Exam update - Cholinesterase inhibitors for dementia

Current situation 

  • Dementia affects 5 per cent of people over the age of 65, and 20 per cent of those over 80 in the UK.
  • NICE guidance on dementia, published in 2007, recommends using the cholinesterase inhibitors donepezil, rivastigmine and galantamine for the treatment of patients suffering from moderate Alzheimer's disease.
  • NICE recommends that these drugs only be used to treat patients who score 10-20 points on the Mini Mental State Examination, and that they should not be used in those with milder symptoms. This excludes more than 50,000 patients with Alzheimer's from NHS treatment with cholinesterase inhibitors.
  • NICE recommends that memory assessment services should be the single point of reference for all patients with dementia.
  • The High Court ruling on the use of cholinesterase inhibitors by the NHS has finally been made. The judge ruled in favour of the NICE decision to restrict them.

What is the evidence?

  • Randomised controlled trials have shown that these drugs have beneficial effects on cognitive and global outcome measures in patients with Alzheimer's.
  • Some experts believe that memory clinics have spent time and money monitoring patients taking cholinesterase inhibitors instead of ensuring the delivery of multidisciplinary care plans (BMJ 2006; 333: 491-3).
  • Meta-analyses have shown that these drugs have modest beneficial effects compared with placebo (Cochrane Database Syst Rev 2006; (1): CD001190, Health Technol Assess 2006; 10: 1).
  • One study showed that patients with dementia are being referred earlier to specialists leading to more cholinesterase inhibitors being prescribed (Psychiatric Bulletin 2006; 30: 131-4).
  • Patients with severe Alzheimer's living at home who are treated with donepezil have been shown to stabilise or decline more slowly than patients given placebo (Neurology 2007; 69: 459-69).

Implications for practice

  • When it adjusted costs to take account of the benefits attributed to these drugs NICE estimated that donepezil, rivastigmine, and galantamine had a cost per quality adjusted life year gained of £48,000, £32,000, and £38,000 respectively.
  • If the NICE recommendations are adopted, the NHS will save of £15 million in the first year, £45 million in the second, and more than £60 million in the third.

Dr Louise Newson is a GP in the West Midlands and author of 'Hot Topics for MRCGP and General Practitioners' PasTest, 2006 Resources

NICE (TA111) Alzheimer's disease - donepezil, galantamine, rivastigmine (review) and memantine: guidance (amended September 2007): www.nice.org.uk

Key Points

Dementia is very common.
Cholinesterase inhibitors may be less effective than initially thought.
The use of cholinesterase inhibitors in Alzheimer's disease is still controversial.

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