4.11 Drugs for dementia

ChoiceDrugDosage
1st choice for mild to moderate dementia in Alzheimer’s diseaseDonepezil tablets 5mg, 10mg; orodispersible tablets 5mg, 10mgDose:
Initially 5mg once daily at bedtime, increased after one month to 10mg daily
2nd choices for mild to moderate dementia in Alzheimer’s disease

Galantamine m/r capsules 8mg, 16mg, 24mg
Gatalin XL® is the recommended cost-effective choice (prescribe by brand)

Dose:
Initially 8mg once daily for 4 weeks increased to 16mg once daily for 4 weeks; maintenance 16-24mg once daily
Or
Rivastigmine capsules 1.5mg, 3mg, 4.5mg, 6mg; patch 4.6mg/24 hours and 9.5mg/24 hoursDose:
Orally: initially 1.5 mg twice daily, increased in steps of 1.5 mg twice daily at intervals of at least 2 weeks according to response and tolerance; usual range 3–6 mg twice daily; max. 6 mg twice daily; if treatment interrupted for more than several days, treatment should be retitrated from 1.5 mg twice daily

Transdermal: initially 4.6mg/24 hours after a min of 4 weeks and if well tolerated the dose should be increased to 9.5mg/24 hours

(see BNF for full details)
First choice for severe dementia in Alzheimer’s disease or for moderate dementia in Alzheimer’s disease for people who cannot take AchE inhibitors Memantine tablets 10mg, 20mg; treatment initiation pack 7x5mg, 7x10mg, 7x15mg and 7x20mg; oral drops 5mg/actuationDose:
Initially 5mg once daily, increased in steps of 5mg at weekly intervals; max 20mg daily

Prescribing Notes

  • See COMPASS therapeutic notes on the management of dementia.
  • See NICE NG97 Dementia: assessment, management and support for people living with dementia and their carers, June 2018.
  • 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.
  • Once a decision has been made to start an AChE inhibitor or memantine, the first prescription may be made in primary care.
  • The doses (as detailed in the table above) are gradually titrated upwards by a Specialist Consultant according to response and side-effects. The dosing schedules are suggested dosing schedules only.
  • Starting doses of AChE inhibitors are not therapeutic doses and should be increased as per titration schedule.
  • In patients progressing to very advanced dementia (end of life care), assess the overall benefit of these agents and consider discontinuation.
  • If nausea develops after initiation of an AChE inhibitor, consider domperidone for up to 5-7 days only. Please note domperidone is associated with a small increased risk of serious cardiac side effects. Its use is now restricted to the relief of symptoms of nausea and vomiting and the dosage and duration of use have been reduced. Domperidone is now contraindicated in those with underlying cardiac conditions and other risk factors. Click here for more information.
  • 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).
  • Be aware of the potential for confusion in dosage units with memantine oral solution. Ensure that dose instructions specify the number of mg and the corresponding number of pumps required. Pharmacists should counsel patients on how to administer the required dose. Refer to Medicines Safety Matters Newsletter – Nov 2014.