Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
TRANSFER of CARE PRESCRIBING AGREEMENT Treatment of Alzheimer’s disease (including mixed Alzheimer’s dementia) with acetylcholinesterase inhibitors (AChEIs) for mild to moderate severity, or memantine for moderate severity (where AChEIs cannot be used) or in severe disease. Additionally, the use of rivastigmine for Parkinson’s disease Dementia and Lewy Body dementia. Section A: To be completed by the specialist initiating treatment GP Practice Details: Patient Details: Name: ……………………………………… Name: ……………………………………………… Address: …………………………………… Address: …………………………………………… Tel no: ……………………………………… DOB: ……/………/………… Fax no: ……………………………………… Hospital number: ………………………………… NHS.net e-mail: …………………………… NHS number (10 digits): ………………………… Specialist name: …………………………… Clinic/Practice name: …………………………………. Contact details: Address: ......................................................................................................................... Tel no: ……………………………………… Fax no: ……………………………………… NHS.net e-mail: …………………………… Diagnosis & Severity: Drug name & dose to be prescribed by GP: …………………………………………………… ……………………………………………………………. Dear Dr. …………………….., Your patient was seen and I have stabilised the patient on the medicine above for the above diagnosis. I request your agreement to transfer the care of this patient from the next supply in 2-4 weeks’ time accordance with the (attached) Transfer of Care Prescribing agreement. Please take particular note of Section 2 where the areas of responsibilities for the specialist, GP and patient for this transfer of care arrangement are detailed. Patient information has been given outlining potential aims and side effects of this treatment. The patient has given me consent to treatment and transfer the care back to you in line with the transfer of care agreement, and has agreed to comply with instructions and follow up requirements by you: Please monitor the following: 1. Encourage adherence. 2. Monitor any side effects of medication. 3. General health. 4. Report any adverse reactions to the MHRA via the ‘yellow card system’. 5. Check for interactions with other medicines. 6. Annually assess for deterioration in cognitive, functional or behavioural problems. 7. Refer back to secondary care between regular reviews if concerned about patient’s condition. The following investigations have been performed and are acceptable for transfer of care: Test / Assessment Tool Result / Score Date Test / Assessment Tool Result / Score Date e.g. SMMSE/ CT/ MR result CAMCOG ECG if indicated Other relevant information: ……………………………………………………………………………………….. ……………………………………………………………………………………………………………………….. Section B: To be completed by the GP and returned to the specialist as detailed in Section A above Please sign and return your agreement to transfer of care within 14 days of receiving this request Tick which applies: □ I accept the transfer of care as per the prescribing agreement and above instructions □ I would like further information. Please contact me on:………………………. □ I am not willing to undertake transfer of care for this patient for the following reason: ………………………………………………………………………………………………………………. GP name: ………………………………………….………. GP signature: ………………………………………………Date: …/…/….. Date approved: 9/2015 Review date: 9/2018 Version: 201701 1 Working in Partnership TRANSFER of CARE PRESCRIBING AGREEMENT Treatment of Alzheimer’s disease (including mixed Alzheimer’s dementia) with acetylcholinesterase inhibitors (AChEIs) for mild to moderate severity, or memantine for moderate severity (where AChEIs cannot be used) or in severe disease. Additionally, the use of rivastigmine for Parkinson’s disease Dementia and Lewy Body dementia. NOTES to the GP The expectation is that these guidelines should provide sufficient information to enable GPs to be confident to take clinical and legal responsibility for prescribing this drug. The questions below will help you confirm this: Is the patient’s condition predictable or stable? Do you have the relevant knowledge, skills, diagnostic tools and access to equipment to allow you to monitor treatment as indicated in this shared care prescribing guideline? Have you been provided with relevant clinical details including monitoring data? Have you followed treatment recommendations are per NICE? If you can answer YES to all these questions (after reading the shared care guideline), then it is appropriate for you to accept prescribing responsibility. If the answer is NO to any of these questions, you should not accept prescribing responsibility. You should write to the specialist within 14 days, outlining your reasons for NOT prescribing. If you do not have the confidence to prescribe, we suggest you discuss this