SummaryDementia currently affects over 750,000 people in the UK, with 650,000 new cases arising each year across the European Union. Alzheimer’s disease is the major cause of dementia and accounts for about 55% of all cases. It is a progressive, degenerative disease which affects memory, judgement, orientation, behaviour and language skills, and can place an enormous stress on family caregivers, 49% of whom are over 70 years of age.
Dementia currently affects over 750,000 people in the UK, with 650,000 new cases arising each year across the European Union. Alzheimer’s disease is the major cause of dementia and accounts for about 55% of all cases. It is a progressive, degenerative disease which affects memory, judgement, orientation, behaviour and language skills, and can place an enormous stress on family caregivers, 49% of whom are over 70 years of age. Alzheimer’s disease is an expensive disease, not only in terms of personal and family resources, but also with regard to direct costs, which are estimated at about £6 billion a year, 75% of which is for patients with more severe dementia.
Attitudes to Alzheimer’s disease and its treatment shifted in 1997 with the introduction of the first cholinesterase inhibitor for mild-to-moderate Alzheimer’s disease, followed by the licensing of memantine for moderate-to-severe disease in 2002. In 2001, guidance from the National Institute for Clinical Excellence (NICE) recommended the use of cholinesterase inhibitors for mild-to-moderate disease. However, NICE also conered that improvements with cholinesterase inhibitors were only modest and recommended that once initial benefit had been lost treatment should be withdrawn, as treatment continuation was not proven to be cost-effective. This guidance is currently under review and will include memantine for the first time.
Despite the generally positive guidance from NICE, many health authorities were reluctant to provide funding for treatment leading to very variable uptake of cholinesterase inhibitors across the country. However, many areas developed memory clinics in secondary care using shared-care guidelines with GPs monitoring their usage. Memory clinic audits show that 60% of patients appeared to achieve response to treatment, but it also became apparent that simple cognitive tests like the Mini-Mental State Examination (MMSE) do not really capture the improvements observed in attention, behaviour, language, apathy, hallucinations, improved function and mood. The Audit Commission’s report Forget Me Not published in 2000, showed that about half of all GPs felt ill-equipped to make a diagnosis of Alzheimer’s disease or had the time to use cognitive scales. However, the kind of holistic assessment that is so important to determine response is exactly what GPs are skilled at performing.
All Primary Care Trusts (PCTs) should now have protocols in place that are agreed with their local specialist services to diagnose, care and treat people with dementia. There is also a growing realisation that monitoring of dementia treatment, if not diagnosis, could be managed in primary care. Memory clinics have provided a great service to patients with Alzheimer’s disease in providing a clear diagnosis, access to services and a validation of the patients’ symptoms. In the future though it seems likely that more GPs, either those taking a special interest or those working in association with specialist memory nurses, will be making the decision to treat and monitor patients in order to free-up specialist memory clinics to diagnose more difficult early cases and to advise on the management of behavioural problems as patients deteriorate. There is evidence that memantine may have an impact on behavioural symptoms in the later stages of the disease, either alone or in combination with the cholinesterase inhibitors, which will help to improve the quality of life of both the patient and their carer whilst we wait for further treatments to emerge.
Future prospects for treatment are promising. Early results from studies using an anti-amyloid vaccine were disappointing but have led to studies with monoclonal antibodies and conjugated vaccines that may yet bear fruit. A number of drugs aimed at clearing amyloid or preventing its abnormal accumulation are in development, as are drugs which target the inflammatory reactions and oxidative stress that amyloid produces. Another pathological hallmark of Alzheimer’s disease – neurofibrillary tangles – contain an abnormally phosphorylated tau protein which is also being targeted. Therefore, it seems that in another 10 years we may see some significant breakthroughs in the treatment of Alzheimer’s disease. As well as pharmacotherapy, we now know that many risk factors can be modified by lifestyle changes. Smoking cessation, reducing elevated cholesterol, controlling cardiovascular disease, diabetes and stroke, increasing exercise and introducing antioxidants in our diet could mean the future for our ageing population may not be as black as it is painted.
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This Editorial has been written by the specialist opinion leader, Dr David Wilkinson
Consultant in Old Age Psychiatry Memory Assessment and Research Centre
Moorgreen Hospital, Southampton and published in the latest issue of the serial publication, Drugs in Context.
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