Understanding the progressive nature of dementia can help in the decision to continue or discontinue dementia medications in patients on hospice care for end-stage dementia. Goals change as patients progress from mild to severe dementia. In mild to moderate dementia, the primary goal is to slow the progression of the disease. As dementia nears its end stages, the goal of care generally shifts to the control of dementia symptoms, especially when patients qualify for hospice care.
Neither the cholinesterase inhibitors nor the NMDA receptor antagonists have been proven beneficial in end-stage dementia. Both classes of medications have the potential to cause significant adverse effects in declining patients whose bodies are less able to efficiently metabolize these medications. Diarrhea, loss of appetite, nausea, symptomatic slow heart rate, and fainting are all potential side effects of cholinesterase inhibitors; memantine puts patients at greater risk for dizziness, headache, confusion and constipation. When such medications are added to others commonly prescribed for patients admitted to hospice for dementia, the rates of these and other adverse effects often increase. Though some patients gain a small benefit from the continuation of dementia medications, the potential dangers of continuing dementia medications must be considered.
The decision to continue or discontinue dementia medications can at first appear difficult, but a simple discontinuation plan can guide therapy options and ease caregiver concerns. A prudent plan often includes a gradual discontinuation of dementia medications, monitoring patients for any new or worsening symptoms. Some symptoms are better managed with other medications commonly used to manage dementia symptoms at end of life. More often than not, patients do well with the discontinuation, have less risk of adverse effects from their remaining medications, and are well managed with conventional symptom management.
References:
Buckley JS, Salpeter SR. A risk-benefit assessment of dementia medications: systematic review of the evidence. Drugs Aging. 2015; 32(6):453-467.
Yang Z, Zhou X, Shand Q. Effectiveness and safety of memantine treatment for Alzheimer’s disease. J Alzheimers Dis. 2013; 36(3):445-458.
Minett TS, Thomas A, Wilkinson LM, Daniel SL, Sanders J. Richardson J, Littlewood E, Myint P, Newby J, McKeith IG. What happens when donepezil is suddenly withdrawn? An open label trial in dementia with Lewy bodies and Parkinson’s disease with dementia. Int J Geriatr Psychiatry. 2003; 18(11):988-93.
