Hostname: page-component-586b7cd67f-dsjbd Total loading time: 0 Render date: 2024-11-30T17:45:45.171Z Has data issue: false hasContentIssue false
  • English
  • Français

Discontinuing cholinesterase inhibitors: results of a survey of Canadian dementia experts

Published online by Cambridge University Press:  20 September 2010

Nathan Herrmann ,
Sandra E. Black ,
Abby Li  and
Krista L. Lanctôt
Nathan Herrmann*
Affiliation:
Department of Psychiatry and Faculty of Medicine, University of Toronto, and Division of Geriatric Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
Sandra E. Black
Affiliation:
Division of Neurology, Department of Medicine, University of Toronto, and Brain Sciences Research Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
Abby Li
Affiliation:
Neuropsychopharmacology Research Group, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
Krista L. Lanctôt
Affiliation:
Department of Psychiatry, University of Toronto, and Brain Sciences Research Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
*
Correspondence should be addressed to: Dr. Nathan Herrmann, Department of Psychiatry, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada. Phone: +1 416-480-6133; Fax: +1 416-480-6022. Email: [email protected].
Get access Rights & Permissions [Opens in a new window]

Abstract

Background: Cholinesterase inhibitors (ChEIs) are being used for increasingly long periods of time, even in patients with severe Alzheimer's disease. Because there is little data to help clinicians to decide on when it is safe and appropriate to discontinue ChEIs after long-term use, practices may vary widely.

Methods: An internet-based survey was undertaken of Canadian dementia experts (geriatric psychiatrists, neurologists, geriatricians) involved in clinical trial research. Recommendations for ChEI discontinuation were determined based on responses to questions dealing with patient/caregiver preference, administrative considerations, effectiveness, and adverse events.

Results: There was reasonable consensus that ChEIs should be discontinued based on patient and caregiver preference, and in the presence of severe bothersome adverse events. There was much less consensus on issues related to effectiveness – in particular, what constitutes greater than expected decline. There was a general reluctance to rely on any single measure of cognition, function and/or behavior, and in particular, the MMSE was seen as unhelpful for making decisions about discontinuation.

Conclusion: Recommendations for discontinuing ChEIs after long-term use from a survey of dementia experts are presented. Ideally, clinical practice guidelines based on controlled discontinuation trials are needed.

Keywords

cholinesterase inhibitorsAlzheimer's diseasedementiatreatment
Type
Research Article
Information
International Psychogeriatrics , Volume 23 , Issue 4 , May 2011 , pp. 539 - 545
Copyright
Copyright © International Psychogeriatric Association 2010

