Acetylcholinesterase inhibitors and memantine in patients newly diagnosed with dementia - treatment initiation and follow up

Initiation of acetylcholinesterase inhibitors and memantine

• Choice of treatment will be decided by the prescriber with Appendix 1 and Appendix 2 available for general guidance.
• Ensure baseline measurements are completed as per Appendix 3. This will be undertaken and/or arranged by the CMHT nurses.
  
  
• Check if the patient is prescribed interacting medications using Stockleys interaction checker (available here: https://www.medicinescomplete.com/#/). In particular, ensure the patient is not prescribed any anticholinergic medication which would counteract the action of an acetylcholinesterase inhibitor.
  
  
• Discuss key side effects (Appendix 2) with the patient and/or their carer.
  
  
• Offer medication information in the form of patient information leaflets from choiceandmedication.org/nhs24. 
  
  
• Consider if the covert medication pathway is applicable and if so ensure this is implemented appropriately with completed forms (Covert medication care pathway form MWC).
• Treatment should be long-term unless specific indications otherwise.
  
  
• Contact GP to request acetylcholinesterase inhibitor or memantine be commenced by them at the initial dose only and CMHT, PDS or CHAT team staff will be in touch following follow up to request further dose amendments.
  
  
• In the case where a patient refuses PDS, CMHT or CHAT monitoring of titration, the team should contact the patients GP to request a review in 4 weeks time and advise of anticipated titration of medication.

Follow up – this will be tailored to meet individual needs, but as a minimum will include:

• Contact at approximately one month to establish initial tolerance of medication, either via CMHT, PDS or CHAT team.
  
  
• Medication should be reviewed at each follow up to assess effectiveness, side effects and compliance and to undertake recommended monitoring as per Appendices 2 & 3. Monitoring will be undertaken by registered nursing staff in PDS/CMHT or CHAT.
  
  
• Arrange follow up reviews depending on clinical need.
  
  
• All patients should be reviewed at the point of full titration of medication by CMHT, PDS or CHAT team or the GP in event of the patient refusing review by the specialist team.
  
  
• All medication updates and amendments must be communicated with the patients GP

Key areas to be addressed in all patients with dementia during follow up period as required. Post Diagnostic Support will be provided via the PDS Team, according to the 5-pillar model.

• Medication should be reviewed at each follow up to assess effectiveness, side effects and compliance and to undertake recommended monitoring as per Appendices 1 & 2.
  
  
• Compliance and adherence should be reviewed by including a physical check of a patients medication supply and medicines management resources (blister pack, MAR chart, boxes of medications etc) to determine as far as possible any issues with taking their medicines as prescribed and intended.
  
  
• Review of whether covert medication pathway is applicable and if so ensure it is implemented appropriately.
  
  
• Review of changes in Activities of Daily Living.
  
  
• Review changes to risk.
  
  
• Review care package (home care, day care).
  
  
• Review patient and carer’s understanding of the written information provided at diagnosis. Provide educational material that may have become relevant since last review.
  
  
• Enquire about changes in physical and social circumstances. Provide information on relevant community supports.
  
  
• Discuss Power of Attorney, Attendance allowance, Council tax, as required.
  
  
• Ensure relevant risk assessments and care plans have been completed.

This is general guidance for the choice of prescribing Acetylcholinesterase Inhibitors (AChEI) and Memantine. AChEI includes donepezil, rivastigmine and galantamine. Prescribing choice should take into account all patient specific factors.

*unlicensed treatment in this disease

Switching between drugs due to intolerance or poor response

Poor tolerance to one drug does not assume poor tolerance to another. An alternative drug can be trialled instead after complete resolution of adverse effects.

Poor benefit from one AChEI does not assume poor benefit from another. An alternative drug can be trialled.

Progression of disease/loss of benefit

Do not stop AChEI in people with Alzheimer’s disease on basis of disease severity alone.

Switching to a different AChEI due to loss of benefit is not recommended.

Treatment breaks

Treatments breaks should always take into account individual patient circumstances.

In general, if there is a break in treatment of donepezil or memantine of less than two weeks, these can be restarted at the previous dose. If there has been a break longer than two weeks, the dose will need re-titrated in accordance with the normal regime.

If there is a break in treatment of galantamine or rivastigmine of 3 days or more, speak to the responsible clinician as these may need to be re-titrated.