A patient with Alzheimer's disease is taking a cholinesterase inhibitor. Which side effects would most concern the nurse due to potential cardiovascular risk?

• A. Bradycardia and fainting
• B. Dizziness, headache, nausea
• C. Cough and hoarseness
• D. Weight gain and edema

Answer: (A)

Cholinesterase inhibitors boost acetylcholine in both the central and peripheral nervous systems, which increases parasympathetic (vagal) effects on the heart. Activation of cardiac muscarinic receptors slows the SA node and slows AV nodal conduction, so the heart rate can drop. In older adults, especially those with underlying conduction abnormalities or who are taking other medications that slow heart rate, this can lead to significant bradycardia and even fainting from reduced cerebral perfusion. That cardiovascular risk—bradycardia with possible syncope—is why the combination of a slow pulse and fainting is the most concerning side effect.

Other common adverse effects like dizziness, headache, and nausea can occur with these drugs but do not carry the same immediate cardiovascular risk. Cough and hoarseness aren’t typical cardiovascular concerns with this class, and weight gain with edema isn’t characteristic. Clinically, monitor heart rate and rhythm, assess for symptomatic bradycardia or syncope, and review concurrent AV-nodal depressants to determine if dose adjustment or discontinuation is needed.