The aim of this guidance is to support consistent, evidence-based practice in the cardiac pre-assessment, monitoring and safe prescribing of acetylcholinesterase inhibitors (AChEIs) for people with dementia. It is intended for clinicians responsible for initiating and monitoring the use of AChEIs and will be useful for commissioners to help inform the development of the dementia care pathway and contracting arrangements with provider services.
Acetylcholinesterase inhibitors (AChEIs) are recommended as first-line treatment for Alzheimer’s Disease. These drugs can slow heart rate which could potentially result in an increased risk of falls. Given that the majority of people with Alzheimer’s Disease are older people and the possible consequences of a fall are more likely to be severe, it is of particular importance that appropriate assessment of a person’s cardiac function is carried out routinely before starting AChEIs. This will enable potential contraindications to be identified and alternative treatment options to be explored if needed.
There is however no definitive national guidance on the required assessment to identify cardiac abnormalities before initiating AChEIs and as a result there is considerable variation in current practice.
The authors reviewed the evidence base for cardiac monitoring, including use of routine electrocardiogram ECG compared with routine pulse monitoring, prior to AChEI initiation. They found that there was no compelling evidence that undertaking a routine ECG in all patients prior to initiation of AChEIs was either justifiable or effective.
The authors recommend that service providers and commissioners should consider adopting the pathway (see Appendix II) proposed by Rowland et al (Rowland, 2007) which incorporates taking a detailed cardiac history, careful pulse checking and subsequent monitoring. In addition to this pathway, the authors recommens use of ECG as standard monitoring in certain ‘higher risk’ groups of patients (see Section 6.3) as an additional safety check.