SHARED CARE PROTOCOL for - NHS Trafford

SHARED CARE PROTOCOL for DONEPEZIL, GALANTAMINE, 

RIVASTIGMINE AND MEMANTINE in Dementia. 

SCOPE 

Greater Manchester West Mental Health NHS Foundation Trust 

NHS Salford 

NHS Bolton 

NHS Trafford 

Issue Date 

May 2011 

Author(s) Originator(s) 

Gillian Moss, GMWMHT, NHS Trust 

Sue Watts, MMG, GMWMHT, NHS Trust 

Joan Miller, MMG, GMWMHT, NHS Trust 

Claire Vaughan NHS Salford 

To be read in conjunction with the following documents 

NICE Technology Appraisal no 217,March 2011 

NICE Guideline Dementia, March 2011 

British National Formulary (current edition) 

Summary of Product characteristics for individual drugs 

Authorised by 

MMG, GMW Mental Health NHS Foundation Trust 

Bolton, Trafford and Salford PCTs MMGs 

Review Date 

May 2013 

1. Introduction 

SCP for Donepezil, Galantamine, Rivastigmine 

and Memantine for the treatment of AD 

Issued May 2011 

Review date May 2013 

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Reference Number 

MMG, GMW, NICE TA 217 

Classification 

SHARED CARE PROTOCOL 

Replaces Local Shared care 

Protocols for prescribing of 

anti dementia drugs 

Donepezil, Galantamine and 

Rivastigmine November 2010. 

The National Dementia Strategy has identified the need for effective collaboration among agencies and 

seamless services between primary care and specialist services. Local Memory Clinics are now well 

established and this Shared Care Protocol (SCP) will facilitate the prescribing of these amber drugs in 

primary care. 

Please note that specialist services are unlikely to remain involved indefinitely with people with 

dementia and their carers and will focus mainly on patients mental health issues. At present, Primary 

Care is the main source of continuity of care and support for people affected by dementias from time of 

diagnosis until end of life. However, dementia services will review all patients being managed under this 

SCP every six months and will be available to be consulted regarding this shared care throughout the 

time patients remain managed under it. 

2. Scope 

This shared care protocol covers people referred with mild to moderate dementia who are clinically 

stable and those with moderate to severe dementia who require treatment with memantine as per NICE 

Guidance. Management of individuals with dementia with challenging behaviours, psychosis or 

significant mood disorder is beyond the scope of this document.

3. Drugs included 

Donepezil 

Galantamine 

Rivastigmine 

Memantine 

NICE concluded that therapy should be initiated with a drug with the lowest acquisition cost. However, 

an alternative acetyl cholinesterase inhibitor could be prescribed where it is considered appropriate 

having regard to adverse event profile, expectations around compliance, medical co morbidity, 

possibility of drug interactions, and dosing profiles. Memantine should only be used in patients with 

moderate Alzheimer’s disease who are intolerant of or have a contraindication to AChE inhibitors or 

those patients with severe Alzheimer’s disease. 

The drug patents for Rivastigmine, Galantamine and Donepezil all expire in early 2012 and generic 

forms with a cheaper acquisition cost are likely to become available. The solution, sustained release 

tablets and patch formulations will, however, remain branded products and the price of these will not 

reduce. For this reason these formulations should be reserved for when there are severe swallowing 

difficulties or compliance issues. 

4. Licensed indications 

DRUG INDICATION DOSAGE RANGE FORMULATION 

Donepezil Mild to moderate 

5-10mg per day Tablets 

Alzheimer’s disease 

Orodispersible tablets. 

