Tier 2: Pharmacological Interventions in Dementia Care

1. Tier 2: Pharmacological Interventions in Dementia Care

2. Aims of webinar session • Common medications • Risks and benefits and impact on daily living • Polypharmacy • Recording and reporting side effects/adverse reactions • Administration and review of medications @NHS_HealthEdEng

3. Case Study: Jake & Alice Jake and Alice have been married for 32 years and live in their own home. Jake has been diagnosed with an Alzheimer-type dementia for 18 months. He and Alice continue to actively enjoy both family-focused and community-based activities as part of a local social support group for people with dementia and their carers. In the past two weeks, Alice has noticed that Jake appears to become increasingly agitated and frustrated towards teatime. She arranges an appointment with you to discuss the possibility of ‘getting something prescribed’ for Jake to help her cope with him during this difficult period of the day . Adopting a person-centred perspective, what are the possible pharmacological or non-pharmacological solutions you can offer to both Jake and Alice? @NHS_HealthEdEng

4. Pharmaceutical options • Dementia – neurodegenerative condition for which there is no cure • Pharmaceutical interventions aim to ‘promote independence, maintain function and treat symptoms’ • Patients in the mild to moderate stages of dementia should be offered access to regular cognitive stimulation therapy sessions @NHS_HealthEdEng

5. Pharmaceutical options • Pharmaceutical interventions would be on the advice of a clinician who has the necessary knowledge and skills. This could include: • Secondary care medical specialists such as psychiatrists, geriatricians and neurologists • Other healthcare professionals such as GPs, nurse consultants and advanced nurse practitioners with specialist expertise in diagnosing and treating Alzheimer's disease (NICE, 2018a) @NHS_HealthEdEng

6. Pharmaceutical options for cognitive symptoms AChE inhibitors: • Rivastigmine • Donepezil Hydrochloride • Galantamine • Memantine Hydrochloride @NHS_HealthEdEng

7. Pause for a poll For which type of dementia would you normal prescribe AChE inhibitors? • Vascular dementia • Alzheimer’s disease • Lewy Body dementia • Frontotemporal dementia @NHS_HealthEdEng

8. Rivastigmine, Donepezil and Galantamine • For the treatment of mild to moderate dementia in Alzheimer’s disease • All work in similar way • Known to the general public as Aricept, Exelon and Reminyl • Cheapest – Donepezil • Between 40% and 70% of people with Alzheimer’s disease benefit from taking an AChE inhibitor (Alzheimer's Society, 2018) • Patients show the best response to AChE inhibitors over 6-12 months (Alzheimer's Society, 2018) @NHS_HealthEdEng

9. Rivastigmine, Donepezil and Galantamine • Benefits include reduced anxiety, improved motivation, memory and concentration and ability to continue daily activities (Alzheimer’s Society, 2018) • The use of AChE inhibitors may lead to a delay in institutionalisation • Risks include limited understanding of short-term effect, remembering to take medication and side effects @NHS_HealthEdEng

10. Common side effects • Muscle cramps • Nausea • Sweating • Tremor • Vomiting • Urinary incontinence • Weight loss • Worsening of Parkinson’s • Drowsiness • Dyspepsia • Extrapyramidal symptoms • Fatigue • Headache • Increased salivation • Insomnia • Malaise • Abdominal pain • Agitation • Anorexia • Anxiety • Bradycardia • Confusion • Diarrhoea • Dizziness @NHS_HealthEdEng

11. Memantine Memantine is recommended as an option for managing Alzheimer's disease for people with: • Moderate Alzheimer's disease who are intolerant of or have a contraindication to AChE inhibitors, or • Severe Alzheimer's disease • Treatment should be under the conditions specified in recommendation 1.5.5 in the NICE guideline on dementia (NICE, 2018a) @NHS_HealthEdEng

12. Pause for a discussion Please write your response to the following question: • How do you decide to prescribe acetylcholinesterase inhibitors? Now let’s think about: • Who benefits from this? • What barriers might there be to prescribing AChE inhibitors? @NHS_HealthEdEng

13. Management of non-Alzheimer’s dementias • Donepezil, rivastigmine, galantamine and memantine can be offered to patients with a non-Alzheimer’s disease. • However, NICE guidance must be followed NICE Guidelines (2018a) @NHS_HealthEdEng

14. Pharmacological options for non cognitive symptoms • Co-morbidities • Depression • Agitation, aggression, distress and psychosis (NICE, 2018a) @NHS_HealthEdEng

15. Pause for a discussion Please write your response to the following question: • Who would prescribe anti-psychotics? • How would you evaluate the risks vs benefits? @NHS_HealthEdEng

16. Risks and benefits – Antipsychotics • Antipsychotic medication is used to treat mental health conditions e.g. Schizophrenia • These can have significant side effects • Some antipsychotics can be used with people with dementia – only in line with the General Medical Council recommendations • Always discuss the risks and benefits with the patient and carer/family • The first prescription of such medication is usually done by a specialist dr @NHS_HealthEdEng

