Download Memory drugs shared careFINAL1

Berkshire Healthcare NHS Foundation Trust and NHS Berkshire
East and West Clinical Commissioning Groups
Cholinesterase Inhibitors / Memantine Prescribing Arrangements
At the time of diagnosis, clinicians in specialist mental health services in BHFT will give patients and
carers written information about the comprehensive management of Dementia. They will be advised
that more useful information about Dementia and other mental health conditions can be found at the
BHFT "choice and medication" website:
www.choiceandmedication.org.uk/berkshirehealthcare
Or can be accessed via the Berkshire Healthcare NHS Foundation Trust internet site at
www.berkshirehealthcare.nhs.uk
(Click on "Medicines")
BHFTs Medicines Information Service, Prospect Park Hospital - Tel: 0118 960 5075
Email: [email protected]
Memory clinic contact details:
To discuss a patient or to request specialist advice, GPs can call their local Memory Service using the
following numbers:
Slough:
Tel:
Fax:
Bracknell:
Tel:
Fax:
Windsor & Maidenhead:
Tel:
Fax:
01753 635075
01753 634204
01344 823 220
01344 823 222
01628 640 350
01628 640 351
Reading:
Tel:
0118 960 5959
Fax:
0118 960 5720
email
[email protected]
or [email protected]
Wokingham:
Tel:
0118 949 5101
Fax:
0118 949 5104
Newbury:
Tel:
01635 292 070
Fax:
01635 292 087
Should you have difficulty contacting your local OPMH Service directly, please call the
Locality Manager for your area:
Area
Locality Manager
Contact Number
Newbury
[email protected]
01635 292020
Reading
[email protected]
0118 960 5158
Wokingham
[email protected]
0118 989 0707
Bracknell
[email protected]
01344 823333
Windsor &
[email protected]
01628 640200
Maidenhead
Slough
[email protected]
01735 690950
Authorised by: BHFT Drug and Therapeutics Committee, March 2015.
Approved by: APC (Berks West) July 2017 EPC Berks East
Date: July 2015
Review date: July 2017 (or sooner, if there are relevant changes to national guidance)
Berkshire Healthcare NHS Foundation Trust
Shared Care Guideline: Acetylcholinesterase inhibitors/memantine
Version 2.2
Page 1 of 19
1.1 Introduction and Purpose
In June 2011, the NICE Guidelines for Dementia were updated with a Technology Appraisal (TA)
which recommended that donepezil, rivastigmine, galantamine could now be prescribed to treat mild
as well as moderate Alzheimer’s disease and that memantine could be prescribed those with severe
Alzheimer’s disease if appropriate (in some cases, mild).
The TA states that treatment should be offered under the following conditions:
•Only specialists in the care of patients with dementia. Carers' views on the patient's
condition at baseline should be sought and documented where possible.
•Treatment should be continued only when it is considered to be having a worthwhile
effect on cognitive, global, functional or behavioural symptoms.
•Patients who continue on treatment should be reviewed regularly using cognitive,
global, functional and behavioural assessment. Treatment should be reviewed by an
appropriate specialist team, unless there are locally agreed protocols for shared care.
Carers' views on the patient's condition at follow-up should be sought and documented.
The purpose of this Shared Care Guideline is to clarify the roles and responsibilities of both
Secondary and Primary Care Clinicians in supporting both the initiation of treatment and
maintenance, i.e., handover to GP care once the patient is stabilised.
1.2 Unlicensed Prescribing of High Dose Cholinesterase Inhibitors and use of
combination therapy with memantine
Old Age Consultant Psychiatrists across the trust have had requests from carers and GPs
for combined prescribing of Memantine and Cholinesterase Inhibitors (ChEIs) and high
doses of Cholinesterase Inhibitors (ChEIs) for patients diagnosed with Alzheimer’s dementia.
Since the NICE guidelines were last reviewed, there have been more recent studies and
reviews investigating the efficacy and tolerability of high dose cholinesterase inhibitors and
use of memantine as an adjunct.
There are benefits albeit modest shown for both high dose Cholinesterase inhibitors
(donepezil and rivastigmine) and use of adjunctive memantine, with few significant adverse
effects reported (4-15).
