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Severe Alzheimer's — MRCPsych Paper B MCQ

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ModerateOld Age PsychiatrySevere Alzheimer'sMRCPsych Paper B

An 80-year-old woman has clinically severe Alzheimer's disease, with an MMSE score of 6/30 and dependence in basic activities of daily living. She is taking donepezil 10 mg daily, which she tolerates. According to NICE NG97, what is the most appropriate pharmacological next step?

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Correct answer: D — Add memantine while continuing donepezil

NICE NG97 recommends offering memantine in addition to an acetylcholinesterase inhibitor for a person with severe Alzheimer's disease who is already taking one. Therefore, memantine should be added while donepezil is continued. Memantine monotherapy is an option for severe Alzheimer's disease when the person is not already receiving an acetylcholinesterase inhibitor, but NICE advises against stopping an acetylcholinesterase inhibitor because of disease severity alone. Switching to rivastigmine or galantamine is not indicated solely because the disease has become severe; such choices are generally driven by tolerability, adherence, interactions or comorbidity. Donepezil 23 mg is not a recommended UK dose: the UK SmPC specifies a maximum of 10 mg daily.

Reference: NICE. Dementia: assessment, management and support for people living with dementia and their carers (NG97), recommendations 1.5.4–1.5.5, 2018, current with minor updates through 2025. https://www.nice.org.uk/guidance/ng97/chapter/Recommendations