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Truong C, Recto C, Lafont C, Canoui-Poitrine F, Belmin JB, Lafuente-Lafuente C. Effect of Cholinesterase Inhibitors on Mortality in Patients With Dementia: A Systematic Review of Randomized and Nonrandomized Trials. Neurology 2022; 99:e2313-e2325. [PMID: 36096687 DOI: 10.1212/wnl.0000000000201161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 07/11/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Cholinesterase inhibitors (ChEIs) have cardiovascular effects in addition to their neurologic activity and might alter mortality. We wanted to know whether treatment with ChEIs modifies mortality in patients with dementia. METHODS We searched PubMed, Embase, Cochrane CENTRAL, ClinicalTrials.gov, and ICRTP, from their inception to November 2021, and screened bibliographies of reviews, guidelines, and included studies. We included randomized controlled trials (RCTs) and nonrandomized controlled studies at lower risk of bias comparing ChEI treatment with placebo or usual treatment, for 6 months or longer, in patients with dementia of any type. Two investigators independently assessed studies for inclusion, assessed their risk of bias, and extracted data using predefined forms. Any discordance between investigators was solved by discussion and consensus. Data on all-cause and cardiovascular mortality, measured as either crude death rates or multivariate adjusted hazard ratios (HRs), were pooled using a random-effect model. Information size achieved was assessed using trial sequential analysis (TSA). We followed Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. RESULTS Twenty-four studies (12 RCTs, 12 cohorts, mean follow-up 6-120 months), cumulating 79,153 patients with Alzheimer (13 studies), Parkinson (1), vascular (1), or any type (9) dementia, fulfilled inclusion criteria. Pooled all-cause mortality in control patients was 15.1 per 100 person-years. Treatment with ChEIs was associated with lower all-cause mortality (unadjusted risk ratio [RR] 0.74, 95% CI 0.66-0.84; adjusted HR 0.77, 95% CI 0.70-0.84, moderate-quality to high-quality evidence). This result was consistent between randomized and nonrandomized studies and in several sensitivity analyses. No difference appeared between subgroups by type of dementia, age, individual drug, or dementia severity. Less data were available for cardiovascular mortality (3 RCTs, 2 cohorts, 9,182 patients, low-quality to moderate-quality evidence), which was also lower in patients treated with ChEIs (unadjusted RR 0.61, 95% CI 0.40-0.93, adjusted HR 0.47, 95% CI 0.32-0.68). In TSA analysis, the results for all-cause mortality were conclusive but not those for cardiovascular mortality. DISCUSSION There is moderate-quality to high-quality evidence of a consistent association between long-term treatment with ChEIs and a reduction in all-cause mortality in patients with dementia. These findings may influence decisions to prescribe ChEIs in those patients. TRIAL REGISTRATION INFORMATION This systematic review was registered in the PROSPERO international prospective register of systematic reviews with the number CRD42021254458 (June 11, 2021).
