Is it appropriate to discontinue donepezil in a patient with severe cognitive impairment, who has been on the medication for over 7 years without reported side effects, but with questionable efficacy?

Discontinuing Donepezil in Severe Dementia

Discontinuing donepezil is appropriate and recommended in this 92-year-old nursing home resident with severe cognitive impairment (MMSE 9, BIMS 3) who has been on the medication for over 7 years without demonstrating meaningful clinical benefit. 1

Rationale for Discontinuation

• Cholinesterase inhibitors like donepezil should be discontinued in individuals with severe or end-stage dementia who are dependent in most basic activities of daily living, as the medication lacks long-term benefit in advanced dementia 1
• The patient's very low cognitive scores (MMSE 9, BIMS 3) indicate severe cognitive impairment, and the need for extensive care and wheelchair use suggests significant functional dependence 1
• Donepezil has not demonstrated meaningful clinical benefit in this patient despite 7 years of treatment, which is a clear indication for discontinuation according to current guidelines 1

Evidence Supporting Discontinuation

• The Canadian Consensus Conference on Diagnosis and Treatment of Dementia specifically recommends discontinuing cholinesterase inhibitors when "no clinically meaningful benefit was observed at any time during treatment" or when "the individual has severe or end-stage dementia" 1
• Mayo Clinic guidelines on polypharmacy management in older adults list cholinesterase inhibitors as medications to consider for deprescribing, noting they are "lacking long-term benefit, particularly in advanced dementia" 1
• Studies show that donepezil is frequently discontinued in patients with advanced dementia, with ineffectiveness being the major reason for discontinuation in patients with severe cognitive impairment 2

Proper Discontinuation Process

• Deprescribing of cholinesterase inhibitors should occur gradually to minimize potential withdrawal effects 1
• Follow a structured tapering schedule: reduce dose by 50% every 4 weeks until reaching the initial starting dose, then discontinue after 4 weeks at this dose 1
• Monitor for any clinically meaningful worsening of cognition, functioning, or neuropsychiatric symptoms during the tapering process 1
• Be prepared to reinitiate treatment if the patient shows significant deterioration that appears related to cessation of therapy 1

Important Exceptions to Consider

• If the patient had demonstrated significant reduction in neuropsychiatric symptoms (like psychosis, agitation, or aggression) with donepezil, continuation might be warranted despite cognitive decline 1
• The patient should not have cholinesterase inhibitors discontinued if they currently have clinically meaningful psychotic symptoms, agitation, or aggression until these symptoms have stabilized 1

Common Pitfalls to Avoid

• Abrupt discontinuation can potentially lead to rapid cognitive or behavioral deterioration in some patients 1
• Failing to monitor for changes during the tapering process may miss an opportunity to identify patients who genuinely benefit from the medication 1
• Continuing medications without periodic reassessment of benefit contributes to unnecessary polypharmacy in elderly patients 1
• Assuming all patients with dementia should remain on cholinesterase inhibitors indefinitely despite progression to severe disease 1

In this specific case, the decision to taper and discontinue donepezil is well-supported by current guidelines given the patient's severe cognitive impairment, lack of meaningful clinical benefit, and functional dependence requiring extensive nursing home care 1.