Effect of discontinuing cholinesterase inhibitor therapy on behavioral and mood symptoms in nursing home patients with dementia.
BACKGROUND
Cholinesterase inhibitors (CHEIs) ameliorate some types of behavioral symptoms in patients with Alzheimer's disease. However, there has been little previous study of the outcomes associated with discontinuing these medications.


OBJECTIVE
The primary aim of this study was to evaluate the extent to which discontinuing CHEI therapy affected behavioral and mood symptoms in a cohort of nursing home residents with a diagnosis of dementia compared with residents receiving longer-term CHEI therapy.


METHODS
This was a retrospective cohort study using Rhode Island Medicaid prescription claims and the Minimum Data Set (MDS). Participants were Rhode Island nursing home residents aged > or =60 years with a diagnosis of Alzheimer's disease or non-Alzheimer's dementia, treated with CHEI monotherapy, and enrolled in the Medicaid program between January 1, 2004, and December 31, 2005. The discontinuation cohort (CHEI-DC) was selected by identifying residents who received 3 to 9 months of uninterrupted CHEI therapy. The continuation cohort (CHEI-CONT) was prescribed continuous CHEI therapy for >9 months. Changes in scores on the Aggressive Behavior Scale (ABS) and the Depression Rating Scale (DRS) for CHEI-DC residents were compared with changes in scores for CHEI-CONT residents. Secondary outcomes included change over time for individual behavioral symptoms and indicators of cognitive and functional status coded on the MDS.


RESULTS
The final matched sample (N = 178) included 62 CHEI-DC cases and 116 CHEI-CONT controls. More than half of the cohort was aged > or =85 years, and the sample was predominantly female. A diagnosis of Alzheimer's disease was documented in 40.3% of the CHEI-DC patients and in 46.5% of the CHEI-CONT patients. Behavioral worsening, indicated by an increase in the estimated mean monthly point change in ABS score, occurred in the CHEI-DC group (0.08; 95% CI, 0.01 to 0.16) but not in the CHEI-CONT group (-0.01; 95% CI, -0.06 to 0.04), and the between-group difference was significant (0.09; 95% CI, 0.01 to 0.18). There were no significant between-group differences in the mean monthly point change in mood symptoms on the DRS (0.04; 95% CI, -0.03 to 0.12). For the secondary outcomes, the mean monthly MDS point change for frequency of repetitive verbal behaviors indicated that CHEI-DC patients exhibited significantly more episodes of repetitive questioning (0.17; 95% CI, 0.05 to 0.29) and repetitive health complaints (0.16; 95% CI, 0.04 to 0.27) compared with CHEI-CONT residents. Continued use of CHEIs was associated with more time spent in leisure-related activities over the study period (-0.26; 95% CI, -0.50 to -0.02), with the CHEI-DC group spending less time in activities (0.11; 95% CI, 0 to 0.23); the between-group difference was also significant (0.37; 95% CI, 0.10 to 0.65).


CONCLUSIONS
Results of this retrospective analysis suggest that, compared with longer duration of CHEI therapy, discontinuation of CHEIs in these nursing home residents with dementia was associated with some adverse behavioral changes and decreased time spent engaging in leisure-related activities.
Daiello
Lori A
LA
Department of Clinical Neurosciences, Alpert School of Medicine, Brown University, Providence, Rhode Island. Idaiello@lifespan.org
Ott
Brian R
BR
Lapane
Kate L
KL
Reinert
Steven E
SE
Machan
Jason T
JT
Dore
David D
DD
D000339:Affect / Q000187:drug effects*; D000368:Aged; D000369:Aged, 80 and over; D000374:Aggression / Q000187:drug effects; D001519:Behavior / Q000187:drug effects*; D002800:Cholinesterase Inhibitors / Q000008:administration & dosage*; D003071:Cognition / Q000187:drug effects; D003704:Dementia / Q000188:drug therapy* / Q000523:psychology; D003863:Depression / Q000209:etiology / Q000517:prevention & control; D004334:Drug Administration Schedule; D005260:Female; D006707:Homes for the Aged; D006801:Humans; D007899:Leisure Activities; D008297:Male; D008484:Medicaid; D008875:Middle Aged; D009735:Nursing Homes; D012189:Retrospective Studies; D012237:Rhode Island; D012919:Social Behavior; D013997:Time Factors; D014481:United States; D014705:Verbal Behavior / Q000187:drug effects
D002800:Cholinesterase Inhibitors