Naturalistic audit of NICE criteria for the use of cholinesterase inhibitors

Abstract

Aims and MethodIn 2001 the National Institute for Clinical Excellence (NICE) produced guidance for the treatment of Alzheimer's disease. NICE encourages the withdrawal of medication when the Mini-Mental State Examination (MMSE) score reaches 12 and advises against the treatment of patients with cholinesterase inhibitors if the MMSE score is below 12. Most health authorities have rigorously enforced these guidelines, which has put old age psychiatrists in a difficult position. Our prospective 12 week audit of consecutive patients examines the response to treatment of patients treated both in accordance with and outside of NICE criteria. We also investigated the effect of stopping the medication according to NICE's recommendation.ResultsOur results suggest that patients outside the NICE criteria respond better than those within the criteria. More disturbingly, when the medication was stopped owing to the MMSE score falling below 12, we found a very high mortality rate (5 out of 25, 20%) or acute deterioration (12 out of 25, 48%). This suggests that the medication is beneficial in the later stages and should not be stopped purely because of the stage of dementia.Clinical ImplicationsIf we are to prevent unnecessary suffering, greater freedom is needed by old age psychiatrists in the use of these antidementia drugs. Patients with severe dementia may benefit from acute treatment. The withdrawal of medication in line with NICE guidance is poor clinical practice and likely to have adverse outcomes in a large proportion of cases.

Assessment of factors that influence physician decision making regarding medication use in patients with dementia at the end of life

“…The impact of discontinuing dementia medications in these patients has not been well studied. Furthermore, the lack of evidence available to guide clinicians on when to discontinue therapy (Birks, 2006;Herrmann et al, 2007a;Herrmann and Gauthier, 2008) and reports of adverse events associated with discontinuation (Doody et al, 2001;Singh and Dudley, 2003;Holmes et al, 2004;Simpson et al, 2005;Okazaki et al, 2006;Daiello et al, 2009;Shega et al, 2009) may also explain the variation in decisions made by physicians in this study.…”

Diagnosis and treatment of dementia: 6. Management of severe Alzheimer disease

“…If the rate of decline appears to be more rapid after the start of therapy, discontinuing the drug would be appropriate. However, in some studies, patients who appeared initially to benefit from the therapy experienced rapid cognitive decline, 67 withdrawal symptoms 68 and poorer prognosis (acute deterioration and death) 69 after cholinesterase inhibitors were stopped. Clinicians should therefore monitor patients closely after discontinuing these drugs because of the risks of significant withdrawal symptoms and cognitive decline.…”

Impact of deprescribing AChEIs on aggressive behaviors and antipsychotic prescribing

“…in establishing the evidence base around deprescribing in this population. Although prior observational studies in patients with severe dementia also suggest no significant worsening of behavioral symptoms following deprescribing AChEIs, [15][16][17] our study has a number of strengths that impart greater clinical significance and translatability to our findings. We used a large, nationally representative sample of nursing home residents with dementia, specifically those with severe dementia.…”