Therapeutic dilemmas: cognitive enhancers and risk of falling in older adults—a clinical review

Key summary points Aim To summarize the falls-related risks of cognitive enhancing medications used to treat neurodegenerative conditions. To assist the clinician in considering the appropriateness of prescribing a cognitive enhancer in an older person at risk of falls and explore the factors that should be considered when reviewing the ongoing use of these medications. Findings Cognitive enhancer use is associated with multiple fall-related side effects, particularly in the initial weeks of administration and up-titration. Acetylcholinesterase inhibitors and memantine differ in their fall-related side effect profiles. Cognitive enhancers can contribute to falls through precipitating cardiac, sleep, neurological (e.g. seizure), extrapyramidal, bladder and/or neuro-psychiatric side effects. Cognitive enhancers should be subject to frequent medication review, including appropriate treatment indication and occurrence of side effects. Several suggested guidelines exist to aid deprescribing decisions, however, these are based on a relatively small number of focused clinical trials. Message An individualised approach should be taken when considering whether cognitive enhancer therapy is still appropriate in older adults at risk of falling. Clinicians should consider the plethora of risks associated with (de-) prescribing these medications.