Treatment of Dementia

Dementia

Dementia is a syndrome caused by a variety of disease processes that result in progressive cognitive and functional decline, and it is recognised as a terminal illness. Dementia affects many cognitive areas including memory, communication, reasoning, planning, and even personality. The most common cause is Alzheimer’s type Dementia, but other neurodegenerative conditions such as Lewy Body Dementia, Frontotemporal Dementia, Vascular Dementia and Parkinson’s disease Dementia, amongst others, are seen in clinical practice. Acetylcholinesterase inhibitors and memantine are licensed for use in certain types of dementia.

Drugs for Alzheimer's type Dementia, and Mixed Vascular and Alzheimer's type Dementia

Prescribers should only start treatment with donepezil, galantamine, rivastigmine or memantine on the advice of a clinician who has the necessary knowledge and skills. This could include secondary care medical specialists such as psychiatrists, geriatricians and neurologists

Parkinson’s Disease Dementia (PDD) / Lewy Body Dementia (LBD)

Acetylcholinesterase inhibitors can be an option for patients with PDD/LBD as per NICE Guidelines Parkinson’s Disease in Adults (NG71) and Dementia: Assessment, Management and Support for People Living with Dementia and their Carers (NG97).

Drugs for other Dementias and Mild Cognitive Impairment

Except as part of properly constructed clinical studies, do not use:

•  Acetylcholinesterase inhibitors or memantine for cognitive decline in vascular dementia.
•  Acetylcholinesterase inhibitors in mild cognitive impairment.

Antipsychotics in Dementia

Advice from the relevant local mental health service should be sought if considering an antipsychotic for  patients with dementia. This patient group are at risk from specific serious and life-threatening side-effects when treated with antipsychotics (MHRA Drug Safety Update 2014 ). The risk of fatal side effects is much higher if you prescribe an antipsychotic for Lewy Body Dementia than for other dementias.

• NICE Decision Aid-Antipsychotic medicines for treating agitation, aggression and distress in people living with dementia NG97 (2018)

Medication review

Some commonly prescribed medications can increase the anticholinergic (antimuscarinic) burden, which can affect cognition. These include antidepressants, antihistamines, antipsychotics and urinary antispasmodics amongst others. Consider if these medicines are necessary and minimise use where possible. This may involve consultation with other specialists and a medication review in line with current NHS Scotland Polypharmacy Guidance. A review of medication should be considered whilst waiting for specialist advice on further treatment.

NHS Scotland Polypharmacy: Manage Medicines 

Anticholinergic Information 

Useful links

SIGN 168 Assessment, diagnosis, care and support for people with dementia and their carers

NHS Lanarkshire Guidance for Review of Antipsychotic Prescribing in Patients with Dementia

Managing Symptoms of Stress and Distress in Dementia Quick Reference Guide

Prescribing Notes:

• If prescribing an acetylcholinesterase (AChE) inhibitor (donepezil, galantamine or rivastigmine), treatment should normally be started with the drug with the lowest acquisition cost, taking into account required daily dose and the price per dose.
• However, an alternative AChE inhibitor could be prescribed if it is considered appropriate when adverse event profile, expectations about adherence, medical co-morbidity, possibility of drug interactions and dosing profiles are considered.
• Treatment should be stopped only if there is evidence of harm eg cognition is worsening as a result of treatment.
• When a decision is made to stop therapy (for reasons other than lack of tolerability), tapering of the dose and monitoring the patient for evidence of significant decline during the next 1–3 months are advised. If such decline occurs, reinstatement of therapy should be considered.
• Physical Health Monitoring - It is recommended that all patients commenced on a cognitive enhancer (donepezil, rivastigmine, galantamine or memantine) should initially have basic monitoring of physical health parameters carried out by secondary care services (see Guidance for Physical Health Monitoring of Cognitive Enhancers for details). 

To indicate the category of a formulary medicine, updated sections adopt the following key: