Chapter 4 Central Nervous System

Chapter 4 Central Nervous System 4.1 Hypnotics and anxiolytics. Insomnia Underlying causes should be identified and treated e.g. depression, anxiety, pain, pruritis, and dyspnoea. In-patients who are prescribed a hypnotic purely to aid sleep while on a hospital ward must not be prescribed a hypnotic on discharge if they did not use a hypnotic prior to admission. Hypnotics should always be prescribed as required, and patients should be encouraged to use them only on an intermittent basis (except long-term, dependent patients - Benzodiazepine Withdrawal). Hypnotics should be avoided if possible in the elderly, who are at risk of becoming ataxic and confused, making them liable to falls and injury. Nitrazepam has a long duration of action and may give rise to residual effects on the following day; repeated doses may be cumulative. Its use is not recommended. Anxiety Treatment should be limited to the lowest possible dose for the shortest possible time to avoid tolerance and dependence. 4.1.1 Hypnotics Indications: short-term use in insomnia Hypnotics must not be prescribed on discharge, except for patients admitted on them. Zopiclone N.B: Zopiclone also has the potential for abuse and dependence, therefore prescribing should be subject to the same precautions as benzodiazepines and it should not be used for longer than 4 weeks, including tapering off. New patients should not be put on a repeat prescription and existing patients should be reviewed and offered the chance to stop or withdraw. Zolpidem can be used for patients with swallowing difficulties only - as this can be crushed and mixed with water for enteral tubes. (NB. Zopiclone can block enteral tubes when crushed and mixed with water.) Chloral Hydrate - paediatrician initiation only Paediatric Elixir 200mg/5ml Solution 500mg/5ml

Additional prescribing advice: The prescribing of hypnotics to children, except for occasional use such as for sedation for procedures is not justified. There is a risk of habituation with prolonged use Problems settling children at night should be managed with behavioural therapy. These drugs accumulate on prolonged use (BNF for children 2012/13) 4.1.2 Anxiolytics Indications: short-term use in anxiety 2-4 weeks only, Short-term use in alcohol withdrawal (see guidelines - chapter 8). First choice: Diazepam Additional prescribing advice: Only indicated for the short-term relief (2-4 weeks) of anxiety that is severe, disabling or subjecting the individual to unacceptable stress. Treatment should be limited to the lowest possible dose for the shortest possible time. Hospital only: Lorazepam (red) For acute inpatient use only. N.B. Intravenous route has a risk of respiratory depression. Chlordiazepoxide (red) For alcohol withdrawal. Short term use only. Not for Discharge. 4.1.3 Barbiturates Barbiturates (CD) should only be prescribed to patients already taking them, who have severe intractable insomnia, when attempts to discontinue treatment have been unsuccessful. 4.2 Drugs used in psychoses and related disorders. NICE CG 82 treatment and management of schizophrenia in adults in primary and secondary care For this section REFER to LANCASHIRE CARE Formulary

4.2.1 Antipsychotic drugs Chlorpromazine Haloperidol Both can also be used for Intractable hiccup 4.2.2 Antipsychotic depot injections see Lancashire care formulary 4.2.3 Antimanic drugs See Lancashire Care Formulary - initiated by consultant psychiatrist only See NPSA alert Safer Lithium Therapy 2009 Lithium Plasma level monitoring - it is essential to monitor lithium plasma levels for each patient, as lithium has a narrow therapeutic/toxic ratio. Plasma concentrations should be maintained in the range 0.4-1.0mmol/litre. Levels should be carried out every 3 months. Patients should be told to maintain an adequate fluid intake, and to avoid dietary changes, which might reduce or increase sodium intake. N.B. All Lithium medication should be prescribed by brand name. Different preparations of lithium liquid vary widely in bioavailability. 4.3 Antidepressant drugs. All antidepressants in section 4.3 should follow the Lancashire Care formulary. 2-4 weeks of therapy is required before any response is seen therefore continue for at least 4 weeks at therapeutic dose before treatment is reassessed for response. Swapping or stopping antidepressants should be done with caution or advice from Pharmacy. Antidepressants should be used at full therapeutic dose - treatment failure may result from use of too low a dose. If an antidepressant is not tolerated at full therapeutic dose, change to an alternative or different class of drug at full therapeutic dose. Treatment should be maintained at full therapeutic dose for at least 4-6 months after recovery before considering withdrawing therapy gradually. Depending on patients individual personal circumstances consideration should be given to long-term prophylactic maintenance therapy (at full

therapeutic dose) after an episode of severe depression, as the risk of relapse is substantial if treatment is stopped. In recurrent depression (e.g. 2 episodes within 5 years), prophylactic maintenance therapy at full therapeutic dose may need to be continued for several years. When an antidepressant is withdrawn after regular treatment for a period greater than 8 weeks, this should preferably be carried out gradually over about 4 weeks. Changing between antidepressants Care should be taken when changing from one antidepressant to another - consult Pharmacy for advice on interactions and washout period required between stopping the first antidepressant and commencing the second OR see The Maudsley Prescribing Guidelines in Psychiatry. 4.3.1 Tricyclic and related antidepressant drugs First choice: Amitriptyline Second choice: Nortriptyline Additional prescribing advice: Amitriptyline is sedating and may be the best choice for agitated or anxious patients (Nortriptyline is less sedating). 1 st Choice for neuropathic pain. Therapy should be initiated with lower starting doses in the elderly, as they may be prone to dizziness or syncope. Caution in patients with cardiovascular disease, due to the risk of arrhythmias. Care is also required in epileptic or diabetic patients. Imipramine can also be used as an alternative in breastfeeding. All antidepressants have a delayed onset of action of 2-4 weeks. Treatment should normally be continued until 6 months after response. Patients who have had 2 or more previous episodes of depression may benefit from long-term antidepressant at therapeutic doses. 4.3.3 Selective serotonin reuptake inhibitors (SSRIs) First choice: Citalopram Second choices: Fluoxetine N.B. Fluoxetine has a long half-life, and account should be taken of this when adjusting dosage. Sertraline

Additional prescribing advice: Renal impairment use Citalopram or Sertraline Liver impairment use Citalopram, Imipramine or Paroxetine Sertraline is the safest in cardiac patients Due to the risk of gastro-intestinal bleeding, SSRIs should be used with caution in patients aged over 80 years, those with prior upper gastrointestinal bleeding, or in those also taking aspirin or another NSAID. Citalopram should be used with caution for concomitant use of other QT interval prolonging medicines or hypokalaemia/hypomagnesaemia inducing drugs as they can prolong the QT interval. Citalopram maximum dose 40mg daily (over 65years max 20mg) 4.3.4 Other Antidepressant Drugs initiated on specialist advice They should not be used as first line therapy, but may be considered in patients who have failed to respond to or tolerate other antidepressants. Mirtazapine Venlafaxine Duloxetine usually for neuropathic pain (see 6.1.5) 4.4 CNS stimulants and drugs used for attention deficit hyperactivity disorder - Amber N.B. For use under direct supervision of specialist consultant only. For Paediatric patients (not to be initiated in adults, but maintain treatment.) Methylphenidate CD Atomoxetine Dexamphetamine (Dexamfetamine) CD Narcolepsy Modafinil consultant neurologist only

4.5 Drugs used in the treatment of obesity 4.5.1 Anti-obesity drugs acting on the gastro-intestinal tract First choice: Diet and lifestyle changes Second choice: Orlistat Additional prescribing advice: Diet and lifestyle changes are the mainstay for management of obesity. Drugs should never be used as the sole element of treatment. Anti-obesity drug should only be considered for those with a BMI of 30kg/m 2 or greater (>27kg/m 2 with associated risk factors) in whom at least 3 months of managed care supervised diet, exercise and behaviour modification fails to achieve a realistic reduction in weight. Treatment should only be continued beyond 12 months after discussing the benefits and risks. The individual should be monitored on a regular basis; should the individual gain weight whilst on drug treatment it will be discontinued. Common side effects may be limited by dietary compliance (decreased fat intake) Discontinue treatment after 3 months if patients fail to lose 5% of their initial body weight (target for initial weight loss may be lower in patients with type 2 diabetes) 4.5.2 Centrally acting appetite suppressants No longer recommended. Prescribers should not issue prescriptions and review any patients on them. 4.6 Drugs used in nausea and vertigo. General Nausea: First choice: Metoclopramide Second choice: Cyclizine Prochlorperazine Metoclopramide is a dopamine antagonist with similar properties to the phenothiazines. However it also has a peripheral action on the gut and may be more suitable for prophylaxis and treatment of nausea and vomiting associated with gastroduodenal, hepatic and biliary disease. Dystonic

