In an elderly patient with advanced dementia who is now receiving hospice care and has had memantine (Namenda) discontinued, should the medication be restarted?

Do Not Restart Memantine in Hospice Patients with Advanced Dementia

Memantine should remain discontinued in this hospice patient with advanced dementia, as the medication is not appropriate for end-stage disease and discontinuation aligns with palliative care goals focused on comfort rather than disease modification. 1, 2

Rationale for Keeping Memantine Discontinued

Guideline-Based Indications for Discontinuation

The decision to stop memantine was appropriate based on multiple criteria:

• Severe or end-stage dementia with limited life expectancy is a clear indication to discontinue memantine, as the medication provides no meaningful benefit when patients are dependent in most basic activities of daily living or unable to respond to their environment 1

• STOPPFrail 2021 criteria specifically recommend discontinuing medications like memantine in frail older adults with less than 1 year of life remaining, as these drugs are used for long-term chronic disease management rather than symptom control 3

• Hospice enrollment itself signals that the goals of care have shifted from disease modification to comfort, making continuation of dementia-specific medications inappropriate 3, 4

Evidence Against Restarting

• Memantine shows efficacy only in moderate to severe Alzheimer's disease for cognition and global function, but these outcomes are no longer relevant treatment goals in hospice care where quality of life and symptom management take priority 1, 5

• The medication was designed to slow cognitive decline, not provide comfort or address end-of-life symptoms 4, 2

• Deprescribing guidelines explicitly state that individuals with severe or end-stage dementia should have ChEIs and memantine discontinued through shared decision-making focused on reducing medication burden 2

Addressing Discontinuation Syndrome Concerns

While rare case reports describe behavioral disturbances after abrupt memantine cessation 6, this should not drive restarting decisions in hospice:

• Any behavioral symptoms that emerge should be managed with appropriate palliative interventions (environmental modifications, treatment of pain or discomfort, judicious use of medications for agitation if needed for comfort) rather than restarting memantine 3

• The natural progression of advanced dementia will continue regardless of memantine use, and any decline observed after discontinuation likely represents disease progression rather than withdrawal 2

Medication Management in Hospice

The focus should shift entirely to comfort-directed prescribing:

• Only medications that directly improve symptom control and quality of life should be continued or initiated in hospice patients 3

• Preventive medications and disease-modifying agents like memantine have no role in end-of-life care 3, 4

• Reducing pill burden through deprescribing can itself improve quality of life by decreasing medication-related adverse effects and simplifying care 2

Clinical Pitfalls to Avoid

• Do not mistake the natural progression of dementia for a "withdrawal effect" from stopping memantine—cognitive and functional decline will continue as part of the disease trajectory 2

• Avoid family pressure to restart medications based on the misconception that stopping treatment caused decline—education about disease progression and hospice philosophy is essential 2

• Do not restart memantine even if the patient had previously appeared to benefit, as the risk-benefit ratio fundamentally changes in end-stage disease with limited life expectancy 1, 2