Deprescribing cholinesterase inhibitors and memantine in dementia: guideline summary

Abstract

Introduction: Cholinesterase inhibitors (ChEIs) and memantine are medications used to treat the symptoms of specific types of dementia. Their benefits and harms can change over time, particularly during long term use. Therefore, appropriate use of ChEIs and memantine involves both prescribing these medications to individuals who are likely to benefit, and deprescribing (withdrawing) them from individuals when the risks outweigh the benefits. We recently developed an evidence-based clinical practice guideline for deprescribing ChEIs and memantine, using robust international guideline development processes. Main recommendations:Our recommendations aim to assist clinicians to:• identify individuals who may be suitable for a trial of deprescribing ChEIs and memantine (such as those who do not have an appropriate indication, those who have never experienced a benefit, those who appear to be no longer benefitting, and those who have severe or end-stage dementia); and• taper treatment and monitor individuals during the deprescribing process. Changes in management as a result of the guideline:• Deprescribing ChEIs and memantine through shared decision making with individuals and their caregivers by: ▶ determining their treatment goals; ▶ discussing benefits and harms of continuing and ceasing medication, from the start of therapy and throughout; and ▶ engaging them in monitoring after discontinuation, while informing carers that the individual will continue to decline after discontinuation.• This approach may reduce adverse drug reactions and medication burden, leading to improved quality of life in people with dementia.

Deprescribing tools: a review of the types of tools available to aid deprescribing in clinical practice

“…Several tools exist to aid deprescribing in people with dementia, such as drug‐specific deprescribing guidelines for antipsychotics and cholinesterase inhibitors and memantine . Holmes et al .…”

“…The Bruy ere Deprescribing Guidelines in the Elderly project (Canada) has developed four drug-specific deprescribing guidelines, and a fifth was developed in conjunction with the University of Sydney (Australia). [21][22][23][24][25][26][27] Their method of developing guidelines 28 is based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) process, 29 Guideline 2.0 checklist, 30 and Appraisal of Guidelines for REsearch and Evaluation (AGREE) II. 31 The fifth guideline also underwent the process required for Australian National Health and Medical Research Council (NHMRC) approval, demonstrating that deprescribing guidelines could be developed to the same robust standards as clinical treatment guidelines as assessed by an external body.…”

“…Several tools exist to aid deprescribing in people with dementia, such as drug-specific deprescribing guidelines for antipsychotics 26 and cholinesterase inhibitors and memantine. 25 Holmes et al 67 reviewed medications taken by people with advanced dementia and used a modified Delphi consensus method to create lists of medications that were never, rarely, sometimes or always appropriate. There were several commonly used medications for which consensus could not be achieved (e.g.…”

Impact of deprescribing AChEIs on aggressive behaviors and antipsychotic prescribing

“…We used a large, nationally representative sample of nursing home residents with dementia, specifically those with severe dementia. The results presented are liable to have the greatest clinical significance in this subpopulation, given that those with severe dementia are the most appropriate candidates for deprescribing AChEIs as suggested by clinical guidelines 4,18 and have been shown in previous studies to have the greatest likelihood for deprescribing 47–50 . We also accounted for time‐dependent confounding in our analytical design, which is important in this population in which many of the fluctuating clinical prognostic factors that drive deprescribing AChEIs may subsequently be affected by the discontinuation of these medications.…”

“…Evidence suggests that BPSD severity varies across the stages of dementia, with the greatest frequency of symptoms being reported in the middle to late stages and a potential decline in end‐stage dementia 10 . Therefore, additional studies are needed in patients with severe dementia to take into account the relevance of BPSD at this stage of the disease when deprescribing is most likely to occur 18 …”