reactions are more common in the young (especially girls and young women) and the very old. Injection of procyclidine can abort dystonic attacks. Domperidone is a dopamine antagonist, which also has a peripheral action on the gut. It does not readily cross the blood brain barrier and so is less likely to cause dystonic reactions; it may be given for levodopa or dopamine agonist-induced vomiting in Parkinsonism or gastric stasis. Ondansetron are specific (5HT 3 ) serotonin antagonists. Use in patients who cannot tolerate, or whose symptoms are not controlled by, other antiemetics. Melts or suppositories are useful if vomiting. Prochlorperazine Buccal tablets 3mg useful if vomiting Motion sickness: First choice Cyclizine Second choice: Hyoscine Hydrobromide Post-operative nausea: See hospital policy and flowchart on post-operative nausea and vomiting. First choice: Cyclizine Second choice: Prochlorperazine Ondansetron Palliative care nausea: Haloperidol Metoclopramide Antiemetic therapy should be reviewed every 24 hours as it may be necessary to substitute the antiemtic or add another one. Metoclopramide is used for nausea and vomiting associated with gastritis, gastric stasis and functional bowel obstruction. Cyclizine is used in those with mechanical bowel obstruction and raised intracranial pressure. Haloperidol, cyclizine or Levomepromazine may be added to a diamorphine syringe driver in palliative care; Levomepromazine also causes marked sedation and may be used where agitation is a symptom in this situation.

Hyoscine hydrobromide injection is mainly used for reduction of respiratory secretions in palliative care. Hyoscine patch 1mg in 72 hours useful for those with swallowing difficulties Nausea and vomiting within Palliative care Vestibular disorders Indications: vertigo, tinnitus and hearing loss associated with Ménière s disease. Betahistine Prochlorperazine Cinnarizine Additional prescribing advice: The antihistamines cyclizine and promethazine, or prochlorperazine, may be used in nausea and vertigo associated with vestibular disorders. Betahistine may be used specifically for Ménière s disease. Prochlorperazine or cinnarizine should be reserved for the treatment of acute symptoms. Prochlorperazine should not be prescribed for dizziness in older patients due to the risk of drug induced parkinsonism, postural hypotension and mental confusion. Flunarizine (unlicensed special) specialist initiation only Hospital Only

4.7 Analgesics ACUTE AND POST-OPERATIVE PAIN MANAGEMENT GUIDELINES 4.7.1 Non-opioid analgesics Mild Paracetamol 1gram four times a day Add in *NSAID (Ibuprofen or Naproxen) Moderate Paracetamol plus NSAID PLUS short acting weak opioid (e.g. Codeine, Dihydrocodeine) Severe Paracetamol plus NSAID PLUS short acting opioid (morphine sulphate elixir) (If Nil by mouth consider intramuscular or intravenous routes) NSAID Choice depends on risk factors. Use lowest effective dose for the shortest period of time. Diclofenac should be used with caution in patients with Cardiovascular risk factors. Naproxen has a higher G.I.risk than Diclofenac

Additional prescribing advice: There is a large individual variation in patient response and so analgesia should be tailored to individual patient requirements. Acute pain should be relieved as soon as possible and the underlying cause should be investigated and treated. Pain and sedation should be assessed and scored regularly and treatment modified accordingly. The requirement for strong analgesics is greatest in the immediate postoperative period and should be stepped down to mild analgesics after a few days - the timing of this will depend on the operation and previous condition of the patient. Non-steroidal anti-inflammatory drugs (NSAIDs) prevent pain associated with tissue swelling, and may be combined with strong analgesics when visceral pain is also present. Surgery see: Oral loading dose of paracetamol for adult elective surgical patients guideline. For drug conversions See Palliative care guidance on opioid conversion. For acute pain from fractured ribs Use moderate pain relief and then refer to the guideline and algorithm. Route of administration The parenteral route is usually only necessary in the immediate postoperative period. Oral analgesics can be restarted once the patient is able to tolerate fluids and light diet. Oral analgesics are most effective when given before previous analgesia has worn off; therefore give oral analgesia 30-60 minutes before a PCA/epidural is discontinued. Paracetamol IV is also available as an alternative when other routes are not possible. Local anaesthetic blocks, epidural or intrathecal administration of opioid +/- local anaesthetic, intravenous or subcutaneous infusion of opiate, or patient controlled analgesia (PCA) of opiate provide alternatives for the management of pain in the immediate post-operative period in selected patients used on the direction of, and under the supervision of, an anaesthetist. N.B. Patients prescribed continuous infusions or patient controlled analgesia (PCA) should not receive other opiates without discussion with the anaesthetist. All analgesic requirements should be reviewed before discharge.

