Management of Behavioural and Psychological Symptoms of Dementia (BPSD).

The guidelines are NOT intended to replace prescribing information contained in the BNF or
Summary of Product Characteristics.

The guidelines are limited to the prescribing of medication and do not include lifestyle
modifiers or treatments in the prevention of dementia. The guidelines do not cover the
diagnosing of dementia.
General Introduction & Advice:
Dementia is a progressive and irreversible reduction in the level of previously attained intellectual,
memory and personality or emotional functioning. The main clinical features are disturbed
behaviour, lack of insight, impaired thinking, poverty of speech and low mood, poor cognitive
function and impaired memory. A variety of sub-types exist and the treatment of each varies.
Only specialists in the care of patients with dementia (that is, psychiatrists including those
specialising in learning disability, neurologists, and physicians with an appropriate level of
expertise in the area) should make diagnosis of dementia, assess whether the individual is
suitable for treatment and initiate treatment where appropriate.
Anticholinergic Cognitive Burden:
Before starting treatment, all medication that the person is taking (including over the counter
medicines) should be reviewed and anticholinergic medicines rationalised. It is estimated that
approximately 50% of patients prescribed an acetylcholinesterase inhibitor (AChEI) are also
prescribed an anticholinergic medicine. Anticholinergics negate the effects of AChEIs, cause
cognitive impairment, confusion and falls, affect the clinical course of Alzheimer’s dementia and
are a risk factor for the onset of psychosis in Alzheimer’s dementia.
Some medications are used for their anticholinergic effect whereas others have anticholinergic
side-effects, therefore an accurate medication history is required to assess the impact of all
medicines taken. Additionally, Alzheimer’s dementia, vascular dementia and Parkinson’s disease
all make the blood brain barrier more permeable to medicines resulting in a greater likelihood of
problems. See appendix 1 for a list of medicines and their cognitive burden.
Rationalise currently prescribed anticholinergic medication before initiating
medication for dementia.
Appendix 1 & 2 set out which medicines should be avoided and safer alternatives.
PG 15 – Pharmacological Management of Dementia
Approved by Drug and Therapeutics Committee: September 2015
Review date: September 2017
Page 3 of 10
Dementia Treatments:
Summary (see text for further details):
Alzheimer’s Dementia
Vascular Dementia
Mixed Dementia
Dementia with Lewy body &
Parkinson’s Dementia
Mild cognitive impairment
First choice Second choice
AChEI
Memantine
None
See predominant dementia
AChEI
Memantine
None
Alzheimer’s Dementia:
Alzheimer’s dementia (Alzheimer’s disease) is the most common type of dementia resulting from
brain neurone death. The severity of Alzheimer’s disease (AD) can be assessed using a variety of
measures, often alongside clinically based assessments such as biographical interview.
When assessing the severity of AD and the need for treatment, professionals should not rely
solely on cognition scores in circumstances in which it would be inappropriate to do so. Such
circumstances include if the cognition score is not clinically appropriate because of the patient’s
learning difficulties or other disabilities (for example, sensory impairments), linguistic or other
communication difficulties (for example, language) or level of education.
In such cases specialists should determine the need for initiation or continuation of treatment by
using another appropriate method of assessment. The criteria to assess response to treatment
and baseline assessment should be clearly recorded in the medical records.
Choice of Treatment:
Mild Alzheimer’s disease
First line: AChEI – donepezil unless otherwise indicated
Second line: If not tolerated, try another AChEI
If the 2nd AChEI prescribed is not tolerated; discontinue treatment and review treatment options
when or if individual meets criteria for ‘moderate Alzheimer’s disease’.
Moderate Alzheimer’s disease
First line: AChEI – donepezil unless otherwise indicated
Second line:
 If not tolerate, try another AChEI or
 If AChEIs contraindicated, memantine
Severe Alzheimer’s disease
First line:
 If prescribed AChEI; continue only if individual still benefiting from current treatment
(unlicensed use).
 If not currently prescribed medication OR not considered to be benefiting from current
treatment with AChEI; memantine.
If memantine not tolerated or not observed to produce any beneficial improvement to symptoms;
discontinue treatment.
PG 15 – Pharmacological Management of Dementia
Approved by Drug and Therapeutics Committee: September 2015
Review date: September 2017
Page 4 of 10
Medication Notes:
Class
Drug
Donepezil
(AChEI
inhibitor)
Acetylcholinesterase
inhibitor
(AChEI)
Rivastigmine
(AChEI and
BuChEI
inhibitor)
Galantamine
(AChEI
inhibitor &
nicotinic
receptor
agonist)
NMDA
antagonist
Available
preparations
- Tablets
- Dispersible
tablets
Initially 5mg at night for 4 weeks
then may be increased to usual
treatment dose (max dose) of 10mg
once daily.