Unlicensed use of Dementia medications would only be considered within BHFT Specialist
Memory Services for particular patients i.e. those who are declining despite having had an
adequate trial of licensed doses of medication. Also, combination therapy would only be
considered for patients who had exhausted monotherapy options. For these patients,
modest improvements gained by having the opportunity to try higher doses or combination
therapy would have a positive impact on their care. In terms of numbers, the Trust does not
anticipate treating more than 6 patients in this manner at any one time.
Further details are noted below in section 2.2.2.
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Version 2.2
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2.
Responsibilities under shared care
2.1 GP responsibilities
1. Initial referral to secondary care to include:
 cognitive screen
 medical history
 blood screening – FBC, U&E (including e-GFR),LFTs, Calcium,
Glucose, thyroid Function, B12 & Folate
 physical examination
 cardiac history including syncope, arrhythmias and bradycardia.
 If pulse rate 60 or below or there is significant cardiac history, to
provide recent ECG
2. To provide repeat prescriptions after stabilisation.
3. To undertake an annual review of patient’s physical health including weight
and blood screening as clinically indicated.
4. To enquire at annual review about worsening cognition and/or new or
distressing symptoms.
5. To report adverse drug reactions to the specialist
6. To act upon results communicated by specialist
7. To notify the specialist team of significant medical changes or cognitive
decline
8. To liaise directly with the specialist team (see front sheet for contact
numbers) if advice is needed about continuation or stopping
9. To assess ongoing benefit and consider a trial discontinuation, in
discussion with the specialist team, if there has been rapid clinical
deterioration or impairment has become severe.
10. To seek advice from the specialist team about discontinuation of treatment
11. To ensure all relevant staff within the practice are aware of the shared care
guidelines
12. To ensure compliance with NICE Quality Standards for Dementia (QS –
see Appendix D)
2.2 Secondary Care Specialist Team’s responsibilities:
2.2.1 Initial Consultation (within 6 weeks of referral):
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Check medical history
Check co-morbidities for contraindications
Check medications for interactions and/or cautions
Assess patients cardiovascular risk factors and request ECG if considered clinically
appropriate
To ensure baseline monitoring of MMSE or alternative cognitive scale if
appropriate is performed and psychiatric assessment using appropriate
rating scales plus any additional relevant investigations e.g. CT and MRI
scan.
To confirm baseline diagnosis of dementia subtype
To provide written and verbal information to newly diagnosed patients and/or their carers
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about their condition, treatment and support options in their local area (see Appendix E for
patient leaflets)
A discussion about the Carer’s view about the patient and their presentation
Discuss and agree with the patient/carer if they would like to receive copies of their blood
test results.
To offer acetylcholinesterase inhibitors to those with mild to moderate Alzheimer’s disease
and mixed dementia.
Patients with severe dementia can be offered treatment with memantine
In advance of starting treatment, patients/carers will be informed that medication will be
discontinued from the point at which it is considered no longer clinically effective.
2.2.2 Subsequent Consultations with Memory Clinics
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To send correspondence to the GP after the initial assessment, following
each further appointment and when any change in the medication regimen
is recommended
To notify the GP of patient’s failure to attend appointments
To advise, educate and support patients and their carers
To provide support for GPs / Practice nurses carrying out reviews, on a
when required basis
For patients arriving from out of area and already established on
medication for Dementia see Appendix C
To ensure compliance with NICE Quality standards for dementia (QS) see
Appendix D
Patient to have annual review with Memory Clinic Teams to be arranged 6
months after GP annual review (i.e. alternating every 6 months between
GP and Memory Clinic).
Mild to Moderate Alzheimer’s disease or Mixed Dementia
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To monitor adverse effects of treatment with an AChEI or memantine
(where indicated) and titrate until optimal dose reached
NB; Memantine would be considered for patients with mild, moderate,
mixed or severe Alzheimer’s disease or Mixed Dementia
To review patient 3 months after a maintenance dose is established and
every 12 months thereafter or sooner if indicated or requested by GP.
Rivastigmine is licensed to treat mild to moderate dementia in Parkinson’s
disease.
Severe Alzheimer’s Dementia
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To provide telephone advice for GP/ practice nurse/ carer/ patient when
needed via Memory Clinic Team.
