Purpose: Rivastigmine is a cholinesterase inhibitor (ChEI), which inhibits both acetylcholinestase and butylcholinestase. Rivastigmine also selectively inhibits the G1 isomer of acetycholinestase and butylcholinestase. Thus, rivastigmine may have greater efficacy for some patients in response to treatment with a ChEI. This retrospective chart review was undertaken to assess the outcome of patients with probable Alzheimer’s disease (AD) who were changed from donepezil to rivastigmine due to progression of their disease.
Methods: Patients with probable AD and receiving treatment with donepezil but who were declining in cognition and also declining in behavior or activities of daily living were offered the opportunity to change treatment to rivastigmine. The selection criteria for this analysis required patients with stable health, stable psychotropic medication usage, and no other confounding factors. 300 charts were reviewed. 20 patients fulfilled these criteria. Cognition was assessed by the Mini-Mental State Exam (MMSE) and behavior by the neuropsychiatric inventory (NPI) at baseline, 6 and 12 months.
Results: The 20 patients consisted of 10 males and 10 females from age 66 to 90 years (mean = 77). 7 patients had improvement of at least 2 points on the MMSE at 6 or 12 months after initiating rivastigmine (p=0.01). 12 of the 20 patients stabilized their MMSE. Two of these patients markedly improved behavior by NPI criteria. 1 patient continued to decline cognitively. 1 patient stopped rivistagmine due to nausea at 9 mg/day (discontinue rate of 5%). Rivastigmine dose ranged from 7.5 to 12 mg/day (mean=11mg/day).
Conclusions: Rivastigmine can offer further therapeutic options for AD patients whose symptoms may be worsening despite donepezil treatment. The dual cholinergic inhibition, including butylcholinesterase, as well as acetycholinesterase, may account for some of the apparent superior efficacy. The selective G1 isomeric inhibition may have an additional beneficial effect. Behavioral improvement was a notable feature of rivastagmine treatment.
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