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Affiliation(s)
- Céline Truong
- From the AP-HP (C.T., C.R., J.B.B., C.L.-L.), Sorbonne Université, Hôpitaux universitaires Pitie-Salpêtrière-Charles Foix, Service de Gériatrie à orientation Cardiologique et Neurologique, Ivry-sur-Seine; Université Paris Est Créteil (UPEC) (C.L., F.C.-P., C.L.-L.), INSERM, IMRB, Clinical Epidemiology and Ageing (CEpiA) Team; and APHP (C.L., F.C.-P.), Hôpital Henri Mondor, Service de Santé Publique, Créteil, France
| | - Caryn Recto
- From the AP-HP (C.T., C.R., J.B.B., C.L.-L.), Sorbonne Université, Hôpitaux universitaires Pitie-Salpêtrière-Charles Foix, Service de Gériatrie à orientation Cardiologique et Neurologique, Ivry-sur-Seine; Université Paris Est Créteil (UPEC) (C.L., F.C.-P., C.L.-L.), INSERM, IMRB, Clinical Epidemiology and Ageing (CEpiA) Team; and APHP (C.L., F.C.-P.), Hôpital Henri Mondor, Service de Santé Publique, Créteil, France
| | - Charlotte Lafont
- From the AP-HP (C.T., C.R., J.B.B., C.L.-L.), Sorbonne Université, Hôpitaux universitaires Pitie-Salpêtrière-Charles Foix, Service de Gériatrie à orientation Cardiologique et Neurologique, Ivry-sur-Seine; Université Paris Est Créteil (UPEC) (C.L., F.C.-P., C.L.-L.), INSERM, IMRB, Clinical Epidemiology and Ageing (CEpiA) Team; and APHP (C.L., F.C.-P.), Hôpital Henri Mondor, Service de Santé Publique, Créteil, France
| | - Florence Canoui-Poitrine
- From the AP-HP (C.T., C.R., J.B.B., C.L.-L.), Sorbonne Université, Hôpitaux universitaires Pitie-Salpêtrière-Charles Foix, Service de Gériatrie à orientation Cardiologique et Neurologique, Ivry-sur-Seine; Université Paris Est Créteil (UPEC) (C.L., F.C.-P., C.L.-L.), INSERM, IMRB, Clinical Epidemiology and Ageing (CEpiA) Team; and APHP (C.L., F.C.-P.), Hôpital Henri Mondor, Service de Santé Publique, Créteil, France
| | - Joel Belmin Belmin
- From the AP-HP (C.T., C.R., J.B.B., C.L.-L.), Sorbonne Université, Hôpitaux universitaires Pitie-Salpêtrière-Charles Foix, Service de Gériatrie à orientation Cardiologique et Neurologique, Ivry-sur-Seine; Université Paris Est Créteil (UPEC) (C.L., F.C.-P., C.L.-L.), INSERM, IMRB, Clinical Epidemiology and Ageing (CEpiA) Team; and APHP (C.L., F.C.-P.), Hôpital Henri Mondor, Service de Santé Publique, Créteil, France
| | - Carmelo Lafuente-Lafuente
- From the AP-HP (C.T., C.R., J.B.B., C.L.-L.), Sorbonne Université, Hôpitaux universitaires Pitie-Salpêtrière-Charles Foix, Service de Gériatrie à orientation Cardiologique et Neurologique, Ivry-sur-Seine; Université Paris Est Créteil (UPEC) (C.L., F.C.-P., C.L.-L.), INSERM, IMRB, Clinical Epidemiology and Ageing (CEpiA) Team; and APHP (C.L., F.C.-P.), Hôpital Henri Mondor, Service de Santé Publique, Créteil, France.
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Shi X, Ren G, Cui Y, Xu Z. Comparative efficacy and acceptability of cholinesterase inhibitors and memantine based on dosage in patients with vascular cognitive impairment: a network meta-analysis. Curr Alzheimer Res 2022; 19:133-145. [PMID: 35048806 DOI: 10.2174/1567205019666220120112301] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 11/27/2021] [Accepted: 12/16/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Considering the lack of direct comparison between cholinesterase inhibitors and memantine in patients with vascular cognitive impairment (VCI), determining how to choose the best treatment plan remains inconclusive. Hence, we conducted the network meta-analysis to compare the efficacy and acceptability of these drugs. METHODS PubMed, the Cochrane Central Register of Controlled Trials, Embase and Web of Science were searched for double-blind randomized controlled trials (RCTs) for the treatment of VCI, which involved donepezil, galantamine, rivastigmine, and memantine, from database inception to January 1, 2020. Then, a network meta-analysis based on the frequency method was conducted. RESULTS Eleven RCTs were included. Compared with the placebo, in terms of efficacy donepezil 5 mg (standardized mean difference = -1.11, 95% confidence interval = -1.88 to -0.34), donepezil 10 mg (-1.44, -2.31 to -0.56), galantamine 24 mg (-1.99, -3.03 to -0.95), and memantine 20 mg (-1.89, -2.93 to -0.86) were more effective on the cognition of ADAS-cog; and donepezil 5 mg (0.46, 0.12 to 0.81), donepezil 10 mg (0.76, 0.34 to 1.17), and rivastigmine 12mg (0.60, 0.10 to 1.10) exhibited superior benefits on the cognition of MMSE. Donepezil 10 mg (-0.25, -0.44 to -0.06; -1.47, -2.79 to -0.15) exhibited improvements on CDR-SB and EXIT25, respectively. In terms of acceptability, the memantine behaved as the best. CONCLUSIONS Donepezil 5 mg, donepezil 10 mg, galantamine 24 mg, memantine 20 mg, and rivastigmine 12 mg have beneficial effects on cognition, and donepezil 10mg provides beneficial effects on executive function and global status. Based on the network meta-analysis, donepezil 10 mg might be the best choice, considering the benefits on cognition function, executive function and global status, but dose-related adverse reactions need to be noted. In the meantime, memantine is a better comprehensive choice, in terms of efficacy and safety acceptability.
