Anti-cholinesterases
Cholinesterase inhibitors (Donepezil, Rivastigmine and Galantamine) and NMDA receptor antagonist Memantine are prescribed to treat symptoms of Alzheimer’s disease and other dementias.
- Despite their common use, little is known about the impact of these medications on gait, falls and fall-related adverse events
- Some studies suggest that cholinesterase inhibitors may reduce falls as they improve gait and balance control through their positive effects on attention and executive balance.1
- Several cases do report falls; this can be logically explained by cholinesterase inhibitors’ ability to increase risk of syncope due to cardio inhibition and bradyarrhythmia.1
- Neurocardiovascular instability such as hypotension can also be exacerbated by cholinesterase inhibitors increasing the risk of falls 1
It is not usually recommended to withdraw these medications as behavioural and cognitive benefit of treatment are lost
- There is no justification in switching agents on basis of fall risk as they are associated with similar incidence of CNS.2
- Alter route of administration by converting Rivastigmine from capsules to patches which is associated with less dizziness.3
- Use patch of the closest strength to establish oral daily dose
- Start the patch on the day after the last oral dose
References
Kim DH, Brown RT, Ding EL, Kiel DP, Berry SD. Dementia medications and risk of falls, syncope, and related adverse events: meta‐analysis of randomized controlled trials. J Am Geriatr Soc. 2011;59(6):1019-1031.
Lockhart I, Mitchell S, Kelly S. Safety and tolerability of donepezil, rivastigmine and galantamine for patients with Alzheimer’s disease: systematic review of the ‘real-world’ evidence. Dement Geriatr Cogn Disord.2009;28(5):478-492.
Birks J, Grimley Evans J, Iakovidou V, Tsolaki M. Rivastigmine for Alzheimer’s disease. Cochrane Database Syst Rev. 2000;4.