Cholinesterase inhibitors to people with mild to moderate Alzheimer's disease
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Since 2001, the National Institute for Health and Clinical Excellence (NICE) has recommended that cholinesterase inhibitors should be available to people with mild to moderate Alzheimer's disease, writes consultant psychiatrist, Anthony Pelosi and colleagues. This was based on evidence that these drugs slowed cognitive (mental) decline, but NICE stressed that further research was required and it planned to revisit its recommendations after several years. The guidelines were welcomed by patient and carer organisations, and a large number of specialist memory clinics were set up for the prescription and monitoring of these medicines, sometimes with funding from the drug manufacturers. But widespread clinics have distorted clinical priorities, argue the authors. They have recruited full multidisciplinary teams while there is a shortage of mental health professionals throughout the United Kingdom, and they do not offer care in the community to their patients as they decline. Patients then have to be referred to ordinary old age psychiatry teams, which have to arrange proper long-term management plans. Further research is now available and shows quite consistently that these medicines have modest beneficial effects compared with placebo. As a result, NICE recommended that the NHS should no longer prescribe cholinesterase inhibitors because they do not provide value for money. But after hostile reactions from clinicians, patients and carers, with support from the lay media, NICE now proposes restricting use to moderate Alzheimer's disease. But doctors are concerned that it will be extremely difficult (perhaps impossible) to wait for a diagnosed patient to deteriorate before starting treatment. NICE has been unfairly accused of ageism and stigmatisation of people with dementia, and it has been claimed that adoption of the revised guidelines would be devastating for patients and carers. But the tragedy is not the proposed restrictions, but the fact that the only currently licensed medicines for a cruel illness have turned out to be of marginal benefit, write the authors. Whatever the final outcome of NICE's deliberations, the human and financial resources that have become tied up in clinics organised around prescription of cholinesterase inhibitors must be diverted to old age psychiatry teams and their social care counterparts, they say. These medicines should no longer be allowed to have such influence on services for patients with Alzheimer's disease and their families.