Galantamine Mild to moderate 

8-24mg per day as single Sustained release tablets 

Alzheimer’s disease daily dose 

8-24mg per day in 2 divided 

doses 

4mg per ml Oral solution 

8-24mg per day in 2 divided 

doses 

Tablets 

Rivastigmine Mild to moderate 

3 - 12mg daily in 2 divided Hard Capsules 

Alzheimer’s disease, doses 

dementia in Parkinson’s 3 - 12mg daily in 2 divided 2mg per ml oral solution 

disease 

doses 

4.6mg in 24hours 

Transdermal patches 

9.5mg in 24 hours 

4.6mg or 9.5mg/24hr 

Memantine Treatment of patients The recommended starting Tablets 

with moderate to severe dose is 5 mg per day, which 5mg 

Alzheimer's disease. 

is stepwise increased over 

the first 4 weeks of treatment 

10mg 

15mg 

reaching the recommended 

maintenance dose as follows: 

20mg 

Oral solution pump 

Week 1: 5mg once daily 




Recommended maintenance 

dose is 20mg once daily 

5mg/0.5mls ( one pump) 

Lewy Body Disease 

This is a diagnosis of exclusion and there are no definitive investigations. Patients with Lewy Body 

Disease may present with complex and challenging symptoms, which are very difficult to manage. 

Patients with LBD are notoriously sensitive to medication, especially anti-psychotics and this causes 

unique management problems. There is no ICD 10 classification for LBD, however, Dementia in 

Parkinson’s disease is classified and is part of the same spectrum of disorder. It is recognised within 

the NICE Guideline for Dementia that this condition may respond very well to the prescription of acetyl 





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cholinesterase inhibitors and as such their use is included within this protocol. Rivastigmine is licensed 

for Dementia in Parkinson’s disease. The GMMMG RAG group has recently reclassified the use of 

acetyl cholinesterase inhibitors in the treatment of Lewy Body Disease as amber, and so it is covered by 

this SCP. 

5. Therapeutic use 

These drugs will be prescribed in line with NICE guidance TA 217; March 2011. 

6. Contraindications and Cautions 

For full list of cautions/ contra indications and more information see BNF/SPC. 

Cholinesterase Inhibitors 

Contraindications 

Patients with known sensitivity to the active ingredient or excipients 

Pregnancy and lactation 

Severe liver disease (see individual SPCs for advice) 

Severe renal disease (see individual SPCs for advice) 

Although not an absolute contraindication, the service would advise avoiding cholinesterase 

inhibitors in individuals with second or third degree heart block, sick sinus syndrome or 

bradycardia persistently less than 50 until assessed and treated. 

Avoid or stop in patients with gastro-intestinal obstruction or recovering from gastrointestinal 

surgery. 

Cautions 

First degree AV Block and any bradycardia 

Other acute or uncontrolled cardiac conditions 

Predisposal to seizures (Note that the illness itself can cause predisposal to seizures - in 

investigating such patients the possibility of heart block or long sinusal pauses should be 

considered.) 

History of syncope 

Active peptic ulceration or predisposition to same as cholinesterase inhibitors can cause an 

increase in gastric acid secretions 

Patients predisposed to urinary obstruction (theoretical risk of bladder outflow obstruction) 

Asthma or Chronic Obstructive Pulmonary Disease - observe for any worsening of airways 

disease 

Body weight below 50kg (GI side effects more likely) 

Epilepsy 

Parkinsonian Syndrome (May cause a worsening of extra pyramidal symptoms). 

Administration concomitantly with other inhibitors of acetyl cholinesterase - agonists or 

antagonists of the cholinergic system should be avoided. (See drug interactions). 

Memantine 

Contraindications 

Hypersensitivity to the active substance or to any of the excipients. 

Cautions 

Caution in epilepsy, former history of convulsions or patients with predisposing factors for 

epilepsy 

Concomitant use of NMDA antagonists such as amantadine, ketamine and dextromethorphan 

should be avoided. Adverse drug reactions esp. CNS-related may be more frequent or more 

pronounced. 

Some factors that may raise urine pH may necessitate careful monitoring of the patient. These 

include drastic changes in diet e.g. from carnivore to vegetarian or massive ingestion of 





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alkalising gastric buffers. Urine pH may also be increased by states of renal tubular acidosis 

(RTA) or severe infections of the urinary tract with Proteus bacteria. 