CHRONIC SEVERE PAIN MANAGEMENT GUIDELINES Establish that the pain is opioid-sensitive. Initially 4 hourly oral morphine should be used and the dose titrated until the patient is pain free between doses. In the elderly or frail, and those with liver or renal impairment the dose is approximately one quarter to half the normal adult dose. Once pain is controlled and daily opiate requirement is known, administration with slow-release morphine is possible. Prn 4 hourly morphine should still be prescribed for breakthrough pain, at a dose equivalent to one sixth of the daily dose. The number of prn doses should be reviewed every 24 hours, and if they are required frequently because the patient is in pain, the regularly administered daily dose should be increased by 30-50%. If the regularly administered dose is increased, then the prn dose may also need to be increased. Buprenorphine patches are only an option for patients unable to take or tolerate oral medication. Amitriptyline may be used as an adjunct in chronic pain. (unlicensed - ) Opioid-induced constipation In patients who will be administered an opioid analgesic on a regular basis for more than a few days should be prescribed a regular laxative to prevent constipation. Opioid-induced nausea - (this is usually temporary) patients administered an opioid analgesic should be prescribed a prn antiemetic e.g. haloperidol, prochlorperazine, but this is normally only required for a few days. PALLIATIVE CARE PAIN MANAGEMENT GUIDELINES See Palliative Care Team - Pain and Symptom Management Guidelines. Refer to the following on the intranet:: - Care of the dying pathway - Opioid conversion guide - Fentanyl transdermal patches - Fentanyl nasal spray - Nausea and Vomiting

4.7.2 Opioid analgesics For conversion between drugs see Palliative care guidance on opioid conversion. Codeine and dihydrocodeine are effective for relief of mild-moderate pain and are of similar analgesic efficacy. Although up to 10% of Caucasians may be unable to metabolise codeine to morphine, dihydrocodeine does not rely on this process for action, therefore may be the better choice and can be used to determine if the patient responds to weak opioids. Morphine is the opiate of choice for the relief of severe, acute, chronic and post-operative pain. It has a duration of action of 4 hours but this does depend on dose and pain severity - it may be given as frequently as every 2 hours if necessary e.g. for pain in the immediate post-operative period. Oxycodone is given orally only for - post-operative pain management following hip/knee arthroplasty using the step down algorithm and administration chart or in renal patients. Other patients should use morphine with antiemetics. Diamorphine is very soluble, allowing large doses to be dissolved in small volumes of diluent. For this reason it is used for administration of doses by continuous subcutaneous infusion in palliative care. Fentanyl patches should be reserved for patients whose pain is constant and stable, with previous exposure to opioids, who have swallowing difficulties, problems with compliance, or renal impairment. Pethidine is short-acting (3 hours) and is unsuitable for the control of prolonged pain due to the necessity for frequent administration.

4.7.3 Neuropathic pain See NICE guidance CG96 First choice: In patients with non-cancer pain Amitriptyline (unlicensed) Gabapentin Duloxetine (diabetics only) Second choice: Switch to an alternative first choice or combine two drugs (amitriptyline + gabapentin) pregabalin Additional prescribing advice: Neuropathic symptoms are characterised by a description of tingling, burning or shooting pains. There may also be allodynia (pain produced by a stimulus that does not normally produce pain - touch) and hyperalgesia (increased response to a stimulus which is normally painful). Pain can often be worse at the end of the day, by hot or cold, touch or movement Neuropathic pain can be a feature of an underlying disease diabetes. Patients are unresponsive to conventional analgesics Patients should be warned of side effects and that medication may have to be taken for 4-6 weeks regularly before the full effect is appreciated. Amitriptyline is best taken in the evening to reduce the hangover effect and titrate slowly to reduce side effects. If intolerable adverse effects develop with amitriptyline but have satisfactory pain reduction consider imipramine or nortriptyline (both unlicensed) Duloxetine is first choice in diabetic neuropathy before using amitriptyline. If after combined treatment there is still unsatisfactory pain reduction the patient should be refered to a specialist. Topical Lidocaine plasters are licensed for postherpetic neuralgia in those intolerant of first line systemic therapies or unable to take oral medication due to medical condition or disability. (Specialist use only) See Policy for Gabapentin/Pregabalin in neuropathic pain Gabapentin is first line and Pregabalin second, as this is NOT a cost effective first line agent for the treatment of peripheral neuropathic pain.