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Affiliation(s)
- Xinxiu Shi
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - GuangHao Ren
- Department of Vascular Surgery, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - Yang Cui
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - ZhongXin Xu
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
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Hager K, Baseman AS, Nye JS, Brashear HR, Han J, Sano M, Davis B, Richards HM. Effect of concomitant use of memantine on mortality and efficacy outcomes of galantamine-treated patients with Alzheimer's disease: post-hoc analysis of a randomized placebo-controlled study. ALZHEIMERS RESEARCH & THERAPY 2016; 8:47. [PMID: 27846868 PMCID: PMC5111338 DOI: 10.1186/s13195-016-0214-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 10/12/2016] [Indexed: 11/17/2022]
Abstract
Background A large, prospective, 2-year, randomized study in patients with mild-to-moderate Alzheimer’s disease or mixed dementia demonstrated reductions in mortality and cognitive/functional decline in galantamine-treated patients. A post-hoc analysis was conducted to study the effect of (the presence or absence of) concomitant memantine use on treatment outcome. Methods Randomized patients (N = 2045) were divided into subgroups based on memantine use. Analyses included demographic and clinical characteristics (age, nursing home placement, Mini-Mental State Examination (MMSE) and Disability Assessment for Dementia (DAD) scores) and mortality endpoints. Results Overall, 496 (24.3 %) patients were memantine users and were older (mean (SD), 74.0 (8.76) vs 72.8 (8.76), p = 0.008), with lower MMSE scores (18.2 (4.16) vs 19.2 (4.02), p < 0.0001) and DAD scores (58.0 (23.49) vs 62.5 (20.52), p < 0.0001) than nonusers. Mortality rates (per 100 patient-years) in memantine nonusers (n = 1549) were lower for galantamine (1.39) vs placebo-treated patients (4.15). In memantine users, mortality rates were similar for placebo-treated (4.49) and galantamine-treated patients (5.57). In memantine nonusers at 24 months, the decline in MMSE scores (effect size (95 % CI) 0.25 (0.14; 0.36)) and DAD scores (0.17 (0.06; 0.28)) from baseline was lower in galantamine patients vs placebo patients. The absence of these benefits in memantine users could not be explained by baseline age, MMSE, or DAD scores. Conclusion This post-hoc analysis shows that the beneficial effects of galantamine at 2 years post treatment were not observed in patients who had been placed on background memantine. The reasons for memantine treatment and the possibility of interaction between memantine and galantamine merit further investigation. Trial registration ClinicalTrials.gov NCT00679627. Registered 15 May 2008. Electronic supplementary material The online version of this article (doi:10.1186/s13195-016-0214-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Klaus Hager
- Clinic for Medicine of the Elderly, Hannover, Germany
| | - Alan S Baseman
- Janssen Research and Development, LLC, Titusville, NJ, USA. .,Janssen Research and Development, LLC, 850 Ridgeview Drive, Horsham, PA, 19044, USA.
