Choosing Wisely:

Don’t prescribe cholinesterase inhibitors for dementia without periodic assessment for perceived cognitive benefits and adverse gastrointestinal effects.

Rationale and Comments: In randomized controlled trials, some patients with mild-to-moderate and moderate-to-severe Alzheimer’s disease achieve modest benefits in delaying cognitive and functional decline and decreasing neuropsychiatric symptoms. The impact of cholinesterase inhibitors on institutionalization, quality of life and caregiver burden are less well established. Clinicians, caregivers, and patients should discuss cognitive, functional, and behavioral goals of treatment prior to beginning a trial of cholinesterase inhibitors. Advance care planning, patient and caregiver education about dementia, diet and exercise, and nonpharmacologic approaches to behavioral issues are integral to the care of patients with dementia, and should be included in the treatment plan in addition to any consideration of a trial of cholinesterase inhibitors. If goals of treatment are not attained after a reasonable trial (e.g., 12 weeks), then consider discontinuing the medication. Benefits beyond a year have not been investigated and the risks and benefits of long-term therapy have not been well established.
Sponsoring Organizations:
  • American Geriatrics Society
  • Sources:
  • Systematic review
  • Disciplines:
  • Geriatric Medicine
  • Neurologic
  • Psychiatric and Psychologic
  • References: • Courtney C, Farrell D, Gray R, Hills R, Lynch L, Sellwood E, Edwards S, Hardyman W, Raftery J, Crome P, Lendon C, Shaw H, Bentham P; AD2000 Collaborative Group. Long-term donepezil treatment in 565 patients with Alzheimer’s disease (AD2000): randomized double-blind trial. Lancet. 2004 Jun 26;363(9427):2105–15.
    • American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012 Apr;60(4):616–31.
    • Kaduszkiewicz H, Zimmermann T, Beck-Bornholdt HP, van den Bussche H. Cholinesterase inhibitors for patients with Alzheimer’s disease: systematic review of randomized clinical trials. BMJ. 2005 Aug 6;331(7512):321–7.
    • Birks J. Cholinesterase inhibitors for Alzheimer’s disease. Cochrane Database Syst Rev. 2006 Jan 25;(1):CD005593.

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