Memantine Discontinuation and the Health Status of Nursing Home Residents With Alzheimer's Disease

Antidementia Medication Use in Nursing Home Residents

BACKGROUND

Antidementia medication can provide symptomatic improvements in patients with Alzheimer's disease, but there is a lack of consensus guidance on when to start and stop treatment in the nursing home setting.

METHODS

We describe utilization patterns of cholinesterase inhibitors (ChEI) and memantine for 3,50,197 newly admitted NH residents with dementia between 2011 and 2018.

RESULTS

Overall, pre-admission use of antidementia medications declined from 2011 to 2018 (ChEIs: 44.5% to 36.9%; memantine: 27.4% to 23.2%). Older age, use of a feeding tube, and greater functional dependency were associated with lower odds of ChEI initiation. Coronary artery disease, parenteral nutrition, severe aggressive behaviors, severe cognitive impairment, and high functional dependency were associated with discontinuation of ChEIs. Comparison of clinical factors related to anti-dementia drug treatment changes from pre to post NH admission in 2011 and 2018 revealed a change toward lower likelihood of initiation of treatment among residents with more functional dependency and those with indicators of more complex illness as well as a change toward higher likelihood of discontinuation in residents having 2 or more hospital stays.

CONCLUSIONS

These prescribing trends highlight the need for additional research on the effects of initiating and discontinuing antidementia medications in the NH to provide clear guidance for clinicians when making treatment decisions for individual residents.

CCCDTD5 recommendations on the deprescribing of cognitive enhancers in dementia

INTRODUCTION

Cognitive enhancers (ie, cholinesterase inhibitors and memantine) can provide symptomatic benefit for some individuals with dementia; however, there are circumstances in which the risks of continuing treatment may potentially outweigh benefits. The decision to deprescribe cognitive enhancers must consider each patient's preferences, treatment indications, current clinical status and symptoms, prognosis, and dementia type.

METHODS

The 5th Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD5) established a subcommittee of experts to review current evidence on the deprescribing of cognitive enhancers. The questions answered by this group included: When should cognitive enhancers be deprescribed in persons with dementia and mild cognitive impairment? How should cognitive enhancers be deprescribed? And, what clinical factors should be considered when deprescribing cognitive enhancers?

RESULTS

Patient and care-partner preferences should be incorporated into all decisions to deprescribe cognitive enhancers. Cognitive enhancers should be discontinued in individuals without ongoing evidence of benefit or when the indication for cognitive enhancer use was inappropriate (eg, mild cognitive impairment). Deprescribing should occur gradually and cognitive enhancers should be reinitiated if patients' cognition or function deteriorates. Cognitive enhancers should be continued in individuals whose neuropsychiatric symptoms improve in response to treatment. Clinicians should not deprescribe cognitive enhancers in individuals with significant neuropsychiatric symptoms until symptoms have stabilized.

CONCLUSION

CCCDTD5 deprescribing recommendations provide evidence-informed recommendations related to cognitive enhancer deprescribing that will facilitate shared decision making among patients, care partners, and clinicians.

Effect of Memantine Treatment and Combination with Vitamin D Supplementation on Body Composition in the APP/PS1 Mouse Model of Alzheimer's Disease Following Chronic Vitamin D Deficiency

BACKGROUND

Vitamin D deficiency and altered body composition are common in Alzheimer's disease (AD). Memantine with vitamin D supplementation can protect cortical axons against amyloid-β exposure and glutamate toxicity.

OBJECTIVE

To study the effects of vitamin D deprivation and subsequent treatment with memantine and vitamin D enrichment on whole-body composition using a mouse model of AD.

METHODS

Male APPswe/PS1dE9 mice were divided into four groups at 2.5 months of age: the control group (n = 14) was fed a standard diet throughout; the remaining mice were started on a vitamin D-deficient diet at month 6. The vitamin D-deficient group (n = 14) remained on the vitamin D-deficient diet for the rest of the study. Of the remaining two groups, one had memantine (n = 14), while the other had both memantine and 10 IU/g vitamin D (n = 14), added to their diet at month 9. Serum 25(OH)D levels measured at months 6, 9, 12, and 15 confirmed vitamin D levels were lower in mice on vitamin D-deficient diets and higher in the vitamin D-supplemented mice. Micro-computed tomography was performed at month 15 to determine whole-body composition.

