Polypharmacy and deprescribing of cholinesterase inhibitors in dementia: a case report and literature review

Abstract: The patient is an 81-year-old female with a past medical history of dementia who presented to the hospital for a mechanical fall. Her medication reconciliation revealed she had been on memantine 10mg BID, galantamine 12mg BID, donepezil 23mg QD, and rivastigmine 6mg BID for several years. These were prescribed by her neurologist who has since retired, and her current primary care physician has continued to order the anti-dementia medications. Throughout her stay, the patient was unable to answer most questions and was typically disoriented. Per her grandson who is her primary caretaker, she has advanced dementia and was around her baseline. She requires assistance with ADLs and IADLs. Patient experiences periods of restlessness at nighttime that are responsive to trazodone. He was unclear if the patient was benefiting from taking the anti-dementia medications. There were no GI symptoms, bradycardia, or prolonged QTc secondary to her medications. The patient was ultimately medically cleared and discharged, but was able to begin the deprescribing cascade of her acetylcholinesterase inhibitors. The patient was strongly recommended to follow up with a geriatrician and work towards reducing polypharmacy. There is insufficient research on the efficacy of having more than one acetylcholinesterase inhibitor for the treatment of dementia. Some studies have found the efficacy of the three acetylcholinesterase inhibitors available on the market is similar and the benefit of administration of these compounds is mild and may not be clinically significant. Further studies on deprescribing acetylcholinesterase inhibitors and their utility in advanced dementia are highly needed.Short Description: By 2060, the number of Alzheimer’s disease cases is expected to increase to 14 million. The condition becomes devastating and debilitating in the severe stages, and there is still yet to be a curative treatment. Limited guidelines exist on polypharmacy of antidementia medications, but overuse has been linked with adverse outcomes. This case report explores the good practice of reevaluating patients after initiation of acetylcholinesterase inhibitors and deprescribing if no beneficial cognitive effects are observed.Name of Sponsoring Organization(s): N/A