| | - Jeffrey S Nye
- Janssen Research and Development, LLC, Titusville, NJ, USA
| | | | - John Han
- Janssen Research and Development, LLC, Titusville, NJ, USA
| | - Mary Sano
- The Mount Sinai Medical Center, New York, NY, USA
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Echeverria V, Yarkov A, Aliev G. Positive modulators of the α7 nicotinic receptor against neuroinflammation and cognitive impairment in Alzheimer's disease. Prog Neurobiol 2016; 144:142-57. [DOI: 10.1016/j.pneurobio.2016.01.002] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 11/07/2015] [Accepted: 01/06/2016] [Indexed: 01/08/2023]
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Manabe T, Mizukami K, Akatsu H, Teramoto S, Yamaoka K, Nakamura S, Ohkubo T, Kudo K, Hizawa N. Influence of pneumonia complications on the prognosis of patients with autopsy-confirmed Alzheimer's disease, dementia with Lewy bodies, and vascular dementia. Psychogeriatrics 2016; 16:305-14. [PMID: 26510708 DOI: 10.1111/psyg.12163] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 09/24/2015] [Accepted: 09/25/2015] [Indexed: 01/28/2023]
Abstract
BACKGROUND Pneumonia is a major, complicated disease in patients with dementia. However, the influence of pneumonia on the prognosis of patients with varying types of dementia has not been fully evaluated. METHODS We retrospectively analyzed the data from medical and autopsy reports. All study patients had been hospitalized and underwent brain autopsy in a hospital in Toyohashi, Japan, between 2005 and 2014. The patients with subtypes of dementia, specifically Alzheimer's disease (AD), dementia with Lewy bodies (DLB), or vascular dementia (VaD), were neuropathologically diagnosed and examined. Pneumonia incidence, cause of death, and the clinical time-course of dementia were compared among the dementia subtypes. The time to death from dementia onset (survival time) was compared by the Kaplan-Meier method among subtypes of dementia with or without pneumonia. Risk factors for survival time on all study patients were analyzed with the Cox proportional hazard model. RESULTS Of the 157 eligible patients, 63 (40.1%) had AD, 42 (26.8%) had DLB, and 52 (33.1%) had VaD. Pneumonia complication was observed with high incidence in each subtype of dementia, especially in DLB (90.5%). The median total duration from dementia onset to death was 8 years in AD and DLB, and 5 years in VaD. The VaD subtype had more male patients than AD or DLB (P = 0.010), and age of death in this group was the youngest among the three groups (P = 0.018). A significant difference was observed in the survival time by the Kaplan-Meier method among the three groups (P < 0.001) and among the groups with pneumonia (P = 0.002). The factors associated with shorter survival time were male gender, pneumonia complications, diabetes mellitus, age of dementia onset ≥ 75 years, and VaD. CONCLUSIONS Pneumonia complications shortened the survival time of patients with AD, DLB, and VaD.
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Affiliation(s)
- Toshie Manabe
- Department of Social Health and Stress Management, University of Tsukuba, Tsukuba, Japan.,Department of Pulmonary Medicine, Graduate School of Comprehensive Human Science, University of Tsukuba, Tsukuba, Japan.,Department of Hygiene and Public Health, Teikyo University School of Medicine, Tokyo, Japan
| | - Katsuyoshi Mizukami
- Department of Social Health and Stress Management, University of Tsukuba, Tsukuba, Japan. .,Faculty of Health and Sport Sciences, University of Tsukuba, Tsukuba, Japan.
