Agitation, aggression, distress and psychosis
- Before starting non-pharmacological or pharmacological treatment for distress in people living with dementia, conduct a structured assessment to:
• explore possible reasons for their distress and
• check for and address clinical or environmental causes (for example pain, delirium or inappropriate care).
- As initial and ongoing management, offer psychosocial and environmental interventions to reduce distress in people living with dementia.
- Only offer antipsychotics for people living with dementia who are either:
• at risk of harming themselves or others or
• experiencing agitation, hallucinations or delusions that are causing them severe distress.
- Follow the MHRA advice for health and social care professionals on prescribing antipsychotics to people living with dementia.
- Be aware that for people with dementia with Lewy bodies or Parkinson’s disease dementia, antipsychotics can worsen the motor features of the condition, and in some cases cause severe antipsychotic sensitivity reactions. Be aware that interventions may need to be modified for people living with dementia.
- Before starting antipsychotics, discuss the benefits and harms with the person and their family members or carers (as appropriate). Consider using a decision aid to support this discussion.
- When using antipsychotics:
• use the lowest effective dose and use them for the shortest possible time
• reassess the person at least every 6 weeks, to check whether they still need medication.
- Stop treatment with antipsychotics:
• if the person is not getting a clear ongoing benefit from taking them and
• after discussion with the person taking them and their family members or carers (as appropriate).
- Ensure that people living with dementia can continue to access psychosocial and environmental interventions for distress while they are taking antipsychotics and after they have stopped taking them.
- For people living with dementia who experience agitation or aggression, offer personalised activities to promote engagement, pleasure and interest.
- Do not offer valproate to manage agitation or aggression in people living with dementia, unless it is indicated for another condition.
|Therapeutic Area||Formulary Choices||Cost for 28|
(unless otherwise stated)
|Rationale for decision / comments|
|Related guidance: NICE Technology Appraisal TA217 (Updated June 2018): Donepezil, galantamine, rivastigmine and memantine for Alzheimer’s disease|
|When assessing the severity of Alzheimer‟s disease and the need for treatment, healthcare professionals should not rely solely on cognition scores in circumstances in which it would be inappropriate to do so (see NICE TA217 for examples).
When using assessment scales to determine the severity of Alzheimer‟s disease, healthcare professionals should take into account any physical, sensory or learning disabilities, or communication difficulties that could affect the results and make adjustments they consider appropriate. Healthcare professionals should also be mindful of the need to secure equality of access to treatment for patients from different ethnic groups, in particular those from different cultural backgrounds.
These should only be initiated by specialists in the care of dementia (psychiatrists, neurologists and physicians specialising in the care of older people). Treatment should be continued only when it is considered to be having a worthwhile effect on cognitive, global, functional or behavioural symptoms. Patients who continue on treatment should be reviewed regularly by an appropriate specialist team, or according to the locally agreed Shared Care Protocol. Carers views on the patient's condition should be sought at baseline and during follow-up.
|Memantine and AChE inhibitor combination treatment.
NICE states that a trial did not show any benefit from combining memantine with an AChE inhibitor on cognitive, functional, behavioural or global outcomes. A trial that compared memantine plus donepezil with donepezil plus placebo was included in NICE technology appraisal guidance 111. Pooling the new trial with the previous trial of memantine in combination with an AChE inhibitor did not show any additional benefit from combination therapy
|Acetylcholinesterase inhibitors||Donepezil||5mg tablets: £0.99 |
10mg tablets: £1.09
5mg tablets: £6.68
10mg tablets: £8.57
|The acetylcholinesterase (AChE) inhibitors: Donepezil, Galantamine and Rivastigmine are recommended as options for mild to moderate Alzheimer‟s disease.
Treatment should be started with the drug of lowest acquisition cost. However, an alternative agent could be prescribed if considered appropriate when taking into account adverse event profile, expectations about adherence, medical co-morbidity, possibility of drug interactions and dosing profiles.
Oral formulations should be used except where patient has poor swallow or experiences side effects with oral treatment which would lead to discontinuing treatment.
Avoid anticholinergic (antimuscarinic) drugs with acetylcholinesterase inhibitors which have the potential to reverse their effects.
Considered bioequivalent to Exelon
Modified release as
|8mg tablets: £61.13 (56)
12mg tablets: £74.10 (56)
8mg m/r capsules: £25.94 (28)
16mg m/r capsules: £32.45 (28)
24mg m/r capsules: £39.90 (28)
8mg m/r capsules: £19.04 (28)
16mg m/r capsules: £23.83 (28)
24mg m/r capsules: £29.31 (28)
|1.5mg capsules: £6.32
3mg capsules: £6.60
4.5mg capsules: £14.37
6mg capsules: £16.80
4.6mg/24hr patch: £35.10 (30)
9.5mg/24hr patch: £19.97 (30)
|NMDA-receptor antagonist||Memantine||10mg tablets: £1.46|
20mg tablets: £1.85
|Memantine is recommended as an option for people with;
Moderate Alzheimer's disease who are intolerant or, or have a contraindication to AChE inhibitors, or
Severe Alzheimer's disease.