Neurology
Anticholinesterase dementia drugs
Donepezil, rivastigmine, galantamine — Help symptoms in Alzheimer's and some other dementias — modest but worthwhile benefit.
Education and reference only. This is a plain-language class overview — it deliberately contains no doses. Always check the current Summary of Product Characteristics (SmPC), the BNF and your local formulary before prescribing or administering any medicine.
What it is
These drugs treat the symptoms of Alzheimer's disease and some related dementias, aiming to maintain memory, thinking and day-to-day function for longer. They manage symptoms rather than altering the underlying disease.
How it works
In Alzheimer's disease levels of acetylcholine — a neurotransmitter important for memory — are reduced. These drugs block the enzyme that breaks acetylcholine down, raising its level at the synapse and supporting the signalling involved in memory and attention.
In practice
In practice these drugs do not cure or stop dementia, but they can produce a worthwhile, if modest, improvement or stabilisation in memory, daily function and behaviour for a period, which matters a great deal to families. They are used in mild-to-moderate Alzheimer's disease (and rivastigmine in Parkinson's-disease dementia and Lewy body dementia). The side-effects flow from boosting acetylcholine: nausea, diarrhoea, loss of appetite and a slow heart rate, so caution is needed in people with a tendency to bradycardia, fainting, peptic ulcers or significant asthma/COPD. Benefit is reviewed, and treatment is generally continued while it is judged to be helping. A practical safety point is that they can slow the heart and interact with other rate-slowing drugs; a patient who faints or has new dizziness warrants a pulse and medication review.
Examples
Practical use
How to take it & use it well
- Take donepezil, rivastigmine or galantamine as prescribed, often building up slowly from a low starting dose to reduce side effects.
- Donepezil is usually taken once a day, and taking it in the evening can help if it causes vivid dreams or sleep changes; follow your prescriber's advice.
- Take rivastigmine and galantamine with food to reduce nausea, and if using a rivastigmine patch, apply it to clean dry skin and rotate the site daily.
- Do not stop the medicine suddenly without advice, as symptoms can worsen; speak to your team first if side effects are troublesome.
- Report a slow or irregular pulse, fainting or significant weight loss, as these may mean the dose needs reviewing.
- Make sure carers know the routine, since people with dementia may need help remembering and taking the medicine reliably.
Common uses
- Mild-to-moderate Alzheimer's disease
- Parkinson's-disease dementia and Lewy body dementia (rivastigmine)
- Symptom maintenance with periodic review
Monitoring
- Cognitive and functional benefit at review (continue while helping)
- Pulse, weight and gastrointestinal tolerance
- Falls or fainting and interacting rate-slowing drugs
Weighing it up
Advantages & disadvantages
Advantages
- Can ease some symptoms of Alzheimer's disease, helping with memory, thinking and day-to-day function for a time.
- May help maintain independence a little longer, which matters to patients and carers.
- Available in different forms, including tablets and a skin patch, to suit individual needs.
- Generally improve symptoms rather than only slowing decline, so benefits can be noticeable to families.
Disadvantages
- Treat symptoms rather than curing the disease, and the benefit may lessen as dementia progresses.
- Commonly cause nausea, vomiting, diarrhoea, loss of appetite and weight loss, especially when starting.
- Can slow the heart rate and rarely cause fainting, so heart rhythm should be considered before starting.
- May cause muscle cramps, vivid dreams or worsening of some other conditions such as stomach ulcers or asthma.
Key safety principles
What to watch for
- Cholinergic effects — nausea, diarrhoea, appetite loss and a slow heart rate.
- Caution with a tendency to bradycardia or fainting, peptic ulcer disease, and significant asthma/COPD.
- Additive heart-rate slowing with other rate-limiting drugs — review if faints or new dizziness occur.
Key interactions
What to avoid or check alongside
- Combining these medicines with heart-rate-lowering drugs such as beta-blockers or certain calcium channel blockers can slow the heart too much.
- Some bladder and gut medicines with anticholinergic effects work against these drugs and may reduce their benefit.
- Medicines that affect particular liver enzymes can change the levels of donepezil and galantamine, increasing side effects.
- Using them with non-steroidal anti-inflammatory painkillers may add to the risk of stomach irritation.
- Tell anaesthetists before surgery, as these medicines can affect certain muscle relaxants used in operations.
Patient & carer advice
- These ease symptoms for a time rather than curing — we will review the benefit
- Nausea or loose stools often settle; tell us if they persist
- Report fainting, marked dizziness or a very slow pulse
Use with
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Answers
Anticholinesterase dementia drugs: frequently asked questions
Do these medicines cure Alzheimer's disease?
No. Donepezil, rivastigmine and galantamine treat symptoms such as memory and thinking for a time, but they do not cure or stop the underlying disease, which continues to progress.
Why can these medicines slow the heart?
They boost a chemical messenger that can also slow the heart rate. Your team usually checks your pulse and heart history before starting, and you should report fainting or a slow, irregular pulse.
What are the most common side effects?
Nausea, vomiting, diarrhoea, reduced appetite and weight loss are common, especially when starting or increasing the dose. Taking the medicine with food and building up slowly can help.
Can I stop the medicine if it does not seem to help?
Do not stop suddenly without advice, as symptoms can worsen. Discuss with your team, who will weigh up the benefit and any side effects and guide any change safely.
Authoritative sources
Always verify against the source
This overview is for orientation. For doses, interactions, contra-indications and the full monograph, use:
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