Dr Richard Harvey, Director of Research, Alzheimer's Society
Dementia is the major health and social care issue of this century. The most common cause of dementia is Alzheimer's disease. It affects 500 000 people in the UK, the majority of whom are over the age of 80. Alzheimer's disease costs the UK more than £1 billion per year.
The decision by NICE to approve the three current drug treatments has great potential to benefit people in the early stages of Alzheimer's disease and their carers.
The decision is sensible and realistic, and, in particular, has taken into account the views and experiences of people with dementia and their carers. In the Alzheimer's Society's survey of more than 2000 patients and carers, 73% reported positive benefits from trying the drug treatments.
Before the NICE decision, half of all health authorities were funding the drugs, and the remainder are now expected to put in place plans for implementation of the NICE recommendations.
All three drugs – donepezil (Aricept), rivastigmine (Exelon) and galantamine (Reminyl) – act through different mechanisms to block the enzyme acetylcholinesterase. This prevents the breakdown of acetylcholine – the key neurotransmitter in Alzheimer's disease – and potentiates its action.
The benefits valued by people with Alzheimer's disease and their carers include increased independence, improved mood and confidence and an extended period of time to come to terms with the disease and to spend with family and friends. This time is priceless and can be used positively.
The challenge to primary and secondary care is now to implement the new guidance as part of a package of early diagnosis combined with long-term care and support.
The responsibility for assessment and initiation of treatment lies with the specialist clinic run by an old age psychiatrist, neurologist or geriatrician, who will:
- Confirm the diagnosis of Alzheimer's disease
- Obtain the views of the patient and carer on treatment, and evaluate likely compliance with treatment
- Initiate treatment if the mini-mental state examination (MMSE) score is 12 points or above
- Reassess response after 2–4 months of stable treatment and decide whether prescribing should continue in the longer term, or at least until the MMSE drops below 12 points.
The key to successful treatment, and the challenge to primary care, is to identify people with Alzheimer's disease early, and to refer them as quickly as possible to a specialist clinic.
People with mild to moderate Alzheimer's disease who still score above 12 on the MMSE will usually have only mild forgetfulness and disorientation, of which they themselves may be unaware. Carers and other family members are usually much more aware of the problems and it is critical to seek their views as part of the initial assessment.
The guidance also has important implications for GPs, who will need to:
- Have a heightened awareness of symptoms of forgetfulness and memory impairment in their older patients, and make routine use of standardised memory assessments such as the MMSE
- Take seriously complaints of memory loss or disorientation from either the patient or the carer and refer early to a specialist clinic
- Ensure that patients and their carers are well supported throughout the illness, whether or not treatment with these drugs is appropriate.
A wide range of care and support is now available in the community, and one of the most important actions the GP can take is to put the patient and his/her family in touch with the Alzheimer's Society.
- The Alzheimer's Society can be contacted on 0845 300 0336 and at www.alzheimers.org.uk. The full NICE guidance can be downloaded from www.nice.org.uk