| | - Hiroyasu Akatsu
- Department of Community-based Medicine, Nagoya City University Graduate School of Medicine, Nagoya, Japan.,Choju Medical Institute, Fukushimura Hospital, Toyohashi, Japan
| | - Shinji Teramoto
- Department of Pulmonary Medicine, Graduate School of Comprehensive Human Science, University of Tsukuba, Tsukuba, Japan
| | - Kazue Yamaoka
- Teikyo University Graduate School of Public Health, Tokyo, Japan
| | - Seiji Nakamura
- Department of Social Health and Stress Management, University of Tsukuba, Tsukuba, Japan
| | - Takayoshi Ohkubo
- Department of Hygiene and Public Health, Teikyo University School of Medicine, Tokyo, Japan
| | - Koichiro Kudo
- Organization of Asia Human Community, Waseda University, Tokyo, Japan.,Department of Infection Control and Respiratory Medicine, Koto Hospital, Tokyo, Japan
| | - Nobuyuki Hizawa
- Department of Pulmonary Medicine, Graduate School of Comprehensive Human Science, University of Tsukuba, Tsukuba, Japan
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Factors determining disease duration in Alzheimer's disease: a postmortem study of 103 cases using the Kaplan-Meier estimator and Cox regression. BIOMED RESEARCH INTERNATIONAL 2014; 2014:623487. [PMID: 24579083 PMCID: PMC3919116 DOI: 10.1155/2014/623487] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Revised: 11/05/2013] [Accepted: 11/24/2013] [Indexed: 12/04/2022]
Abstract
Factors associated with duration of dementia in a consecutive series of 103 Alzheimer's disease (AD) cases were studied using the Kaplan-Meier estimator and Cox regression analysis (proportional hazard model). Mean disease duration was 7.1 years (range: 6 weeks–30 years, standard deviation = 5.18); 25% of cases died within four years, 50% within 6.9 years, and 75% within 10 years. Familial AD cases (FAD) had a longer duration than sporadic cases (SAD), especially cases linked to presenilin (PSEN) genes. No significant differences in duration were associated with age, sex, or apolipoprotein E (Apo E) genotype. Duration was reduced in cases with arterial hypertension. Cox regression analysis suggested longer duration was associated with an earlier disease onset and increased senile plaque (SP) and neurofibrillary tangle (NFT) pathology in the orbital gyrus (OrG), CA1 sector of the hippocampus, and nucleus basalis of Meynert (NBM). The data suggest shorter disease duration in SAD and in cases with hypertensive comorbidity. In addition, degree of neuropathology did not influence survival, but spread of SP/NFT pathology into the frontal lobe, hippocampus, and basal forebrain was associated with longer disease duration.
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Hager K, Baseman AS, Nye JS, Brashear HR, Han J, Sano M, Davis B, Richards HM. Effects of galantamine in a 2-year, randomized, placebo-controlled study in Alzheimer's disease. Neuropsychiatr Dis Treat 2014; 10:391-401. [PMID: 24591834 PMCID: PMC3937252 DOI: 10.2147/ndt.s57909] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Currently available treatments for Alzheimer's disease (AD) can produce mild improvements in cognitive function, behavior, and activities of daily living in patients, but their influence on long-term survival is not well established. This study was designed to assess patient survival and drug efficacy following a 2-year galantamine treatment in patients with mild to moderately severe AD. METHODS In this multicenter, double-blind study, patients were randomized 1:1 to receive galantamine or placebo. One primary end point was safety; mortality was assessed. An independent Data Safety Monitoring Board monitored mortality for the total deaths reaching prespecified numbers, using a time-to-event method and a Cox-regression model. The primary efficacy end point was cognitive change from baseline to month 24, as measured by the Mini-Mental State Examination (MMSE) score, analyzed using intent-to-treat analysis with the 'last observation carried forward' approach, in an analysis of covariance model. RESULTS In all, 1,024 galantamine- and 1,021 placebo-treated patients received study drug, with mean age ~73 years, and mean (standard deviation [SD]) baseline MMSE score of 19 (4.08). A total of 32% of patients (661/2,045) completed the study, 27% (554/2,045) withdrew, and 41% (830/2,045) did not complete the study and were discontinued due to a Data Safety Monitoring Board-recommended early study termination. The mortality rate was significantly lower in the galantamine group versus placebo (hazard ratio [HR] =0.58; 95% confidence interval [CI]: 0.37; 0.89) (P=0.011). Cognitive impairment, based on the mean (SD) change in MMSE scores from baseline to month 24, significantly worsened in the placebo (-2.14 [4.34]) compared with the galantamine group (-1.41 [4.05]) (P<0.001). Functional impairment, based on mean (SD) change in the Disability Assessment in Dementia score (secondary end point), at month 24 significantly worsened in the placebo (-10.81 [18.27]) versus the galantamine group (-8.16 [17.25]) (P=0.002). Incidences of treatment-emergent adverse events were 54.0% for the galantamine and 48.6% for the placebo group. CONCLUSION Long-term treatment with galantamine significantly reduced mortality and the decline in cognition and daily living activities, in mild to moderate AD patients. IDENTIFICATION This study is registered at ClinicalTrials.gov (NCT00679627).
