Clinician Article
Cholinesterase inhibitors and falls, syncope and injuries in patients with cognitive impairment: a systematic review and meta-analysis.
PMID: 37993407
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GeriatricsRelevance - 6/7
Newsworthiness - 6/7 -
NeurologyRelevance - 6/7
Newsworthiness - 5/7 -
Internal MedicineRelevance - 5/7
Newsworthiness - 5/7 -
Family Medicine (FM)/General Practice (GP)Relevance - 5/7
Newsworthiness - 4/7 -
General Internal Medicine-Primary Care(US)Relevance - 5/7
Newsworthiness - 4/7
Abstract
BACKGROUND: Cholinesterase inhibitors are commonly used to treat patients with neurocognitive disorders, who often have an elevated risk of falling. Effective use of these medications requires a thoughtful assessment of risks and benefits.
OBJECTIVE: To provide an update on previous reviews and determine the association between cholinesterase inhibitors and falls, syncope, fracture and accidental injuries in patients with neurocognitive disorders.
METHODS: Embase, MEDLINE, Cochrane Central Register of Controlled Trials, Cumulative Index of Nursing and Allied Health Literature and AgeLine were systematically searched through March 2023 to identify all randomised controlled trials of cholinesterase inhibitors (donepezil, galantamine, rivastigmine) in patients with cognitive impairment. Corresponding authors were contacted for additional data necessary for meta-analysis. Inclusion criteria consisted of adults =19 years, with a diagnosis of dementia, Parkinson's disease, mild cognitive impairment or traumatic brain injury. Data were extracted in duplicate for the aforementioned primary outcomes and all outcomes were analysed using random-effects meta-analysis.
RESULTS: Fifty three studies (30 donepezil, 14 galantamine, 9 rivastigmine) were included providing data on 25, 399 patients. Cholinesterase inhibitors, compared to placebo, were associated with reduced risk of falls (risk ratio [RR] 0.84 [95% confidence interval [CI] = 0.73-0.96, P = 0.009]) and increased risk of syncope (RR 1.50 [95% CI = 1.02-2.21, P = 0.04]). There was no association with accidental injuries or fractures.
CONCLUSION: In patients with neurocognitive disorders, cholinesterase inhibitors were associated with decreased risk of falls, increased risk of syncope and no association with accidental trauma or fractures. These findings will help clinicians better evaluate risks and benefits of cholinesterase inhibitors.
Clinical Comments
Geriatrics
As a Geriatrician who is seeing more patients with cognitive impairment and with few medications to treat, this meta-analysis is quite informative. Cholinesterase inhibitors are widely used in these patients with modest results. When using them, it is important to understand the risks versus benefits. The finding that fall risk is decreased is very reassuring.
Internal Medicine
Although this meta-analysis is a little reassuring, it is a bit contradictory that syncope risk is increased but fall risk is decreased. Also, the authors cite a study that observed the decreased risk for fall in patients with mild cognitive impairment. It may be that risk of fall was less because cognitive disability was less. Nonetheless, we can continue using this medicine until we have a better option.
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