- Capsules
- Liquid
Initially 1.5mg twice daily, increased
in steps of 1.5mg twice daily at
intervals of at least 2 weeks to
usual treatment dose (max dose) of
6mg twice daily.
- Patches
Initially 4.6mg/24hrs patch daily for
4 weeks then can increase to
9.5mg/24hrs.
Increase
to
13.3mg/24hrs after 6 months &
meaningful cognitive decline.
Switching:
From 3-6mg/daily oral = 4.6mg/24hr
≥9mg oral = 9.5mg/24hr.
Initially 4mg twice daily for 4 weeks
increasing to 8mg twice daily for 4
weeks. Usual treatment dose (max
dose) 12mg twice daily.
- Immediate
release tablets
- Liquid
- Modified
release caps
- Tablets
- Pump spray
Memantine
Dosage instructions
Initially 8mg modified release
capsule once daily for 4 weeks.
Increase dose by 8mg every 4
weeks to usual treatment dose
(max dose) of 24mg once daily.
Initially 5mg once daily for 7 days
then increase by 5mg per week to
maximum of 20mg daily.
Side-effects &
cautions
Diarrhoea,
nausea,
headache,
agitation,
syncope. Caution in
peptic ulcer, asthma,
COPD and sick sinus
syndrome.
Anorexia,
dizziness,
nausea,
vomiting,
diarrhoea.
Rate & extent of
absorption affected by
food.
Caution in gastric
ulcer, asthma, COPD
and
sick
sinus
syndrome.
(GI
side-effects
reduced with patch)
Nausea,
vomiting,
decreased
appetite,
anorexia, syncope.
Caution
in
peptic
ulcer, asthma, COPD
and
sick
sinus
syndrome.
Somnolence, dizziness,
headache. Caution in
hepatic impairment &
epilepsy/seizures.
1. If prescribing an AChEI, treatment should normally be started with the drug with the lowest
acquisition cost. At the time of writing and for the last few years this has been donepezil
tablets.
An alternative AChEI could be prescribed if it is considered appropriate when taking into
account adverse event profile, expectations about adherence, medical co-morbidity, possibility
of drug interactions and dosing profile.
2. Poor tolerability with one AChEI does not rule out better tolerability with another alternative
AChEI due to differing pharmacodynamics. Cochrane concluded that donepezil may be
slightly better tolerated than rivastigmine or galantamine.
3. In practice, benefits of treatment with AChEI are lost when drug treatment is interrupted and
may not be fully regained when drug treatment is reinitiated.
4. When switching between AChEIs due to intolerance; stop initial AChEI and wait for sideeffects to resolve before starting the new medication. Switches to memantine can also be
done as above or overnight if due to lack of efficacy.
5. While discontinuation symptoms can occur, abrupt stops appear to be as well tolerated as
gradual reductions.
6. Maintenance treatment can be continued for as long as a benefit for the individual exists.
PG 15 – Pharmacological Management of Dementia
Approved by Drug and Therapeutics Committee: September 2015
Review date: September 2017
Page 5 of 10
7. An ECG is not routinely required before prescribing, however should be conducted if any risk
factors are present or the patient is bradycardic. It is good practise to take a pulse before
prescribing.
8. Clinicians may wish to check renal function, if suspected to be a problem, before starting
memantine; renal insufficiency may limit the maximum licensed dose.
9. The combination of an AChEI with memantine (for the management of Alzheimer’s
dementia) is NOT recommended, as current evidence has not demonstrated any
significant
benefits.
NB If the addition of memantine to an AChEI is being considered for the management of severe
behavioural and psychological symptoms of dementia (BPSD) refer to Prescribing guideline PG14.
Monitoring:
Benefit is assessed at around 3 months. Such assessment cannot demonstrate how the disease
may have progressed in the absence of treatment but it can give a guide to response. Up to half
the patients given these medicines show a slower rate of cognitive decline compared to those not
receiving these medicines. Medication for those thought not to be responding should be
discontinued. Cognitive assessment may be repeated 4 – 6 weeks after discontinuation to assess
deterioration; if significant deterioration occurs during this short period, consideration should be
given to restarting therapy – noting point 3 above.
Continuation of Treatment –
Shared/Continued Care Guidelines
Treatment should be continued only when it is considered to be having a worthwhile effect
on cognitive, global, functional or behavioural symptoms. Individuals who continue on
treatment should be reviewed regularly using cognitive, global, functional and behavioural
assessment.
Treatment should be reviewed by the specialist team and / or GP in accordance with locally
agreed protocols for continued care.
Carers’ views on the individual’s condition at follow-up should be sought.
Monitor for emergence of side effects associated with mediation. Discuss with individual or
carer and review treatment if side effects intolerable or severe.
