For most families navigating end-stage Alzheimer’s disease, the answer to this question is yes — it is generally safe to stop Alzheimer’s medications at the end of life, and in many cases, doing so is the right medical decision. Research supports that discontinuing cholinesterase inhibitors such as donepezil, rivastigmine, and galantamine in advanced dementia is not associated with meaningful decline in cognition, behavior, or day-to-day function. A systematic review published in PMC found no clinical deterioration when these drugs were stopped through a structured, multidisciplinary process. A 2022 study of institutionalized patients with advanced dementia reached the same conclusion: discontinuation did not negatively impact quality of life compared to continuing the medications. Consider a common scenario: a woman in her late eighties with severe Alzheimer’s who no longer recognizes her children, can no longer feed herself, and is receiving hospice care.
Her physician recommends stopping donepezil. Her family is frightened — they worry she will decline faster without it. But the evidence suggests their fear, while understandable, is not supported by the data. At this stage of the disease, the medications are unlikely to provide meaningful benefit, and the burden of managing them — including side effects and swallowing difficulties — may outweigh any potential good. This article covers when guidelines recommend stopping these medications, how to do it safely, what the research says about quality of life, and how to have this conversation with a care team.
Table of Contents
- What Does the Research Say About Stopping Alzheimer’s Medication at End Stage?
- When Do Clinical Guidelines Recommend Stopping Alzheimer’s Medications?
- How Should Alzheimer’s Medications Be Stopped Safely?
- Weighing the Burden vs. Benefit of Continuing Medications at End of Life
- What About Newer Alzheimer’s Drugs Like Lecanemab and Donanemab?
- The Role of the Hospice Team in Medication Decisions
- Looking Forward — How This Conversation Is Changing
- Conclusion
- Frequently Asked Questions
What Does the Research Say About Stopping Alzheimer’s Medication at End Stage?
The medications most commonly used to treat Alzheimer’s disease fall into two categories: cholinesterase inhibitors (donepezil, rivastigmine, galantamine) and the NMDA receptor antagonist memantine. These drugs were studied and approved for mild-to-moderate and, in some cases, moderate-to-severe Alzheimer’s. Critically, clinical trial evidence for their effectiveness does not extend to the end stage of the disease. A survey of hospice medical directors published in PMC found that a significant number considered continuing cholinesterase inhibitors and memantine in end-stage patients to be of questionable benefit for exactly this reason: the evidence base simply does not cover this population. The systematic review published through PMC analyzed multiple studies on discontinuing cholinesterase inhibitors in patients with advanced dementia and found no significant worsening of cognitive scores, behavioral symptoms, or functional status after stopping the drugs. This is a meaningful finding.
It tells clinicians and families that the feared “crash” after stopping these medications — a sudden, dramatic decline — is not what the evidence shows. Compared to continuation, discontinuation performed equivalently across quality-of-life measures in the 2022 institutionalized dementia study. There is an important distinction to draw here, however. These findings apply to end-stage and advanced dementia specifically. For patients in early or moderate stages, discontinuing these medications without clinical guidance would be a different matter entirely. The safety of stopping is context-dependent, tied to where the person is in the disease trajectory and what the goals of care have become.
When Do Clinical Guidelines Recommend Stopping Alzheimer’s Medications?
The Palliative Care Network of Wisconsin has published specific clinical criteria for when deprescribing cholinesterase inhibitors is appropriate. These include: a life expectancy of less than one year, loss of the ability to perform basic daily functions such as self-feeding, no longer recognizing family members or finding comfort in their presence, a shift in care goals from active treatment to palliative and comfort-focused care, and a documented decline from moderate to severe dementia. These are not arbitrary thresholds — they reflect the point at which the biological mechanisms these drugs target are overwhelmed by neurodegeneration, and the realistic potential for benefit has diminished substantially. In practice, this often means the conversation about stopping medications should happen around the time a patient enters hospice or transitions to comfort-focused care. A patient who can no longer swallow pills reliably, who has lost 15 pounds in three months, and who sleeps most of the day has a fundamentally different clinical picture than the patient for whom donepezil was originally prescribed years earlier.
Continuing the same medication regimen without reassessment at this stage reflects a failure to adapt care to the person’s actual condition. However, there is a meaningful caveat: not every patient or family is ready for this conversation at the same time, and care goals are not always clearly established. If a family remains focused on active treatment and has not yet transitioned to a palliative framework, a physician may continue medications longer while having ongoing conversations about goals. The guideline thresholds are clinical anchors, not automatic triggers. Context, relationship, and communication all shape how and when deprescribing happens.
