CCCDTD5 recommendations on the deprescribing of cognitive enhancers in dementia

Nathan Herrmann; Zahinoor Ismail; Rhonda Collins; Philippe Desmarais; Zahra Goodarzi; Alexandre Henri-Bhargava; Andrea Iaboni; Julia Kirkham; Fadi Massoud; Andrea Moser; James Silvius; Jennifer Watt; Dallas Seitz

doi:10.1002/trc2.12099

CCCDTD5 recommendations on the deprescribing of cognitive enhancers in dementia

Alzheimers Dement (N Y). 2022 Jan 31;8(1):e12099. doi: 10.1002/trc2.12099. eCollection 2022.

Authors

Affiliations

¹ Department of Psychiatry Sunnybrook Health Sciences Centre University of Toronto Toronto Ontario Canada.
² Departments of Psychiatry, Clinical Neurosciences, and Community Health Sciences, Cumming School of Medicine; Hotchkiss Brain Institute and O'Brien Institute of Public Health University of Calgary, Calgary, Alberta, Canada.
³ Department of Family Medicine McMaster University Chief Medical Officer, Revera Inc Hamilton Ontario Canada.
⁴ Department of Medicine Division of Geriatrics and Department of Neurosciences Centre de Recherche du Centre Hospitalier de l'Université de Montréal Montréal Québec Canada.
⁵ Division of Geriatrics, Department of Medicine, Cumming School of Medicine; Hotchkiss Brain Institute; O'Brien Institute of Public Health University of Calgary Calgary Canada.
⁶ Division of Neurology, Faculty of Medicine University of British Columbia; Division of Medical Sciences, University of Victoria, Victoria, British Columbia, Canada.
⁷ Department of Psychiatry University of Toronto Toronto Ontario Canada.
⁸ Kite Research Institute, Toronto Rehabilitation Institute University Health Network Toronto Ontario Canada.
⁹ Department of Psychiatry Cumming School of Medicine, University of Calgary.
¹⁰ Department of Medicine University of Sherbrooke Sherbrooke Quebec Canada.
¹¹ Department of Family and Community Medicine University of Toronto, Associate Medical Director, Jewish Home for the Aged, Baycrest Toronto Ontario Canada.
¹² Division of Geriatric Medicine, Department of Medicine, Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada.
¹³ Division of Geriatric Medicine Department of Medicine, University of Toronto Toronto Ontario Canada.

Abstract

Introduction: Cognitive enhancers (ie, cholinesterase inhibitors and memantine) can provide symptomatic benefit for some individuals with dementia; however, there are circumstances in which the risks of continuing treatment may potentially outweigh benefits. The decision to deprescribe cognitive enhancers must consider each patient's preferences, treatment indications, current clinical status and symptoms, prognosis, and dementia type.

Methods: The 5th Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD5) established a subcommittee of experts to review current evidence on the deprescribing of cognitive enhancers. The questions answered by this group included: When should cognitive enhancers be deprescribed in persons with dementia and mild cognitive impairment? How should cognitive enhancers be deprescribed? And, what clinical factors should be considered when deprescribing cognitive enhancers?

Results: Patient and care-partner preferences should be incorporated into all decisions to deprescribe cognitive enhancers. Cognitive enhancers should be discontinued in individuals without ongoing evidence of benefit or when the indication for cognitive enhancer use was inappropriate (eg, mild cognitive impairment). Deprescribing should occur gradually and cognitive enhancers should be reinitiated if patients' cognition or function deteriorates. Cognitive enhancers should be continued in individuals whose neuropsychiatric symptoms improve in response to treatment. Clinicians should not deprescribe cognitive enhancers in individuals with significant neuropsychiatric symptoms until symptoms have stabilized.

Conclusion: CCCDTD5 deprescribing recommendations provide evidence-informed recommendations related to cognitive enhancer deprescribing that will facilitate shared decision making among patients, care partners, and clinicians.

Keywords: cholinesterase inhibitor; cognitive enhancer; dementia; deprescribing; discontinuation; memantine.