with your local Trust/specialist service, which will be willing to provide training and support. If you still lack the confidence to accept clinical responsibility, you still have the right to decline. Your CCG pharmacist will assist you in making decisions about shared care. It would not normally be expected that a GP would decline to share prescribing on the basis of cost. The patient’s best interests are always paramount Date prepared: October 2015 Approved by (date approved): SWL & St. George’s Mental Health NHS Trust’s DTC October 2015 Review date: Sept 2018 South West London Mental Health Interface Prescribing Forum March 2016 NHS Richmond CCG NHS Kingston CCG NHS Wandsworth CCG GPwSI update approved Dec 2016 This shared care prescribing guideline has been signed off by the following individuals on behalf of their respective organisations: Participating Clinical Commissioning Groups (CCGs) NHS Kingston CCG Dr Jonathan Edwards, GP on behalf of Medicines Management Committee Dr Anthony Hughes, GP, Kingston CCG NHS Richmond CCG NHS Wandsworth CCG Dr Stavroula Lees, Lead GP for Mental Health Dr Gillian Ostrowsky, Associate Medical Director Emma Richmond, Head of Medicines Management Nick Beavon, Chief Pharmacist Participating Hospital Trusts St George’s University Hospitals NHS Foundation SWL & St. George’s Mental Health NHS Trust Dr. Debbie Stinson (Old Age Psychiatrist) Trust Dr. Jeremy Isaacs (Neurologist, Dementia) Dianne Adams (Chief Pharmacist) Chris Evans (Chief Pharmacist) Date approved: 9/2015 Review date: 9/2018 Version: 201701 2 TRANSFER of CARE PRESCRIBING AGREEMENT Acetylcholinesterase Inhibitors and Memantine 1. TRANSFER OF CARE (Discharge of patients on anti-dementia medicines to primary care) Shared care does not apply where patients are prescribed antidementia medicines for Alzheimer’s disease mild to moderate severity without non-cognitive symptoms, or for treatment with memantine in moderate severity dementia (where AChEIs cannot be used) without non-cognitive symptoms of dementia. These patients are assessed by specialist services, once stable are discharged to primary care with a comprehensive care plan to GPs. Other dementias e.g. dementia of mixed type, vascular dementia, fronto-temporal dementia are also excluded from this guideline. Some mixed dementias have a more prominent domain e.g. Alzheimer’s that will be included in this agreement (see shared care agreement). Severity and Type of Dementia For Transfer of care AChEIs, Mild/ Moderate without non-cognitive symptoms (SMMSE score: mild=21-26, moderate 10-20) Yes Memantine, Moderate without non-cognitive symptoms where AChEIs cannot be used (SMMSE score 10-20) Yes EXCLUDED Combination treatment with memantine and an acetylcholinesterase inhibitor is not recommended, and should only be initiated on approval from SWLStG Drug and Therapeutics committee as it is outside this agreement and NICE guidance. Date approved: 9/2015 Review date: 9/2018 Version: 201701 3 TRANSFER of CARE PRESCRIBING AGREEMENT Treatment with medicines care pathway Patient identified with cognitive impairment. Basic assessment of cognition and exclusion of other causes Referred to the memory assessment service Specialist Memory Clinic assessment, diagnosis and further management including suitability for dementia medicines (stabilised on medicines for at least 4-12 weeks) Shared Care All other forms of dementia where medicines are commenced Kingston Dementia Support Service (KDSS) Patients stabilised on medication by 2o care are discharged from memory assessment service and referred to the KDSS. The KDSS will continue to review these patients. Any changes to medication will be commenced in the KDSS by the GP with a Special Interest. Prescribing will then be transferred to the patient's GP if they are in agreement. GP continues to prescribe and review as per the shared care monitoring recommendations. Specialist will continue to clinically review the patient and communicate progress and management to the GP as per the shared care agreement Transfer of Care Mild/moderate Alzheimer’s without BPSD GP continues prescribing medicines with 12 monthly review, continued irrespective of cognitive performance. Issues with medicines or clinical management of the patient should be referred back to the specialist. These patients will be seen within 2 weeks should there be clinical need for reassessment. Date approved: 9/2015 Review date: 9/2018 Version: 201701 4 TRANSFER of CARE PRESCRIBING AGREEMENT 1. AREAS OF RESPONSIBILITY Specialist (Old Age or Learning Disabilities Psychiatrist, Care of the Elderly Physician, GP with Special Interest Dementia, or Neurologist) 1. Confirm diagnosis of Alzheimer’s disease of: mild to moderate severity with non-cognitive symptoms, severe Alzheimer’s Disease with or without non-cognitive symptoms, Parkinson’s Disease Dementia, or Lewy Body Dementia with duration > 6 months and communicate the severity to the GP (for example based on SMMSE score). In certain circumstances the SMMSE will be inappropriate for assessing severity as scores are biased by learning disability, high or low education, where English is not the first language, with deafness and by cultural factors. Other tools (e.g. CAMCOG, CAMDEX, DMR, DSDS, DSQIID) may be appropriate and assessment of severity will be a matter for specialist clinical judgement. 