How Should Alzheimer’s Medications Be Stopped Safely?
The method of stopping matters. Abrupt discontinuation of cholinesterase inhibitors is not recommended. Instead, the Palliative Care Network of Wisconsin advises a tapering approach: halving the dose each week and stepping down through available formulations to the lowest dose before stopping entirely. For donepezil, this typically means moving from 10 mg to 5 mg for one week before stopping. For rivastigmine patch, it means stepping down through patch sizes. This gradual reduction allows the body to adjust and reduces the risk of any discontinuation effects, however modest those risks may be.
To illustrate the practical process: a patient on donepezil 10 mg daily might be moved to 5 mg for one to two weeks, then discontinued. The prescribing physician or hospice medical team would document the rationale, communicate the plan to caregivers and family, and monitor for any changes in the days following. In most cases, families report no observable change in the patient’s condition. Occasionally, a patient may seem slightly more restless or confused in the first week, which should prompt a call to the hospice nurse, though this is typically transient and not evidence that the drug was providing significant benefit. A situation where this taper approach becomes more complex is when a patient is also on memantine. Memantine is sometimes continued longer than cholinesterase inhibitors because it is better tolerated and easier to administer, but the same principles of reassessment apply. At true end stage, continuing memantine because it is less burdensome than stopping it is a reasonable default for some clinicians — but it should still be a deliberate, revisited decision rather than a passive continuation.
Weighing the Burden vs. Benefit of Continuing Medications at End of Life
At the heart of deprescribing in end-stage dementia is a straightforward but often emotionally complicated calculation: does continuing this medication produce enough benefit to justify its burdens? In earlier stages of Alzheimer’s, cholinesterase inhibitors offer modest cognitive and functional benefits that can meaningfully improve daily life. The calculus at end stage looks very different. The drugs can cause nausea, vomiting, diarrhea, appetite loss, dizziness, and vivid dreams — side effects that are tolerable in a person who is otherwise functional but can significantly reduce comfort in someone who is already frail and declining. The palliative care consensus, reflected in guidance from ProCare Hospice and a review published in Tandfonline, is that when comfort is the primary goal of care, the burden-to-benefit ratio of continuing cholinesterase inhibitors and memantine typically favors stopping them. This does not mean the medications failed — they may have provided real benefit for years.
But a drug that helped maintain independence at moderate-stage disease is operating in an entirely different context when the patient is bedbound, non-verbal, and in the final chapter of life. The tradeoff families often face is between the concrete risk of distressing side effects and the abstract fear that stopping will cause decline. The research consistently supports that the fear is not well-founded. The side effects are real and present. That asymmetry — one risk is documented and the other is not supported by evidence — should inform how families and clinicians approach the conversation.
What About Newer Alzheimer’s Drugs Like Lecanemab and Donanemab?
Lecanemab (Leqembi) and donanemab (Kisunla) represent a newer class of Alzheimer’s treatment: disease-modifying therapies that target amyloid plaques in the brain. These drugs have generated significant attention and represent a genuine shift in what is pharmacologically possible in Alzheimer’s treatment. However, they are approved only for early-stage Alzheimer’s disease, and they are not part of the end-stage care conversation in any clinical context. They are not used in advanced dementia. Beyond their stage-specific approval, these drugs carry serious risks that make them inappropriate for end-stage patients under any circumstances.
As reported in Nature in 2025, lecanemab and donanemab are associated with brain bleeds and stroke-like events, a side effect profile known as ARIA (amyloid-related imaging abnormalities). These risks are managed in early-stage patients through regular MRI monitoring and careful patient selection — conditions that are not compatible with end-of-life care, where the goal is comfort rather than active intervention. The warning here is specific: families who have read about these newer drugs and hope they might help a loved one in end-stage Alzheimer’s should understand that these medications are not applicable to that stage of disease. The science of disease-modifying therapy for Alzheimer’s is advancing, but it is advancing at the early end of the disease continuum, not the late end. Do not conflate excitement about new treatments with options for patients who are already in the final stages.
The Role of the Hospice Team in Medication Decisions
Hospice teams, including hospice medical directors and nurses, play a central role in reviewing and rationalizing medication lists for patients in end-stage dementia. A hospice admission is, in many ways, a structured opportunity for medication review. Hospice medical directors routinely assess whether medications prescribed during earlier phases of a disease continue to serve the patient’s current goals. For Alzheimer’s patients, cholinesterase inhibitors are among the first medications evaluated for discontinuation.