Patients who have had a recent MI, uncompensated CCF(NYHA III-IV), or uncontrolled 

hypertension should be closely monitored due to limited evidence. 

Oral solution contains sorbitol. Patients with rare hereditary problems of fructose intolerance 

should not take this medicine. 

7. Prescribing in pregnancy and lactation 

N/A 

8. Dose regimen and titration 

Drug Initial Dose Increased / Maximum Doses 

Donepezil 5mg once daily at increased if necessary to 10mg after one month 

bedtime 1 

Galantamine 4mg twice daily 

for 4weeks 

Galantamine XL 8mg once daily 

for 4 weeks 

Rivastigmine 1.5mg twice daily 

for at least 

2weeks 

Rivastigmine 

patches 

Initially 

4.6mg/24hour 

applied daily for 

at least 4weeks 

Memantine 5mg od for 7 days 

Memantine 

solution 

5mg/0.5mls : one 

downward pump 

for 7 days 





Increased to 8mg twice daily for 4weeks then 

consider increasing to 12mg twice daily 

Increased to 16mg once daily for 4 weeks then 

consider increasing to 24mg daily 

3mg twice daily for at least two weeks, 4.5mg twice 

daily for at least two weeks,6mg twice daily for at 

least two weeks. Usual maintenance dose 3-6mg 

twice daily. 

Then 9.5mg/24hour daily 

(site of replacement patches needs to be rotated. 

Avoid using same area for 14days 

Then 

10mg once daily for 7 days 

15mg once daily for 7 days 

20mg once daily thereafter 

Then 

10mg/1mls; two downward pumps for 7 days 

15mg/1.5mls three downward pumps for 7 days 

20mg/2mls; four downward pumps thereafter 

For detail explanation of using the pump see PIL or 

SPC. 

1 Although the SPC suggests taking the once daily dose at bedtime, generally it is preferable to take the tablet after food, which reduces 

the risk of side effects in addition it may be practical to prescribe the tablet to be taken in the morning or when home carers visit. 

An individual who is frequently sensitive to a range of medications may need a smaller starting 

dose and a slower titration. 

Individuals who have difficulty with swallowing tablets may prefer a liquid or orodispersible 

preparation. 

A patient who suffers unpleasant gastrointestinal side effects may tolerate a transdermal patch. 

A patient or carer who has difficulty with complicated dose titrations may prefer the relatively 

straightforward titration regime of Donepezil. 

A patient who is receiving supervision in the community may need the drug prescribed at a 

specific time or via a monitored dosage system, which may dictate the choice of drug. 

9. Drug Interactions 

Individuals being treated with drugs affecting cognitive function will require review as below before 

initiation of these drugs. 

Alcohol misuse: 

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Patients currently drinking unsafe amounts of alcohol will not be treated with cholinesterase 

inhibitors or memantine, but may be considered for treatment if they have Alzheimer’s disease 

or Lewy Body Disease and their alcohol intake is reduced to be within safe limits. 

Benzodiazepines: 

Consideration must be given to whether the benzodiazepines may be affecting cognitive 

function especially in large doses, if so they must be reduced gradually and stopped. 

Non Steroidal Anti Inflammatory Drugs (NSAID): Increased risk of acid production with 

Cholinesterase inhibitors review need for NSAID. Patients may need increased monitoring for 

gastric complications if using NSAID. 

Drugs that may cause bradycardia e.g. digoxin, beta blockers: There is an increased risk 

of potentiation of bradycardia with cholinesterase inhibitors. This is particularly important in 

‘sick sinus syndrome’ or AV block. Increased monitoring is required. 

