Practical Approach to the Use of Cholinesterase Inhibitors in Patients With Early Alzheimer's Disease

David B. Hogan, MD, FRCPC


Geriatrics and Aging. 2009;12(4):202-207. 

In This Article

Abstract and Introduction


Cholinesterase inhibitors are a treatment option for most people with Alzheimer's disease of mild to moderate severity. This article offers an approach to their use, based on the recommendations of the Third Canadian Consensus Conference on the Diagnosis and Treatment of Dementia. Treatment decisions must be individualized. Monitoring includes evaluating both safety and effectiveness, which entails more than just assessing cognition. Treatment is clinically beneficial when there is evidence of improvement, stabilization, or a slowing of the rate of decline seen prior to the start of treatment without unacceptable side effects.


There are approximately 60,000 new cases of dementia in Canada each year.[1] About 70% of them are due to Alzheimer's disease (AD), either as the sole cause or in combination with another brain condition (usually cerebrovascular disease).[2] Historically, the detection of dementia has been unreliable in primary care,[3] but an approach for improving the clinical diagnosis of this condition has been described.[4]

The management of dementia is a complex task.[5] This article restricts its focus to the pharmacotherapy of AD that is mild (Mini-Mental State Examination [MMSE] score > 18, Global Deterioration Scale [GDS] stage 4) to moderate (MMSE 10-18, GDS 5 or 6). Medications used primarily for the management of the behavioural and psychological symptoms of a dementia, such as agitation, psychosis, depression, and sleep disturbances, are not discussed. This article deals only with the available cholinesterase inhibitors (ChEIs) (donepezil, galantamine, rivastigmine); while memantine can be used for a moderate stage, this agent is not covered. Cholinesterase inhibitors are now the sixth-largest neurological drug class in terms of overall retail spending in Canada. In 2007, the total cost for ChEIs was $162 million.[6]

The first guidelines on drug treatment for AD were published in 1997.[7] This article is based on the recommendations of the Third Canadian Consensus Conference on the Diagnosis and Treatment of Dementia.[5,8,9] The following questions are addressed: Who should be started on a ChEI? Which ChEI should be used? How should therapy be monitored? When can you decide that treatment has been successful? and, When should you stop therapy?


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