2. Specialist assessment including: Tests of cognitive domain (e.g. SMMSE or MoCA) Clinical evaluation of non-cognitive domains (e.g. hallucinations, delusions, agitation, behaviours that challenge) Assessment of activities of daily living (ADLs) Assessment of global function Likely compliance with treatment, before drug is prescribed The main therapeutic targets should be confirmed e.g. cognition, psychosis, behaviours that challenge and/or ADL Level of carer distress 3. When clinically appropriate undertake a CT or MRI scan to exclude vascular aetiology or other pathology. 4. Test for syphilis serology or HIV in patients at risk due to their histories, or if clinically indicated. 5. ECG to be performed if a cardiac contra-indication to acetylcholinesterase inhibitor treatment (e.g. sick sinus syndrome or other supraventricular conduction abnormalities) is suspected. 6. Assess patient’s capacity and seek consent including, where appropriate, consultation with carers 7. Identify a carer who will undertake to monitor concordance and agree with the treatment plan. 8. Seek agreement that treatment will be stopped if no benefit or if deterioration. 9. Check for medication interactions 10. Exclude serious adverse effects during dose escalation. 11. Report any serious adverse effects to the MHRA via the ‘yellow card system’. 12. Arrange secondary care assessment within 12 weeks of diagnosis, and until the patient is stabilised on medication (at least 4-12 weeks of treatment will be supplied, duration will depend on severity, indication and tolerability of the medicine). 13. Seek carers’ views of patient’s condition at baseline and at each follow-up. 14. Stop treatment if: Poor concordance Major adverse effects Patient asks to stop Medication not effective (global, functional & behavioural condition is below a level where the drug is considered to have a worthwhile effect e.g. which may be an SMMSE <10) 15. Activity /audit report to be sent regularly to commissioners. TRANSFER OF CARE Diagnosis of Alzheimer’s disease of mild to moderate severity without non-cognitive symptoms, or for treatment with memantine in moderate severity dementia (where AChEIs cannot be used) without noncognitive symptoms 16. Commenced treatment for at least 4-12 weeks (duration will depend on severity, indication and tolerability of the medicine), by when serious adverse effects have been excluded and stabilised 17. Shared care may not be appropriate for these patients. Support the GP to take over the whole care providing assistance where there are minor queries. 18. Discharge from the service will be planned following a care planning review and actively incorporating the views of patients, their family and carers, and feedback from voluntary or independent sector agencies providing care or support to the service user where applicable. A final care plan will be produced with the service user’s/carer’s involvement and sent to GPs. Date approved: 9/2015 Review date: 9/2018 Version: 201701 5 TRANSFER of CARE PRESCRIBING AGREEMENT GP responsibilities 1. Before referral confirm history (including time period) of cognitive decline from patient or independent informant; exclude delirium with recent onset of cognitive impairment. Communicate the carer’s views to the specialist where they are assessed. 2. As per NICE guidance before referral undertake initial dementia blood screening (blood glucose, FBC, U&E, calcium, B12, folate, TFTs & LFTs). 