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4.11 Drugs for dementia

ChoiceDrug
1st choice cholinesterase inhibitor

Donepezil tablets 5mg,10mg; orodispersible tablets 5mg, 10mg

If sleep disturbances are noted the time of dosing may be chosen on individual tolerability. 

2nd choices cholinesterase inhibitors

Galantamine m/r capsules 8mg, 16mg, 24mg

 

Or

Rivastigmine capsules 1.5mg, 3mg, 4.5mg, 6mg; patch 4.6mg/24 hours and 9.5mg/24 hours
In line with NICE guidance

Memantine tablets 10mg, 20mg; treatment initiation pack 7x5mg, 7x10mg, 7x15mg and 7x20mg; oral solution 10mg/ml sugar free

Prescribing Notes

  • See COMPASS therapeutic notes on the ‘management of dementia’ available on NICPLD or Medicines NI website.
  • See NICE NG97 Dementia: assessment, management and support for people living with dementia and their carers, June 2018 and BMJ visual summary.
  • For people who are not taking an AChE inhibitor or memantine, prescribers should only start treatment with these 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
    • other healthcare professionals (such as GPs, nurse consultants and advanced nurse practitioners), if they have specialist expertise in diagnosing and treating Alzheimer’s disease.
  • Some commonly prescribed medicines are associated with increased anticholinergic burden and therefore cognitive impairment. Various tools have been devised to assess anticholinergic burden and aid medication reviews, e.g. Anticholinergic Cognitive Burden (ACB) Scale.
  • Before starting treatment with an AChE Inhibitor check if the patient is taking a bladder anticholinergic. Co-prescribing is not recommended, see Urinary Incontinence (UI) in Dementia article, Medicines Management Newsletter February 2020.
  • Once a decision has been made to start an AChE inhibitor or memantine the first prescription may be made in primary care.
  • Serious skin reactions have been reported in patients receiving galantamine. Patients should be informed about the signs of serious skin reactions and that galantamine should be discontinued at first appearance of rash.
  • Offer co-prescription of AChE inhibitor and memantine for severe Alzheimer’s disease and consider co-prescription in moderate disease.
  • For people with an established diagnosis of Alzheimer’s disease primary care prescribers may start memantine without taking advice from a specialist clinician.
  • Starting doses of AChE inhibitors are not therapeutic doses and should be increased as per titration schedule (refer to BNF).
  • Do not stop AChE inhibitors because of disease severity alone. However, in patients progressing to very advanced dementia (end of life care), review the overall benefit of these agents and consider discontinuation.
  • If nausea develops after initiation of an AChE inhibitor, reduce the dose and titrate up more slowly.
  • Donepezil orodispersible tablets are available for patients who have difficulty in swallowing solid oral dose formulations.
  • Rivastigmine patches may be an appropriate choice of formulation where a trial of oral medicine was poorly tolerated (see BNF notes on switching from oral to transdermal therapy).
  • See MHRA for information on ‘rivastigmine transdermal patch: risk of medication errors’.
  • The person administering memantine oral solution should be counselled on how to administer the required dose.