Donepezil and Alzheimer's Disease-Part XIV
A recent audit of the assessment and treatment of patients who are using donepezil in routine clinical practice in a district in England (Leeds) was reported in the International Journal of Geriatric Psychiatry (2000; 15:887-891). Donepezil is prescribed for those individuals diagnosed with mild-moderate Alzheimer’s disease. Past clinical trials have shown modest improvements in cognitive function with use of this medication. This study attempted to identify the proportion of individuals who will respond to donepezil.
It should be understood that there is no evidence that any medication for Alzheimer’s disease will reverse the process. At present the available medications may, at best, slow down the progressive deterioration.
The researchers gathered data on 117 patients whose mean age was 76 years, with females outnumbering males by about 2:1. The data included information related to demographics, assessment procedures, diagnosis, initiation of treatment, evaluation of treatment response at three (3) months and discontinuation of treatment.
The audit revealed that 10% of the patients were prescribed donepezil despite relative contra-indications before start of treatment. These contra-indications included supra ventricular cardiac conduction disorders, asthma, and seizure disorder. Sixteen (16) patients stopped the treatment due to wrong diagnosis (3), nausea/GI disturbance (5), poor compliance (2), other (6).
After three months of being on the medication, 93 patients, a formal cognitive evaluation was completed on 71 patients to measure possible changes in cognitive functioning. It was found that 47% of these patients demonstrated an improvement in cognition, activities of daily living or positive comments by those who were supervising ("carers") for the patients. These "carers" noted an improvement in 24 out of 61 recorded "carers" responses, most reflected in improved mood ("calmer", "less anxious", "less irritable"), with only three reporting improvement in memory. However, 33% of the patients were still on donepezil despite no evidence of benefit.
Geriatric psychiatrists were consulted in only 9% of the cases.
The authors of this audit indicate that only 142 patients got treatment out of an estimated 3500 potentially needing the treatment in this district in England. The reasons for this discrepancy include lack of certainty over benefits of medication, concerns about cost and lack of resources to treat a greater amount of individuals.
They feel strongly that anyone getting this treatment should have an activities of daily living assessment (ADL) to determine effects of medication along with a mini-mental status examination. There is a need to develop a monitoring measure that is able to indicate changes in cognitive functioning due to the anti-dementia drug that is pharmacosensitive and relatively easy to administer.
The guidelines they would like to see established for the use of donepezil in mild-moderate cases of dementia are:
Before guidelines can be instituted, there is a need to incorporate the clinical data that is currently available to those who prescribe medications (evidentiary medicine). Application of guidelines needs to involve individual patient’s clinical data. The combination of these two factors will define the level of appropriate prescribing. Algorithms, when used expeditiously, have the potential to enhance the quality of medical care in an environment where patients feel the quality of care is eroding. The danger is that managed care companies may strictly apply these guidelines and deny care to patients in need of the service. Timely and propitious use of medication would seem an important step in the rode to a healthier population. Studies that audit use of medications are the building blocks of this goal.
Cameron I, Curran S, Newton P, Petty D, Wattis J. Use of Donepezil for the treatment of mild-moderate Alzheimer’s disease: An audit of the assessment and treatment of patients in routine clinical practice. International Journal of Geriatric Psychiatry 2000; 15:887-891.
See: Alzheimer's Disease Part I-Medications for Alzheimer's.
See: Alzheimer’s Disease Part II- Selegiline and AD.
See: Alzheimer's Disease Part III- Use of Gingko Biloba in memory problems of Alzheimer patients.
See: Alzheimer's Disease PartIV-Alternative Treatment.
See: Alzheimer's Disease Part V-Possible New Drugs for Alzheimer's Disease Treatment.
See: Alzheimer's Part VI -Early Diagnosis.
See: Alzheimer's Part VII -New Medication-Metrifonate
See:Alzheimer's Disease PartVIII - Implications of Longer Life Expectancies
See: Alzheimer's Part IX-Ethical Care Principles
See: Alzheimer's Disease Part X-Estrogen and Alzheimer's Disease
See: Alzheimer's Disease Part XI-Pocket Smell Test
See: Alzheimer's Disease Part XII-MAO-B
See: Alzheimer's Disease Part XIII-Critical Flicker Fusion Threshold Test
See: Alzheimer's Disease Part XV-Cerebrolysin
See: Alzheimer's Disease Part XVI-MCI
See: Alzheimer's Disease Part XVII-Summary
See: Alzheimer's Disease Part XVIII-NO Releasing NSAIDs
See: Alzheimer's Disease Part XIX-Vitamin E
See: Alzheimer's Disease-Part XX-Clinical Trials
See: Alzheimer's Disease Part XXI-The Brain
See Dementia with Lewy Bodies- Part XXII-by Gourete Broderick
See: Alzheimer's Disease-Part XXIII-HMG
See: Alzheimer's Disease-Part XXIV-A Prequel
See: Alzheimer's Disease-Part XXV-Psychosis
See: Alzheimer's Disease-Part XXVI-Amyloid-beta Hypothesis Controversy
See: Alzheimer's Disease-Part XXVII- AD and Diabetes
See: Alzhemeir's Disease-Part XXVIII - Insulin and AD
FOR AN INFORMATIVE AND PERSONAL ARTICLE ON PRACTICAL SUGGESTIONS WHEN SELECTING A NURSING HOME SEE OUR ARTICLE "HOW TO SELECT A NURSING HOME"
Harold Rubin, MS, ABD, CRC, Guest Lecturer
November 3, 2000
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