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Affiliation(s)
- Klaus Hager
- Clinic for Medicine of the Elderly, Hannover, Germany
| | | | - Jeffrey S Nye
- Janssen Research and Development, LLC, Raritan, NJ, USA
| | | | - John Han
- Janssen Research and Development, LLC, Raritan, NJ, USA
| | - Mary Sano
- The Mount Sinai Medical Center, New York, NY, USA
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Implications of early treatment among Medicaid patients with Alzheimer's disease. Alzheimers Dement 2013; 10:214-24. [PMID: 23643457 DOI: 10.1016/j.jalz.2013.01.015] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Revised: 10/31/2012] [Accepted: 01/11/2013] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The objective of this study was to examine the effect of treatment timing on risk of institutionalization of Medicaid patients with Alzheimer's disease (AD) and to estimate the economic implications of earlier diagnosis and treatment initiation. METHODS New Jersey Medicaid claims data (1997-2009) were used retrospectively to study the effect of treatment on time to institutionalization. Observed Medicaid payments were used to calculate savings from delayed institutionalization, adjusting for cost offsets resulting from concurrent changes in use of other medical services. RESULTS Initiation of existing therapies at earliest symptomatic onset is predicted to delay institutionalization by 91 days, reducing Medicaid costs by $19,108/institutionalized patient. Incorporating an 18.5% cost offset from increased use of other medical services as well as drug costs associated with earlier treatment results in net savings of $12,687/patient. Projected annual Medicaid savings exceed $1 billion. CONCLUSION Earlier treatment leads to a small delay in institutionalization among AD patients, resulting in significant costs savings to Medicaid.
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Butler R, Radhakrishnan R. Dementia. BMJ CLINICAL EVIDENCE 2012; 2012:1001. [PMID: 23870856 PMCID: PMC3437526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Dementia is characterised by chronic, global, non-reversible deterioration in memory, executive function, and personality. Speech and motor function may also be impaired. METHODS AND OUTCOMES We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments on cognitive symptoms of dementia (Alzheimer's, Lewy body, or vascular)? What are the effects of treatments on behavioural and psychological symptoms of dementia (Alzheimer's, Lewy body, or vascular)? We searched: Medline, Embase, The Cochrane Library, and other important databases up to July 2011 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS We found 49 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS In this systematic review, we present information relating to the effectiveness and safety of the following interventions: acetylcholinesterase inhibitors (donepezil, galantamine, rivastigmine), antidepressants (clomipramine, fluoxetine, imipramine, sertraline), antipsychotics (haloperidol, olanzapine, quetiapine, risperidone), aromatherapy, benzodiazepines (diazepam, lorazepam), cognitive behavioural therapy (CBT), cognitive stimulation, exercise, ginkgo biloba, memantine, mood stabilisers (carbamazepine, sodium valproate/valproic acid), music therapy, non-steroidal anti-inflammatory drugs (NSAIDs), omega 3 (fish oil), reminiscence therapy, and statins.
