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70 Interventions in Alzheimer’s Disease KCE Reports 111 6.3.5.2 Analysis of time to discontinuation of ChEI treatment, by ChEI No significant differences between ChEIs were seen as illustrated below. Figure 5: Time to discontinuation by ChEI (censored for death and end of follow-up) 6.3.5.3 Analysis of time to discontinuation of ChEI, by setting of first prescription A major difference in ChEI treatment duration (censored for death and follow-up period as before) was seen according to the setting of the first prescription (hospital vs non-hospital). The median duration of ChEI therapy started in a hospital was 376 days (95%CI: 257 to 505 days) versus 1177 days (95% CI: 1072 to 1348 days) if ChEI treatment was not started in a hospital. The proportion of patients with only one ChEl prescription is also much higher if the first prescription is in the hospital setting. Figure 6: Time to discontinuation of ChEl, by setting of first prescription
KCE Reports 111 Interventions in Alzheimer’s Disease 71 6.3.5.4 What happens after ChEI therapy is discontinued? We selected those patients who started ChEIs in 2002-2006 but for whom there were no ChEI prescriptions during the last 6 months of 2006. Of the 1186 patients thus identified, 310 (26%) died during the 3 month period following the last ChEI prescription, while another 76 patients (6.5%) died 4 to 6 months after the last ChEI prescription. These data suggest ChEI prescriptions are continued in some patients until the end of life. In this context, monitoring the use of ChEIs in patients with a MMSE < 5 has been suggested as a role of the coordinating physician of the ROB/RVT-MR/MRS (Domino woon en zorgcentrum presentation, “De CRA en het geneesmiddelen verbruik in het RVT”, 18 FEB 2009). 6.3.6 Concomitant use of antipsychotics and antidepressants Table 19: Concomitant use of antipsychotics and antidepressants in AD patients receiving ChEIs (sample, full 2002-2006 period). Antipsychotics Antidepressants N n % % Any use Timing of start of medication compared to ChEI 2502 844 33.7 908 36.3 Before or concomitant to start of ChEI treatment 2502 438 17.5 608 34.3 After start of ChEI treatment 2502 406 16.2 300 12.0 Chronic use (a single versus multiple prescriptions over time) Only a single prescription of antipsychotic or antidepressant By setting of first prescription of ChEI Before or concomitant to start of ChEI treatment 2502 125 5.0 99 4.0 First prescription of ChEl in Hospital 699 264 37.8 271 38.8 First prescription of ChEl in ROB/RVT-MR/MRS 214 46 21.5 71 33.2 First prescription of ChEl in Ambulatory (= care at home) 1588 128 8.1 266 16.7 On the 844 patients receiving antipsychotics concomitantly with ChEl treatment, about half of them started antipsychotics before or concomitantly with the start of ChEl treatment, while for antidepressants this ratio is around two thirds to one third. The proportion of patients with a single prescription is around 5% for antipsychotics and 4% for antidepressants. The use of antipsychotics and antidepressants is also very dependent of the setting of the start of ChEI treatment: 38% of the patients who started their ChEI treatment in a hospital started antipsychotic treatment before the start of ChEI or concomitantly. This percentage is only 8% for patients who started their ChEl treatment at home. 6.3.6.1 Institutionalization and concomitant use of antipsychotics and antidepressants Next, we considered patients who received prescriptions for ChEIs in 2006 and grouped those 1497 patients based on residence status in 2006. We considered for these patient groups the concomitant use (prescription date between first and last ChEI prescription date) of antipsychotics and antidepressants, overall and for 2006 only. Nearly half (45%) of the institutionalized patients received at least one prescription for a antipsychotic in between prescriptions for a ChEI. This proportion is lower (21%) in non-institutionalised patients. When restricted to the year 2006 these proportions are 24% and 16%.
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