To assess ongoing benefit and consider a trial discontinuation if there has
been rapid clinical deterioration after a trial of appropriate doses or
combinations of anti-dementia drugs. A MMSE score less than 10 is some
guide to clinical decision making but should not be the only indication for
stopping medication. This would be done in discussion with the Carer and
GP.
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Shared Care Guideline: Acetylcholinesterase inhibitors/memantine
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To initiate prescribing of memantine according to NICE guidance as
clinically appropriate. Where memantine has been prescribed for mild or
moderate Dementia, monitoring will be as described above under Shared
Care. This includes using memantine for behavioural symptoms in any
subtype of dementia. A clear record of the indications for memantine
should be recorded in the notes.
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Where memantine has been prescribed for severe Dementia, ongoing
prescription and monitoring will be handed to GP 3 months after initiating
medication.
Off-License use of AChEi’s and memantine
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In patients who are declining despite medication consultant psychiatrists
may consider the use of higher than BNF doses of acetylcholinesterase
inhibitors and/or combination with memantine. It is the responsibility of the
consultant psychiatrist to ensure that the patient is appropriately monitored
in terms of cardiac side effects. This may include ECG or consultations
with cardiologist. Higher than BNF doses should be discussed with GP on
a case by case basis.
 Before handing over to the GP to continue management of patient, the
Psychiatrist should ensure that the GP is willing to accept this
responsibility for unlicensed prescribing.
 To provide telephone advice for GP/ practice nurse/ carer/ patient
 To assess ongoing benefit and consider a trial discontinuation if there has
been rapid clinical deterioration after a trial of appropriate doses or
combinations of anti-dementia drugs. A MMSE score less than 10 is some
guide to clinical decision making but should not be the only indication for
stopping medication. This would be done in discussion with the Carer and
GP.
2.2.3 Provision of information.
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For suggested template of letter to GP/Patient/Carer, see Appendix A
It is important for GP to be supplied with a more detailed letter from the Consultant
Psychiatrist detailing; diagnosis, relevant examinations and findings and any
pertinent information specific to the patient/family.
2.3 Patient/carer responsibilities
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To attend appointments
To inform the GP if new health problems occur
To ensure correct medication administration
To be aware of side effects, and report any relevant symptoms such as
severe nausea or syncope
To accept that treatment with these drugs will only continue as long as
they are effective
To be aware that any medication will be discontinued if there are
unacceptable adverse effects
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Shared Care Guideline: Acetylcholinesterase inhibitors/memantine
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3. Baseline data and routine monitoring
Parameter
Cognitive screen
Annual Physical Health Review
Dementia Review Checklist
(see Appendix A)
Responsibility
Initially and annually by Specialist
team
GP annually - optional
GP/Practice nurse
GP /Practice Nurse optional
Unlicensed Prescribing of High Dose Cholinesterase Inhibitors
Acetylcholinesterase inhibitor doses above BNF limits can be prescribed by consultant psychiatrists for
adults where there is a clinical indication and the potential benefits outweigh the risks. There needs to
be careful liaison between the psychiatrist and the GP to ensure there is appropriate follow up. The
psychiatrist should take responsibility for the prescribing until the patient is fully established on the
above BNF limits dose/combination with memantine (as mentioned above in 1.2).
MEDICATION CHECK
In cases where people are not able to self medicate or are living alone – or no relative/carer to
prompt patient to take their medication then a medication check may need to be arranged or it may
be necessary to consider stopping the medication
INTERRUPTIONS IN DRUG TREATMENT
The following guidance is suggested:
a) Rivastigmine patch and capsules should be re-titrated if there is a gap in treatment of 3 days or
more back up to the previously stabilised maintenance dose i.e. :
 restart at 1.5mg twice daily (with food) for at least two weeks. Increase in steps of 1.5mg
twice daily at intervals of at least two weeks until the previous dose is reached (oral) or
 restart at 4.6mg per 24 hours by patch increasing if needed after a
minimum of 4 weeks to 9.5mg in 24 hours
This can be done safely by the GP – contact the memory clinic if further advice is needed.
b) Donepezil
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If the patient has only taken this for up to 3 weeks, then any treatment break would have to
be discussed with specialist clinician. Although, the 5mg dose is usually prescribed for four
weeks before reviewing dose.
