Cholinesterase Inhibitor Use in Dementia
Cholinesterase Inhibitor Use in Dementia
Alzheimer's disease (AD) is the most common cause of dementia and the fourth leading cause of death in adults 65 years of age or older. Currently, approximately 4 million people in the United States are suffering from dementia, with annual treatment costs approaching $150 billion. The incidence of AD is projected to quadruple over the next 50 years. Early diagnosis of AD is critical not only to individual patients, but also from a public health care perspective. When AD is identified in its early stages, patients and families have time to engage in educational services, develop psychosocial support systems, and consider financial and legal planning. Early diagnosis also allows patients to receive optimal benefits from medical treatments. Medical interventions that delay progression to costly endpoints, such as placement in a nursing home, could have an enormous impact on patients' quality of life and the public health care burden.
The loss of cholinergic neurons is central to the impairment of learning, memory, and other cognitive deficits that are characteristic of AD. As such, cholinesterase inhibitors (ChEIs) have become the primary therapy for augmenting cholinergic neurotransmission in patients with mild to moderate AD. Four ChEIs are approved in the United States for the treatment of mild to moderate AD: tacrine, donepezil, rivastigmine, and galantamine. Each has been shown to improve or maintain cognition in patients with AD relative to placebo. In addition, evidence suggests that ChEIs can improve or maintain global functioning, reduce behavioral problems, and reduce care-giver burden associated with AD.
Although numerous studies have demonstrated the potential benefits of ChEIs, the use of these drugs in clinical practice has not been well described and may differ from that in clinical trials. In clinical practice, initiation of drug therapy in patients with AD is typically a joint decision of the clinician, patient, caregivers, and family members and based on various factors, including potential benefits versus risks, drug dosing and frequency, tolerability, adverse-event profiles, concurrent drug therapy, insurance coverage, and cost. Because of the lack of available treatments for dementia or AD, ChEIs may be initiated in clinical practice in situations for which they are not indicated or for patients who will not necessarily benefit from them, such as in more advanced stages of AD or non-AD types of dementia or in patients taking anticholinergics. The perceived benefit of ChEI therapy may differ among clinicians, patients, and families, as expectations of drug therapy may be higher for patients, caregivers, and families than for clinicians. Moreover, there is no consensus on the recommended duration of therapy with ChEIs, so the perceived benefit may affect the length of time a patient receives treatment. The cost of ChEI therapy and patients' insurance coverage (or lack thereof) may also determine who receives or continues therapy.
The primary objectives of this retrospective study were to describe ChEI use in elderly outpatients diagnosed with dementia and compare the use of ChEIs in clinical practice and clinical trials.
Alzheimer's disease (AD) is the most common cause of dementia and the fourth leading cause of death in adults 65 years of age or older. Currently, approximately 4 million people in the United States are suffering from dementia, with annual treatment costs approaching $150 billion. The incidence of AD is projected to quadruple over the next 50 years. Early diagnosis of AD is critical not only to individual patients, but also from a public health care perspective. When AD is identified in its early stages, patients and families have time to engage in educational services, develop psychosocial support systems, and consider financial and legal planning. Early diagnosis also allows patients to receive optimal benefits from medical treatments. Medical interventions that delay progression to costly endpoints, such as placement in a nursing home, could have an enormous impact on patients' quality of life and the public health care burden.
The loss of cholinergic neurons is central to the impairment of learning, memory, and other cognitive deficits that are characteristic of AD. As such, cholinesterase inhibitors (ChEIs) have become the primary therapy for augmenting cholinergic neurotransmission in patients with mild to moderate AD. Four ChEIs are approved in the United States for the treatment of mild to moderate AD: tacrine, donepezil, rivastigmine, and galantamine. Each has been shown to improve or maintain cognition in patients with AD relative to placebo. In addition, evidence suggests that ChEIs can improve or maintain global functioning, reduce behavioral problems, and reduce care-giver burden associated with AD.
Although numerous studies have demonstrated the potential benefits of ChEIs, the use of these drugs in clinical practice has not been well described and may differ from that in clinical trials. In clinical practice, initiation of drug therapy in patients with AD is typically a joint decision of the clinician, patient, caregivers, and family members and based on various factors, including potential benefits versus risks, drug dosing and frequency, tolerability, adverse-event profiles, concurrent drug therapy, insurance coverage, and cost. Because of the lack of available treatments for dementia or AD, ChEIs may be initiated in clinical practice in situations for which they are not indicated or for patients who will not necessarily benefit from them, such as in more advanced stages of AD or non-AD types of dementia or in patients taking anticholinergics. The perceived benefit of ChEI therapy may differ among clinicians, patients, and families, as expectations of drug therapy may be higher for patients, caregivers, and families than for clinicians. Moreover, there is no consensus on the recommended duration of therapy with ChEIs, so the perceived benefit may affect the length of time a patient receives treatment. The cost of ChEI therapy and patients' insurance coverage (or lack thereof) may also determine who receives or continues therapy.
The primary objectives of this retrospective study were to describe ChEI use in elderly outpatients diagnosed with dementia and compare the use of ChEIs in clinical practice and clinical trials.
