Deprescribing Alzheimer's Drugs: The Crowdsourced Opinion

Charles P. Vega, MD

Disclosures

February 24, 2020

In a recent edition of Cases in Deprescribing, I presented a case drawn from my own practice involving deprescribing of drugs for Alzheimer's disease (AD). My question to readers was whether it was reasonable to deprescribe one or more of an elderly patient's AD drugs at this juncture.

To recap: The patient was a 78-year-old man who was taking rivastigmine and memantine for AD symptoms, and sertraline for possible depression. He spends his days sleeping and watching television. His family wanted to simplify his medication regimen in anticipation of moving him into long-term care in the near future. I recommended tapering him off of the sertraline but continuing the AD drugs at the present time. I asked all of you to share your thinking about this case, especially if you disagreed with my plan.

Thank you so much for the thoughtful and constructive comments. It is clear that everyone has the best interests of this patient and his supporters at heart.

One clear theme that emerged was to look beyond the patient's medical therapy to consider other therapeutic options for AD, and, beyond that, to establish the patient's and supporters' goals for care. AD is a great example of an illness that requires a holistic and empathic approach from the healthcare provider. Particularly in moderate to severe dementia, maintenance of quality of life and the patient's dignity become of paramount importance. At the same time, caregivers should be routinely assessed for burnout and provided resources to help with the care of their loved one.

Most comments suggested discontinuing his AD medications along with sertraline. After all, this was about "deprescribing." However, I would follow the advice of one reader to discuss quality of life with him and his supporters first. I may discontinue sertraline now but would not taper off all three drugs too hastily.

Some readers were justifiably concerned about this patient's level of inactivity and daytime sleepiness. Exercise is not only an effective means to prevent AD, but it is associated with improvements in cognitive function and mood. Importantly for this patient, it can also help to preserve his ability to function and his quality of life.

Socialization is also important for this patient and is yet another means to reduce caregiver burden. The combination of lack of activity and poor socialization frequently leads to isolation, worse mood, and not only worse AD outcomes, but also poor control of other chronic illnesses. This can lead to a vicious cycle of worsening overall health for the patient with AD.

I also agree that the patient's family should not rush into a decision about the institutionalization of a patient whose behaviors seem manageable in the home. Those of us who care for institutionalized patients are familiar with the "merry-go-round" of frequent emergency department visits and admissions (thank you, Dr Rangel!) that destroy quality of life. Again, this decision warrants a careful discussion with the patient and his supporters. I often find that these meetings are a great opportunity to locate additional resources, such as senior centers, home health aides, or support groups, which can avert institutionalization.

It seems reasonable to emphasize exercise, healthy sleep, and socialization and then see how these interventions affect the patient. I agree with the comments that these interventions may help his symptoms substantially, and I would not be surprised if his dementia improves to the point where his AD drugs can be considered more effective. Of course, these drugs could be tapered off in the future if his dementia does not improve with lifestyle and social interventions.

Charles P. Vega, MD, is a clinical professor of family medicine at UC Irvine and also serves as the UCI School of Medicine assistant dean for culture and community education. He focuses on medical education with an intent to resolve health disparities.

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