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Kavanagh S, Gaudig M, Van Baelen B, Adami M, Delgado A, Guzman C, Jedenius E, Schäuble B. Galantamine and behavior in Alzheimer disease: analysis of four trials. Acta Neurol Scand 2011; 124:302-8. [PMID: 21615354 DOI: 10.1111/j.1600-0404.2011.01525.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Many individuals with Alzheimer's disease (AD) experience behavioral and neuropsychiatric symptoms, which may cause caregiver distress and lead to the institutionalization of the patient. This analysis characterized behavioral symptoms and caregiver distress in trials of galantamine and their response to treatment. MATERIALS AND METHODS Data were pooled from four randomized, placebo-controlled clinical trials of galantamine in patients with mild to moderate AD (three studies) or AD plus cerebrovascular disease (one study) (n = 2177). Behavior and associated caregiver distress were assessed in each study using the Neuropsychiatric Inventory (NPI) and NPI distress (NPI-D), respectively. RESULTS After 5/6 months, but not after 3 months, NPI score was significantly improved with galantamine vs placebo (P = 0.013). The benefit was particularly pronounced in patients categorized as having advanced moderate AD. At 5/6 months, there was a numerical benefit of galantamine over placebo in terms of caregiver distress; the difference was statistically significant in patients with moderate or advanced moderate AD. CONCLUSIONS Galantamine reduces behavioral symptoms in patients with mild to moderate AD, leading to reduced caregiver burden. The reductions were greatest in patients with moderate or advanced moderate disease.
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Affiliation(s)
- S Kavanagh
- Johnson & Johnson Pharmaceutical Services, Beerse, Belgium
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Cappell J, Herrmann N, Cornish S, Lanctôt KL. The pharmacoeconomics of cognitive enhancers in moderate to severe Alzheimer's disease. CNS Drugs 2010; 24:909-27. [PMID: 20932064 DOI: 10.2165/11539530-000000000-00000] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Alzheimer's disease is associated with a substantial economic impact on patients, their caregivers and society. Due to the current rise in the aging population, the prevalence and impact of Alzheimer's disease are expected to increase greatly. The cost of caring for someone with Alzheimer's disease is magnified in the more severe stages of the disease. There are four cognitive enhancers commonly used for the treatment of Alzheimer's disease: three cholinesterase inhibitors (donepezil, rivastigmine and galantamine) and one NMDA receptor antagonist (memantine). Of these, donepezil and memantine have been approved in many countries as pharmacological treatments for moderate to severe Alzheimer's disease, while donepezil, rivastigmine and galantamine are approved treatments for mild to moderate Alzheimer's disease. While cost effectiveness has been well studied in mild to moderate Alzheimer's disease, the cost-benefit information for drug therapy in moderate to severe Alzheimer's disease is less clear. This article reviews the pharmacoeconomic data available on these four drugs, with a specific focus on moderate to severe Alzheimer's disease, including economic burden, cost drivers, clinical outcomes and pharmacoeconomic studies. A key driver of the cost of Alzheimer's disease is the severity of the disease, indicating that the ability to stabilize the disease state is a potential source of cost savings. Drug therapies that can limit increases in behavioural problems and cognitive and functional impairment, and postpone institutionalization without an increase in longevity may serve to reduce the economic burden on Alzheimer's disease patients. The data suggest that, while the available, approved agents offer only modest improvements in clinical outcomes, they could be cost-effective treatments for moderate to severe Alzheimer's disease when viewed from the societal perspective. For memantine and donepezil, data are available that suggest that the cost of these drugs is offset by the clinical and societal benefits provided by slowing the progression of Alzheimer's disease. While there are few head-to-head comparison trials, the similarity in costs of the treatments and efficacy against placebo suggest that cost effectiveness will not be substantially different among treatments. More studies that examine longitudinal resource utilization and its relationship to drug treatment in the moderate to severe stages are needed to clarify cost benefit in this population and possibly differentiate between individual medications.
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Affiliation(s)
- Jaclyn Cappell
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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