RESULTS

In mice deprived of vitamin D, memantine increased bone mineral content (8.7% increase, p < 0.01) and absolute skeletal tissue mass (9.3% increase, p < 0.05) and volume (9.2% increase, p < 0.05) relative to controls. This was not observed when memantine treatment was combined with vitamin D enrichment.

CONCLUSION

Combination treatment of vitamin D and memantine had no negative effects on body composition. Future studies should clarify whether vitamin D status impacts the effects of memantine treatment on bone physiology in people with AD.

[Not Available]

PURPOSE

The modalities for anti-dementia drugs' discontinuation are not consensual.

OBJECTIVE

The objectives of the study were the followings, describe: i) the reasons for discontinuation of anti-dementia drugs of patients treated in a residency for dependent elderly people, ii) security of sudden discontinuation, iii) evolution of troubles.

METHODS

Our longitudinal descriptive pilot study aimed at observing consequences of the sudden discontinuation of anti-dementia drugs in a population with a moderate to severe stage of Alzheimer's disease. The study took place in a French residency for dependent elderly people, treated with at least one of the following treatments: rivastigmine, donepezil, galantamine and/or memantine. Based on multidisciplinary decision, as recommended, patient's anti-dementia treatment have been stopped or not. Criteria have been collected for 6months and compared between the two groups: safety, motivation for discontinuation, score mini-mental state examination (MMSE), psycho-behavior criteria and finally the concomitant prescription of psychotropic drugs.

RESULTS

Thirty-three patients were included: the revaluation of anti-dementia treatment led to 22 discontinuations and 11 continuations. Motivations to stop antidementia treatment were: too advanced dementia (48%), lack of therapeutic benefit (28%) or too much of psychotropic medications (24%). The sudden discontinuation was well tolerated with no withdrawal syndrome observed. The variation of MMSE at 6months was -1.8 (SD 2.2) in the discontinuation group (n=14) versus -2.2 (SD 2.0) in the continuation group (n=6). The psycho-behavior disorders have not been aggravated. A reduction in number of psychotropic drugs in the discontinuation group was observed.

CONCLUSION

In this pilot study, the revaluation in accordance with the recommendations of the Haute autorité de santé (HAS) led to the discontinuation of two third of anti-dementia drugs. Safety of sudden discontinuation of MSD remains to be studied.

[Pharmacological treatment of dementia: when, how and for how long. Recommendations of the Working Group on Dementia of the Catalan Society of Geriatrics and Gerontology]

Dementia in general--and Alzheimer's disease (AD) in particular--are bound to loom large among the most acute healthcare, social, and public health problems of the 21st century. AD shows a degenerative progression that can be slowed down--yet not halted--by today's most widely accepted specific treatments (those based on cholinesterase inhibitors as well as those using memantine). There is enough evidence to consider these treatments advisable for the mild, moderate and severe phases of the illness. However, in the final stage of the disease, a decision has to be made on whether to withdraw such treatment or not. In this paper, the Working Group on Dementia for the Catalan Society of Geriatrics and Gerontology reviews the use of these specific pharmacological treatments for AD, and, drawing on the scientific evidence thus gathered, makes a series of recommendations on when, how, and for how long, the currently existing specific pharmacological treatments should be used.

Ethical framework for medication discontinuation in nursing home residents with limited life expectancy

A recent editorial by health economist Victor Fuchs summarized the current challenges with health care delivery in this way: “Most physicians want to deliver ‘appropriate’ care. Most want to practice ‘ethically’, but it is difficult to know what is ‘appropriate’ and what is ‘ethical’. This characterization is particularly true for medication use and deprescribing in elderly NH residents with limited life expectancy. Medical ethics sets 4 key principles (beneficence, nonmaleficence, patient autonomy, and justice) to guide practice. However, decisional conflicts will continue between providers and patients, and physicians will continue to struggle with the dilemma of balancing the primacy of patient welfare, values, and beliefs against the desire for promising, but often minimally beneficial and harmful, medications that threaten limited clinical resources. Despite these challenges, physicians should be able to perform systematic medication reviews and monitor discontinuation trials in their NH patients for whom this is consistent with their goals of care.