3. Continue prescribing after specialist has commenced treatment for at least 4-12 weeks (duration will depend on severity, indication and tolerability of the medicine) on receiving a care plan, by when serious adverse effects have been excluded and stabilised. Date approved: 9/2015 Review date: 9/2018 Version: 201701 6 TRANSFER of CARE PRESCRIBING AGREEMENT TRANFER OF CARE Diagnosis of Alzheimer’s disease of mild to moderate severity without non-cognitive symptoms, or for treatment with memantine in moderate severity dementia (where AChEIs cannot be used) without noncognitive symptoms: GP recommended action Comment Management Supply the formulation as recommended Continue prescribing by the specialist and add to the practice after specialist has system as per local prescribing commenced treatment recommendation in relation to quantities for at least 4-12 weeks and duration of review. (duration will depend on severity, indication and tolerability of the medicine), by when serious adverse effects have been excluded and patient has been stabilised. Support and education of patients and Refer back to a specialist if there Encourage adherence carers. is poor adherence or the patient asks to stop. For more information on prescribing for non-cognitive symptoms associated with dementia, refer to: Medicines for behavioural and psychological symptoms in dementia (BPSD). See the SWLStG website: http://www.swlstg-tr.nhs.uk/forhealth-professionals/ Report any adverse reactions to Monitor any side effects the MHRA via the ‘yellow card of medication or system’. interaction(s) Monitor general health No specific physical health checks are recommended for these medicines other than those at baseline and initiation or dose change. Annually assess for deterioration in cognitive, functional or behavioural problems The Trust uses a range of assessments to develop care plans, below are some standard area GPs may find useful to include Cognitive domain (e.g. SMMSE or MoCA) Non-cognitive domain (e.g. hallucinations, delusions, agitation, behaviours that challenge) Activities of daily living (ADLs) Global function. However, often a global impression with feedback from a family member or carer will give sufficient information without the need to complete a formal score. Stop the medicine and refer back where there are intolerable or serious side-effects (see section 5). Refer back if there are new major co-morbid contraindications that mean the medicine needs to be stopped e.g. acute cardiac deterioration. Refer back where there is deterioration in their functional, cognitive ability or behaviour that causes distress to the patient or carer. See the monitoring requirements for tools used in the Trust GPs may find useful. Refer back should the patient or care want the medicine stopped. Patient and carers’ Should report any adverse effects, deterioration and response to medicines to the mental health team and/or GP. Date approved: 9/2015 Review date: 9/2018 Version: 201701 7 TRANSFER of CARE PRESCRIBING AGREEMENT 2. COMMUNICATION AND SUPPORT Specialist contacts: (the referral letter will indicate named specialist) Kingston Older Peoples (OP) CMHT 020 3513 5205 Kingston Dementia Support Service: 020 8549 4747 Merton OP CMHT 020 3513 6325 Richmond OP CMHT 020 3513 3680 Sutton OP CMHT 020 8335 4116 Wandsworth OP CMHT 020 3513 6320 Out of hours contacts & procedures: Advice via on call specialist doctor (organisation switch board) or on call Mental Health Pharmacist via SWLStG switch (020 3513 5000). Tel: Fax: E-mail: Kingston Dementia Support Service: [email protected] Specialist support/resources available to GP including patient information: Information is available from your psychiatric Medicines Information 020 3513 6829 and the ‘Choice and Medication’ website (http://www.choiceandmedication.org/swlstg-tr/) Patient information leaflets in 10 different languages available from SWLStG intranet, contact Mental health team or MI above for copies. Date approved: 9/2015 Review date: 9/2018 Version: 201701 8 TRANSFER of CARE PRESCRIBING AGREEMENT 3. CLINICAL INFORMATION Indication(s) Place in therapy Therapeutic summary Dose and route of administration Duration of treatment Acetylcholinesterase inhibitors (donepezil, galantamine and rivastigmine) are licensed for the treatment of mild to moderate Alzheimer’s disease. Additionally, rivastigmine is licensed for the treatment of mild to moderate dementia in Parkinson’s disease. Memantine is licensed for the treatment of moderate to severe Alzheimer's disease. Acetylcholinesterase inhibitors are recommended as 1st line treatment for mild to moderate Alzheimer’s disease (and rivastigmine for the treatment of mild to moderate dementia in Parkinson’s disease or dementia with Lewy body). Memantine may be used 2nd line for moderate severity Alzheimer’s dementia where acetylcholinesterase inhibitors are ineffective or not tolerated. Combination treatment with memantine and an acetylcholinesterase inhibitor is not recommended, and should only be initiated on approval from SWLStG Drug and Therapeutics committee as it is outside this agreement and NICE guidance. Rivastigmine patches may be used where there are swallowing difficulties or where there has been a best interests discussion approving the use of covert administration (following organisational policy) or the patient is under the Mental Health Act. The patches should be switched to oral as soon as clinically