O3‐01‐01: Examining the discontinuation of cholinesterase inhibitor therapy from the perspectives of Alzheimer's disease caregivers and physicians

Abstract

Background: Cholinesterase inhibitors (ChEIs) are now widely prescribed first-line drugs in the treatment of mild to moderate Alzheimer's disease and related dementias (ADRD).Yet, there is inconsistent evidence about the benefits of these drugs and howbest to determine their effectiveness, particularly when these drugs are prescribed over the long term. The issue of when to discontinue ChEI drugs is thus complex and subject to much debate. Against this backdrop, the experiences of prescribing physicians and family caregivers have been largely ignored even though it has been recognized that discontinuation of this drug treatment may have significant implications for quality of life. Methods: This study presents qualitative data from 26 in-depth interviews with caregivers to persons with ADRD who were withdrawn from drug therapy or were in the process of being withdrawn. Additionally 19 family physicians participated in four focus groups about their prescribing practices. Results: The findings reveal that the decision to discontinue ChEIs involves a complex interplay between caregiver appraisal of the benefits of ChEIs and physician interpretation of ambiguous psychometric findings in the assessment of treated patients. Once treatment began, physicians took their lead from caregivers as to howlong to continue prescribing a ChEI even in instances where prescribing might have been contraindicated on the basis of continued poor performance on psychometric testing. Caregivers offered rich narratives about discontinuation being a source of anxiety and conflict within the family, with siblings often disagreeing on the benefits of ChEIs. Caregivers tended to view ChEIs as the last line of defense against the loss of self and felt obliged to continue with treatment despite uncertainty about its effectiveness. The decision of the physician to stop prescribing a ChEI almost always occurred in instances of severe adverse reactions or when institutionalization could no longer be delayed. Conclusions: The study's findings suggest a need for developing "best practice" guidelines to assist physicians and other health care professionals in supporting caregivers and care recipients with the process of ChEI discontinuation. Such initiatives could potentially reduce the costs of funding these drugs and improve the quality of life of caregivers and care recipients.