If the patient has been prescribed and has taken donepezil 10mg daily for more than three
weeks then a break of less than 7 days would not significantly affect plasma levels and the
patient can be restarted on the same 10mg daily dose. Breaks of more than 7 days would
need the patient to be retitrated (by restarting at a daily dose of 5mg donepezil at night and
increased after 28 days to 10mg). With donepezil, however, it should be noted that 5mg is a
treatment dose in itself.
c) Galantamine (ordinary and 'XL') –
 Although there is no formal guidance, the manufacturers state that for treatment breaks
longer than 7 days, the dose should be retitrated. (For XL preparation, this means restarting
Berkshire Healthcare NHS Foundation Trust
Shared Care Guideline: Acetylcholinesterase inhibitors/memantine
Version 2.2
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at 8mg daily (with food) for 28 days then increasing to 16mg daily for 28 days and (if
previously stabilised on 24mg) increasing to 24mg daily.
d) Memantine - The manufacturers state that:
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Break of 1-2 days - the patient can restart at their original dose.
Break of 3-7 days - dose would be titrated starting from 10mg daily for 7 days then
increasing to 15mg daily for 7 days then increasing to 20mg
Break of more than 7 days - retitrate from 5mg daily (i.e. by
prescribing the memantine treatment initiation pack)
References
1. Summary of product characteristics Aricept ® tablets; Reminyl XL® tablets; Exelon® capsules,
patches & oral solution; Ebixa® tablets and Ebixa® 5mg/pump oral solution www.medicines.org.uk
2. NICE Technology Appraisal Number TA217, Alzheimer’s disease – donepezil, rivastigmine,
galantamine and memantine (March 2011)
3. NICE Clinical Guidelines CG42, Dementia (Nov 2006)
4. Muayqil T., Camicoli R. Systemic Review and Meta-Analysis of Combination Therapy
with CHEIs and Memantine in AD and Other Dementias. Dement Geriart Cogn Disorder
Extra. 2012;2: 546-572.
5. Howard R et al. Donepezil and Memantine for Moderate-to-Severe Alzheimer’s Disease.
N Eng J Med. 2012; 366:893-903.
6. Farrimont LE., Roberts E., McShane R. Memantine and Cholinesterase Inhibitor
combination therapy for Alzheimer’s disease: systematic review. BMJ Open 2012; 2:
e000917. Doi:10.1136/bmjopen-2012-000917.
7. Tariot at al. Memantine treatment in patients with moderate to severe AD already
receiving Donepezil: RCT. JAMA. 2004; 291:317-324.
8. Doody RS., et al. Efficacy and Safety of Donepezil 23 mg v 10 mg for moderate to severe
AD: subgroup analysis in patients already taking or not taking concomitant Memantine.
Dement Ger Cogn Disord. 2012; 33: 164-173.
9. Molino I., et al. Efficacy of Memantine, Donepezil, or Their Association in Moderate –
Severe Alzheimer’s Disease: A Review of Clinical Trials. Review Article. The Scientific Word
Journal. 2013;Article ID925702, 8 pages htt://dx.doi.org/10.1155/2013/925702.
10. Zhu at al. Long term association between cholinesterase inhibitors and Memantine use
and health outcomes among patients with Alzheimer’s disease. Alzheimer’s &Dementia.
2013 (1-8). In press.
11. Cummings J, et al. Double-blind, Parallel-Group, 48-Week Study for Efficacy and
Safety of a Higher-Dose Rivastigmine Patch ( 15 vs. 10 cm²) in AD. Dement Geriatr Cogn
Disord. 2012;33:341-353.
12. Doody, R. S., Corey-Bloom, J., Zhang, R., Li, H., Ieni, J., Schindler, R., (2008).
Safety and Tolerability of Donepezil at Dozes up to 20 mg/day. Results from a Pilot Study in
Patients with Alzheimer’s disease. Drugs Aging, 25 (2): 163-174.
13. Farlow, M. R., Salloway S., Tarioot, P. M., Yardley J., Moine, M. L., Wang, Q., BrandSchieber E., Zou, H., Hsu, T., Satin, A., (2010). Effectiveness and tolerability of high-dose
(23 mg/d) versus standard- dose (10 mg) donepezil in moderate to severe Alzheimer’s
disease: a 24-week, randomized, double-blind study. Clin Ther, 32(7): 1234-1251.