Tricyclic antidepressants have anticholinergic effects: 

Tricyclic antidepressants as an antidepressant: 

Consider changing to an SSRI/ SNRI or Mirtazapine if still requiring treatment. Individual drugs 

vary in their capacity to interact so check before prescribing an antidepressant. For example 

there is an interaction between paroxetine and galantamine, which may increase the levels of 

the cholinesterase inhibitor. 

Tricyclic Antidepressants as an adjunct to pain control: 

If prescribed for pain in small dosage, and still required after review, continue with caution. 

Other Anticholinergic drugs: review the need for these drugs as they may oppose the effect 

of cholinesterase inhibitors. 

Drugs with Cholinomimetic properties: 

o Peripherally Acting Cholinesterase inhibitors: Such as neostigmine or 

pyridostigmine. 

o Cholinergic drugs e.g. pilocarpine. 

Drug Interactions with memantine 

Warfarin: Memantine has been seen to increase INR in some patients and so close monitoring 

of INR may be required until patient is stabilised. 

L-dopa.dopaminergic agonists and anticholinergics may be enhanced. Effects of 

barbiturates and antipsychotics may be reduced. Concomitant administration with 

antispasmodics, dantrolene or baclofen can modify their effects and dosage adjustment may 

be necessary. 

Amantadine should be avoided due to risk of pharmacotoxic psychosis. Ketamine and 

dextromethorphan may have same effects and one case with phenytoin. 

Increased plasma levels possible with cimetidine, ranitidine, procainamide, quinidine, quinine 

and nicotine. 

Possible reduced serum level of hydrochlorothiazide 

10. Adverse effects 

See SPC for full list of side effects 

The main side effects seen in clinical practice for cholinesterase inhibitors are diarrhoea, muscle 

cramps, fatigue, nausea, vomiting, anorexia and insomnia. These are usually seen at initiation and at 

dose increases. 

The main side effects for memantine are dizziness, headache, constipation, somnolence and 

hypertension though adverse events were usually mild to moderate. 

11. Baseline investigations 

Before referral to the memory service or specialist the GP should have carried out 





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Full Blood count 

Biochemical profile (include U and E’s and LFT’s) 

Thyroid function 

Serum B12 and folate 

Syphilis serology if applicable 

Lipid profile 

Cognitive screening (e.g. AMTS etc) 

12. Ongoing monitoring by the GP 

The GP will monitor for ongoing side effects and discuss with memory clinic or specialist if any arise for 

advice on dose reduction, discontinuation etc. If patients cardiac health changes appropriateness of 

prescription will need to be discussed with the memory clinic team/specialist. 

13. Secondary care contact information 

See local appendices. 

14. Criteria for shared care 

Patient has been assessed in line with NICE guidance by memory services/specialist services. 

15. Responsibilities for secondary care 

NICE guidelines state that these medications should be initiated by specialist services after a formal 

diagnosis has been made. Monitoring of the effects of these medications is undertaken by specialist 

services within a shared care protocol. 

See Appendices for local procedures in Bolton, Salford and Trafford. 

The following is a list of interventions that should be provided but this is subject to local variation and 

available resources. 

Undertake a comprehensive assessment of people newly presenting with possible mild to 

moderate dementia – including domiciliary assessment when appropriate 

Arrange, undertake or refer for specialist investigations as appropriate, for example: 

o Neuroimaging – MRI, SPECT, CT 

o Psychometric assessment 

Sensitive delivery of diagnosis 

Formulate an appropriate care plan involving other agencies as necessary 

Provide information and support including adjustment to diagnosis, advice around secondary 

prevention and management of condition to patients and carers. 

Provide advice about psychosocial management of cognitive impairments 

Occupational Therapy interventions, as required 

Initiate, or provide information for GP to initiate or continue medication where appropriate. 

Monitor effects of medication and associated side effects 

Signpost patients to other services where appropriate 

Inform GP of patient’s progress. 

Inform GP of any change in medication or if medication is to be stopped. 