Ensure on-going physical monitoring is carried out appropriate to the medication prescribed.
Associated Guidelines:
Exeter, East, Mid & North Devon: http://www.newdevonccg.nhs.uk/who-weare//medicines-and-treatments//shared-care-guidelines/central-nervous-system/100561
South Devon: http://www.southdevonandtorbayccg.nhs.uk/aboutus/policies/Documents/joint-formulary-shared-care-guidelines.pdf
Bristol: http://www.bnssgformulary.nhs.uk/Shared-Care-Protocols/
Service Protocols & Information:
Memory Clinics:
http://daisy.exe.nhs.uk/directorates/older-people/devon-memory-service.aspx
Bristol Dementia Partnership:
http://daisy.exe.nhs.uk/directorates/older-people/bristol-dementia-partnership.aspx
PG 15 – Pharmacological Management of Dementia
Approved by Drug and Therapeutics Committee: September 2015
Review date: September 2017
Page 6 of 10
Vascular Dementia:
Vascular dementia comprises of about 10-50% of dementia cases. It is caused by ischaemic
damage to the brain and is characterised by executive dysfunction rather than memory
impairment. The management options are currently very limited and focus on controlling the
underlying risk factors for cerebrovascular disease.
Currently there are no medicines licenced for the treatment of vascular dementia in the UK. There
is no conclusive evidence that treating hyperlipidaemia with statins or clotting abnormalities with
aspirin affect vascular dementia incidence or disease progression.
While there is some data to suggest small benefits in cognition of uncertain clinical significance for
both AChEI and memantine, the data is insufficient to support widespread use in vascular
dementia. Note that it is impossible to diagnose with certainty vascular or Alzheimer’s dementia
and mixed dementia. This may explain why AChEIs appear to work in some cases of vascular
dementia.
Choice of Treatment:
No current treatment options available. Review medication to minimize cognitive burden.
Mixed Dementia:
Many cases of dementia may have mixed pathology (for example, Alzheimer's disease & vascular
dementia or Alzheimer's disease & DLB). Such cases should be managed according to the
condition that is thought to be the predominant cause of dementia.
Choice of Treatment:
See recommendations under predominant dementia.
Lewy Body Dementia (DLB) & Parkinson’s Disease Dementia (PDD):
Dementia with Lewy bodies accounts for approximately 15-25% of dementia cases. It is
characterised by fluctuating cognitive ability, early and persistent visual hallucinations and
spontaneous motor features of Parkinson’s, falls and syncope. Extreme sensitivity to
antipsychotics and anticholinergics is common. DLB and PDD are neurobiologically
indistinguishable.
The use of AChEIs in DLB is debatable. Cochrane found no significant improvement in support of
their use. A further, wider comparative study found no evidence to prefer one AChEI over another.
Use of memantine was found to be mildly beneficial in behavioural symptoms and global clinical
status; however there are reports of some patients worsening or responding adversely and so
caution in required.
Rivastigmine is the only AChEI licensed for the treatment of PDD, the use of alternative AChEIs is
off-label.
Choice of Treatment:
First line: AChEI – rivastigmine specifically licensed for PDD (see Medication Notes)
Second line: Memantine (see Medication Notes)
PG 15 – Pharmacological Management of Dementia
Approved by Drug and Therapeutics Committee: September 2015
Review date: September 2017
Page 7 of 10
Mild Cognitive Impairment (MCI):
Mild cognitive impairment is hypothesised to represent a pre-clinical stage of dementia. A
Cochrane review of the safety and efficacy of AChEIs in MCI found little evidence to support their
ability to affect progression to dementia or on cognitive test scores. The weak evidence was
countered by an increased risk of adverse events meaning AChEIs should not be recommended.
50% of people with MCI later develop dementia.
Choice of Treatment:
First line: Review medication and reduce anticholinergic burden.
User-friendly resources
Leaflets for patients/family/carers on dementia can be found on the Alzheimer’s Society website:
www.alzheimers.org.uk/Facts_about_dementia/factsheets.htm
A patient decision aid (which includes information on relative side effects but also some nonformulary treatments) is available from: http://www.choiceandmedication.org.uk/devon
PG 15 – Pharmacological Management of Dementia
Approved by Drug and Therapeutics Committee: September 2015
Review date: September 2017
Page 8 of 10
Appendices:
Appendix 1: Anticholinergic Cognitive Burden Scale
PG 15 – Pharmacological Management of Dementia
Approved by Drug and Therapeutics Committee: September 2015
Review date: September 2017
Page 9 of 10
Appendix 2
PG 15 – Pharmacological Management of Dementia
Approved by Drug and Therapeutics Committee: September 2015
Review date: September 2017
Page 10 of 10