Physician’s Weekly: online CME courses, articles on hypertension, arthritis

The long duration of disease, caregiver burden, and costs associated with providing care for patients with dementia each contribute to making the disease a major healthcare problem. Researchers estimate that the prevalence of Alzheimer’s disease, one of the most common types of dementia, will quadruple in the next 50 years. Although there is currently no cure, pharmacologic interventions are being used to delay disease progression and to improve symptoms.

In 2008, the American College of Physicians (ACP) and American Academy of Family Physicians (AAFP) released their first-ever guidelines for treating dementia with the currently available and FDA-approved pharmacologic therapies—four cholinesterase inhibitors and a neuropeptide-modifying agent, memantine—to improve outcomes in cognition, global function, behavior and mood, and quality of life and activities of daily living.

3 Key Recommendations

The ACP/AAFP guidelines provide three important recommendations for physicians treating patients with dementia. First, clinicians are advised to base decisions on initiating a therapy trial with a cholinesterase inhibitor or memantine on individualized assessments. For example, in more advanced dementia, family or other decision makers may not view stabilization or slowing of decline as a desirable goal if quality of life is considered poor. All of the drugs approved for dementia have known adverse events, so the decision to use these agents should balance harms against modest or even no benefit.

The guidelines also recommend that clinicians base the choice of pharmacological agents on tolerability, adverse effect profile, ease of use, and cost of medication. Few clinical trials have compared one drug with another, making the evidence about effectiveness insufficient to support the choice of specific drugs for treating dementia. As such, the aforementioned factors are reasonable criteria to help select treatments.

The last key recommendation from the ACP/AAFP guidelines is that there’s an urgent need for more research on the clinical effectiveness of pharmacological therapies for dementias. We also need more research to assess whether these treatments truly affect outcomes. More evaluations of the appropriate duration of therapy, head-to-head comparisons between agents, and assessments on combination therapy may help us improve outcomes in the future.

Control for Expectations

Perhaps one of the most important actions clinicians should take is to inform patients that there is no pharmacologic cure for dementia. Some patients and/or caregivers may have unrealistic expectations of what the available medications will accomplish, and most are hoping for a miracle. Physicians should take the time to have real conversations with patients and talk about the issues surrounding dementia so that they have realistic expectations. The drugs we have are helpful in that they can alleviate symptoms and slow the progression of dementia, but patients should be forewarned that their effect may only be minimal, depending on their characteristics.

The ACP and AAFP will revisit these recommendations periodically over the next few years as more evidence emerges and will adjust the guidelines based on findings from major trials that have serious implications for managing dementia. The hope is that more research will further assess the available pharmacotherapies and determine the magnitude of their effect. Much information regarding the appropriate courses of treatment is missing, but there’s hope that answers will emerge in time.

Amir Qaseem, MD, PhD, MHA has indicated to Physician’s Weekly that he has received unrestricted educational grants/research aid from the Agency for Healthcare Quality and Research, the Robert Wood Johnson Foundation, Endo Pharmaceuticals, Boehringer-Ingelheim, and Atlantic Philanthropies.