4.7.4 Antimigraine drugs See LTH Headache Management Pathway Proposal Most treatments can be started and managed in Primary Care 4.7.4.1 Treatment of acute migraine Soluble analgesics are absorbed quickly and have a more rapid effect than non-dispersible tablets. Diclofenac suppositories may be useful for pain relief if vomiting occurs during migraine. Aspirin should not be given to patients under 16 years due to the risk of Reye s syndrome, unless specifically indicated. Metoclopramide can cause acute dystonic reactions especially in patients under 20 years of age. Domperidone may be better tolerated. If analgesics are inadequate, an attack may be treated with a 5HT agonist NICE CG150 recommends using Triptan plus NSAID together First choice: Sumatriptan 50mg Second choices: Rizatriptan Zolmitriptan Additional Prescribing Advice Interaction between propranolol and rizatriptan: a 5-mg dose of rizatriptan (rather than the more usual 10 mg) should be used in the presence of propranolol, with a maximum of two or three doses in 24 hours. Nasal zolmitriptan may be a suitable alternative if oral preparations are ineffective. If this is ineffective, then subcutaneous sumatriptan should be considered or alternatively intramuscular diclofenac. Sumatriptan 50mg and 100mg are equally efficacious. Sumatriptan 50mg produces fewer side-effects and is considered the optimum dose. 4.7.4.2 Prophylaxis of migraine See Headache Pathway Botox A (NICE TA260) possible treatment for preventing headaches in some adults with chronic migraine.

4.7.4.3 Cluster headache and the trigeminal autonomic cephalalgias under neurologist supervision Treatment: Sumatriptan subcutaneous (or nasal) Alternatively, 100% oxygen at a rate of 7-12 litres/minute is useful in aborting an attack. Prophylaxis: Prednisolone Topiramate Lithium Verapamil Prophylaxis is considered if the attacks are frequent, or last over 3 weeks, or if the attacks cannot be treated effectively. 4.8 Anti-epileptic drugs - Initiation by specialist. Primary care repeat prescribing, monitoring and dose adjustment 4.8.1 Control of epilepsy See NICE guidance CG20. Partial seizures with or without secondary generalisation: Lamotrigine To minimise the risk of rash, initial dosages and dose titration regimes should not be exceeded. Carbamazepine N.B. Suppositories for short-term use (maximum 7 days) when oral therapy temporarily not possible. 125mg as suppositories is approximately equivalent to 100mg orally, but final dose adjustment should always depend on clinical response To minimise the risk of rash, initial dosages and dose titration regimes should not be exceeded and HLA testing is advised before prescribing to Han Chinese. Sodium valproate Topiramate

For specialist initiation only: Levetiracetam Oxcarbazepine Gabapentin/Pregabalin Vigabatrin Zonisamide Retigabine as per NICE TA232 Eslicarbazepine Consultant Only (after failure of 2 other agents) Absence seizures: Ethosuximide All forms of epilepsy: Phenytoin N.B. Plasma concentration for optimum response is 10-20mg/litre (40-80 micromol/litre) but plasma levels should be interpreted in light of clinical response. Phenobarbitone (Phenobarbital) CD Primidone Clonazepam Adjunct in epilepsy Clobazam Adjunctive treatment of partial seizures: Lacosamide- Consultant initiation only Adjunctive treatment of seizures in Lennox-Gastaut syndrome Rufinamide consultant initiation only

Additional Prescribing Advice Prescribe by brand as different preparations may vary in bioavailability; it may be prudent to avoid changing the formulation to avoid reduced effect or excessive side-effects. Interactions between antiepileptic drugs are complex and may enhance toxicity without a corresponding increase in antiepileptic effect. Antiepileptic drugs that induce hepatic enzymes may impair the efficacy of oral contraceptives; see BNF for details. All antiepileptic drugs carry a risk of teratogenicity. Increasing the number of drugs increases the risk; ideally, women planning to conceive should use adequate contraception until on monotherapy. Sodium valproate should not be taken concomitantly during pregnancy. Routine plasma drug level monitoring is generally unnecessary unless sideeffects are a problem, non-compliance is suspected, or phenobarbital or phenytoin are administered. Monitoring is seldom of value for patients on sodium valproate. Vigabatrin is restricted to patients in whom all other combinations are inadequate or are not tolerated. If patients are established on vigabatrin, the potential for long-term visual side effects should be considered. 4.8.2 Drugs used in status epilepticus First choice: Lorazepam IV Second choices: Diazepam rectal/iv Phenytoin injection NB. ECG monitoring and 0.2micron filter required Midazolam buccal (Buccolam) Paraldehyde injection (unlicensed) N.B. If using plastic syringe must be administered immediately; otherwise use glass syringe. Additional Prescribing Advice: Where facilities for resuscitation are not immediately available, diazepam can be administered as a rectal solution. Intravenous Diazepam is effective but associated with a high risk of thrombophlebitis. Absorption from intramuscular injection or suppositories is too slow for treatment of status epilepticus. If seizures recur or fail to respond within 30 minutes, phenytoin should be used. If this fails within 60 minutes seek ICU support.

