Choosing Wisely:

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

Rationale and Comments: Although some randomized controlled trials suggest that cholinesterase inhibitors may improve cognitive testing results, it is unclear whether these changes are clinically meaningful. It is uncertain whether these medicines delay institutionalization, improve quality of life, or lessen caregiver burden. No studies have investigated benefits beyond a year nor clarified the risks and benefits of long-term therapy. Clinicians, patients, and their caregivers should discuss treatment goals of practical value that can be easily assessed and the nature and likelihood of adverse effects before beginning a trial of cholinesterase inhibitors. If the desired effects (including stabilization of cognition) are not perceived within 12 weeks or so, the inhibitors should be discontinued.
Sponsoring Organizations:
  • American Geriatrics Society
  • Sources:
  • Systematic review
  • Disciplines:
  • Neurologic
  • Geriatric Medicine
  • 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.
    • Lin JS, O’Connor E, Rossom RC, Perdue LA, Eckstrom E. Screening for cognitive impairment in older adults: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med.2013 Nov 5;159(9):601-12.

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