Should Aricept (donepezil) be held during hospitalization?

Management of Donepezil (Aricept) During Hospitalization

Donepezil (Aricept) should generally be continued during hospitalization unless specific contraindications develop, as abrupt discontinuation may lead to worsening cognitive function and potentially complicate hospital course.

Rationale for Continuing Donepezil During Hospitalization

Donepezil is a selective acetylcholinesterase inhibitor used in the treatment of Alzheimer's disease that works by increasing acetylcholine levels in the brain. While there are no specific guidelines addressing donepezil management during hospitalization, we can apply principles from heart failure and other chronic medication management guidelines:

• Current cardiology guidelines emphasize that chronic medications should be continued during hospitalization unless specific contraindications develop
• The 2022 AHA/ACC/HFSA guideline for heart failure management states: "In patients with HFrEF requiring hospitalization, preexisting GDMT should be continued and optimized to improve outcomes, unless contraindicated" 1
• This principle can be applied to other chronic medications like donepezil

Algorithm for Managing Donepezil During Hospitalization

1. Initial Assessment

   • Review current donepezil dosing (typically 5mg or 10mg daily)
   • Assess current cognitive status as baseline
   • Check for potential drug interactions with new hospital medications

2. Continue Donepezil Unless:

   • Patient develops significant bradycardia (<50 bpm)
   • New QT prolongation occurs
   • Patient develops severe nausea/vomiting/diarrhea
   • Patient is NPO and unable to take oral medications
   • New medication with significant interaction is required

3. Temporary Discontinuation Scenarios:

   • If patient requires NPO status:
     • Document reason for holding
     • Resume as soon as oral intake is possible
   • If significant drug interaction occurs:
     • Consider temporary discontinuation
     • Resume when interacting medication is discontinued

4. Monitoring During Hospitalization:

   • Observe for changes in cognition that may indicate withdrawal
   • Monitor for cholinergic side effects (nausea, vomiting, diarrhea)
   • Assess heart rate daily (bradycardia risk)

Potential Risks of Discontinuation

Abrupt discontinuation of donepezil may lead to:

• Rapid cognitive decline
• Increased confusion and delirium risk
• Behavioral disturbances
• Worsened functional status
• Increased caregiver burden upon discharge

Special Considerations

• Perioperative Management: If surgery is planned, donepezil can generally be continued through the perioperative period
• NPO Status: If patient must remain NPO, consider documenting the temporary hold and resuming as soon as oral medications can be taken
• Delirium Risk: Hospitalized elderly patients are at high risk for delirium; discontinuing donepezil may exacerbate this risk

Discharge Planning

• Ensure donepezil is included in discharge medication reconciliation
• If temporarily discontinued, provide clear instructions for resumption
• Consider dose adjustment if adverse effects were noted during hospitalization

By maintaining donepezil therapy during hospitalization when possible, clinicians can help prevent unnecessary cognitive decline and potentially reduce hospital complications related to confusion or delirium.