Download Guideline for agitation in Alzheimer`s dementia - G-Care

NHS
Gloucestershire Health Community
Guideline for agitation in Alzheimer’s dementia
Step 1
Pain
Environmental
Medication
Think
"PINCH ME"
to identify
treatable
causes of
symptoms
Infection
Constipation
Hydration
Step 2: Psychosocial/caring advice: from primary care, consider referral to Community
Dementia Nurse or Care Home Support Team (which care homes can access direct)
Step 3: If taking an ACI drug (donepezil, rivastigmine or galantamine), reduce dose of it and add
memantine (see note below). Discuss with Community Dementia Nurse
Step 4: Stop ACI drug -any reduction in agitation usually apparent within 10 days
Step 5: Either: Mirtazepine 15mg nocte if symptoms seem anxiety-driven or if sleep disturbance
is a major issue
Or: time limited course of risperidone, 0.5mg nocte increasing if needed to 0.5mg bd 3-6 weeks,
after discussing risks with patient and/or carer. (See information sheet below for carers/care
home).
Step 6: If symptoms reappear when risperidone stopped or if otherwise needed, refer to
secondary care.
Notes
Memantine: Guidance in the Shared Care Guideline below.
An information sheet about antipsychotic drugs in dementia for patients, families and care homes
is on the following pages.
Author: N Ardagh-Walter, 2gether NHSFT Drugs and therapeutics Committee , January 2016. Review date: January 2018
Antipsychotics and Dementia
What are antipsychotics?
Antipsychotics are a group of medicines. They are often used for people who
have mental illness, and have unusual thoughts and experiences.
Antipsychotics are also used in people with Dementia who have extreme
anxiety and agitation. We should use antipsychotics in Dementia only when
all other medical and non-medical approaches have either failed or are not
suitable.
How do antipsychotics work?
Antipsychotics affect the action of chemicals in the brain which brain cells
need to talk with each other. Antipsychotics control the symptoms, but do not
get rid of them.
Why are antipsychotics used in Dementia?
People with dementia can have periods of agitation, restlessness, and
aggression. They may also have unusual thoughts and experiences.
Medicine trials have shown that antipsychotics can have a small but positive
effect on these symptoms. They can help the patient feel calmer, without
making him/ her feel slowed down or drowsy.
These effects are usually seen when antipsychotics are taken for a period of
6 - 12 weeks.
What are the common side-effects of antipsychotics?
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Dry mouth
Constipation
Tremor and stiffness
Increased risk of falls
Interference with sex life
Sleepiness and slowness
Increased risk of stroke and mini-stroke (TIA)
Also, antipsychotics can sometimes increase the rate of decline of dementia.
Risks
If 1000 people with
Dementia take an
antipsychotic for around
12 weeks
Up to 200 patients
may show
About 17 will suffer
from side effects
About 10 people will
die due to the
such as stroke and
The risks are reduced if antipsychotics are used in low doses and for short
span of time.
For further information please contact:
Managing Memory 2gether: 0800 6948800
Gloucestershire Health Community
NHS
Memantine
Shared Care Guideline
Therapeutic Use
This shared care guideline has been agreed for the purpose of prescribing memantine to
new patients according to NICE Technology Appraisal 217, and also to describe its use for
patients known to suffer from Alzheimer’s disease with agitation, as part of the agreed
pathway.
NICE TA217 recommends memantine as a treatment option in patients with moderate
Alzheimer’s disease where there is intolerance to, or contraindications to cholinesterase
inhibitors (i.e. donepezil, galantamine, rivastigmine), and as an option for managing severe
Alzheimer’s disease: under these circumstances treatment should be initiated by a
physician experienced in the diagnosis and treatment of dementia (i.e. a neurologist, old
age / learning disability psychiatrist or elderly care physician).
In addition, memantine can be used as a treatment option for treating agitation in patients
with a known diagnosis of Alzheimer’s disease: this use is described in the agreed pathway
(see above).
The aims of treatment are to promote independence, maintain function and treat
symptoms including cognitive, non-cognitive (hallucinations, delusions, anxiety, marked
agitation and associated aggressive behaviour), behavioural and psychological symptoms.
Contra-indications
Known hypersensitivity to memantine, or to any of the excipients used in the formulation.
