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Chapter 4
Nervous system
CONTENTS
Dementia
page 315
Epilepsy and other seizure disorders
Status epilepticus
2.1
Mental health disorders
Anxiety
3.1
Attention deficit hyperactivity disorder
3.2
Bipolar disorder and mania
3.3
Depression
3.4
Inappropriate sexual behaviour
3.5
Psychoses and schizophrenia
3.6
Movement disorders
Dystonias and other involuntary movements
4.1
Parkinson’s disease
4.2
Dementia
Dementia
Description of condition
Dementia is a progressive clinical syndrome characterised by
a range of cognitive and behavioural symptoms that can
include memory loss, problems with reasoning and
communication, a change in personality, and a reduced
ability to carry out daily activities such as washing or
dressing. Alzheimer’s disease is the most common type of
dementia; other common types of dementia include vascular
dementia (due to cerebrovascular disease), dementia with
Lewy bodies, mixed dementia, and frontotemporal dementia.
Aims of treatment
The aim of treatment is to promote independence, maintain
function, and manage symptoms of dementia.
Non-drug treatment
g Patients with all types of mild-to-moderate dementia
presenting with cognitive symptoms should be given the
opportunity to participate in a structured group cognitive
stimulation programme. Group reminiscence therapy (use of
life stories to improve psychological well-being), and
cognitive rehabilitation or occupational therapy to support
daily functional ability, should also be considered. h
Management of cognitive symptoms
g Some commonly prescribed drugs are associated with
increased antimuscarinic (anticholinergic) burden, and
therefore cognitive impairment; their use should be
minimised. h Drugs with antimuscarinic effects include
some antidepressants (e.g. amitriptyline hydrochloride
p. 390, paroxetine p. 384), antihistamines (e.g.
chlorphenamine maleate p. 297, promethazine
hydrochloride p. 301), antipsychotics (e.g. olanzapine p. 416,
quetiapine p. 419), and urinary antispasmodics (e.g.
solifenacin succinate p. 823, tolterodine tartrate p. 823).
Nervous system
Nausea and labyrinth disorders
page 448
Ménière’s disease
5.1
Pain
Headache
6.1
6.1a Migraine
Neuropathic pain
6.2
Sleep disorders
Insomnia
7.1
Narcolepsy
7.2
Substance dependence
Alcohol dependence
8.1
Nicotine dependence
8.2
Opioid dependence
8.3
Alzheimer’s disease
g In newly diagnosed patients, drug treatment should
only be initiated under the advice of a specialist clinician
experienced in the management of Alzheimer’s disease.
In patients with mild-to-moderate Alzheimer’s disease,
monotherapy with donepezil hydrochloride p. 316,
galantamine p. 317, or rivastigmine p. 318
(acetylcholinesterase inhibitors) are first-line treatment
options. If acetylcholinesterase inhibitors are not tolerated
or contra-indicated, memantine hydrochloride p. 320 is a
suitable alternative in patients with moderate Alzheimer’s
disease. Memantine hydrochloride is the drug of choice in
patients with severe Alzheimer’s disease.
In patients already receiving an acetylcholinesterase
inhibitor to treat Alzheimer’s disease, the addition of
memantine hydrochloride should be considered if they
develop moderate or severe disease; in this case, memantine
hydrochloride can be initiated in primary care without advice
from a specialist clinician. h
In patients with moderate Alzheimer’s disease,
discontinuing acetylcholinesterase inhibitor treatment can
cause a substantial worsening in cognitive function; g
treatment discontinuation should not be based on disease
severity alone. h
Non-Alzheimer’s dementia
g Donepezil hydrochloride [unlicensed indication] or
rivastigmine [unlicensed indication] should be given to
patients with mild-to-moderate dementia with Lewy bodies;
galantamine [unlicensed indication] can be considered only
if treatment with both donepezil hydrochloride or
rivastigmine is not tolerated. Donepezil hydrochloride
[unlicensed indication] or rivastigmine [unlicensed
indication] can also be considered in patients with severe
dementia with Lewy bodies. Memantine hydrochloride
[unlicensed indication] can be considered as an alternative in
patients with dementia with Lewy bodies in whom
acetylcholinesterase inhibitors are contra-indicated or not
tolerated.
Acetylcholinesterase inhibitors [unlicensed indication] or
memantine hydrochloride [unlicensed indication] should
only be considered in patients with vascular dementia if they
have suspected co-morbid Alzheimer’s disease, Parkinson’s
disease dementia, or dementia with Lewy bodies.
Acetylcholinesterase inhibitors and memantine
hydrochloride are not recommended in patients with
frontotemporal dementia or cognitive impairment caused by
multiple sclerosis. h
For management of Parkinson’s disease dementia see
Parkinson’s disease p. 429.
Nervous system
Management of non-cognitive symptoms
Agitation, aggression, distress and psychosis
g Patients with dementia should be offered psychosocial
and environmental interventions such as counselling and
management of pain and delirium to reduce distress.
Antipsychotic drugs should only be offered to patients
with dementia if they are either at risk of harming
themselves or others, or experiencing agitation,
hallucinations or delusions that are causing them severe
distress. h The CHM/MHRA has reported (2009) an
increased risk of stroke and a small increased risk of death
when antipsychotic drugs are used in elderly patients with
dementia. The balance of risks and benefits should be
carefully assessed, including any previous history of stroke
or transient ischaemic attack and any risk factors for
cerebrovascular disease such as hypertension, diabetes,
smoking, and atrial fibrillation.
g Antipsychotic drugs should be used at the lowest
effective dose and for the shortest time possible, with a
regular review at least every 6 weeks. h
In patients who have dementia with Lewy bodies or
Parkinson’s disease dementia, antipsychotic drugs can
worsen the motor features of the condition, and in some
cases cause severe antipsychotic sensitivity reactions. See
also management of psychotic symptoms in Parkinson’s
disease p. 429.
Depression and anxiety
g Psychological treatments (e.g. cognitive behavioural
therapy (CBT), multisensory stimulation, relaxation, or
animal-assisted therapies) should be considered for patients
with mild-to-moderate dementia who have mild to moderate
depression or anxiety; antidepressants should be reserved
for pre-existing severe mental health problems. h
Sleep disturbances
g Patients should be offered non-drug treatment
approaches to manage sleep problems and insomnia,
including sleep hygiene education, exposure to daylight, and
increasing exercise and activity. h
Useful Resources
Dementia: assessment, management and support for people
living with dementia and their carers. National Institute for
Health and Care Excellence. NICE guideline 97. June 2018.
www.nice.org.uk/guidance/ng97
Other drugs used for Dementia Risperidone, p. 421
ANTICHOLINESTERASES › CENTRALLY ACTING
PDF pages 336, 337, 338