Liaison with 

o Primary Care 

o Social services 

o Liaison with local voluntary agencies 

o CMHT 

o Cerebral Function Unit or local specialist neurology service. 

o Other agencies as relevant e.g. Court of Protection, DVLA, Police 





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If and when dementia becomes severe or treatment has been ineffective, review and 

discontinue medication as appropriate, provide support and further signposting to services as 

needed. 

16. Responsibilities for GP 

Provide regular prescriptions for cholinesterase inhibitors or memantine as per locally agreed 

protocols. 

See Appendices for local procedures in Bolton, Salford and Trafford. 

Be aware of side effects and common drug interactions as documented in this SCP. 

Provide regular health checks including where relevant the review of clients with vascular 

dementia or mixed dementia and provision of advice about lifestyle. 

Inform specialist services of any relevant physical health problems at the earliest opportunity. 

If patient suffers any adverse reaction, GP should liaise with secondary care/specialist services. 

If patient develops bradycardia with symptoms on cholinesterase inhibitors, such as lightheadedness 

or syncope, stop the drug and notify Memory Clinic. If patient develops 

bradycardia without symptoms and if the rate is persistently less than 50, stop the drug and 

notify Clinic, if rate is 50-60, continue drug and notify Memory Clinic. 

If patient develops second or third degree AV block, stop drug, consider referral to cardiology 

and notify memory clinic. 

The specific needs of older and cognitively impaired people should be taken into account. Please 

consider: 

Simple drug regimes, preferably no more than once or twice daily dosages 

Use of compliance aids 

Involving carers in discussions about medication and heath promoting advice 

Providing essential information in writing 

Effects of polypharmacy – medication regimes need regular review and simplification 

Prompt treatment of intercurrent physical conditions that may worsen symptoms of dementia 

People with dementia may need a more flexible appointments system 

It may be in the best interests of people with dementia to keep carers informed and capacity 

assessments may need to be undertaken when considering issues of confidentiality 

Assessment of needs and health of informal carers should be offered. 

Advice for patients having General Anaesthetics: 

Donepezil, Galantamine and Rivastigmine 

Donepezil, Galantamine and Rivastigmine can enhance the effects of suxamethonium and the 

duration of the block may be prolonged. Donepezil and Rivastigmine can antagonise the effects of 

non-depolarising muscle relaxants such as atracurium, cisatracurium, mivacurium, pancuronium, 

rocuronium, vecuronium. 

Memantine 

No specific studies looking at use of memantine in patients undergoing surgery.In addition the 

company are not aware of any studies looking at memantine use with anaesthetics. Theoretically there 

may be a risk of pharmacotoxic psychosis if memantine is used concomitantly with ketamine. This is 

based on a report for amantadine as there are no reports with ketamine specifically (April2011). 

Neuroleptics and anticholinergics used in surgical procedures may interact with memantine. The 

effect of neuroleptics may be reduced and the effect of anticholinergics may be enhanced although 

these interactions may be overcome by change of dose. See section 9 and SPC for full list of drug 

interactions. 





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Drug Situation Advice 

Donepezil Planned operations Stop 2 – 3 weeks before operation for complete wash out. 

Rivastigmine 

Galantamine 

Emergency 

Inform the anaesthetist of potential of prolonged muscle 

operations 

relaxation. 

Post-operative Re-introduce during post-surgical rehabilitation. 

Planned Operations Miss the last dose prior to surgery, i.e., if the operation is in the 

morning miss the previous night-time dose. 

Emergency 


operations 

relaxation. 

Post-operative Re-introduce during post-surgical rehabilitation. 

Planned Operations stop two days before surgery for washout 

Emergency 


operations 

relaxation. 

Post-operative re-introduce during post-surgical rehabilitation 

Memantine Planned operations If a decision is made to discontinue memantine before surgery 

the total washout period would be 2 to 3weeks. When to 

restart memantine will depend on the dose and half life of the 

drug used in surgery. 

