Chapter 4: Central nervous system

CAUTION: Risk of falls/fractures, confusion, memory impairment

• See Section 3.4 for specific information on benzodiazepines and Z drugs withdrawal, and see insomnia guidelines

CAUTION: Risk of dependency

Safety

CAUTION: Risk of stroke and death in elderly patients with dementia. See Antipsychotics

CAUTION: Anticholinergic ADRs for phenothiazines (e.g. chlorpromazine). See Anticholinergics

CAUTION: Worsening of Parkinson’s disease (specialist advice is recommended)

Safety

• Formally assess benefit: Continue if drug benefits global, functional or behavioural symptoms
  • Cognitive scores e.g. MMSE can help as a guide but should not rely only on cognition scores if these are inappropriate in the individual patient e.g. communication, language difficulty. See NICE Guidance.

Need

Confirm need (First episode: Treat for 6-9 months; Second + episode: Treat for ≥2 years)

CAUTION: Anticholinergic ADRs. See Anticholinergics. SSRIs are better tolerated in the elderly

CAUTION: Risk of GI bleeding may be increased

Avoid combination with MAOIs because of the risk of serotonin syndrome

Safety

Now only licensed for a maximum of 5 days (does not apply to off label use in palliative care)

Safety

CAUTION: Worsening of Parkinson’s disease (domperidone is more suitable but note contra-indications in cardiac disease and severe liver disease)

Need

Rarely indicated for long term treatment of vertigo

Need

Anticholinergic ADRs. See Anticholinergics

Safety

Assess effectiveness/choice (is pain neuropathic or otherwise not responsive to opiates? e.g. chronic back pain, widespread pain, fibromyalgia, medically unexplained symptoms)

See:

• SIGN 136 Management of Chronic Pain
• SIGN 106 Control of Pain in Adults with Cancer (now archived)

Effectiveness

CAUTION: Constipation. Use laxatives
CAUTION: Cognitive impairment and respiratory depression, dependency, immunosuppression and suppression of sex hormones

Safety

CAUTION: Overdosing

• Ensure patient is aware of minimum interval between doses and maximum daily dose
• Avoid more than 1 paracetamol containing product
• Dose reduction where low body weight [<50kg]or renal or hepatic impairment

Safety

Assess effectiveness/dose if used for pain management: Is pain neuropathic, use DN4 or LANSS to aid diagnosis. Titrate dose up to assess effectiveness. Limited evidence for musculoskeletal pain/fibromyalgia) See Chronic Pain Scotland and SIGN 136

Effectiveness

CAUTION: Dizziness, blurred vision and sedation. Check renal function. Reduce dose in CKD.

Safety