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

American Psychiatric Association (2007). Practice guidelines for the treatment of patients with Alzheimer's disease and other dementias. Second Edition. American Journal of Psychiatry, 164, 1–56.Google Scholar
Ballard, C. G. et al. (2004). A 3-month, randomized, placebo-controlled, neuroleptic discontinuation study in 100 people with dementia: the neuropsychiatric inventory median cutoff is a predictor of clinical outcome. Journal of Clinical Psychiatry, 65, 114–119.CrossRefGoogle ScholarPubMed
Behl, P., Lanctôt, K. L., Streiner, D. L. and Black, S. E. (2008). The effect of cholinesterase inhibitors on decline in multiple functional domains in Alzheimer's disease: a two-year observational study in the Sunnybrook dementia cohort. International Psychogeriatrics, 20, 1141–1159.CrossRefGoogle ScholarPubMed
Bullock, R. and Dengiz, A. (2005). Cognitive performance in patients with Alzheimer's disease receiving cholinesterase inhibitors for up to 5 years. International Journal of Clinical Practice, 59, 817–822.CrossRefGoogle ScholarPubMed
Burns, A., Gauthier, S. and Perdomo, C. (2007). Efficacy and safety of donepezil over 3 years: an open-label, multicentre study in patients with Alzheimer's disease. International Journal of Geriatric Psychiatry, 22, 806–812.CrossRefGoogle ScholarPubMed
Daiello, L. A., Ott, B. R., Lapane, K. L., Reinert, S. E., Machan, J. T. and Dore, D. D. (2009). Effect of discontinuing cholinesterase inhibitor therapy on behavioral and mood symptoms in nursing home patients with dementia. American Journal of Geriatric Pharmacotherapy, 7, 74–83.CrossRefGoogle Scholar
Gill, S. S. et al. (2009). Syncope and its consequences in patients with dementia receiving cholinesterase inhibitors: a population-based cohort study. Archives of Internal Medicine, 169, 867–873.CrossRefGoogle ScholarPubMed
Herrmann, N. (2007). Treatment of moderate to severe Alzheimer's disease: rationale and trial designs. Canadian Journal of Neurological Sciences, 34, 103–108.CrossRefGoogle Scholar
Herrmann, N., Gauthier, S. and Lysy, P. (2007a). Clinical practice guidelines for severe Alzheimer's disease. Alzheimer's and Dementia, 3, 385–397.CrossRefGoogle ScholarPubMed
Herrmann, N. et al. (2007b). A population-based study of cholinesterase inhibitor use for dementia. Journal of the American Geriatrics Society, 55, 1517–1523.CrossRefGoogle ScholarPubMed
Hogan, D. B. et al. (2007). Management of mild to moderate Alzheimer's disease and dementia. Alzheimer's and Dementia, 3, 355–384.CrossRefGoogle ScholarPubMed
Holmes, C. et al. (2004). The efficacy of donepezil in the treatment of neuropsychiatric symptoms in Alzheimer disease. Neurology, 63, 214–219.CrossRefGoogle ScholarPubMed
Jones, R. et al. (2009). DOMINO-AD protocol: donepezil and memantine in moderate to severe Alzheimer's disease - a multicentre RCT. Trials, 10, 57.CrossRefGoogle ScholarPubMed
Kaduszkiewicz, H., Zimmermann, T., Beck-Bornholdt, H. P. and van den Bussche, H. (2005). Cholinesterase inhibitors for patients with Alzheimer's disease: systematic review of randomised clinical trials. BMJ, 331, 321–327.CrossRefGoogle ScholarPubMed
Lanctôt, K. L. et al. (2003). Efficacy and safety of cholinesterase inhibitors in Alzheimer's disease: a meta-analysis. Canadian Medical Association Journal, 169, 557–564.Google ScholarPubMed
Lanctôt, K. L., Rajaram, R. and Herrmann, N. (2009). Therapy for Alzheimer's disease: how effective are current treatments? Therapeutic Advances in Neurological Disorders, 2, 163–180.CrossRefGoogle ScholarPubMed
Lee, J., Monette, J., Sourial, N., Monette, M. and Bergman, H. (2007). The use of a cholinesterase inhibitor review committee in long-term care. Journal of the American Medical Directors Association, 8, 243–247.CrossRefGoogle ScholarPubMed
Raskind, M. A., Peskind, E. R., Truyen, L., Kershaw, P. and Damaraju, C. V. (2004). The cognitive benefits of galantamine are sustained for at least 36 months: a long-term extension trial. Archives of Neurology, 61, 252–256.CrossRefGoogle ScholarPubMed
Ruths, S., Straand, J., Nygaard, H. A., Bjorvatn, B. and Pallesen, S. (2004). Effect of antipsychotic withdrawal on behavior and sleep/wake activity in nursing home residents with dementia: a randomized, placebo-controlled, double-blinded study. The Bergen District Nursing Home Study. Journal of the American Geriatrics Society, 52, 1737–1743.CrossRefGoogle Scholar
Seltzer, B. (2007). Is long-term treatment of Alzheimer's disease with cholinesterase inhibitor therapy justified? Drugs and Aging, 24, 881–890.CrossRefGoogle ScholarPubMed
Simpson, S., Beavis, D., Leddy, A. and Ball, S. (2005). Naturalistic audit of NICE criteria for the use of cholinesterase inhibitors. Psychiatric Bulletin, 29, 410–412.CrossRefGoogle Scholar
Singh, S. and Dudley, C. (2003). Discontinuation syndrome following donepezil cessation. International Journal of Geriatric Psychiatry, 18, 282–284.CrossRefGoogle ScholarPubMed
Vellas, B. et al. (2005). Consensus statement on dementia of Alzheimer type in the severe stage. Journal of Nutrition, Health and Aging, 9, 330–338.Google ScholarPubMed