Rivastigmine Patch Instructions for Elderly Patients with Dementia
Start with the 4.6 mg/24h patch (5 cm²) applied once daily to clean, dry, hairless skin on the upper or lower back, upper arm, or chest, rotating sites daily to minimize skin irritation. 1, 2
Initial Dosing and Titration
Begin with 4.6 mg/24h patch for a minimum of 4 weeks before considering dose escalation, as this allows assessment of tolerability and minimizes gastrointestinal side effects. 1
After 4 weeks, increase to the maintenance dose of 9.5 mg/24h patch (10 cm²) if the initial dose is well tolerated—this represents the recommended therapeutic dose for most patients. 2, 3
For patients who continue to decline functionally and cognitively on the 9.5 mg/24h patch, escalate to 13.3 mg/24h patch (15 cm²), which provides additional benefit in slowing functional deterioration. 4
Application Technique
Apply to intact, clean, dry, hairless skin on the upper or lower back (preferred to prevent removal by patient), upper arm, or chest—avoid areas with skin irritation, cuts, or rashes. 2, 3
Rotate application sites daily and do not apply to the same site for at least 14 days to minimize local skin reactions. 2, 3
Apply at the same time each day, typically in the morning, and remove the old patch before applying the new one. 2
Press firmly for 30 seconds to ensure good adhesion, particularly around the edges. 3
Critical Monitoring in First Month
Week 1 monitoring is essential to catch early adverse effects:
- Assess for nausea, vomiting, diarrhea, appetite changes, and food intake daily during the first week. 1
- Monitor weight, especially in patients under 50 kg who have higher toxicity risk. 1
Weekly assessment for 4 weeks should evaluate:
- Tolerability of current dose (gastrointestinal symptoms, dizziness, falls). 1
- Cognitive and functional stability using standardized measures. 1
- Behavioral changes or emergence of hallucinations. 1
Advantages of Patch Over Oral Formulation
The transdermal patch reduces gastrointestinal side effects by approximately three times compared to oral capsules by avoiding peak drug concentrations. 1, 2
Provides smooth, continuous drug delivery that maintains therapeutic levels while avoiding the peaks and troughs of oral administration. 2
Simplifies dosing with once-daily application and one-step titration to therapeutic dose, improving compliance in elderly patients. 2, 3
Common Adverse Effects
The most frequent side effects are nausea, vomiting, diarrhea, anorexia, headache, dizziness, and abdominal pain, all consistent with cholinergic actions. 5
Application-site reactions occur but are typically mild, including erythema, pruritus, or irritation—these can be minimized by proper site rotation. 6, 3
Withdrawal rates due to adverse events range from 12% to 29% in treatment groups versus 0% to 11% in placebo groups, though the patch formulation has lower discontinuation rates than oral rivastigmine. 7, 2
When to Discontinue
Discontinue rivastigmine if:
- Intolerable side effects develop despite dose adjustment. 5
- No stabilization or improvement occurs after 3 months of adequate trial. 7
- Slowing decline is no longer a meaningful treatment goal in advanced dementia. 7
- Quality of life is judged poor and stabilization is not achievable. 7
Special Considerations for Elderly Patients
In advanced dementia with frailty, rivastigmine's side effects (vomiting, weight loss, falls) may outweigh potential cognitive benefits, requiring careful individualized assessment of whether to initiate or continue treatment. 7
For patients with Parkinson's disease dementia or dementia with Lewy bodies, rivastigmine has specific indications and may provide additional benefit for hallucinations and behavioral symptoms. 8, 1
Rivastigmine does not cause hepatotoxicity and requires no hepatic monitoring, unlike tacrine. 1
Combination Therapy
For moderate to severe Alzheimer's disease, add memantine 20 mg/day to rivastigmine, as this combination provides statistically significant improvements in global assessment and quality of life. 5
Never combine rivastigmine with another cholinesterase inhibitor (donepezil, galantamine), as this amplifies cholinergic side effects without enhancing efficacy. 5
Expected Outcomes
The goal is to slow progression of cognitive and functional decline, not to reverse dementia—patients will continue to decline despite treatment. 5
Rivastigmine produces a 3-point improvement on the ADAS-cog scale compared to placebo, representing a statistically significant but modest clinical benefit. 5
Evaluate therapeutic response at 6-12 months using cognitive measures (ADAS-cog, MMSE) and functional assessments (activities of daily living scales). 5