appropriate. Doses of 4.6mg and 9.5mg/24 hour patch correspond to 3mg BD PO and 6mg BD PO respectively. Manufacturers advise to consider retitration in cases where GI side effects occur. Lower oral doses may be used in situations where this has been agreed with the specialist. Donepezil, galantamine & rivastigmine: acetylcholinesterase inhibition Memantine: moderate affinity and uncompetitive n-methyl- D-aspartate receptor antagonism Titration week & dose (mg) Medicine Frequency 1 2 3 4 5 7 9 Daily (oral) 5 10 Donepezil 1st line Galantamine 2nd line Daily (oral) 8 16 24 (modified release) Galantamine 4 8 12 Twice daily (oral) Rivastigmine 1.5 3 4.5 6 Twice daily (oral) Daily (clean dry skin) 4.6 9.5 Rivastigmine patch* Memantine Daily (oral) 5 10 15 20 *Dose of rivastigmine patch may be increased to 13.3mg/24hrs after 6 months if required The Psychiatrist will decide when treatment should be stopped. This is considered if: Poor concordance Major adverse effects Patient asks to stop Medication not effective (global, functional & behavioural condition is below a level where the drug is considered to have a worthwhile effect e.g. which may be an SMMSE <10) GPs should refer back to a specialist should a patient need to stop their medicines. Summary of adverse effects Adverse effect Acetylcholinesterase Gastro-intestinal symptoms (incl. anorexia, inhibitors (See Summary of Product Characteristics (SmPC) for full list or BNF) Very common: >1/10 Common: >1/100, <1/10 Uncommon: >1/1000, <1/100 Rare: >1/10,000, <1/1000 Date approved: 9/2015 Review date: 9/2018 Version: 201701 nausea, vomiting, diarrhoea) May enhance predisposition to peptic ulceration Frequency Very common Uncommon / rare Management Refer to specialist who may try an alternative acetylcholinesterase inhibitor or switch to memantine if severe Care with active or predisposition to gastric or duodenal ulcers. Consult specialist. 9 TRANSFER of CARE PRESCRIBING AGREEMENT May cause bradycardia Uncommon / rare May cause bronchoconstriction No data available May exacerbate bladder outflow problems No data available May lower seizure threshold Hepatic impairment (galantamine, rivastigmine) Renal impairment (galantamine, rivastigmine) Syncope (donepezil, galantamine & rivastigmine) Fatigue, dizziness and muscle cramps Uncommon / rare No data available No data available Uncommon / rare Common Memantine (See Summary of Product Characteristics (SmPC) for full list or BNF) Somnolence Dizziness Common Common: >1/100, <1/10 Uncommon: >1/1000, <1/100 Hypertension Common Dyspnoea Common Constipation Headache Fungal infections Gait abnormal Venous thrombosis/thromboembol ism Confusion Hallucinations Psychosis Fatigue Date approved: 9/2015 Review date: 9/2018 Version: 201701 Stop treatment and consult specialist. Caution in “sick sinus syndrome”, sinoatrial or atrioventricular block or concomitant treatment with digoxin or beta-blockers Avoid in COPD or asthma, consult specialist to review treatment. Caution if history of prostatic conditions, urinary retention. (Galantamine contraindicated in obstruction or post bladder surgery) Review treatment with specialist if seizures develop as may be caused by underlying disease. Contra-indicated in severe impairment. Stop treatment and consult specialist. Contra-indicated in severe impairment. Stop treatment and consult specialist. Consult specialist. Common Uncommon Uncommon Uncommon (not known for psychosis) The ability of the patient to continue driving or operating complex machinery should be evaluated. Consult specialist if problematic for the patient. The ability of the patient to continue driving or operating complex machinery should be evaluated. Consult specialist if problematic for the patient. Avoid in those with uncontrolled hypertension or cardiac disease. Review treatment with a specialist if this develops. Avoid in those with uncontrolled COPD or asthma, consult specialist to review treatment. Refer back to psychiatrist if severe or is not self-limiting. Refer back to psychiatrist if severe. Refer for treatment of VTE, and review memantine with a specialist. Refer back to specialist for review. 10 TRANSFER of CARE PRESCRIBING AGREEMENT Pancreatitis Vomiting Monitoring Requirements: Unknown (uncommon for vomiting) Stop if severe, refer back to specialist. There are no specific physical health checks recommended for ongoing monitoring of these medicines. Assessments are of the functional, cognitive & behavioural features of dementia are required (as recommended in the specialist and GP responsibilities above). Twelve-monthly review by the specialist service (functional, cognitive and behavioural clinical assessment), review may be more frequent dependent upon clinical needs of the patient. GPs Follow the recommended monitoring in section 3 GP responsibilities. 