1. Memantine (Ebixor) Joanne Lily Wombwell Senior Memory Clinic Nurse Hartington Unit, CNDRH

2. How it works Memantine in Alzheimer's, however, appears to work by protecting the brain’s nerve cells against glutamate, which is a chemical released in excess by cells damaged by Alzheimer’s or other neurological disorders. Glutamate plays an essential role in learning and memory by triggering NMDA receptors to allow a controlled amount of calcium to flow into the nerve cells. Too much glutamate, however, over stimulates the receptors, leading to the neuronal cell death that is common to all degenerative diseases. Glutamate binds to receptors in the brain, allowing calcium to flow freely into the cell, a process known as ‘overexcitation.’ Chronic overexposure to calcium in turn leads to cell degeneration. Memantine is believed to work by preventing this destructive process by blocking the action of glutamate at NMDA receptor sites.

4. INDICATIONS Moderatly severe AD (MMSE 13/30 and under) with behavioural problems Cardiac complications preventing AcHI trial Unable to tolerate AcHI and moderatly impaired

5. Side Effects Raised blood pressure Dizzy spells Constipation Headache Fatigue Drowsiness Vomiting Increased confusion

6. Efficacy A pooled analysis of efficacy trials of the NMDA antagonist Memantine indicates that it is superior to placebo for treating and preventing behavioural symptoms in Alzheimer’s disease patients; however, the therapeutic benefit appears to be modest.

7. Cost Memantine titration pack £43.13 for initial 28 days supply Maintenance dose £69.01 for 28 days supply

8. Case Study (MRS T) Female aged 69 (Mrs T) In Dementia care NH Donepezil stopped 8wk ago as outside NICE guidelines, MMSE 8/30, aggressive Challenging behaviours Care home not coping Visited and prescribed Memantine titration pack Discussed with Consultant and made aware of situation Referred to CMHT OA for care home advice

9. Review 2 Review 2, 8 weeks on Memantine, MMSE not done Less agitation Fewer incident reports Advised to continue behaviour monitoring chart Seen by CPN and advice given to staff on coping and managing behaviours

10. Review 3 12 weeks on Memantine MMSE 13/30 Slightly calmer but remains paranoid and has aggressive outbursts. Continue behaviour chart Covert administration of medication care plan implemented with daughters consent Continue Memantine Review in 6 months Consultant to visit to review and has recently started quetiapine Remains under care of CMHT OA

11. References http://www.primarypsychiatry.com/aspx/articl edetail.aspx?articleid=1596 http://www.primarypsychiatry.com/aspx/articl edetail.aspx?articleid=1596 www.lundbeck.co.uk BNF 60