Deprescribing in advanced dementia with multimorbidity
An 84-year-old woman with advanced Alzheimer dementia (FAST 6d: doubly incontinent, needs help dressing, speaks few words) lives in a nursing home. Her daughter is her health care proxy. Current medications: donepezil 10 mg, memantine 20 mg, atorvastatin 40 mg, metformin 1000 mg twice daily (A1c 6.4%), lisinopril, aspirin 81 mg (primary prevention, no vascular disease), calcium/vitamin D, and omeprazole. She has had two hospitalizations in 6 months for aspiration pneumonia and a urinary tract infection. She eats about 25% of meals, has lost 6 kg in 6 months, and has had two falls. The daughter asks, "Shouldn't we be doing everything?"
1. Apply a deprescribing framework to her medication list. Which agents should be reconsidered and why?
Read the worked answer
Framework. Use a structured approach (e.g., identify all drugs, estimate benefit vs. harm given life expectancy and goals, prioritize, taper, monitor). In advanced dementia with recurrent aspiration and weight loss, the goal shifts toward comfort and avoiding harm.
Reconsider/stop:
- Donepezil and memantine. Benefit in advanced dementia is minimal; donepezil can cause bradycardia, GI upset, anorexia, and weight loss - directly relevant here. Consider tapering donepezil (and memantine) given advanced stage and poor intake.
- Atorvastatin. Primary/secondary prevention benefit accrues over years; in advanced dementia with limited life expectancy, little benefit and contributes to polypharmacy. Reasonable to stop.
- Aspirin for primary prevention. No established vascular disease; bleeding risk without clear benefit - stop.
- Metformin. A1c 6.4% is over-treated for an older adult with weight loss and poor intake; risk of hypoglycemia and GI effects. Deprescribe or reduce, and relax glycemic targets.
- Omeprazole. Reassess indication; if no active GERD/ulcer/bleeding risk, consider stopping (though sometimes continued for aspiration-related reflux).
- Lisinopril, calcium/vitamin D. Review blood pressure target (avoid orthostasis given falls) and continue vitamin D/calcium if appropriate for bone health.
Taper and monitor. Stop one or a few at a time, monitor for withdrawal or symptom change, and document the rationale.
2. How do you respond to the daughter's "do everything" question and align on goals?
Read the worked answer
Reframe "everything." Explain that "doing everything" can include stopping treatments that no longer help and may cause harm - that is still active, compassionate care. Clarify what her mother would have valued (comfort, dignity, being at home, avoiding repeated hospitalizations).
Use shared decision-making:
- Elicit the daughter's understanding and fears; acknowledge her love and desire to do right.
- Explain the trajectory of advanced dementia and that some medications (e.g., statin, aspirin, tight glucose control) offer little benefit now and carry burdens.
- Discuss what matters most: comfort, avoiding aspiration, maintaining function.
Advance care planning. Clarify code status and preferences for hospitalization, antibiotics, and artificial nutrition/hydration; document in the chart and honor the proxy's decisions. Consider palliative care involvement. Reassure that deprescribing is not abandonment.
3. She has recurrent aspiration pneumonia. What supportive and preventive measures are appropriate?
Read the worked answer
Feeding and swallowing: speech-language pathology evaluation; modify food/liquid consistency; upright positioning during and after meals; oral care to reduce aspiration pneumonia risk. Avoid routine percutaneous feeding tubes in advanced dementia - they do not prevent aspiration and may increase restraint use and complications; hand-feeding with comfort focus is preferred.
Medications: avoid sedatives that impair swallow; review for anticholinergics; treat reflux if present.
Infection management: discuss with the proxy the role of antibiotics for recurrent pneumonia - symptom-focused treatment versus repeated hospital transfers; align with goals of care.
Comfort and function: pain assessment, skin care, mobilization as tolerated, and a palliative approach. Document the plan and revisit as her condition changes.