17. Responsibilities of the patient/carer 

The GP or memory clinic/specialist staff should be informed of any adverse effects to treatment, 

compliance issues with treatment, deterioration in physical health and progression of dementia. 





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18. Supporting documentation 

APPENDIX 1 : Statement of Agreement between GP and Consultant. 

REFFERAL FORM FROM CONSULTANT PSYCHIATRIST TO GP 

SHARED CARE PROTOCOL for CHOLINESTERASE INHIBITORS 

From: 

(Name of Consultant Psychiatrist) 

Name of GP practice: 

Name of Patient: 

Date of Birth: 

NHS Number: 

Medication Prescribed: 

Reason for Choice (tick 

as appropriate): 

Indication (delete as 

appropriate): 

Name of Memory Clinic 

Contact: 

Telephone Number 





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To: 

(Name of GP) 

Cost effectiveness 

Poor tolerance of other options 

Simplicity of regime 

Licensed indication 

Swallowing problems 

Side effect profile 

Compliance 

Other 

Alzheimer’s Disease / Dementia in Parkinson’s Disease 

For the Consultant Psychiatrist 

I would be grateful if we could adopt the shared care protocol for the above patient. 

I accept my responsibilities as outlined in the enclosed SCP. 

Signed Consultant 

Date: 

Psychiatrist/Senior 

Clinician 

For the GP 

I accept my responsibilities as outlined in the enclosed guideline. YES/NO 

Signed GP 

Date:

Local Salford Service Variations 





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Appendix 2 

Diagnosis and Early Intervention for Mild to Moderate Dementias Including Treatment with Antidementia 

Drugs. 

1. Referrals to the Memory Clinic 

1.1 Referrals may be received from a variety of sources; mainly from Primary Care, but many are 

received from Social Services, CMHT’s, Neurology, Department of Health Care for the Elderly, 

General Psychiatry services and other secondary care sources. Prior to referral, the referring agent 

should explain the reason for the referral to the patient and carer as appropriate with a brief 

description of the service to which they are being referred. 

1.2 The Memory Clinic accepts referrals of individuals of all ages with possible mild to moderate 

dementia requiring assessment, diagnosis and consideration for treatment in keeping with the 

recommendations of the National Dementia Strategy: 

www.dh.gov.uk/en/SocialCare/Deliveringadultsocialcare/Olderpeople/NationalDementiaStrategy/DH_0 

83362. This may include individuals with mild cognitive impairment, some of whom will later progress 

to dementia (see NICE, NDS). 

1.3 The service does not see urgent referrals or people whose main presenting problems 

include significant challenging behaviours, major mood disorder or psychotic symptoms. 

Referrals of people with these problems should be addressed initially to the Older People’s 

CMHT single point of entry (Tel: 0161 607 7111), or A and E in an emergency. 

1.4 If major physical investigations are in progress consider delaying referral until stable/consult clinic 

for advice. 

1.5 Referrals should include the following information (see standard referral form attached) 

Demographic data 

Brief history of presenting problem 

Dementia screening test results (see below) 

Information about recent physical assessment 

Blood pressure 

Medical history and current medication 

Use of compliance aids 

ECG if possible/available 

Recent hospital correspondence/test results if relevant 

Information about smoking and alcohol intake (and other substance misuse if relevant) 

Contact details for patient and main carer 

Risks 

Whether it is reasonable to ask patient to attend a clinic 

1.6 Dementia screening tests 

Full Blood count 

Biochemical profile (include U and E’s and LFT’s) 

Thyroid function 

Serum B12 and folate 

Syphilis serology if applicable 

Lipid profile 

Cognitive screening (eg AMTS etc) 

2.0 Specialist Service Responsibilities 

Undertake a comprehensive assessment of people newly presenting with possible mild to 

moderate dementia – including domiciliary assessment when appropriate 

Arrange, undertake or refer for specialist investigations as appropriate, for example:

o Neuroimaging – MRI, SPECT, CT 

o Psychometric assessment 

Sensitive delivery of diagnosis 

Formulate an appropriate care plan involving other agencies as necessary 

Provide information and support including adjustment to diagnosis, advice around 

secondary prevention and management of condition to patients and carers 

Advice about psychosocial management of cognitive impairments 

Occupational Therapy interventions 

Recommend medication based on cost effectiveness, individual patient tolerance, simplicity 

of dosage regime, licensed indication, ability to swallow, side effect profile etc. 

