Donepezil, rivastigmine, galantamine and memantine for ...

as one component of their care. A number of
conditions to the use of the drugs were suggested,
including:
● Diagnosis that the form of dementia is AD must
be made in a specialist clinic according to
standard diagnostic criteria.
● Assessment in a specialist clinic, including tests
of cognitive, global and behavioural functioning
and of activities of daily living, should be made
before the drug is prescribed.
● Clinicians should also exercise judgement about
the likelihood of compliance; in general, a carer
or care-worker who is in sufficient contact with
the patient to ensure compliance should be a
minimum requirement.
● Only specialists (including old-age psychiatrists,
neurologists and care of the elderly physicians)
should initiate treatment. Carers’ views of the
patient’s condition at baseline and follow-up
should be sought. If GPs are to control
prescribing, it is recommended that they should
do so under an agreed shared-care protocol
with clear treatment endpoints.
● A further assessment should be made, usually
2–4 months after reaching maintenance dose of
the drug. Following this assessment, the drug
should be continued only where there has been
an improvement or no deterioration in MMSE
score, together with evidence of global
improvement on the basis of behavioural and/or
functional assessment.
● Patients who continue on the drug should be
reviewed by MMSE score and global, functional
and behavioural assessment every 6 months.
The drug should normally only be continued
while their MMSE score remains above
12 points and their global, functional and
behavioural condition remains at a level where
the drug is considered to be having a
worthwhile effect. When the MMSE score falls
below 12 points, patients should not normally
be prescribed any of these three drugs. Any
review involving MMSE assessment should be
undertaken by an appropriate specialist team,
unless there are locally agreed protocols for
shared care.
These recommendations have resulted in a change
in the provision of dementia services. Increased
demand has generally been met by stretching
existing resources within generic old-age
psychiatric services, leading to a relatively low
penetration into the pool of unmet need for care
in dementia. One response has been to establish
memory clinics; however, these vary from large
centres of research excellence to more traditional
© Queen’s Printer and Controller of HMSO 2006. All rights reserved.
Health Technology Assessment 2006; Vol. 10: No. 1
outpatient-style clinics. Memory clinics have the
capacity to see only a small proportion of people
with dementia and are currently not universally
available. 31 The role of specialist services and
memory clinics has been further clarified by the
National Service Framework for Older People. 32
This states that patients should be referred to
specialist services for diagnostic uncertainty, for
consideration of drug therapy or if the patient is a
danger to themselves or others, such as in
consideration of fitness to drive.
Current best practice is for care of the person with
AD to be provided by a multidisciplinary team.
This may consist of a consultant old-age
psychiatrist, community mental health nurses,
clinical psychologists, occupational therapists and
social workers. Additional support may be
provided by other professionals allied to medicine
and community services such as domiciliary care,
outpatients services, outreach services and
daycare. 32 The aim of treatment is to support
patients in the community and in their own homes
if possible. In addition, dementia patients may
have access to day hospitals and acute and
rehabilitation hospital beds. Other aspects of care
consist of financial and legal support and help for
carers (Mather R, Oxford Memory Clinic, Personal
communication; 2004; Buss L, Southampton
Memory Clinic, Personal communication; 2004 33 ).
Patients with more severe dementia may benefit
from memantine, which is licensed for the
treatment of moderate to severe AD, although
there is currently no guidance on its use.
Day-to-day care for those with dementia is
frequently undertaken by family carers. Caring
for someone with dementia can be very
burdensome; people with dementia may have
communication difficulties, challenging behaviour,
incontinence, problems with eating and
difficulties with other activities of daily living 34
and carers require extra support. In many cases
these family carers are frail themselves. In some
cases support can be provided by the local
authority, for example by equipment and house
adaptations, ‘home help’, ‘meals-on-wheels’ and
occasionally respite care schemes; however, these
are often limited resources for carers and the level
of assistance can differ between local authorities. 35
Residential and nursing homes provide an
essential contribution towards the care of people
with dementia, with most people with dementia
cared for within the private sector 36 with social
services contributing to the cost of care on a
means-tested basis.
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