The use of anti-dementia medication is expected to rise with increasing demand and a growing elderly population. With the implementation of the “Living well with Dementia: National Dementia Strategy” document in the United Kingdom, there is an increased awareness along with an urge for early diagnosis and initiation of treatment.
Eligibility for starting treatment with both acetylcholinesterase inhibitors (AChEIs) and memantine has been scrutinized quite closely in UK National Health Service organizations as these medications were expensive and most places had been extremely vigilant to monitor the appropriate use of these drugs. However, the circumstances of cessation of this group of medications have not been subjected to the same level of attention and analysis. With the huge cost implications associated with some of these compounds becoming generic, it will be worthwhile to explore whether this will affect the duration of treatment of dementia patients. Recently published evidence from the “Donepezil and Memantine for Moderate-to-Severe Alzheimer's Disease” (DOMINO-AD) study (Howard et al., Reference Howard2012) suggested the benefit of continuing AChEIs in severe stages of Alzheimer's disease.
We conducted a national survey to explore in what circumstances clinicians within the United Kingdom feel it appropriate to discontinue anti-dementia medication and whether their prescribing practice will be affected with the advent of cheaper generic alternatives, and the latest research evidence suggesting benefit of continuing anti-dementia medications in the severe stages of Alzheimer's Disease. The primary aim of this project was to get an overview of the practice followed within the country. The response generated from this survey provides us with valuable data toward developing a consensus or clinical guideline regarding future prescribing of anti-dementia medication.
An online survey questionnaire was generated and circulated via e-mail to 2,127 members of The Old Age Faculty within the Royal College of Psychiatrists in the month of September 2012. We received 410 responses in total (19%). The respondents varied in their work experience in Elderly Psychiatry ranging from 52.8% (201) with more than ten years, 21.3% (81) between five and ten years, 21.5% (82) between one and five years, and 4.5% (17) less than a year experience.
The participants were allowed four weeks to complete the survey. The online questionnaire consisted of 15 simple questions, which could be completed within 10 to 15 minutes. The responses were limited to either “yes” or “no” in most cases, with the option of adding a comment in three areas (for full details please refer to Figure A1, available as supplementary material attached to the electronic version of this letter at www.journals.cambridge.org/jid_IPG).
Naming the preferred drug among the AChEIs, 97.6% (335) of respondents said they prefer donepezil to the other two compounds. Only 1.45% (5) clinicians preferred rivastigmine, and galantamine was named by 0.87% (3) of the respondents. The reasons for preferring donepezil were clarified as easier titration, historically being the first drug within the class, once a day dosing, lowest cost, and patient preference possibly due to more media coverage.
In the section on reasons for discontinuation of anti-dementia drugs, 94.9% (355) of respondents have highlighted side effects of AChEIs as the main reason. This is followed by 47.9% (179) discontinuing these medications after a steady physical decline, 45.5% (170) mentioned Mini-Mental State Examination (MMSE) score less the 10 being a deciding factor, 40.1% (150) would stop if collateral information from relatives and carers suggest a cognitive decline, 22.2% (83) considered entering institutional care as a reason, and 1.1% (4) said that they would never discontinue these drugs. Other comments included onset of swallowing difficulties, consensus view of multidisciplinary team suggesting no benefit, end of life care, and switching over to memantine as possible reasons for discontinuing treatment with AChEIs.
When commenting on the circumstances of initiating memantine, 61.5% (230) of respondents said that they would consider memantine after stopping AChEIs and 76.3% (283) of clinicians would continue patients on a combination therapy of both these medications. Side effects of AChEIs, treatment failure, and symptoms like behavioral and psychological symptoms are the main reasons for swapping over to memantine.
With respect to the research evidence in DOMINO-AD study, 65.8% (244) of respondents feel that future practice of prescribing AChEIs and memantine will alter based on this new information and 34.2% (127) deny any future impact. The comments made in this regard include a general attitude to continue to prescribe these medications in the severe stages of the illness and less reluctance among professionals to discontinue. Combination therapy of memantine and AChEIs has been suggested by a few as being the trend in the future and people have questioned whether there is any need to consider stopping these drugs from economical perspective as the generic alternatives are cheap.
Forty-three percent (155) of clinicians expect a major change of prescribing with the advent of generic alternatives and 56.9% (205) do not anticipate a significant change. Common themes noted while describing the change include anti-dementia drugs to be more readily available to people as general practitioners will start prescribing and commissioning groups will support continued prescription as drugs are cheaper. There may be a future trend of empirical prescription and lower rates of referral to secondary care for straightforward cases of Alzheimer's dementia. More research and trials will be encouraged for the use of these medications in other forms of dementia.
In summary it is clear that most clinicians feel that anti-dementia drugs will continue to be prescribed for a longer duration irrespective of cognitive decline and there is a trend to commence these drugs at a very early stage of the illness. In the light of these comments there seems to be an urgent need for clinical guidance groups like the National Institute of Clinical Excellence (NICE, 2010) in England and Wales to review their prescribing guidelines. There needs to be more work done in terms of research to consolidate the understanding of the benefits of continued treatment with AChEIs in the late stages of Alzheimer's disease.
Conflicts of interest
None.
