Should my dementia medication be continued or stopped?

There are two types of medications currently approved for dementia treatment in Canada: cholinesterase inhibitors and memantine (Ebixa). There are three different cholinesterase inhibitors available – donepezil (Aricept), galantamine (Reminyl), and rivastigmine (Exelon). Some people with dementia experience small benefits in cognition, function, and behaviour with these medications, while others experience no improvement.^1,2 There is no clear evidence that these medications reliably improve quality of life and the likelihood of needing to live in a nursing home, or other outcomes that are important to patients and their families.^1,3

Cholinesterase inhibitors can cause side effects such as nausea and vomiting, diarrhea, muscle cramps, difficulty sleeping, weight loss, and headaches.⁴ They can also slow down the heart rate and cause fainting, which increases the risk of falls.⁵ These side effects are about two times more common in people aged 85 and over.⁶ Memantine has fewer side effects but can cause drowsiness, dizziness, and headache.⁷ Furthermore, side effects of these medications may be mistaken as a new medical condition and lead to the unnecessary prescription of even more medications.⁵

The benefits and harms of any medication can change over time. These medications tend to be used for much longer in real life than they were in research studies. Appropriate use of any medication involves both prescribing to people who are most likely to benefit, and stopping, also known as “deprescribing”, when there are possible side effects, or we don’t think the medication is helpful anymore.¹ In November 2022, Choosing Wisely Canada updated their recommendations to highlight the importance of regularly assessing if these medications should be continued and to consider deprescribing if the risks may outweigh the benefits.⁸

There is evidence that deprescribing cholinesterase inhibitors for people living in long-term care with dementia is safe. In one study, stopping cholinesterase inhibitors in this population did not have any impact on cognition, function, behaviour, quality of life, caregiver distress, or safety, compared to continuing these medications.⁹

Potential benefits include lower risk of side effects, including interactions with other medications your resident is taking. Improvement in side effects that are harder to identify, such as low appetite, weight loss, or trouble sleeping, may only be noticed after stopping the medication. It will also help reduce the burden of medications that need to be taken every day. When a cholinesterase inhibitor or memantine is deprescribed, the dose will be lowered gradually while watching for any change in cognition, function, or behaviour.¹⁰ While deprescribing is generally well-tolerated, if there is any worsening in cognition, function, or behaviour, the dose can be increased again, or the medication restarted.

If your resident is taking a cholinesterase inhibitor or memantine, you can communicate with their healthcare team to periodically reassess if they are benefitting, or if they may be experiencing any side effects. Regular review of these medications is important, and deprescription can be considered if potential risks outweigh potential benefits. If you or your resident would like to discuss stopping one of these medications, please let your physician know.

1. Reeve E, Farrell B, Thompson W, Herrmann N, Sketris I, Magin PJ, et al. Deprescribing cholinesterase inhibitors and memantine in dementia: guideline summary. Med J Aust. 2019 Mar;210(4):174–9.
2. Birks JS. Cholinesterase inhibitors for Alzheimer’s disease. Cochrane Dementia and Cognitive Improvement Group, editor. Cochrane Database Syst Rev [Internet]. 2006 Jan 25 [cited 2022 Oct 17];2016(3). Available from: http://doi.wiley.com/10.1002/14651858.CD005593
3. Renn BN, Asghar-Ali AA, Thielke S, Catic A, Martini SR, Mitchell BG, et al. A Systematic Review of Practice Guidelines and Recommendations for Discontinuation of Cholinesterase Inhibitors in Dementia. Am J Geriatr Psychiatry. 2018 Feb;26(2):134–47.
4. Howard R, McShane R, Lindesay J, Ritchie C, Baldwin A, Barber R, et al. Donepezil and Memantine for Moderate-to-Severe Alzheimer’s Disease. N Engl J Med. 2012 Mar 8;366(10):893–903.
5. Gill SS, Mamdani M, Naglie G, Streiner DL, Bronskill SE, Kopp A, et al. A Prescribing Cascade Involving Cholinesterase Inhibitors and Anticholinergic Drugs. Arch Intern Med. 2005 Apr 11;165(7):808.
6. Buckley JS, Salpeter SR. A risk-benefit assessment of dementia medications: Systematic review of the evidence. Drugs & Aging. 2015;32(6):453–67.
7. McShane R, Westby MJ, Roberts E, Minakaran N, Schneider L, Farrimond LE, et al. Memantine for dementia. Cochrane Dementia and Cognitive Improvement Group, editor. Cochrane Database Syst Rev [Internet]. 2019 Mar 20 [cited 2022 Nov 7]; Available from: https://doi.wiley.com/10.1002/14651858.CD003154.pub6
8. Geriatrics [Internet]. Choosing Wisely Canada. [cited 2023 Sep 17]. Available from: https://choosingwiselycanada.org/recommendation/geriatrics/
9. Herrmann N, O'Regan J, Ruthirakuhan M, Kiss A, Eryavec G, Williams E, Lanctot KL. A randomized placebo-controlled discontinuation study of cholinesterase inhibitors in institutionalized patients with moderate to severe Alzheimer disease. Journal of the American Medical Directors Association. 2016 Feb 1;17(2):142-7.
10. Bruyere. Acetylcholinesterase inhibitors and memantine deprescribing guideline [Internet]. Deprescribing.org. 2019 [cited 2023 Feb 26]. Available from: https://deprescribing.org/news/acetylcholinesterase-inhibitors-and-memantine-deprescribing-guideline/