Chapter 4: Central nervous system

Hypnotics and anxiolytics

CAUTION: Risk of falls/fractures, confusion, memory impairment

  • See Section 3.4 for specific information on benzodiazepines and Z drugs withdrawal, and see insomnia guidelines 

CAUTION: Risk of dependency

Antipsychotics

CAUTION: Risk of stroke and death in elderly patients with dementia. See Antipsychotics

CAUTION: Anticholinergic ADRs for phenothiazines (e.g. chlorpromazine). See Anticholinergics

CAUTION: Worsening of Parkinson’s disease (specialist advice is recommended)

Antidementia Drugs
  • Formally assess benefit: Continue if drug benefits global, functional or behavioural symptoms
    • Cognitive scores e.g. MMSE can help as a guide but should not rely only on cognition scores if these are inappropriate in the individual patient e.g. communication, language difficulty. See NICE Guidance.
Antidepressant Tricyclics

Confirm need (First episode: Treat for 6-9 months; Second + episode: Treat for ≥2 years)

CAUTION: Anticholinergic ADRs. See Anticholinergics. SSRIs are better tolerated in the elderly

CAUTION: Risk of GI bleeding may be increased

Avoid combination with MAOIs because of the risk of serotonin syndrome

Metoclopramide

Now only licensed for a maximum of 5 days (does not apply to off label use in palliative care)

CAUTION: Worsening of Parkinson’s disease (domperidone is more suitable but note contra-indications in cardiac disease and severe liver disease)

Antihistamines

Rarely indicated for long term treatment of vertigo

Anticholinergic ADRs. See Anticholinergics

Opioids

Assess effectiveness/choice (is pain neuropathic or otherwise not responsive to opiates? e.g. chronic back pain, widespread pain, fibromyalgia, medically unexplained symptoms)

CAUTION: Constipation. Use laxatives
CAUTION: Cognitive impairment and respiratory depression, dependency, immunosuppression and suppression of sex hormones

Paracetamol

CAUTION: Overdosing

  • Ensure patient is aware of minimum interval between doses and maximum daily dose
  • Avoid more than 1 paracetamol containing product
  • Dose reduction where low body weight [<50kg]or renal or hepatic impairment
Antiepileptics

Assess effectiveness/dose if used for pain management: Is pain neuropathic, use DN4 or LANSS to aid diagnosis. Titrate dose up to assess effectiveness. Limited evidence for musculoskeletal pain/fibromyalgia) See Chronic Pain Scotland and SIGN 136

CAUTION: Dizziness, blurred vision and sedation. Check renal function. Reduce dose in CKD.