Cognitive enhancers — consultant viva

Station structure

Time: 8–10 minutes. Depth: consultant teaching registrar. Expect named mechanisms, doses, subtype trials (DLB/PDD), DOMINO-AD continuation logic, AD2000 critical appraisal without nihilism, and MCI non-indication fluency.[4][6][8][9]

Core questions and model points

1. What are cognitive enhancers? Symptomatic AChEIs (donepezil, rivastigmine, galantamine) and memantine (NMDA antagonist) — not disease-modifying biologics.[9][10]

2. Donepezil dose? 5 mg daily → 10 mg after ≥4 weeks if tolerated; Rogers-level efficacy teaching.[1][9]

3. Memantine role? Mainly moderate–severe AD (Reisberg); add-on to donepezil (Tariot); Cochrane supports mod–severe more than mild.[2][3][10]

4. DOMINO-AD? Continuing donepezil better than stopping for cognition/function in moderate–severe AD — do not auto-withdraw for severity alone.[4]

5. DLB/PDD? McKeith rivastigmine DLB; EXPRESS rivastigmine PDD.[6][7]

6. MCI? Petersen: temporary conversion delay, more AEs; not routine lifelong pure-MCI therapy.[8]

7. AD2000? Pragmatic trial, limited long-term disability/institutionalisation benefits, appraisal controversies — does not erase broader RCT/Cochrane efficacy.[5][9]

8. Safety? GI effects, bradycardia/syncope, review anticholinergics; renal adjust memantine.[9][10]

Pass criteria

• Distinguishes symptomatic vs disease-modifying claims.[9]
• Names donepezil 5→10 mg and memantine titration scaffold.[1][2]
• DOMINO-AD continuation one-liner correct.[4]
• DLB/PDD rivastigmine trials named.[6][7]
• MCI non-routine stance with Petersen-level reasoning.[8]
• AD2000 appraised, not weaponised as universal futility.[5]