Deprescribing of Acetylcholinesterase Inhibitors in Older Adult Nursing Home Residents with Severe Dementia

Clinical guidelines and expert opinion suggest that deprescribing or discontinuing AChEIs may be an appropriate strategy to reduce medication burden and risk for adverse events, given the lack of evidence to support their effectiveness in patients with severe dementia. There have been few well-designed studies with adequate sample size that have evaluated the effects of deprescribing AChEIs on outcomes. The findings of this dissertation address a critical gap in the literature by examining the epidemiology and outcomes associated with deprescribing AChEIs. The first study examined the epidemiology of deprescribing AChEIs and found that deprescribing was more likely in older residents who exhibited signs of declining clinical status. By contrast, regional rurality and non-geriatric prescriber specialty was associated with reduced likelihood of deprescribing. In the second study, we evaluated the association of deprescribing AChEIs with behavioral outcomes including depression severity and aggressive behaviors. The overall prevalence of behavioral symptoms in this population was low and deprescribing AChEIs was not found to be associated with a significant change in depressive symptoms or aggressive behaviors. Finally, we examined the downstream impact of deprescribing AChEIs on the use of other medications. Deprescribing AChEIs was associated with a general reduction in the total number of other non-AChEI medications prescribed, including a reduced likelihood of receiving new antipsychotic prescriptions. Deprescribing was not associated with an increased likelihood of discontinuing strong anticholinergic medications that may have originally been prescribed as part of the cholinergic prescribing cascade. The findings presented in this dissertation suggest that deprescribing AChEIs may be a safe approach to reduce medication burden without worsening behavioral symptoms in older nursing home residents with severe dementia. Targeted educational interventions aimed at non-geriatric prescribers in rural nursing facilities may help to improve the dissemination and implementation of deprescribing in clinical practice.