1. TRANSFER OF CARE An annual review is recommended. Useful tools for the full annual review may be found on the link or embedded documents below: http://www.swlstg-tr.nhs.uk/for-health-professionals/ for SMMSE ACE-III ACE-III Scoring Administration (English).pdf (English).pdf Clinically relevant drug interactions: (See (SmPC) for full list) Date approved: 9/2015 Review date: 9/2018 Version: 201701 MoCA-Test-English_7 MoCA-Instructions-E _1.pdf nglish_2010.pdf Acetylcholinesterase inhibitors: Erythromycin, ketoconazole & Itraconazole, fluoxetine, paroxetine, fluvoxamine increase plasma concentration of galantamine and donepezil Quinidine increases plasma concentration of donepezil Enzyme inducers may reduce levels of donepezil Donepezil, galantamine, rivastigmine may alter effect of succinylcholine-type muscle relaxants All three AChEIs are not to be given with cholinomimetics and are antagonised by anticholinergic medications Memantine: Ketamine, Dextromethorphan & Amantadine avoid concomitant use, increased risk of CNS toxicity (psychosis). Dantrolene & Baclofen’s effects are modified. Warfarin, Selegiline, antimuscarincs & dopaminergics effects are enhanced. Primidone, antipsychotics & Barbiturates therapeutic effects may be reduced. Cimetidine, ranitidine, procainamide, quinidine, quinine and nicotine may cause increase in memantine serum levels. 11 TRANSFER of CARE PRESCRIBING AGREEMENT Practical issues: Donepezil Oral: once daily Tablets (5mg & 10mg) Orodispersible tablets (5mg & 10mg) Galantamine Oral: twice daily: Tablets (4mg, 8mg & 12mg) Solution (4mg in 1ml) once daily: XL prolonged release capsules (8mg, 16mg, 24mg) Rivastigmine Oral: twice daily Capsules (1.5mg, 3mg, 4.5mg, 6mg) Solution (2mg in 1ml) Transdermal patches: skin patch replaced once a day (4.6mg/24hours, 9.5mg/24hours, 13.3mg/24hrs) Memantine Oral: once daily 5mg/pump oral solution (pump five times before first use, refer to patient information leaflet for more information available at www.medicines.org.uk) Tablets (10mg and 20 mg) NICE recommendation for acetylcholinesterase inhibitors: Use the drug with the lowest acquisition cost (taking into account the daily dose, adverse effects, comorbidity, drug interactions and dosing profile). Donepezil is currently recommended as the 1st line acetylcholinesterase inhibitor for mild to moderate Alzheimer’s disease. If a patient does not tolerate one acetylcholinesterase inhibitor (e.g. due to diarrhoea), it may be reasonable to try another (see SmPC for full details) or switch to memantine. *N.B. Rivastigmine is also licensed for the symptomatic treatment of Parkinson’s disease Dementia (PDD), and its use as described in the NICE Clinical Guideline 42 for PDD is supported and included under this shared prescribing guideline. The respective areas of responsibility of the specialist and the GP remain the same as for its use in Alzheimer’s Disease (as outlined in Section 2). Key references: 1. 2. 3. 4. 5. 6. 7. 8. 9. Date approved: 9/2015 Review date: 9/2018 Version: 201701 Lyketsos CG, Steele C, Galik E, et al. Physical aggression in dementia patients and its relationship to depression. American Journal of Psychiatry 1999;156(1):66–71. Levy ML, Cummings JL, Fairbanks LA, et al. Longitudinal assessment of symptoms of depression, agitation, and psychosis in 181 patients with Alzheimer’s disease. American Journal of Psychiatry 1996;153(11):1438–43. Holtzer R, Tang MX, Devanand DP, et al. Psychopathological features in Alzheimer’s disease: course and relationship with cognitive status. Journal of the American Geriatrics Society 2003;51(7): 953–60. Parnetti L, Amici S, Lanari A, Gallai V. Pharmacological treatment of non-cognitive disturbances in dementia disorders. Mechanisms of Ageing and Development, 2001;122(16): 2063–9. Schneider et al, Clinical Antipsychotic Trials of Intervention Effectiveness- Alzheimer’s disease (CATIE-AD) trial. NEJM 2006;355:1525-1538. NICE Technology Appraisal 217, March 2011 (replaces NICE TA 111, November 2006) Alzheimer's disease - donepezil, galantamine, rivastigmine and memantine NICE Clinical Guideline 42, November 2006 (updated Oct 2012 and includes TA 217) Dementia: supporting people with dementia and their carers in health and social care British National Formulary, 65th Edition accessed on line, 16/8/13. www.BNF.org Summaries of Product Characteristics for Aricept , Exelon, Reminyl (as of January 25th 2008) http://www.medicines.org.uk/, document histories checked for updates (24/8/15) Summary of Product Characteristics. Ebixa 5mg/pump oral solution, 20mg and 10 mg Tablets and Treatment Initiation Pack. last updated on the eMC: 30/9/2014. http://www.medicines.org.uk/ 12