This is not a decision made in isolation. Good hospice practice involves the physician, the nurse, the social worker, and the family in discussions about medication burdens. A hospice nurse who visits twice weekly is in a position to notice whether a patient is tolerating swallowing medications, whether there are signs of GI distress, or whether the pill routine is causing distress to both patient and caregiver. That frontline observation feeds directly into the medication review process. Families should feel empowered to ask hospice staff directly: “Is there a reason to keep giving these medications? What would happen if we stopped?”.
Looking Forward — How This Conversation Is Changing
The movement toward intentional deprescribing in advanced dementia reflects a broader cultural and medical shift: the recognition that more treatment is not always better treatment. For decades, stopping a medication felt like giving up. That framing is slowly being replaced by a more nuanced understanding — that removing a medication that no longer helps, and may be causing harm, is itself a form of good clinical care.
Organizations including the Palliative Care Network of Wisconsin, the American Academy of Hospice and Palliative Medicine, and others are developing more explicit deprescribing protocols to help clinicians navigate these conversations with confidence. As the population of people living with Alzheimer’s grows, and as more families face these decisions, the field will likely develop clearer guidance for when and how to stop each class of medication. The goal is not to hasten death or to abandon treatment, but to ensure that every intervention a person receives in their final months is one that genuinely serves their comfort and dignity.
Conclusion
Stopping Alzheimer’s medications at the end stage of the disease is not only safe in most cases — it is often the medically appropriate decision. Research consistently shows that discontinuing cholinesterase inhibitors in advanced dementia does not cause the decline families fear, and the palliative care consensus is that when comfort is the priority, continuing these medications typically does more harm than good. Clinical guidelines from the Palliative Care Network of Wisconsin identify clear criteria for when deprescribing is appropriate, including a life expectancy under one year, loss of basic self-care function, and a shift to comfort-focused goals. When stopping, a gradual taper — rather than abrupt discontinuation — is the recommended approach.
For families in this situation, the most important next step is a direct conversation with the hospice team or the patient’s physician about medication goals. Ask what each drug is still intended to accomplish. Ask what the evidence says about its benefit at this stage. Ask what stopping it might look like, and what you would watch for. These are not difficult questions to ask, and the answers will almost always lead to a care plan that better fits the person in front of you — not the person they were five years ago when the prescription was first written.
Frequently Asked Questions
Will my loved one decline faster if we stop donepezil at end stage?
The evidence does not support this fear. A systematic review of multiple studies found that discontinuing donepezil and similar drugs in advanced dementia did not cause measurable decline in cognition, behavior, or function. The feared rapid deterioration after stopping is not what research shows in end-stage patients.
Can we stop Alzheimer’s medications all at once, or does it need to be gradual?
Gradual tapering is recommended. The standard approach is to halve the dose each week, stepping down through available formulations to the lowest dose before stopping. For example, a patient on donepezil 10 mg would typically be reduced to 5 mg for one to two weeks before the medication is stopped entirely.
What if my loved one’s doctor wants to keep them on the medication?
This is worth a direct conversation. Ask your doctor what specific benefit they expect the medication to provide at this stage, and whether that benefit is supported by clinical evidence. If your loved one is in hospice, the hospice medical director can also weigh in. Goals of care drive these decisions, and if the goal is comfort, that should be reflected in the medication list.
Are the newer Alzheimer’s drugs like lecanemab an option at end stage?
No. Lecanemab and donanemab are approved only for early-stage Alzheimer’s and are not used in advanced or end-stage disease. They also carry serious risks including brain bleeds, which make them inappropriate for end-of-life care regardless of stage.
Is stopping Alzheimer’s medication the same as giving up?
No. Deprescribing medications that no longer benefit a patient — and may be causing discomfort — is a form of good clinical care, not abandonment. Palliative care specialists emphasize that removing a burden without evidence of benefit is consistent with high-quality, compassionate care. The goal is always the patient’s wellbeing, whether that means starting, continuing, or stopping a medication.
What about memantine — should that be stopped too?
Memantine is typically reassessed alongside cholinesterase inhibitors when a patient reaches end stage. While it is generally better tolerated than cholinesterase inhibitors, the same burden-benefit analysis applies. Hospice medical directors and palliative care guidelines recommend evaluating memantine under the same framework: if the patient’s goals are comfort-focused and evidence of benefit at this stage is lacking, stopping is generally appropriate.
