Physical health monitoring of cognitive enhancers

MyPsych App
NHS GGC

Acetylcholinesterase inhibitors

Before treatment, inform patient and carer of potential adverse effects. Provide Patient Information Leaflet when possible, available via choice and medication website.

In addition to the table below, other physical health checks as felt to be clinically indicated – e.g. physical examination, renal function should be carried out.

 

Blood pressure/Pulse

Weight

Adverse effects**

ECG***

Baseline (at initiation of medication)

X

X e.g. via MUST

 

only if indicated

1 week after starting treatment* & after any dose increase

X

 

X

 

Before dose increase

X

X- if clinically indicated

X

 

4 weeks after stabilised on maximum tolerated dose

X

X

X

 


*Keep in mind that it may take time for the GP to issue the prescription. This monitoring would start 1 week after the first dose is taken.
**See cognitive enhancer summary and appendix 1 in the full guidance.
***Consider cardiac status during workup (refer galantamine blog & Medicines Update Extra bulletin for risk factors associated with QTc prolongation). If cardiac risk identified obtain U&Es and ECG at baseline and once stable therapeutic dose is established
No routine monitoring is required unless felt to be clinically indicated. ECGs should only be carried out when clinically appropriate, for example if cardiac symptoms emerge or a patient is started on medication known to cause QTc prolongation

Memantine

The guidance below applies when memantine is used as a single agent or to augment treatment with a cholinesterase inhibitor.

Before treatment, inform patient and carer of potential adverse effects.  Provide Patient Information Leaflet when possible, available via choice and medication website.

In addition to the table below, other physical health checks as felt to be clinically indicated – e.g. ECG, physical examination, renal function should be carried out.

 

Blood pressure/Pulse

Adverse effects**

Baseline (at initiation of medication)

X

 

7 days after starting treatment*

X

X

14 days after starting treatment*

X

X

After dose titration completed*

X

X

4 weeks after stabilised on maximum tolerated dose

X

X

 *If slower dose titration indicated adjust physical monitoring as appropriate.

**See cognitive enhancer summary and appendix 2 of the full guidance.

No further routine monitoring is required unless felt to be clinically indicated. e.g. repeat of renal function

Cognitive enhancer summary

Medication

Licensed Indication

Oral Dose(other doses indicated for patches)

Common adverse effects(See SPC and BNF for full details)

 

 Donepezil

 

 

 

Mild to moderately severe Alzheimer's dementia.

 

Start at 5mg daily at night. After one month can be increased to 10mg once daily.

 

Adverse effects include GI disturbances (nausea, vomiting & diarrhoea), reduced appetite & weight loss, bradycardia, dizziness & syncope, headache, tiredness & fatigue, agitation & anxiety, urinary incontinence, sleep disturbance, muscle cramps, seizures.

Rivastigmine oral

 

 

 

Mild to moderately severe Alzheimer's dementia /

Mild to moderately severe dementia in idiopathic Parkinson’s disease.

Dementia with Lewy Bodies

 

 

Start at 1.5mg twice daily with morning and evening meals.

 

Increase dose by 1.5mg twice daily at a minimum of two weekly intervals, if tolerated, to maximum of 6mg twice a day.

 

Effective dose is 3 to 6 mg twice a day; to achieve maximum therapeutic benefit patients should be maintained on their highest well-tolerated dose.

 

As above

 

 

Rivastigmine transdermal patch

Mild to moderately severe Alzheimer's dementia /

Mild to moderately severe dementia in idiopathic Parkinson’s disease.

Dementia with Lewy Bodies

Started with 4.6mg/24h.

 

After a minimum of four weeks of treatment and if well tolerated the dose should be increased to 9.5mg/24h, this is the daily recommended effective dose, which should be continued for as long as the patient continues to demonstrate therapeutic benefit.

 

If well tolerated and only after a minimum of six months of treatment at 9.5mg/24h, the treating physician may consider increasing the dose to 13.3mg/24h in patients who have demonstrated a meaningful cognitive deterioration and/or functional decline

Transdermal administration (patch) is less likely to cause side effects although may cause skin reaction/rash. Provide instruction to ensure correct use of patches to reduce risks e.g. skin rash, risk of multiple patch application

Galantamine – use modified release preparation

 

 

Mild to moderately severe Alzheimer’s dementia.

Starting dose 8mg once daily in the morning with food, increased to 16mg after 4 weeks (minimum effective dose)

May be increased to 24mg daily after 4 weeks if tolerated.

 

As Above

 

Rarely serious skin rash*

 

Memantine

Moderate to severe Alzheimer's disease.

 

5mg daily for 7 days, then 10mg daily for 7 days, then 15mg daily for 7 days then to 20mg daily. Doses may be split if clinically appropriate

Dizziness, headache, constipation, somnolence, bradycardia and hypertension, heart failure, venous thromboembolism and rarely seizures

*If skin reaction occurs stop immediately.

If adverse effects emerge consider reducing to previously tolerated lower dose as clinically indicated or if severe discontinue treatment or consider an alternative preparation e.g. rivastigmine patch.

Editorial Information

Last reviewed: 25/01/2023

Next review date: 01/12/2024

Author(s): PMG-MH.

Version: 1

Author email(s): PrescribingManagementGroup.MentalHealth@ggc.scot.nhs.uk.

Approved By: PMG-MH

Reviewer name(s): Lead Clinical Pharmacist, Clinical Effectiveness Pharmacist.