Is finasteride (5-alpha-reductase inhibitor) still necessary for a 94-year-old male patient with Alzheimer's disease and daily incontinence?

Discontinuing Finasteride in a 94-Year-Old Male with Alzheimer's and Incontinence

Finasteride should be discontinued in this 94-year-old male patient with Alzheimer's disease and daily ongoing incontinence, as the potential benefits no longer outweigh the risks and side effects at this advanced age.

Rationale for Discontinuation

Age and Benefit-Risk Assessment

• At 94 years of age, the patient is significantly older than populations studied in clinical trials for finasteride (most studies included men with mean ages between 62-66 years) 1
• The potential benefits of finasteride in preventing urinary retention and need for surgical intervention become less relevant in a patient with established incontinence
• The primary benefits of finasteride include:
  • Reduction in risk of acute urinary retention (from 5.6% to 3.3%) 1
  • Reduction in need for surgical intervention (from 3.3% to 1.7%) 1
  • These benefits are less meaningful in a patient already experiencing incontinence

Side Effects and Quality of Life Considerations

• Finasteride is associated with sexual adverse effects that may persist even after discontinuation 2:
  • Erectile dysfunction (2-4% higher than placebo) 1
  • Decreased libido
  • Decreased ejaculate volume
  • Gynecomastia
• In a patient with advanced age and Alzheimer's disease, these side effects may negatively impact quality of life without providing meaningful benefits
• Post-finasteride syndrome can include neurological and psychiatric effects that could potentially worsen cognitive symptoms 3

Clinical Decision-Making Algorithm

1. Assess current urological status:

   • Patient has established daily ongoing incontinence
   • Benefits of finasteride in preventing urinary retention are negated by existing incontinence

2. Consider age-related factors:

   • At 94 years, the patient is well beyond the age groups studied in clinical trials
   • Geriatric patients have altered pharmacokinetics with finasteride:
     • Longer half-life (8 hours vs 6 hours in younger men) 4
     • 15% higher AUC in men ≥70 years compared to younger men 4

3. Evaluate medication burden:

   • Reducing unnecessary medications is particularly important in elderly patients with cognitive impairment
   • Polypharmacy increases risk of adverse effects and drug interactions

4. Weigh quality of life impact:

   • Sexual side effects, while possibly less relevant at advanced age, still impact quality of life
   • Neurological effects of 5α-reductase inhibitors may potentially affect cognition 3

Implementation of Discontinuation

1. Gradual discontinuation is not necessary:

   • Finasteride can be stopped immediately without tapering
   • No withdrawal syndrome has been documented

2. Monitor for changes after discontinuation:

   • Watch for any changes in urinary symptoms over 1-3 months
   • If urinary retention develops (unlikely given established incontinence), reassess the decision

3. Consider alternative management for incontinence:

   • Focus on practical management of incontinence with appropriate products
   • Ensure adequate hydration while managing fluid intake timing

Potential Pitfalls and Caveats

• PSA monitoring: If the patient was being monitored for prostate cancer, note that PSA levels will increase after finasteride discontinuation (approximately doubling within 3-6 months) 1
• Prostate growth: Some prostate regrowth may occur after discontinuation, but this is unlikely to be clinically significant given the patient's age and existing incontinence 5
• Documentation: Clearly document the rationale for discontinuation in the medical record to inform other healthcare providers

In conclusion, the evidence strongly supports discontinuing finasteride in this 94-year-old patient with Alzheimer's disease and established incontinence. The potential benefits no longer outweigh the risks and side effects, and discontinuation aligns with principles of appropriate prescribing in geriatric patients.