Alzheimer's Disease — MRCPsych Paper B MCQ

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ModerateOld Age PsychiatryAlzheimer's DiseaseMRCPsych Paper B

An 82-year-old man has clinically severe Alzheimer's disease and is taking donepezil, which he tolerates. His family asks whether his cognitive-enhancing treatment should be changed. According to NICE NG97, what is the most appropriate pharmacological step?

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Correct answer: D — Add memantine to donepezil

Explanation lettering: D = shown as A · E = shown as B · B = shown as D · A = shown as E

B is correct. NICE NG97 recommends offering memantine in addition to an acetylcholinesterase inhibitor when a person already taking the inhibitor has severe Alzheimer's disease. Donepezil should therefore be continued and memantine added, assuming treatment remains tolerated and clinically appropriate. Donepezil should not be stopped solely because the dementia has become severe, excluding C and D. Continuing donepezil alone does not follow the recommendation to offer adjunctive memantine in severe disease, so A is less appropriate. Switching to galantamine is not indicated merely because the disease has progressed; galantamine is another acetylcholinesterase inhibitor rather than the recommended adjunct in this situation. Severity should be assessed clinically, and NICE cautions against relying inappropriately on a cognitive score alone.

Reference: National Institute for Health and Care Excellence. Dementia: assessment, management and support for people living with dementia and their carers (NG97), recommendations 1.5.4, 1.5.5 and 1.5.8. Published 2018; last reviewed 24 October 2025. https://www.nice.org.uk/guidance/ng97/chapter/Recommendations