When to Stop Medications in Advanced Dementia

by: Claire Larson

Throughout medical training, we devote extensive time learning when to start medications. We memorize the pharmacology, indications for use, side effects, and sentinel trials showing their efficacy. Yet, not until my fellowship training in Geriatrics, did I learn another key part of medication prescribing: when to stop.

We’ve all seen it: patients with lists of 10, 20 or more medications, to which we are always adding and never subtracting. Most were added with good intentions and defined indications, but over time, like the medications themselves, the indications expire.

The case of one of my home visit patients stands out: a 65 year-old man with very advanced early onset Alzheimer’s disease. Bedbound, nonverbal, and aspirating, when I became his primary care provider, he was still taking donepezil and memantine, which he had taken for the last 10 years. When I discussed his care with his neurologists, they were reluctant for these medications to be stopped for fear of him worsening, despite recognizing that there was no evidence to support continued benefit.

I recently led a journal club where we reviewed, “Use of Medications of Questionable Benefit in Advanced Dementia.”1 This cross-sectional study examined medication use by nursing home residents with advanced dementia. Medications of questionable benefit were defined as “never appropriate” medications as determined by the consensus of a group of Geriatricians.2

Over half of nursing home residents with advanced dementia (53.9%) received at least one medication of questionable benefit. The most commonly prescribed were cholinesterase inhibitors (36.4%) and memantine hydrochloride (25.2%). Continuing these medications does not increase survival or alter the course of advanced disease, can cause side effects, and contributes to increased health care costs.3

So why are so many patients with advanced dementia still taking medications of questionable benefit?

While stopping a medication may seem straightforward, as clinicians we know that stopping a medication is frequently more difficult than starting one. We often lack the knowledge and evidence to help us know when to discontinue medications.

Next, stopping medications involves discussing the balance of risks and benefits with patients and their families, and probably hardest, explaining that the disease has advanced beyond the point where the medication is helpful. For the families of my patients with dementia, stopping donepezil or memantine is most difficult, for this is often closely tied to their hope that the medication will cease or significantly slow the progressive course of the disease.

As clinicians we also may be uncomfortable taking away medications, as we are trained to always “do” something. But stopping these medications does not mean we stop caring for the patient, we simply shift our focus.

For my patient, a focus on careful hand-feeding and skin care, quality time spent with his family, and continued enjoyment of music and time outdoors was more important and helpful than any medication. Learning and studying when to stop medications, can help us start taking better care of our patients.

References

1. Tjia J, Briesacher BA, Peterson D, Liu Q, Andrade SE, Mitchell SL. Use of medications of questionable benefit in advanced dementia. JAMA Intern Med. 2014;174(11):1763-1771. 
2. Holmes HM, Sachs GA, Shega JW, Hougham GW, Cox Hayley D, Dale W. Integrating palliative medicine into the care of persons with advanced dementia: identifying appropriate medication use. J Am Geriatr Soc. 2008;56(7):1306-1311. 
3. Buckley, JS and Salpeter, SR. A Risk-Benefit Assessment of Dementia Medications: Systematic Review of the Evidence. Drugs Aging. 2015 May 5. [Epub ahead of print]