Dementia Medicines Care Staff Guide: Donepezil, Memantine and Antipsychotics

Medicines can help some people with dementia, but they are not a cure, they do not work for everyone, and some carry real risks. Care staff are often the people who give these medicines, notice their effects and speak up when something does not seem right. Knowing what each type is for, and what national guidance says, helps you do this well.

This guide summarises NHS information and NICE guideline NG97 on the main medicines used in dementia. It is not a substitute for the prescriber's or pharmacist's advice, and care staff should never start, stop or change a medicine themselves.

Two groups of medicines for memory and thinking

Acetylcholinesterase inhibitors

The NHS names three medicines in this group: donepezil, galantamine and rivastigmine. They increase levels of acetylcholine, a brain chemical that helps nerve cells communicate. Rivastigmine is also available as a patch. The NHS says they are used for people with early- to mid-stage Alzheimer's disease, and that the latest guidelines recommend continuing them in the later, severe stages. Common side effects are nausea, vomiting and loss of appetite, which usually improve after about two weeks.

Memantine

Memantine works differently: it blocks the effects of excess glutamate in the brain. The NHS says it is used for moderate or severe Alzheimer's disease, for people who cannot take or do not tolerate an acetylcholinesterase inhibitor, and for people with severe disease who already take one. Side effects can include headaches, dizziness and constipation, which are usually temporary.

What NICE says about who should be offered them

NICE guideline NG97 sets out recommendations by type and severity of dementia:

• Mild to moderate Alzheimer's disease: donepezil, galantamine and rivastigmine are recommended as options.
• Moderate or severe Alzheimer's disease: memantine is recommended for people who are intolerant of or cannot take acetylcholinesterase inhibitors, or who have severe disease. It can be considered or offered alongside an acetylcholinesterase inhibitor depending on severity.
• Not stopped because of severity: NICE says acetylcholinesterase inhibitors should not be stopped in Alzheimer's disease because of disease severity alone.
• Dementia with Lewy bodies: donepezil or rivastigmine should be offered for mild to moderate disease. Our guide to Lewy body dementia explains why care in this condition needs particular attention.
• Vascular dementia: these medicines should only be considered if Alzheimer's disease, Parkinson's disease dementia or dementia with Lewy bodies is also suspected.
• Frontotemporal dementia: NICE says not to offer acetylcholinesterase inhibitors or memantine.

The NHS adds that acetylcholinesterase inhibitors can only be prescribed by specialists, or by GPs on a specialist's advice or with particular expertise.

Antipsychotic medicines: a different level of caution

Medicines for distress and behaviour are different from medicines for memory. The NHS says risperidone, an antipsychotic, may be prescribed by a consultant psychiatrist for persistent aggression or extreme distress when other approaches have not worked, and that antipsychotics have serious side effects, so the lowest dose for the shortest time is advised.

NICE is clear about the conditions:

• Antipsychotics should only be offered to people who are at risk of harming themselves or others, or who are experiencing agitation, hallucinations or delusions that are causing them severe distress.
• The benefits and harms should be discussed with the person and their family members or carers before starting.
• The lowest effective dose should be used for the shortest possible time.
• The person should be reassessed at least every six weeks to check whether they still need the medicine.
• The medicine should be stopped if there is no clear ongoing benefit, after discussion with the person and their family or carers.

Our guide to STOMP and antipsychotic medication review in dementia care homes explains how homes can support these reviews.

Non-drug approaches come first

Both the NHS and NICE emphasise non-drug treatments. The NHS lists cognitive stimulation therapy, cognitive rehabilitation, and reminiscence and life story work. NICE recommends group cognitive stimulation therapy for people with mild to moderate dementia, considering group reminiscence therapy, and personalised activities for agitation or aggression. Before any medicine is considered for distress, NICE advises checking for pain, delirium or inappropriate care. Staff observations are central to this.

What care staff can do

• Give medicines exactly as prescribed and record them accurately. If a person refuses or cannot swallow a medicine, report it rather than finding your own workaround.
• Follow the instructions for patches and any special administration requirements, and check with the pharmacist if unsure.
• Watch for and report side effects, especially nausea, reduced appetite, weight loss, dizziness and new drowsiness. Our guide to polypharmacy and deprescribing explains why regular medicines reviews matter.
• Record what the person was like before and after a medicine was started, so prescribers can judge whether it is helping.
• Know the review date for any antipsychotic and make sure it is not missed.

Keeping your knowledge up to date

NICE expects providers to train all staff in person-centred, outcome-focused dementia care. Understanding medicines is part of that. Record your learning in a CPD log, discuss real examples in supervision, and browse our CPD resources for care staff to extend your knowledge.

Frequently asked questions

Do dementia medicines cure the condition?

No. The NHS says they may help with some symptoms for some people, but not everyone benefits.

Are antipsychotics a first-line way to manage distress?

No. NICE recommends psychosocial and environmental approaches first, and says antipsychotics should be limited to specific situations, used at the lowest dose for the shortest time, and reviewed.

Can a care worker ask for a medicine review?

Yes. Share your observations with the senior on shift, the GP or the pharmacist. Good observation is a key part of safe prescribing.

This article draws on NHS information on Alzheimer's disease treatment (reviewed July 2024) and NICE guideline NG97.