Initiating and reviewing cognitive enhancers in Alzheimer disease (MEQ)

(i) What enhancers do. Cognitive enhancers (AChEIs and memantine) are symptomatic, not disease-modifying cures or amyloid antibodies. Donepezil RCTs (Rogers) and Cochrane synthesis show modest average gains on cognition and global measures in AD dementia; set expectations with daughter honestly.[1][7]

(ii) Pre-treatment and counselling. Confirm AD dementia diagnosis and stage; baseline pulse (ECG if conduction risk), weight, goals of care, carer education. Stop or review oxybutynin (anticholinergic opposing AChEI). Counsel nausea, diarrhoea, anorexia, weight loss, bradycardia/syncope red flags, and need for review. Capacity and shared decision; no promise of cure.[7][8]

(iii) Donepezil plan. Start donepezil 5 mg oral once daily; if tolerated after ≥4 weeks, increase to 10 mg daily. Review early for GI/cardiac symptoms; structured efficacy/tolerability review ~3 months then ~6-monthly with same cognitive/functional anchors and carer global impression.[1][7][8]

(iv) Memantine timing. Not first-line now in mild–moderate stage. For moderate–severe AD: memantine has standalone (Reisberg) and add-on to donepezil (Tariot 2004) evidence; titrate from 5 mg daily toward 10 mg twice daily with renal awareness. Combination is an option later, not an automatic dual start today.[2][3]

(v) MCI and stopping. This patient has dementia, not pure MCI — Petersen/Tricco argue against routine long-term AChEI as disease modification in pure MCI. Stopping: intolerable harm, no meaningful benefit after adequate trial, or end-stage comfort goals — but DOMINO-AD shows continuing donepezil can still help in moderate–severe AD versus automatic withdrawal when severity rises.[4][5][6]