4.11 Drugs for dementia

 First choice:
mild to moderate dementia

Second choice:
moderate to severe dementia

Doses are gradually titrated upwards according to response and side–effects.

  • donepezil tablets 5mg, 10mg, orodispersible tablets 5mg, 10mg: see BNF for dosing schedule.
  • galantamine m/r capsules 8mg, 16mg, 24mg: see BNF for dosing schedule.
  • rivastigmine capsules 1.5mg, 3mg, 4.5mg, 6mg: initially 1.5mg twice daily for 4 weeks, then 3mg twice daily for 6 weeks, then 4.5mg twice daily for 6–10 weeks; max dose 6mg twice daily if tolerated.
  • rivastigmine patch 4.6mg/24 hours, 9.5mg/24 hours, 13.3mg/24 hours: see BNF for dosing schedule.
  • memantine tablets 10mg, 20mg; orodispersible tablets 10mg, 20mg; oral solution 10mg/mL: see BNF for dosing schedule.
Prescribing Notes
  • Referral to specialist services should be made in the usual way if any doctor considers that a patient may have Alzheimer’s disease and may be suitable for treatment.
  • Special arrangements exist for patients with learning disability.
  • Prescribers should only start treatment with donepezil, galantamine, rivastigmine or memantine on the advice of a clinician who has the necessary knowledge and skills. [NICE]
  • Dose titration, assessment of efficacy and tolerability, and any necessary monitoring will be undertaken by the specialist service recommending the treatment for the first 6 months.

  • Further information is available in the [NICE CG42] Dementia: supporting people with dementia and their carers in health and social care

  • In selecting an appropriate drug for the individual patient the choice of treatment will take into account the adverse event profile, expectations about adherence, medical comorbidity, possibility of drug interactions and dosing profiles.

  • Memantine may be prescribed for patients with moderate dementia in Alzheimer's disease who are intolerant of or have a contraindication to acetylcholinesterase inhibitors.

  • Memantine may be used first line in patients with severe dementia in Alzheimer's disease.

  • Rivastigmine may be considered first line in patients with dementia in Parkinson's disease and in dementia with Lewy bodies.

  • In case of local skin irritation with rivastigmine patches, patients may be switched to an alternative brand.

  • Local specialists recommend a slower titration of oral rivastigmine than suggested in the BNF in order to minimise potential gastro-intestinal side-effects.

  • Some of the drugs used in dementia are available in orodispersible tablets or oral solution. These formulations should be reserved for patients with swallowing difficulties.

  • Rivastigmine patches may be an appropriate choice of formulation for some patients.
  • Where more than one therapeutic  agent and/or formulation is a suitable choice for the individual patient choose the one with the lowest acquisition cost.

  • Treatment should be continued only when it is considered to be having a worthwhile effect on cognitive, global, functional or behavioural symptoms [NICE]

  • One of the potential side-effects of the acetylcholinesterase inhibitors is bradycardia; it is recommended that pulse monitoring should be conducted in those patients at increased risk. For example where there is co-administration of beta-blockers or digoxin.