14. Sabbagh M, et al. Evaluating the cognitive effects of donepezil 23 mg/d in moderate and
sever Alzheimer’s disease: analysis of effects of baseline features on treatment response.
BMC Geriatrics 2013; http://www.biomedcentral.com/1471-2318/13/56.
15. Christensen DD. High dose (23 mg/day) Donepezil formulation for the treatment of
patients with moderate-to-severe Alzheimer’s disease. Postgrad Med, (2012) Nov;124(6):
110-6.
Berkshire Healthcare NHS Foundation Trust
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Appendix A: Suggested Letter Template
GP ADDRESS
Date:
Ref:
Dear
Re: Name – DOB:
Address
Diagnosis:
ICD Code:
READ Code: Eu
Please add this to your GP QOF Dementia Register
Date of Review
Summary of Assessment
Cognitive Testing
MMSE:
MOCA:
Current Medication
Clock:
BADLS:
Care Plan
1.
2.
3. This patient is prescribed (insert drug name) and will require a review in 6
months e.g. weight, BP, pulse, FBC, U&E,C, glucose, lipids and LFTs. (please
delete if not required)
4. This patient falls within shared care guidelines (copy enclosed) and we would
be pleased if you could take over prescribing. They commenced on ………….
on dd/mm/yyyy and are now taking xx mg daily. They are stable on this. The
last prescription was written on ……… and they were given a …. month supply.
They will need a new prescription ……………..
(please delete this point if not required)
Please note that your patient may receive varied brands of the same medicines.
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Version 2.2
Page 8 of 19
As these may differ in appearance, please ensure your patient knows to finish
one preparation before starting the next.
5. This patient will next be reviewed (insert) (please delete if not relevant).
This patient will now be discharged to your care. (please delete if not relevant).
If you require any additional information or if we can be of any assistance prior to the
next review, please do not hesitate to contact the team.
Yours sincerely
Name
Job Title
Dr
Memory Clinic Consultant
Enc (if enclosing shared care guidelines)
cc
Patient
(Memory Clinic Administrator)
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Version 2.2
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Appendix B
For detailed information about dose, adverse effects, cautions/ contraindications,
please refer to the product Summary of Product Characteristics which can be
accessed via:
www.medicines.org.uk
Common (frequency estimate 1% to 10%) side effects include
For AChE inhibitors:
Diarrhoea, nausea, vomiting, dyspepsia, anorexia, dizziness, fatigue, insomnia, headache,
agitation, hallucinations and tremor
There is a reduced incidence of nausea using the rivastigmine patch compared to the oral
formulation.
For Memantine:
Headache, constipation, hypertension; dyspnoea; dizziness; drowsiness
Suspected adverse drug reactions
If an adverse reaction to the drug is suspected, a Yellow card should be completed:
For black triangle drugs all adverse reactions should be reported
For established drugs only serious adverse reactions should be reported
Note none of the products covered by these guidelines have “black triangle” status
Main Cautions
AChE inhibitors should be used with caution in patients with sick sinus syndrome or other
cardiac conduction abnormalities as they may have vagotonic effects on heart rate e.g.
bradycardia. Their use is also cautioned in patients with susceptibility to peptic ulcers, asthma,
chronic obstructive pulmonary disease, renal and hepatic impairment. Contra-indicated in sever
hepatic impairment.
Memantine is contra-indicated in severe hepatic impairment. Caution is recommended in
patients suffering from epilepsy, former history of convulsions or predisposing factors for
epilepsy. Caution in renal and hepatic impairment. Memantine is also known to cause
bradycardia.
Further specialist advice can be sought if necessary from BHFT Medicines Information
Service (For BHFT telephone: 0118 960 5075) or Southampton Regional Medicines Information
Centre (02381206908)
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Shared Care Guideline: Acetylcholinesterase inhibitors/memantine
Version 2.2
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APPENDIX C: Patients from out of area (and/or prescribed by a non-BHFT prescriber)
 Patients arriving from out of area (and/or prescribed by a non-BHFT prescriber) and already
established on a AChE inhibitor or memantine can be reviewed by the specialist team with regard
to continuing benefit or whether the drug should be discontinued, if the GP requires this.
