Deprescribing cholinesterase inhibitors and memantine in dementia: guideline summary

Reeve, Emily; Farrell, Barbara; Thompson, Wade; Herrmann, Nathan; Sketris, Ingrid; Magin, Parker J; Chenoweth, Lynn; Gorman, Mary; Quirke, Lyntara; Bethune, Graeme; Hilmer, Sarah N

doi:10.5694/mja2.50015

Topics

Pharmaceutical preparations

Nervous system diseases

General medicine

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:
1. determining their treatment goals;
2. discussing benefits and harms of continuing and ceasing medication, from the start of therapy and throughout; and
3. 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.

1 NHMRC Cognitive Decline Partnership Centre, Kolling Institute of Medical Research, Northern Clinical School, University of Sydney, Sydney, NSW
2 Dalhousie University and Nova Scotia Health Authority, Halifax, Canada
3 Bruyère Research Institute, Ottawa, Canada
4 University of Ottawa, Ottawa, Canada
5 University of Southern Denmark, Odense, Denmark
6 Sunnybrook Health Sciences Centre, Toronto, Canada
7 University of Toronto, Toronto, Canada
8 Dalhousie University, Halifax, Canada
9 University of Newcastle, Newcastle, NSW
10 NSW and ACT Research and Evaluation Unit, GP Synergy Regional Training Organisation, Sydney, NSW
11 Centre for Healthy Brain Ageing, UNSW, Sydney, NSW
12 University of Notre Dame, Sydney, NSW
13 St Martha's Regional Hospital, Antigonish, Canada
14 Consumer Network, Alzheimer's Australia, Canberra, ACT
15 Dementia Training Australia
16 Nova Scotia Health Authority, Halifax, Canada
17 Royal North Shore Hospital and University of Sydney, Sydney, NSW

Correspondence: emily.reeve@sydney.edu.au

Funding:

The guideline development, publication, dissemination and implementation were funded through an NHMRC‐ARC Dementia Research Development Fellowship awarded to Emily Reeve (APP1105777). The funding body had no involvement in guideline development and, as such, the views and/or interests of the funding body have not influenced the final recommendations.

Acknowledgements:

We thank Lisa Kouladjian O'Donnell, Judith Godin, Caitlin Lees, Emma Squires, Ivanka Hendrix and Robin Parker, who contributed to the systematic review which informed the development of the guideline.

Competing interests:

Emily Reeve has received support to attend conferences to present work related to deprescribing by the NHMRC Cognitive Decline Partnership Centre, Canadian Frailty Network, TUTOR‐PHC Program (Western University), University of Sydney Medical School, Ramsay Research and Teaching Fund (Kolling Institute Travel Award, Royal North Shore Hospital Scientific Staff Council), Swiss Society of Internal Medicine and the Pharmacy Association of Nova Scotia; has received prize money from Bupa Health Foundation; and has received grants from the Canadian Frailty Network, CC‐ABHI Knowledge Mobilisation Partnership Program and the US National Institutes of Health for work related to deprescribing. Barbara Farrell has received consultancy fees and grants (including reimbursement for travel for research meetings or education sessions) from the Institute for Healthcare Improvement, College of Psychiatric and Neurologic Pharmacists, European Association of Hospital Pharmacists, Nova Scotia College of Pharmacists, Canadian Society of Hospital Pharmacists, and Ontario Pharmacists Association; and has received research grants from the Canadian Foundation for Pharmacy, Centre for Aging Brain Health and Innovation, Canadian Institute of Health Research, and Ontario Ministry of Health and Long‐Term Care for work related to deprescribing. Wade Thompson received a Master of Science stipend from government of Ontario for work on deprescribing, and speaking fees to present at conferences on deprescribing from the Advanced Learning in Palliative Medicine Conference, Ontario Long‐Term Care Clinicians Conference, and Geriatrics in Primary Care conference (University of Ottawa). Nathan Herrmann has received consultancy fees for dementia drug development from Lilly, Astellas and Merck; grants from Lundbeck and Roche for dementia investigational drug trials; and support from the Canadian Consortium on Neurodegeneration in Aging (CCNA) funded by the Canadian Institute of Health Research and several partners. Ingrid Sketris receives a partial salary stipend from Canadian Institute of Health Research (CIHR) as part of the Canadian Network for Observational Effect Studies and has received grants from CIHR (including funds utilized to present research results) and the Nova Scotia Department of Health and Wellness. Parker Magin has received grants from the Judith Jane Mason & Harold Stannett Williams Memorial Foundation Medical Program Grants, and the Royal Australian College of General Practitioners: Education Research Grant for potentially related work. Sarah Hilmer has received funding from the NHMRC Cognitive Decline Partnership Centre to support work related to deprescribing in people with dementia.

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