Provide information for GP to initiate or continue medication where appropriate 

Monitor effects of medication and associated side effects. This takes place in accordance 

with NICE guidance utilising a local protocol and takes place at least 6 monthly, in some 

cases by telephone. 

Inform G.P. of any change in medication including drug titration schedules or if medication 

is to be stopped. 

Signpost patients to other services where appropriate 

Inform G.P. of patient’s progress. 

Liaison with 

o Primary Care 

o Social Services 

o Age Concern/local voluntary agencies 

o CMHT 

o Cerebral Function Unit 

o Other agencies as relevant e.g. Court of Protection, DVLA, Police 

If and when dementia becomes severe, review and discontinue medication as appropriate, 

provide support and further signposting to services as needed. 

Educational Role – Within available resources, memory clinic staff will contribute to 

educational programmes for a variety of agencies and including service users and carers. 

Research, evaluation and audit – Memory Clinics will participate in well-designed research 

projects and continuously evaluate and audit services. Approaches will assess patient and 

carer experience will be incorporated on a regular basis. 

3. Written information provided to patient 

3.1 Information leaflets about the Memory Assessment and Treatment Service are provided with 

appointment details and may be provided to primary care if requested. 

3.2 Information leaflets are available about all 3 cholinesterase inhibitors and are provided to 

patients and carers as appropriate. 

3.3 Information leaflet on memantine are provided to patients and carers as appropriate 

All patients and carers receive information about their diagnoses, implications and proposed 

management. After initial face-to-face discussion, this may be provided in the form of standardised 

leaflets or individualised written material or a combination of both. This includes as appropriate, 

Information about driving in dementia, 

Issues relevant to mental capacity including 

o Lasting Power Of Attorney 

o Advance Directives 

Information about local support services for service users and carers. 

Other sources of relevant information such as web sites. 

4. General Practitioner and Primary Care Services 

Refer to service according to guidance in paragraph 1.5 

Initiate and continue regular prescriptions for cholinesterase inhibitors as per guidance from 

specialist services/secondary care. 

Be aware of side effects and common drug interactions 

Provide regular health checks including where relevant the review of clients with vascular 

dementia or mixed dementia and provision of advice about lifestyle. 





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Inform specialist services of any relevant physical health problems at the earliest opportunity. 

If patient suffers any adverse reaction, GP should liaise with secondary care/specialist 

services. 

If patient develops bradycardia with symptoms, such as light-headedness or syncope, stop the 

drug and notify Memory Clinic. If patient develops bradycardia without symptoms and if the rate 

is persistently less than 50, stop the drug and notify Clinic, if rate is 50-60, continue drug and 

notify Memory Clinic. 

If patient develops second or third degree AV block, stop drug, consider referral to cardiology 

and notify memory clinic. 

Back-up care available to GP from Hospital, including emergency contact procedures and help 

line numbers. 

Salford Memory Assessment and Treatment Service - 0161 703 1045 

The Memory Clinic is not an emergency service, so there is no out of hours arrangement at present. 

During the day there is an answer phone system when administrative staff are not available. 

During the working day there is an emergency Duty System for the Department of Psychiatry of Later 

Life based at Humphrey Booth Resource Centre, and accessed via 0161 607 7111). 

Emergencies out of hours should be referred to the Out of Hours GP service or A&E. 





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SHARED CARE PROTOCOL for - NHS Trafford

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