Pharmacological Strategies

There has been controversy about the cost effectiveness of antidementia drugs. Current NICE guidance advises the use of specific drugs; but with some caveats.

Specific drugs

For moderate AD, current NICE guidance advises the use of:

• Acetylcholinesterase inhibitors
• Donepezil
• Galantamine
• Rivastigmine

However, there are caveats:

• It must be prescribed by a specialist
• MMSE score of 10-20 is required unless:
  • >20 with significant impairment of social functioning
  • <10 with a poor pre-morbid level of cognition
  • The patient has learning difficulties
  • The patient is not English speaking
• Review of the patient and response to treatment must occur every six months
• The carer’s view of response to treatment must be taken into consideration

Current evidence suggests they are not helpful in the management of VD, DLB or FTD.

Memantine

Memantine is a drug prescribed in the past for moderate to severe dementia.

It is now advised to be started only as part of well designed trials.

Antidepressants and antipsychotics

Dementia patients may also be on antidepressants and antipsychotics to try to help control the behavioural aspects of their disease.

These should only be given to patients with severe symptoms as they are associated with an increased risk of death.

Urgent situations

In an urgent situation, where the behaviour of a patient with dementia may cause danger to themselves or others, sedative and antipsychotic medication may be appropriate.

NICE advises the following strategy:

• Lorazepam or haloperidol are the drugs of choice
• IM injection is the preferred route of delivery
• The lowest effective dose should be used
• A single agent should be used except where rapid tranquilisation is required

Patients and carers should be given the opportunity to discuss the events surrounding involuntary sedation, and the reasons why it was necessary.

Learning Bite

Acetylcholinesterase inhibitors can be helpful for reducing cognitive impairment in moderate Alzheimer’s disease. There is no evidence to support their use for other dementia subtypes at present.