Cholinesterase inhibitors (CHEIs) are the most commonly prescribed agents to delay the progression of cognitive decline from dementia, Parkinson’s disease, and other degenerative neurologic diseases.

Progression of dementia is associated with loss of cholinergic neurons and decreased levels of acetylcholine. CHEIs inhibit the cholinesterase enzyme from breaking down acetylcholine and thereby increases both the level and duration of action of acetylcholine in the brain. Three CHEIs are approved for mild to moderate dementia -- donepezil, galantamine, and rivastigmine; donepezil is also approved for severe Alzheimer’s disease.

CHEIs are associated with a mild but statistically significant improvement in cognitive function, behavior, and activities of daily living (ADLs).
But they have not been shown to slow the progression of dementia, prolong survival, nor prevent nursing home admissions. And as dementia progresses, the effectiveness of CHEIs diminish while adverse effects can rise (nausea, vomiting, diarrhea, dizziness and headaches.

Then, it can be hard to justify continuing CHEIs for dementia patients who become bed bound or dependent on all ADLs.

CHEI discontinuation should be considered in the following situations:
• Intolerable side effects or poor adherence.
• Significant cognitive or functional decline.
• Life expectancy to < 1 year.
• Prior to hospice admission.
• Aspiration pneumonia, a fracture, dysphagia, or frequent falls.

See reference for more information.

Adapted from Liao P, Perri GA. Deprescribing cholinesterase inhibitors at the end of life. Palliative Care Network of Wisconsin. Fast facts and concepts #354. Internet. Accessed on January 5, 2019