 The specialist team will not be able to advise on prescribing until an assessment of the patient has
been made – the patient should be asked to obtain at least 3 months supply from their previous
(eg out of area) prescriber to ensure sufficient time for an appointment and assessment to be
made.
 If a patient is unable to obtain a supply from their previous prescriber, then it will be the
responsibility of the patient’s new GP to decide whether to continue prescribing the AChE Inhibitor
or memantine until such time as the patient can be assessed by BHFT.
 In the event of dispute with the family about stopping acetylcholinesterase inhibitors or memantine
in those who are outside of the NICE guidelines and no other clinical indication for continuation
can be found, these patients can be referred to the GP and/or original prescriber. If independent
arbitration is required the case can be referred to the relevant CCG’s case review committee
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APPENDIX D:
NICE Quality Standard for Dementia- Checklist for compliance
Quality statement
1
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People with dementia receive care
from staff appropriately trained in
dementia care.
Quality Measure Structure
 Evidence of local arrangements to provide and maintain up to date dementia training for staff.
Process
 Proportion of staff working with people with dementia who have dementia care training
 Numerator: the number of staff who are trained in dementia care.
 Denominator: the number of staff working with people with dementia.
Required Action
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2
People with suspected
dementia are referred to a
memory assessment service
specialising in the diagnosis
and initial management of
dementia.
Service providers ensure that all health and social care workers are appropriately trained in
dementia care according to their roles and responsibilities.
Health and social care professionals who work with people with dementia ensure they
receive training in dementia care consistent with their roles and responsibilities.
Quality Measure Structure
 Evidence that memory assessment services specialising in the diagnosis and initial management of
dementia are the single point of referral for people with a possible diagnosis of dementia.
Process
 Proportion of people with suspected dementia who are referred to a memory assessment service
specialising in the diagnosis and initial management of dementia.
 Numerator: the number of people who are referred to a memory assessment service specialising
in the diagnosis and initial management of dementia.
 Denominator: the number of people with suspected dementia.
Required Action
 Service providers ensure they offer a full range of services to aid diagnosis and initial management of
dementia.
 Health and social care professionals working with those with a possible diagnosis of dementia are
aware of the process by which referrals can be made to the local memory assessment service
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3
.
4
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People newly diagnosed with
dementia and/or their carers
receive written and verbal
information about their condition,
treatment and the support options
in their local area.
Quality measure Structure
Evidence of local arrangements to ensure written information on dementia is available to staff.
People with dementia have an
assessment and an ongoing
personalised care plan, agreed
across health and social care
that identifies a named care
coordinator and addresses their
individual needs.
Quality measure Structure
Process
 Proportion of people newly diagnosed with dementia receiving written and verbal information about their
condition, treatment and the support options in their local area.
o Numerator: the number of people receiving written and verbal information about their condition,
treatment and the support options in the local area.
o Denominator: the number of people newly diagnosed with dementia.
Required Action
 Service providers ensure that written information about dementia, treatment and local area support
options is available to staff.
 Health and social care professionals provide written and verbal information about dementia, treatment
and local area support options once a diagnosis of dementia is established.
 Evidence of local arrangements to ensure services are tailored to an individual's needs.
Process
 Proportion of people with dementia whose individual needs are assessed and whose care plan states
how those needs will be addressed.
o Numerator: Number of people with an assessment of individual needs and a care plan
addressing identified needs.
o Denominator: Number of people with dementia
 Proportion of people with a named health or social care coordinator.
o Numerator: the number of people with a named health or social care coordinator.
o Denominator: the number of people with dementia.
Required Action
 Service providers ensure that protocols are in place to ensure that personalised care plans identify
named care coordinators and address the individual needs of people with dementia.
 Health and social care professionals ensure that personalised care plans identify a named care
coordinator and address the individual needs of the person with dementia.
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5
People with dementia, while
they have capacity, have the
opportunity to discuss and
make decisions, together with
their carer/s, about the use of:
advance statements, advance
decisions to refuse treatment,
Lasting Power of Attorney,
Preferred Priorities of Care.
