Understanding Deprescribing in Alzheimer's Care

Deprescribing refers to the planned and supervised process of reducing or stopping medications that may no longer be beneficial or could be causing harm. For patients with advanced dementia, the continued use of acetylcholinesterase inhibitors (AChEI) and memantine has been a subject of debate for over a decade.

A 2009 survey revealed that while 80% of hospice medical directors recommended discontinuing these medications in terminal dementia, some still believed in their continued benefit¹. Although many clinical guidelines now support deprescribing under specific conditions, no universal consensus exists. Family members and caregivers often express concerns and anxieties about stopping these treatments, making clear communication and shared decision-making vital.

Why Consider Deprescribing?

Clinical guidelines suggest deprescribing Alzheimer's medications for various reasons. In fact, a recent review discovered that more than two-thirds of guidelines advised deprescribing AChEi and/or memantine in certain conditions². The guideline-cited reasons for discontinuing are below³:

1. Lack of Effectiveness: If the medication is no longer providing noticeable benefits, discontinuation may be appropriate.
2. Adverse Effects: Side effects such as nausea, diarrhea, weight loss, and bradycardia can outweigh the potential benefits. Mainly due to acetylcholinesterase-inhibitors.
3. Severe Cognitive Decline: When cognitive and functional impairments reach advanced stages (e.g., Mini-Mental State Examination score < 10), the medications often offer minimal benefit.
4. Institutionalization: If a patient is already in a care facility, the primary goal of preventing institutionalization is no longer relevant.
5. Medical Status: Patients with terminal illness, active infections, or other serious medical conditions may not benefit from continued medication use.
6. Patient and Caregiver Preferences: Respecting the wishes of patients and their families is crucial in the deprescribing process.

Guidelines Supporting Deprescribing³

Several organizations advocate for deprescribing under appropriate circumstances, including:

• American Academy of Family Physicians
• American Geriatrics Society
• National Institute for Health and Care Excellence (NICE)
• Canadian Consensus Conference on Dementia

These guidelines highlight the importance of individualized care and thorough evaluations when considering discontinuation.

How to Approach Deprescribing Conversations

Effective communication is key when discussing deprescribing with patients and caregivers. The BUILD model provides a helpful framework⁴:

• Build trust by acknowledging concerns and fears.
• Understand the family's knowledge and beliefs about the medication.
• Inform them about clinical evidence and potential outcomes.
• Listen to their goals and expectations.
• Develop a collaborative plan for tapering or discontinuing the medication.

Sample conversational phrases⁷:

• "We understand this can be a difficult decision. If you're not ready now, we can revisit this discussion later."
• "Stopping the medication can be done as a trial. We'll monitor closely and can restart if needed."
• "Our priority is your loved one's comfort. If the medication is causing more harm than benefit, it's worth considering a change."

Best Practices for Deprescribing

When discontinuing Alzheimer's medications, a gradual tapering process is generally recommended to reduce the risk of withdrawal symptoms. A 50% dose reduction per week over 2-4 weeks is commonly used. Close monitoring is crucial, particularly for patients with baseline psychosis or significant behavioral symptoms.⁵ ⁶

Signs of withdrawal may include agitation, anxiety, mood changes, and insomnia. If these symptoms arise, a slower taper or reintroduction of medication may be required.⁸

Putting Guidance into Practice

These conversations remind us that hospice care is as much about communication as it is about clinical expertise. That’s why we’re focused on building tools that help providers navigate medication decisions with clarity and confidence.

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