Medication Management for Dementia

• Advise patients to use a medicine dispenser or to ask the pharmacist to blister pack the medications.
• It is likely that the patient will have been commenced on a Cholinesterase Inhibitor e.g. Donepezil (Aricept), Rivastigmine (Exelon), Glanatamine (Reminyl)
  • It is important to manage the patients and their families’ expectations of these medications. They are unlikely to see a significant improvement in memory or function on the treatment but they will hopefully see stabilisation of the person’s condition for 6-9 months.

Cholinesterase Inhibitors

Licenced for use in mild to moderately severe Alzheimer’s Disease.

Side effects:

The most common side effects are nausea and GI upset which are often dose related and improves over time or with dose reduction. The GI symptoms can occasionally be overcome by use of a topical rivastigmine patch. Less common side effects include heart arrhythmias, increased dreaming and nightmares.

Due to the potential to cause arrthymias, prior to commencing a cholinesterase inhibitor a baseline ECG is recommended – sometimes patients are on a beta-blocker and the addition of a cholinesterase inhibitor in individuals with conduction block could precipitate heart block or lead to syncope.

Memantine

Memantine is NMDA receptor antagonist, not an acetylcholinesterase inhibitor. Memantine is licensed in moderate to severe Alzheimer ’s disease. Memantine may occcasionally be prescribed in addition to an acetylcholinesterase inhibitor.

Although memantine is occasionally used to manage aggression and agitation in PwD, trials to date have not found evidence to support its use to manage these symptoms.

The maximum daily dose is 20 mg per day. In order to reduce the risk of undesirable effects, the maintenance dose is achieved by upward titration of 5 mg per week over the first 3 weeks as follows:

Example of a memantine titration schedule

• Week 1 (day 1-7): 5mg OD  (1/2 a 10mg tablet)
• Week 2 (day 8-14): 10mg daily
• Week 3 (day 15-21): 15mg daily
• Week 4 on: 20mg daily

The recommended maintenance dose is 20 mg per day.

Side Effects include:

Headaches dizziness, constipation, confusion, decreased renal function.

Although memantine is generally well-tolerated, some persons with dementia, particularly those with Lewy body pathology, may be susceptible to developing adverse effects which include increased aggression, new delusions, hallucinations or agitation.

Note: In patients with moderate renal impairment (creatinine clearance 30 - 49 ml/min) daily dose should be 10 mg per day. If tolerated well after at least 7 days of treatment, the dose could be increased up to 20 mg/day according to standard titration scheme. In patients with severe renal impairment (creatinine clearance 5 – 29 ml/min) daily dose should be 10 mg per day.

How to Successfully Withdraw an Antipsychotic

• In general, antipsychotics can be successfully withdrawn in people with dementia.
• Many people have no worsening of symptoms when antipsychotics are discontinued and for those patients that do have worsening behaviour, most of them are effectively managed with watchful waiting.
• However, there is some evidence to suggest that individuals who had higher baseline levels of symptoms or who were taking higher baseline doses of antipsychotic were more likely to have recurrent symptoms with discontinuation.
• Withdrawal of anti-psychotics is most effective when a non-pharmacological intervention such as social interaction or exercise is provided in parallel.

Which patients should you attempt an antipsychotic withdrawal in?

All patients with dementia on antipsychotics for behavioural problems who have not had a trial discontinuation in the last 3 months unless:

• The antipsychotic was prescribed for a pre-existing condition prior to the dementia diagnosis
• The patient is under regular review by a specialist for NCS
• There is a documented plan in place for ongoing antipsychotic use and this is under regular review

How to withdraw an antipsychotic

If the patient is receiving a low dose of an antipsychotic then it can be discontinued directly, there is no need to taper.

The following doses are considered low doses:

• Risperidone low dose = 0.5mg (500 micrograms)

• Olanzapine low dose = 2.5mg

• Quetiapine low dose = 50mg

• Aripiprazole low dose = 5mg

If the patient is receiving a higher dose then taper the dose over one month

1. Reduce to half dose for two weeks
2. GP review at two weeks
3. Discontinue immediately after a further two weeks
4. Review again after one week.

However in some cases if the antipsychotic is prescribed at a high dose it will be necessary to withdraw the drug more slowly.

Monitoring for re-emergence of symptoms

If the PwD is living in the community then

• Ask the carer to keep a diary of the PwD’s behaviour for one week before stopping or reducing the dose and for one week after the dose reduction to assess the impact on the PwD.
• Consider leaving the carer with a prescription for a small supply of the medication in case the drug needs to be reinstated, this re-commencement would need to be agreed with the prescriber

If the PwD is a resident in a nursing home then

• Ask staff members to monitor the PwD behaviour closely for several weeks
• Try stopping the antipsychotic in those patients that are considered the least likely to need it to give the nursing home confidence in the process.
• Any stop date should usually be planned for a Monday so that if behavioural symptoms reappear these can be assessed during the working week.

What to do if symptoms re-emerge

• If symptoms reappear then it may be necessary to restart the antipsychotic but a trial of ‘watchful waiting’ often results in resolution of the symptoms without restarting the antipsychotic.
• If it is decided to restart the drug then it should be restarted at the usual starting dose.
• NCS can persist and treatment with atypical antipsychotics may be needed in the long term but should always be reviewed on a 3 monthly basis.

Related Files

An Example of an Antipsychotic Withdrawal Schedule

This document gives an example of an antipsychotic withdrawal schedule for prescribers of psychotropic medication.

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