Do you stop donepezil (acetylcholinesterase inhibitor) in a patient who has had a fall?

Management of Donepezil in Patients Who Have Fallen

Donepezil should be discontinued in patients who have experienced a fall, as it is associated with increased fall risk due to its side effects including bradycardia, dizziness, and nightmares. 1, 2

Rationale for Discontinuation

The decision to discontinue donepezil after a fall is supported by several key considerations:

1. Medication-Related Fall Risk Factors:

   • Donepezil is listed in the Mayo Clinic's deprescribing guidelines as a medication that can cause bradycardia, which increases fall risk 1
   • It can cause nightmares when taken at bedtime, potentially disrupting sleep and increasing fall risk 1
   • The American Geriatrics Society identifies cholinesterase inhibitors as medications with adverse effects including dizziness that can contribute to falls 1

2. Limited Long-Term Benefit:

   • The Mayo Clinic guidelines note that cholinesterase inhibitors like donepezil lack long-term benefit, particularly in advanced dementia 1
   • The modest cognitive benefits (temporary slowing of cognitive decline) are outweighed by the risk of serious injury from falls 1

Clinical Decision Algorithm

1. After a fall occurs:

   • Immediately assess for injuries and treat accordingly
   • Review medication list with focus on fall-risk medications
   • Discontinue donepezil if it is identified as a contributing factor

2. Monitor for withdrawal effects:

   • Donepezil can be safely tapered to off, especially when there is perceived lack of benefit 1
   • Monitor for potential worsening of cognitive symptoms

3. Consider alternatives:

   • Non-pharmacological approaches for managing dementia symptoms
   • Environmental modifications to reduce fall risk
   • If pharmacological treatment is still needed, consider memantine which may have a more favorable side effect profile in patients with fall risk 1

Important Considerations

• Bradycardia Risk: Donepezil can slow heart rate, especially in combination with beta-blockers like metoprolol, increasing fall risk 1

• Nighttime Dosing Issues: When taken at bedtime, donepezil may cause nightmares that disrupt sleep and increase fall risk 1

• Risk-Benefit Analysis: The modest cognitive benefits of donepezil (equivalent to approximately one year's worth of decline) must be weighed against the significant morbidity and mortality associated with falls in elderly patients 2

• Monitoring After Discontinuation: After stopping donepezil, patients should be monitored for:

  • Changes in cognitive status
  • Improvements in gait stability
  • Resolution of side effects like dizziness or bradycardia

Evidence Quality Assessment

The recommendation to discontinue donepezil after a fall is based on high-quality evidence from clinical practice guidelines:

• The Mayo Clinic's deprescribing guidelines specifically identify cholinesterase inhibitors as medications that can be safely discontinued, especially when there is perceived lack of benefit 1

• The American Geriatrics Society expert panel on care of older adults with multimorbidity provides clear evidence of the interaction between donepezil and fall risk 1

• The American Heart Association/American Stroke Association acknowledges that while cholinesterase inhibitors may provide small improvements in cognition, they are "complicated by adverse events" that can impact safety 1

In contrast to the common recommendation to continue medications despite falls, this approach prioritizes patient safety and recognizes that the modest cognitive benefits of donepezil do not outweigh the significant risk of recurrent falls and their potentially catastrophic consequences in elderly patients.