Physician's Weekly Article - Practical Recommendations for Alzheimer’s Care

       A panel of experts has created new recommendations for Alzheimer’s disease and related dementias that address screening, medical therapy, and primary care management.

      Although Alzheimer’s disease and related dementia (ADRD) are debilitating, progressive, fatal diseases, published studies have demonstrated that patients benefit greatly from proper management and treatment. These conditions affect roughly 4.5 million Americans nationwide, but effective treatments are available that can slow symptom progression and ease disease burden.

      Evidence-based clinical practice guidelines for ADRD were published in 2001, but advances have occurred since then. Clinical trials have demonstrated the pivotal role that anti-dementia therapies play in treatment and patient management. In response to the new developments surrounding these conditions, a panel of leading experts in the field has released new recommendations for the treatment of ADRD in managed care (Table 1). The guidelines were published in a 2006 supplemental issue of the American Journal of Geriatric Pharmacotherapy.

      Improve Screening in Primary Care Settings

      According to Howard M. Fillit, MD, one of the experts on the panel that created the guidelines, ADRD should be screened for, diagnosed, managed, and treated mainly in primary care. “Alzheimer’s disease is best managed when it’s diagnosed in the earliest stages because that’s when effective medical management can result in slowed disease progression and a reduction of excess costs. In most cases, the diagnosis of Alzheimer’s and development of a treatment strategy usually falls to the primary care physician. The reality is that this disease can be prevalent in up to 20% of individuals aged 75 and older. We recommend brief, office-based screenings for cognitive impairment in patients in this age group or when a patient or caregiver notes the presence of symptoms such as memory loss or confusion [Figure 1].”

      The expert panel noted that use of medical evaluation and neuroimaging to eliminate the presence of reversible causes of dementia and structural abnormalities are recommended. Patients should also be referred to specialists when they present with rapid mental deterioration, abnormal neurologic signs, or very early onset or frontotemporal dementia.

      Combination Therapy Improves Outcomes

      Pharmacological treatment can be managed in primary care effectively, and Dr. Fillit says that there are now two major drug classes available for the treatment of ADRD. “Cholinesterase inhibitors [CHEIs] have been available for quite some time now and have been shown to significantly improve symptoms of ADRD. We also now have a second class of drugs called N-methyl-D-aspartate [NMDA] receptor antagonists that are effective both as monotherapy and in combination therapy with CHEIs. The panel advises that CHEIs be used in cases of mild Alzheimer’s disease as standard care. Moderate and severe Alzheimer’s disease should be managed with a combination of CHEI and an NMDA antagonist.” The panel also cautions that discontinuation of medical therapy can result in a significant loss of function and/or cognition that may not be recoverable. The panel recommends that anti-dementia therapy be continued during periods of illness and hospitalization, as well as during transitions between care settings.

      Provide Counseling for Patients & Caregivers

      One of the key recommendations from the panel states that geriatric care management and counseling should be made available to all patients with Alzheimer’s disease as well as their caregivers. Dr. Fillit says, “the care of ADRD represents a significant burden to the healthcare system independent of the disease. The economic costs of Alzheimer’s disease are estimated to be more than $100 billion; this includes costs related to lost caregiver productivity. The management of the disease must include considerations for the mental and physical health of the patient’s caregivers. Medicare managed care organizations [MCOs], insurance providers, and other public service organizations, such as the Alzheimer’s Association, can provide help and counseling for these people.”

      Consider the Roles of Medicare & Insurance

      Medicare and insurance providers play important roles in the treatment and management of Alzheimer’s disease, and the panel recommends that CHEIs and NMDA receptor antagonists be placed in distinct classes in Medicare Advantage and prescription drug plan formularies. “This is important in order to ensure that both classes of these agents continue to be available to members,” Dr. Fillit explains. “To further ensure access, the panel also states that Medicare MCOs should not discriminate against the use of these drugs through administrative barriers such as preauthorization requirements and appeals.”

      Reduce the Economic Burden

      Appropriate utilization of medical therapy and optimizing care are key elements to improving quality of life in patients with ADRD and their caregivers, according to Dr. Fillit. “Moreover, early detection and management of these conditions can significantly reduce excess cost for the entire healthcare system. The guidelines that we’ve produced are meant to provide practical strategies that are applicable to both primary and specialty care. When appropriate screening, therapy, and care management are applied, ADRD can be effectively managed for a significant length of time.”

      Dr. Fillit has indicated to Physician’s Weekly that he has or has been a consultant, been a grantee, or received honoraria from Advanced Monitored Caregiving, Inc., Eisai, Inc., Elan Pharmaceuticals, Inc., Forest Laboratories, Inc., HealthCare Dimensions Incorporated, Novartis Pharmaceuticals Corporation, Innovus, Ortho-McNeil Neurologics, Inc., PacifiCare Health Systems, Pfizer Inc., the sanofi-aventis Group, and SeniorBridge Family Companies, Inc.