17. Risks and benefits – Anti-depressants • Types of anti-depressants are: • Sertraline • Citalopram • Mirtazapine • Trazodone • These may help to reduce symptoms of agitation – although research is not conclusive on the impact of their use @NHS_HealthEdEng

18. Risks and benefits – Anticonvulsants • Medication is used for those experiencing fits or epilepsy • Occasionally used to treat aggression or agitation in people with dementia • Carbamazepine has been used • This has a number of side effects • Sedation; blood disorder; low sodium; falls risk; rashes • This is not advised for use with people with dementia • There is ongoing research into the use of other medication, no conclusive evidence to date @NHS_HealthEdEng

19. Risks and benefits – Anxiolytics • Anxiolytics are used to treat anxiety or panic attacks • Usually prescribed for short term use only – due to their addictive properties • Drowsiness and dizziness are common side effects • Symptoms of withdrawal can be experienced when coming off these drugs • Mild symptoms of anxiety could be treated with non-pharmacological activity such as meditation or exercise @NHS_HealthEdEng

20. Polypharmacy Co-morbidities Consider • The number and type of medicines a person is taking and how often • Any harms from medicines • Non-pharmacological treatments such as diets, exercise programmes and psychological treatments @NHS_HealthEdEng

21. Administer and review • Usually, once a person has stabilised on a drug, the routine prescribing will continue with the GP (Alzheimer's Society, 2018) • Regular reviews should be undertaken to monitor: • How the drug is working • Side effects • When to withdraw medication • Shared care prescribing will usually take place, with the specialist consultant and GP monitoring the use of medication @NHS_HealthEdEng

22. Recording and reporting side effects/adverse reactions • Side effects, adverse reactions should be reported to the health professional who prescribed the medication (NICE, 2014) @NHS_HealthEdEng

23. Pause for a discussion Please write your response to the following question: • Thinking about the process of withdrawal from medication, how might the patient experience this? @NHS_HealthEdEng

24. Resources and useful links • Alzheimer’s Society (2017) Antipsychotic drugs https://www.alzheimers.org.uk/about-dementia/treatments/drugs/antipsychotic-drugs • Care Calls, service which contacts people to prompt them to take medications - • https://carecalls.co.ukNICE Guidelines (2014) Managing medicines in care homes. https://www.nice.org.uk/Guidance/SC1 • Health Education England, dementia training resources - https://www.hee.nhs.uk/our-work/dementia-awareness/resources-tier-one-two-three • Health Education England, Dementia guide for carers and care providers e-book, available from: iBooks, the Kindle Store, and Smashwords. It is also available as a standalone app through the Apple App Store. • NICE Guidelines (2017) Managing medicines for adults receiving social care in the community. https://www.nice.org.uk/guidance/ng67 • NICE Guidelines (2018a) Dementia: assessment, management and support for people living with dementia and their carers. https://www.nice.org.uk/guidance/ng97 • NICE Guidelines (2018b) Donepezil, galantamine, rivastigmine and memantine for the treatment of Alzheimer's disease. https://www.nice.org.uk/guidance/ta217/chapter/1-Guidance • NHS Choices, (2017) Dementia Guide. https://www.nhs.uk/Conditions/Dementia/ • University of Nottingham, Improving Dementia Education and Awareness (IDEA) - https://idea.nottingham.ac.uk/resources @NHS_HealthEdEng

25. References: • Alzheimer’s Society (2016) Treating depression https://www.alzheimers.org.uk/about-dementia/symptoms-and-diagnosis/treating-depression#content-start • Alzheimer’s Society (2017) Antipsychotic drugs https://www.alzheimers.org.uk/about-dementia/treatments/drugs/antipsychotic-drugs • Alzheimer’s Society (2018) Drug treatments for Alzheimer's disease https://www.alzheimers.org.uk/about-dementia/treatments/drugs/drug-treatments-alzheimers-disease • BPS, (2016) Psychological dimensions of dementia: Putting the person at the centre of care • Dementia Australia (2018) Drug treatments for Alzheimer’s disease cholinesterase inhibitors: https://www.dementia.org.au/files/helpsheets/Helpsheet-DementiaQandA01-CholinesteraseInhibitors_english.pdf • NHS Choices, (2017) Dementia Guide • NICE Guidelines (2014) Managing medicines in care homes. https://www.nice.org.uk/Guidance/SC1 • NICE Guidelines (2017) Managing medicines for adults receiving social care in the community. https://www.nice.org.uk/guidance/ng67 • NICE Guidelines (2018a) Dementia: assessment, management and support for people living with dementia and their carers. https://www.nice.org.uk/guidance/ng97 • NICE Guidelines (2018b) Donepezil, galantamine, rivastigmine and memantine for the treatment of Alzheimer's disease. https://www.nice.org.uk/guidance/ta217/chapter/1-Guidance • Skills for Health, Health Education England & Skills for Care, (2018). Dementia Training Standards Framework @NHS_HealthEdEng