Should Alzheimer's Drugs Be Discontinued in the Late Stages?

Considering Stopping an Alzheimer's Medication?
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Picture this; You're the main caregiver for your loved one, and you want to provide the best care possible for him. That includes considering which medications he's receiving and whether they should be continued. Of course, these decisions are made in partnership with his physician, but after the doctor provides the rationale for their recommendations, she will probably ask you for your opinion. So, what to do?

What Are the Benefits of Medications in Alzheimer's Disease?

Medications are prescribed for people with dementia with the hope of slowing down the progression or even improving the cognitive functioning for a time. Research has shown that there is some benefit from these medications, although they don't cure the disease.

Medications for the Treatment of Alzheimer's Disease

There are two types of medications prescribed to treat Alzheimer's disease.

Cholinesterase Inhibitors

  • Aricept (donepezil): Approved for mild, moderate and severe Alzheimer's
  • Exelon (rivastigmine): Approved for mild to moderate Alzheimer's
  • Razadyne (galantamine): Approved for mild to moderate Alzheimer's

N-Methyl D-Aspartate (NMDA) Antagonists

Namenda (memantine) is another medication that is used to try to slow down the progression of dementia and is approved for use in moderate to severe Alzheimer's disease.

Is There a Time When Medications for Dementia Should Be Discontinued?

Consider discontinuing medications when one or both of the following two factors arise:

  • Side Effects

If there are too many side effects or they diminish the quality of life for the person, strong consideration should be given towards discontinuing the medication.

  • No Benefit

If the patient or loved one has been on the medication for quite some time and now her dementia has progressed to the late stages, physicians and pharmacists will sometimes recommend discontinuing the medication if there is no observed benefit.

This decision may, at times, be made when a person elects hospice care, but at other times it is considered an option simply if the perceived benefit is little or none.

How Should Medications Be Discontinued?

  • Discontinue medications gradually
  • Discontinue medications one at a time

When discontinuing medications, monitor your loved one or patient closely. If you start to see a significant decline in cognition or behavior, you may want to ask the physician to restart the medication.

If a notable decline in functioning develops after discontinuation, restarting the medication sooner rather than later may increase the likelihood of the person returning close to his previous (prior to stopping the medicine) level of functioning.

What Has Research Shown?

There has not been a lot of research conducted on stopping medications for the treatment of dementia. However, some research seems to indicate that people whose dementia medications were discontinued declined in cognition and behavior more quickly.

One study compared nursing home residents with dementia who were receiving cholinesterase inhibitor medications to treat dementia to other nursing home residents whose cholinesterase inhibitors were discontinued. The researchers found that those whose medications were discontinued experienced more behavioral challenges such as repetitive questioning and frequent health concerns. This group also participated less in activities compared to those who were still on their medication.

Make an Educated Decision

In my clinical experience, I've witnessed a range of results after medications for dementia have been discontinued. At times, there has been a decline in functioning as described above after discontinuing the medications; however, there have also been other situations where there was very little change, if any, after medications for dementia were discontinued.

The key is for family members is to be aware that the possibility for decline exists and to make this decision together with their loved one's physician.

Food for Thought

One physician proposed the following question when considering whether or not to discontinue medication for the treatment of Alzheimer's disease:

"Is there anything going on in this life that is good and might be missed if the medication is stopped?" (Dr. Gene Lammers)

Sources:

American Family Physician. 2011 Jun 15;83(12):1403-1412. Treatment of Alzheimer Disease. http://www.aafp.org/afp/2011/0615/p1403.html

American Journal of Geriatric Pharmacotherapy. 2009 Apr;7(2):74-83. Effect of discontinuing cholinesterase inhibitor therapy on behavioral and mood symptoms in nursing home patients with dementia. http://www.ncbi.nlm.nih.gov/pubmed/19447360

BC Medical Journal, Vol. 53, No. 8, October 2011, page(s) 404-408. Cholinesterase inhibitors. http://www.bcmj.org/articles/cholinesterase-inhibitorsphealey_stop_medication_2007-0314.ppt - IDND

Healey, P. March 14, 2007. Is there a time to stop dementia-specific medication? phealey_stop_medication_2007-0314.ppt - IDND

Neurodegenerative Disease Management. 1.3 (June 2011): p191. Ask the Experts: When do you stop a cholinesterase inhibitor in Alzheimer's disease? http://www.futuremedicine.com/doi/abs/10.2217/nmt.11.30

The New England Journal of Medicine. 2012; 366:893-903. Donepezil and Memantine for Moderate-to-Severe Alzheimer's Disease. http://www.iranneurology.com/component/content/article/224-donepezil-and-memantine-for-moderate-to-severe-alzheimers-disease.html

End of Life / Palliative Education Resource Center. Dementia Medications in Palliative Care. Accessed February 16, 2014. http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_174.htm

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