Rethinking medicines part 4: cognition

Clinical scenario

Rose, 86, lives with dementia. Recently, her daughter has noticed that she is increasingly drowsy, less engaged in conversations and needing more help with everyday activities. Her GP has ordered tests to rule out potential underlying causes, including urinary tract infection, vitamin B12 deficiency, hypothyroidism and anaemia. The family is concerned that her dementia is progressing. Her medicines have been largely unchanged since her last review and include a benzodiazepine at night, an antipsychotic and donepezil, a cholinesterase inhibitor.

Medicine burden and cognition

Older people taking multiple medicines may be exposed to medicines that contribute to sedation, confusion or cognitive impairment. These effects can be additive and increase overall treatment burden, making it difficult to distinguish medicine-related adverse effects from progression of an underlying condition.

What does the guideline recommend?

Deprescribing guidelines (available at deprescribing.com) suggest considering deprescribing when the potential harms or treatment burdens of a medicine outweigh its benefits, with decisions tailored to the individual’s goals and circumstances.

Some relevant recommendations include:

• Benzodiazepines: consider offering deprescribing to older people taking benzodiazepines, as potential harms (for example, sedation, cognitive impairment, falls and dependence) generally outweigh benefits, except in certain circumstances.
• Antipsychotics: consider deprescribing when adverse effects or drug interactions outweigh potential benefits, including when antipsychotics are used in people with Parkinson’s disease or Lewy body dementia without psychotic symptoms. For changed behaviours, consider deprescribing when treatment has continued beyond 12 weeks and there has been limited response, or symptoms have resolved, are unlikely to recur or remain stable.
• Cholinesterase inhibitors: consider deprescribing when there is no clear ongoing benefit, dementia has progressed to severe or end-stage disease, or significant side effects are affecting quality of life.

For Rose, a medication review could help determine whether any of her medicines are contributing to her drowsiness and functional decline, and whether deprescribing may be appropriate. This is important to ensure each medicine continues to provide meaningful benefit that outweighs its potential harms and burden.

Coming up

The next article in the Rethinking medicines series will explore anticholinergic and sedative burden.

Dr Xisco Reus and Professor Christopher Etherton-Beer are medical practitioners. Dr Amanda Quek and Associate Professor Amy Page are pharmacists. They are all researchers at The University of Western Australia.

Read other clinical stories here
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