4.9 Drugs used in Parkinsonism and related disorders Initiation by specialist, Primary care repeat prescribing, monitoring and dose adjustment. 4.9.1. Dopaminergic drugs used in Parkinson s disease - Patients with suspected Parkinson s disease should be referred to a specialist to confirm the diagnosis; the diagnosis should be reviewed every 6-12 months. - Medication should only be changed on the advice of the specialist. - Anti-parkinsonian drug therapy should never be stopped abruptly as this carries a small risk of neuroleptic malignant syndrome. - In the elderly these drugs can cause confusion therefore start with low doses and increase the dose gradually. Levodopa: Levodopa Co-beneldopa Co-careldopa Additional Prescribing Advice: Modified release preparations may help with end-of-dose deterioration or nocturnal immobility and rigidity. Dopamine receptor agonists: Pramipexole Ropinirole Rotigotine Apomorphine shared care Additional Prescribing Advice May be used to reduce motor fluctuations in patients with levodopa induced symptoms These drugs can cause excessive daytime sleepiness and sudden onset of sleep. Patients and carers should be informed about the risk of impulse control disorders. If the patient develops this the dopamine-receptor agonist or levodopa should be withdrawn or dose reduced until symptoms resolve. Apomorphine should have specialist supervision throughout treatment.

Monoamine-oxidase-B inhibitors: Rasagiline (consultant initiation only) Selegiline Additional Prescribing Advice: Selegiline is used in conjunction with levodopa to reduce end-of-dose deterioration in advanced Parkinson s disease. It may be appropriate to start with a dose of 2.5mg daily, particularly in the elderly, to avoid initial confusion and agitation. Catechol-O-methyltransferase inhibitors: Entacapone Additional Prescribing Advice: Combination product with co-careldopa Stalevo Consider Stalevo only for patients on a stable dosage of levodopa or other problems affecting compliance Amantadine: Amantadine Reserved for patients in whom other drug classes cannot be used. (Consultant only) 4.9.2 Antimuscarinic drugs used in Parkinsonism Trihexyphenidyl Procyclidine Additional Prescribing Advice Reserved for patients, typically young with early disease and severe tremor in which other classes cannot be used. Should not be withdrawn abruptly in patients receiving long-term treatment.

4.9.3 Drugs used in essential tremor, chorea, tics and related disorders Specialist initiation only Riluzole To extend life in patients with motor neurone disease who have amyotropic lateral sclerosis Piracetam Adjunctive treatment for myoclonus of cortical origin Tetrabenazine To control movement disorders in huntington s chorea and related disorders. Torsion dystonias and other involuntary movements Botulinum toxin type A Under specialist supervision 4.10 Drugs used in substance dependence 4.10.1 Alcohol dependence See hospital policy for alcohol withdrawal chapter 8 Chlordiazepoxide Pabrinex injection Thiamine 4.10.2 Nicotine dependence See Hospital Policy on Nicotine replacement therapy NB. Supply one week on discharge only if a referral to smoking cessation has been made. First choice: Nicorette invisi patches

Second choice: Nicorette Inhalator Third choice: Nicorette mini lozenges 4.10.3 Opioid dependence Opioid substitution therapy only occurs whilst an inpatient. No supply is provided on discharge. Continuation of supply via their normal routine can then restart. 4.11 Dementia Specialist only See Lancashire Care Formulary. Only to be prescribed on recommendation from the Lancashire Care geriatricians. National Dementia strategy: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/do cuments/digitalasset/dh_094051.pdf It is recommended that: Low dose anti-psychotics should not be used in the elderly to treat mild to moderate psychotic symptoms. Initial doses of anti-psychotic drugs in elderly patients should be reduced (to half the adult dose or less), taking into account factors such as the weight, co-morbidity and concomitant medication. Treatment should be reviewed regularly.