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AChEI Continuation — MRCPsych Paper B MCQ

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ModerateOld Age PsychiatryAChEI ContinuationMRCPsych Paper B

A 75-year-old man with moderate Alzheimer's disease has taken donepezil 10 mg daily for 18 months. Adherence is good, and he has no significant adverse effects or new contraindications. His cognition has continued to decline, with his MMSE score falling from 18 to 11. His family asks whether the cognitive deterioration means that donepezil should now be stopped. Which action best accords with NICE NG97?

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Correct answer: E — Continue donepezil because disease progression alone is not a reason to stop an AChEI

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

B is correct. NICE NG97 states that acetylcholinesterase inhibitors should not be stopped in Alzheimer's disease because of disease severity alone. A declining MMSE is therefore not, by itself, evidence that donepezil should be withdrawn, particularly when adherence is good and there are no adverse effects or contraindications. Options C and D are incorrect because cognitive decline alone is not an indication to switch between AChE inhibitors; selection is instead influenced by factors such as tolerability, adherence, comorbidity and interactions. Option E is incorrect because memantine monotherapy for moderate Alzheimer's disease is recommended when AChE inhibitors are contraindicated or not tolerated. Memantine may instead be considered as an adjunct to the existing AChEI in moderate disease.

Reference: National Institute for Health and Care Excellence. Dementia: assessment, management and support for people living with dementia and their carers (NG97), recommendations 1.5.3–1.5.6. 2018. https://www.nice.org.uk/guidance/ng97/chapter/Recommendations