Treatment initiation and follow up of cholinesterase inhibitors in patients newly diagnosed with dementia

NHS Borders clinical guidelines
NHS Borders

Follow up of newly diagnosed patients with dementia

Objective To have a clear procedure in place for the follow up of patients newly diagnosed with dementia, including initiation of cholinesterase inhibitors, for staff working in the MHOAS
Scope To provide guidance for team members
To identify the responsibilities of team members.
Responsibility The clinical or prescribing staff have a responsibility for agreeing the process to ensure the system in place is fully functioning.
The team manager has a responsibility for implementing the process.
All staff have a responsibility to adhere to the process.
Process stages

Initiation of acetyl-cholinesterase inhibitors

  • Treatment should be considered to be long-term unless specific indications otherwise
  • See table below for titration of individual medication (appendix 1)
  • Outline plan for titration in initial letter, with a comment that team will be in touch if this is not to proceed for any reason (appendix 2)
  • Check or enquire about baseline weight
  • Check baseline pulse rate, and ascertain whether on rate-reducing medication.
  • Memantine: check baseline blood pressure and repeat at 1 month and 3 month review
  • Discuss key side effects: see table below Provide a Patient Information leaflet specific to the chosen drug. This can be found here: https://www.choiceandmedication.org/nhs24
  • Check if the patient is prescribed interacting medications using Stockleys interaction checker (available here: https://www.medicinescomplete.com/#/)
  • Check if the patient is prescribed any anticholinergic medication which would counteract the action of an acetyl- cholinesterase inhibitor.


Follow up – this will be tailored to meet individual needs, but as a minimum will include:

  • Contact at one month to establish initial tolerance of medication, either via CMHT or PDS team
  • Arrange follow up reviews depending on clinical need
  • At one month review and subsequent reviews enquire about weight changes, check pulse and blood pressure (memantine only)

 

Key areas to be addressed in all patients with dementia during follow up period as required. Post Diagnostic Support will be provided via the PDS Team, according to the 5-pillar model.

  • Review of side effect profile
  • Check pulse: If less than 60 beats per minute, enquire about symptoms of dizziness, unexplained falls or loss of consciousness and concurrent prescription of beta blockers. If less than 50 beats per minute discuss ECG and current medications (including B-blockers) with responsible clinician
  • Check or enquire about weight changes
  • Memantine: check blood pressure
  • Review of changes in Activities of Daily Living
  • Review changes to risk
  • Review care package (home care, day care)
  • Review patient and carer’s understanding of the written information provided at diagnosis. Provide educational material that may have become relevant since last review.
  • Enquire about changes in physical and social circumstances. Provide information on relevant community supports
  • Discuss Power of Attorney, Attendance allowance, Council tax, as required
  • Ensure relevant risk assessments and care plans have been completed
Other useful information Appendix 1
Validation date November 2022
Review period November 2024
Authors Dr Lucy Calvert and Kyna Harvey

Appendix 1: Medication specific information

Read this table as a PDF

Drug Titration Ideal treatment dose Caution Side effects Notes
Donepezil 5mg mane one month then
increase to 10mg		 10mg Sick sinus syndrome
Peptic ulcer disease, asthma or COPD, hepatic impairment		 Loss of appetite, weight loss, bradycardia, headache, feeling of nauseous, tiredness, diarrhoea, muscle cramps, poor sleep, abnormal dream  Available in tablet, orodispersible and liquid form
Galantamine prolonged release 8mg for a month, increase monthly by 8mg 24mg As above and urinary retention, congestive heart failure, history of seizures, unstable angina, creatinine clearance <9mL/min Available in prolonged release capsules and liquid
Rivastigmine 1.5mg bd, increase by 1.5mg bd every month 3 – 6mg bd As above, monitor body weight Available in capsule, oral solution and transdermal patch.
Transdermal administration (patch) is less likely to cause side effects although may cause skin reaction/rash. Provide instruction to ensure correct use of patches to reduce risks e.g. skin rash risk of multiple patch application
For switching to patches check appropriate dose (section 4.2): HERE
Memantine 5mg daily, increase by 5mg a week 20mg Convulsions,
Reduce dose to 10mg if Creatinine clearance 30-49mL/min
Check BNF for guidance in creatinine clearance lower than 30
Calculate creatinine clearance: HERE		 Hypertension, dizziness, drowsiness, constipation, headache, shortness of breath Tablet, orodisperisble tablet and oral solution (as a pump) available.