Quality measure Structure
 Evidence of local protocols on the discussion of advance decision making.
Process
 Proportion of people with dementia, while they have capacity, and their carer/s, who are given the
opportunity to discuss with health and social care professionals about the use of:
 advance statements
 advance decisions to refuse treatment
 Lasting Power of Attorney
 Preferred Priorities of Care.
 Numerator: the number of people who are given the opportunity to discuss advance decision making.
 Denominator: the number of people with dementia.
 Numerator: the number of carers who are given the opportunity to discuss advance decision making.
 Denominator: the number of carers of people with dementia.
Description of what the quality statement means for each audience
 Service providers ensure staff are appropriately trained to provide information on advance
statements, advance decisions to refuse treatment, Lasting Power of Attorney and Preferred Priorities
of Care.
 Health and social care professionals offer the person with dementia, whilst they have capacity, the
opportunity to discuss and make decisions together with their carer/s about the use of:
 advance statements
 advance decisions to refuse treatment
 Lasting Power of Attorney
 Preferred Priorities of Care
6
Carers of people with dementia
are offered an assessment of
emotional, psychological and
social needs and, if accepted,
receive tailored interventions
identified by a care plan to
Quality measure Structure
 Evidence that those carrying out a carers' assessment identify any emotional and psychological
needs and the social impact on the carer and offer the carer psychological therapy, including
cognitive behavioural therapy (CBT), if clinically appropriate.
 Evidence that this is an ongoing process and includes any period after the person with dementia has
entered residential care.
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7
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address those needs.
Evidence that care plans for carers of people with dementia involve a range of tailored interventions,
which consist of multiple components including:
o individual or group psychoeducation
o peer-support groups with other carers, tailored to the needs of individuals depending on the
stage of dementia of the person being cared for and other characteristics.
Process
 Proportion of carers of people with dementia who are offered an assessment of their needs.
o Numerator: the number of carers offered an assessment of their needs.
o Denominator: the number of carers of people with dementia.
 Proportion of carers of people with dementia receiving interventions tailored to their needs.
o Numerator: the number of carers receiving interventions tailored to their needs
o Denominator:the number of carers of people with dementia who have an agreed care plan.
Description of what the quality statement means for each audience
 Service providers ensure that carers of people with dementia are offered an assessment of needs
and receive tailored interventions to address any identified.
 Health and social care professionals ensure that carers accepting an assessment of their needs
receive a care plan containing a range of tailored interventions including
 Psychological therapy including CBT.
 Psychoeducational programmes.
 Peer support.
People with dementia who
develop non-cognitive
symptoms that cause them
significant distress, or who
develop behaviour that
challenges, are offered an
assessment at an early
opportunity to establish
generating and aggravating
factors. Interventions to improve
Quality Measure Structure
 Evidence that people with dementia who develop non-cognitive symptoms that cause them significant
distress, or who develop behaviour that challenges, are offered an assessment at an early opportunity.
 Evidence that individually tailored care plans, that help carers and staff address the behaviour that
challenges, are recorded in the notes and reviewed regularly.
Process
 Proportion of people with dementia who develop non-cognitive symptoms that cause them significant
distress, or who develop behaviour that challenges, who receive an assessment to establish likely factors
that may generate, aggravate or improve such distress or behaviour.
o Numerator: the number of people who receive an assessment.
o Denominator: the number of people with dementia who develop non-cognitive symptoms that
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such behaviour or distress
should be recorded in their care
plan.
cause them significant distress or who develop behaviour that challenges.
 Proportion of people with dementia who develop non-cognitive symptoms that cause them significant
distress, or who develop behaviour that challenges, with an individualised care plan identifying actions to
address the distress or behaviour.
o Numerator: the number of people with an individualised care plan identifying actions to address
the distress or behaviour.
o Denominator: the number of people with dementia who develop non-cognitive symptoms that
cause them significant distress or who develop behaviour that challenges.
 Proportion of people with dementia with mild-to-moderate non-cognitive symptoms who are prescribed
anti-psychotic medication. (Goal to be 0% reflecting the Department of Health report on the use of antipsychotic medication for people with dementia and its aim to reduce the use of anti-psychotic medication
for people with dementia.)
o Numerator: the number of people prescribed anti-psychotic medication.
o Denominator: the number of people with dementia with mild-to-moderate non-cognitive
symptoms.