Dosage and administration
Initially 5mg once daily, increased in steps of 5mg at weekly intervals; max 20mg daily.
Occasionally patients may become more confused shortly after and increase to the 15mg
or 20mg dose: under these circumstances, the dose should be reduced to 10mg.
Renal impairment:
CrCl ≥50ml/min
no dose adjustment required
CrCl 30-49ml/min max. 10mg daily (increase up to 20mg with caution, if tolerated)
CrCl 5-29ml/min
max. 10mg daily
Hepatic impairment:
Not recommended in severe hepatic impairment.
Precautions for use
Caution is not recommended in patients with epilepsy or history of convulsions. Caution in
patients with cardiac failure.
Side-effects
For a full list of adverse effects see the summary of product characteristics.
Common side effects include: dizziness, headache, constipation, somnolence and
hypertension. Less commonly: vomiting, thrombosis, heart failure, confusion, fatigue,
hallucinations, abnormal gait; very rarely seizures, pancreatitis, psychosis, depression,
suicidal ideation.
Drug interactions
For a full list of interactions see the summary of product characteristics.
Levodopa, dopaminergic agonists, and antimuscarinics may be enhanced by memantine.
Concomitant use with amantadine, ketamine, dextromethorphan and phenytoin should be
avoided. Memantine may increase INR in patients taking warfarin.
Aspects of care for which the Hospital is responsible:
Initiation:
 To make an appropriate assessment and initiate treatment
 Carers’ views on the patient’s condition at baseline should be sought.
 Information on benefits and side-effects of treatment should be provided to the patient
/ carer.
 Regular assessment until patient is stabilised on a dose.
 Duration of secondary care prescribing: 3 months unless clear reason to the contrary.
After initiation:
 Once stabilised, to write to GP requesting shared care and enclosing a copy of these
guidelines or advising where they can be found on the intranet.
 To undertake a 6 monthly review including cognitive, global, functional and
behavioural assessment. This review to be undertaken by an appropriately qualified
health care professional. Patients and carers will be given contact details for specialist
services so that they may contact them direct to ask for earlier review.
 At review, to consider whether or not the drug should be discontinued.
 To inform the GP of the results of the 6 monthly review.
 To advise the GP when to change dose or stop prescribing based on results of 6
monthly review.
 Report any adverse events to the MHRA via the Yellow Card Scheme.
Aspects of care for which the GP is responsible
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If the patient is known to have Alzheimer’s and agitation is a significant problem, to
consider the issue and, if appropriate within the countywide guidance , to initiate the
drug and refer the patient to the appropriate service – including the Community
Dementia Nursing service or the Care Home Support Team – for ongoing
management and monitoring by qualified professionals.
If agreeing to accept shared care for this drug, to prescribe it on an ongoing basis.
Report any adverse events to the MHRA via the Yellow Card Scheme.
Report to and seek advice from Specialist team on any aspect of patient care which is
of concern to the GP and may affect disease treatment.
Aspects of care for which the patient/carer is responsible
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To ensure they have a clear understanding of their treatment.
To request further supplies, store appropriately and take/administer as directed.
Report any adverse effects to their GP.
To report back to managing doctor any problems with medication compliance.
Cost
Tablets (generic): 10mg
Tablets (generic): 20mg
Liquid
28 days
£1:46
£1:61
£59:61
Availability of back-up advice and support
GHT Hospital number: 0300 422 2222
Consultants: Psychiatric services via contact centre: 08000 151 499
Medicines Information Services: Gloucester 0300 422 6108 (Mon to Fri, 9 – 5.30pm)
Cheltenham 0300 422 3030 (Mon to Fri, 9 – 5.30pm)
Written: … 2016
Review date: … 2018
This document has been produced by … and agreed via the Medicines Management Interface Group
(MMIG)
The information contained in this guideline is issued on the understanding that it is the best available
from the resources at our disposal on the date of issue. Further information may be obtained from the
specialist or your local medicines information centre.
This guideline does not contain a complete list of indications, precautions, warnings etc. For further
information please refer to the product Summary of Product Characteristics for full details.
▼ Suspected ADRs associated with Blank Triangle drugs should be reported via the CSM Yellow Card Scheme. ▼
▼ Suspected ADRs associated with Blank Triangle drugs should be reported via the CSM Yellow Card Scheme. ▼
This can be found at http://emc.medicines.org.uk/