Appendix 2: Patient and carer information sheet: drug treatments for dementia

The information sheet as a PDF

This leaflet aims to summarise the key information regarding drug treatments for memory problems. Your Specialist Doctor or Community Nurse will have already discussed the medications with you. If you have any further questions or concerns your key worker would be very happy to address them.

 

Aims of drug treatment

The treatments are available for those with a diagnosis of either Alzheimer’s dementia or Mixed dementia. They may also benefit patients with a diagnosis of Lewy Body dementia.
The effect of the drug will vary for different people. Some people may find their condition improves or stabilises over time. The main benefits tend to be within memory and thinking abilities. Other benefits may include improvement in mood, ability to cope in general, and ability to carry out daily activities. There is evidence that for some people the medication may delay or slow the memory loss over time resulting in the person remaining as independent for as long as possible. Some people may not notice any effect.

 

How the medication works

The brain uses chemicals to carry messages between brain cells. The treatments help to increase the amount of these chemicals in the brain, in order to improve memory and thinking.

 

Types of drugs available

There are 4 main drugs available:

Donepezil (Aricept) - Once a day tablet, taken morning or night

Rivastigmine (Exelon) - Twice a day tablet, or patch applied once per day

Galantamine (Reminyl) - Either once or twice a day tablet

Memantine (Ebixa) - Once a day tablet, taken in the morning

 

Taking your medication

Your specialist doctor or nurse will arrange for a prescription through your own GP. Normally you will start on a low dose initially, to ensure there are no side effects. After a month the dose will usually be increased. After 3 months your doctor or nurse will review your progress, which will include a discussion with your relative or carer.

If you wish to stop the medication for any reason, please contact your specialist doctor or nurse to discuss it. This is because after the drug is stopped, you may lose the benefit that the medication has previously given you. For this reason, we advise that people remain on the treatments long term.

 

How to take them

It is important that you take the medications every day, as directed on the box or blister pack. If a dose is missed, it should be taken as soon as you remember if it is the same day. If it is the next day, do not take an extra dose, but continue as normal. Some people find it helpful to have a carer or relative to remind them to take their medication.

 

Possible side effects

The majority of people have no problems taking this medication. As with any medication, there is a small risk you may experience some side effects. These may include:

  • feeling sick (nausea)
  • vomiting or diarrhoea
  • headaches
  • difficulty passing water
  • difficulty getting to sleep, or bad dreams

Often, these side effects will pass after a few days. If not, contact your specialist doctor or nurse for advice. It may be that a different medication would suit you better.

If you have previously suffered stomach ulcers, certain heart problems or serious breathing problems, the drugs may not be suitable for you. Your doctor will have considered these issues before prescribing the medication.

 

Useful contacts

If you need any advice or further information regarding your treatment, contact your key-worker on the following number:

Mental Health Older Adults Team
01896827105 (Central and West) /01573226760(East and South)

Further information can also be found at: www.alzscot.org
Medicine specific information can be found at: https://www.choiceandmedication.org/nhs24

Editorial Information

Last reviewed: 30/11/2022

Next review date: 30/11/2024

Author(s): Harvey K.

Version: V3

Author email(s): kyna.harvey@borders.scot.nhs.uk.

Approved By: Mental Health Governance

Reviewer name(s): Calvert L, Torrance I.