The cholinesterase inhibitors like Aricept (i.e., donepezil) have been available for treatment of dementias such as Alzheimer’s disease since the mid 1990s. It is clear that long term use of these medications slows the progression of Alzheimer’s disease (in those who tolerate them) and that discontinuing the medication after extended use produces a more rapid decline even in those so impaired that they are in skilled nursing facilities. Despite these findings, the cholinesterase inhibitors are often maligned, not used, or discontinued too soon because they do not produce dramatic effects and do not stop or reverse decline.

One way to determine the efficacy of these medications is to determine if treatment reduces the burden that caregivers express (“Effects on caregiver burden of donepezil hydrochloride dosage increase to 10 mg in patients with Alzheimer’s disease,” Nakamura et al. Patient Preference and Adherence, 2014, 8, 1223-1228, PMID: 25258516). Normally, Aricept is initially given at a dose of 5 mg and increased to 10 mg after about 4 weeks. This study followed 27 Japanese patients (who tolerated treatment) (average age = 86.5) with moderate to severe Alzheimer’s disease. Participants were assessed before and after being switched to 10 mg donepezil and observed for 16 weeks. Assessments were made of severity of disease (i.e., orientation, speech, bathing, toileting, and dressing), caregiver burden, and swallowing at week 4, 8 12, &16. All study participants were still cared for at home.

The increase in dose from 5 to 10 mg. had no statistically significant effect on severity of the disease. However, the higher dose significantly reduced self-report of caregiver strain. The increased dose also produced small improvements in dressing, bathing, and toileting. Finally, the higher dose of donepezil improved swallowing in those participants that had swallowing problems at the beginning of the study.

Of course, this was a small study that did not include a placebo treatment and was only carried out over the course of 6 weeks. However it makes clear that rather than relying on impressionistic feelings, we need simple objective rating scales other than just the Mini Mental State Exam to gather data to inform clinical decision-making. A small increase in dose of Aricept improved both caregiver distress and self-care/swallowing in patients. Although cholinesterase inhibitors do not have dramatic actions or cure dementia, they do have a positive effect for many who tolerate them.