Description of what the quality statement means for each audience
 Service providers ensure that all people with dementia who develop non-cognitive symptoms that
cause significant distress, or who develop behaviour that challenges, are given a comprehensive
assessment.
 Health and social care professionals working with people with dementia who develop non-cognitive
symptoms carry out a comprehensive assessment. A behavioural and functional analysis should be
conducted by health and social care professionals with specific skills, in conjunction with carers and
care workers, and an individually tailored care plan should be developed to address the issues.
People with suspected or
known dementia using acute
and general hospital inpatient
services or emergency
departments have access to a
liaison service that specialises
in the diagnosis and
Quality Measure Structure
 Evidence of local arrangements to provide a liaison service specialising in the diagnosis and
management of dementia and older people's mental health.
Process
 Proportion of people with suspected or known dementia using acute and general hospital facilities
that are assessed by a liaison service that specialises in the diagnosis and management of dementia
and older people's mental health.
o Numerator: the number of people who are assessed by a liaison service that specialises in the
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management of dementia and
older people´s mental health.
diagnosis and management of dementia and older people's mental health.
Denominator: the number of people with suspected or known dementia who are admitted to
acute or general hospital inpatient services or attending emergency departments.
Description of what the quality statement means for each audience
 Service providers ensure that a liaison service specialising in dementia and older people's mental
health is available in acute and general hospital settings to assess inpatients and emergency
department attendances with suspected or confirmed dementia.
 Health care professionals working in acute and general hospital settings ensure they can access a
liaison team that specialises in the diagnosis and management of dementia and older people's mental
health.
People in the later stages of
dementia are assessed by primary
care teams to identify and plan
their palliative care needs.
Quality Measure Structure
 Evidence of local arrangements for primary care teams to assess the palliative care needs of people
in the later stages of dementia.
Process
 Proportion of people in the later stages of dementia whose palliative care needs are assessed by
primary care teams and the resulting information is communicated within the team and with other
health and social care staff.
o Numerator: the number of people whose palliative care needs are assessed by a primary care
team and communicated within the team and with other health and social care staff.
o Denominator: the number of people in the later stages of dementia.
Description of what the quality statement means for each audience
 Service providers ensure that all people in the later stages of dementia have their palliative care
needs assessed by primary care teams and that the needs are communicated to other health and
social care staff.
 Health and social care professionals ensure that people who are in the later stages of dementia have
their palliative care needs met in accordance with the DH's End of Life Care Strategy. This includes
use of appropriate tools and pathways including:
Preferred priorities for care. Gold Standards Framework. Liverpool Care Pathway.
o

1
Carers of people with dementia
Quality Measure Structure
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0
have access to a comprehensive
range of respite/short-break
services that meet the needs of
both the carer and the person with
dementia

Evidence that health and social care managers ensure that carers of people with dementia have
access to a comprehensive range of respite/short-break services which meet the needs of both the
carer and the person with dementia.
Process
 Proportion of carers of people with dementia who access respite/short-break services when required.
o Numerator: the number of carers accessing respite/short-break services.
o Denominator: the number of carers of people with dementia requesting respite/short-break
services.
Description of what the quality statement means for each audience
 Service providers ensure that information is available to health and social care staff on the range of
respite/short-break services available to carers of people with dementia.
 Health and social care professionals ensure that carers of people with dementia are aware of the
options available to them locally for respite/short-break services, and that access to such services is
facilitated when needed.
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Appendix E
COST OF MONTHLY TREATMENT
Please refer to the electronic Drug Tariff for the current FP10 price. - http://www.ppa.org.uk/ppa/edt_intro.htm
The Drug tariff is updated monthly.
Acknowledgment: Sussex Partnership NHS Foundation Trust and West Sussex PCT
Please click on following link for medicines information leaflets for patients and carers:
http://www.choiceandmedication.org/berkshirehealthcare/
Medicines Information enquiries for healthcare professionals: 0118 960 5075 (Prospect Park Hospital- Pharmacy)
Medicines Information enquiries for patients and carers
: 0118 960 5059 (Prospect Park Hospital- Pharmacy)
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