Cholinesterase inhibitors and Alzheimer's disease

Simpson et al (Psychiatric Bulletin, November 2005, 29, 410-412) state in their audit of the use of cholinesterase inhibitors that stopping these drugs in the latest stages of dementia ‘ is poor clinical practice and likely to have adverse outcomes’. They base this opinion on the fact that many of the patients in their sample deteriorated or died after their memory enhancers were discontinued when their Mini-Mental State Examination scores fell below 12. The authors acknowledge that this high death rate could be because the patients who deteriorated or died were probably the most physically ill. In fact, this would be the simplest and most likely explanation. Therefore, the conclusion that stopping these drugs in the advanced stages of dementia constitutes poor clinical practice is really unfounded and could only be supported after the hypothesis is tested successfully in a controlled trial.