Reply by Tripathi and Kumar

The featured image (above) is from the Alzheimer's Society and is 
their position statement on current anti-dementia medications.

This is the BMJ rapid-response reply by Assistant Professor Shailendra Mohan Tripathi Ambrish Kumar, Department of Geriatric Mental Health, King George’s Medical University, Lucknow, India. It is dated 15th April 2014.

“Anti-dementia” drugs improve the outcome
The author has been very judgmental in reaching a conclusion that anti-dementia drugs neither modify the disease nor improve the outcome. I differ on his statement that anti-dementia drug do not improve the outcome. It is true that anti-dementia drugs do not stop the progression of the disease but the statement regarding non-improvement in outcome is a little harsh. It is clear that there remains no medical or pharmacological treatment for dementia especially Alzheimer’s disease that can reverse or stop the progression of the disease. Anti-dementia drugs, particularly the cholinesterase inhibitors for people with mild to moderate Alzheimer’s disease and memantine for people with moderate to severe Alzheimer’s disease, are intended for symptom management to help improve cognition, function, behaviour, language and quality of life. Even combination of the two can be tried with very beneficial effect. By working with Geriatric patients I have come to know that symptomatic improvement can be brought in patients with Alzheimer’s dementia. This may not be that beneficial for other kind of dementias.

Improvement in patients with dementia is based on many factors. Recent studies have investigated whether specific domains of cognitive or non-cognitive symptoms respond to different treatments. An analysis of three mild to moderate Alzheimer studies showed that memantine had particular benefits in domains of orientation, following commands, praxis and comprehension (Mecocci et al., 2009). Gauthier et al. in 2008 found non-cognitive benefits for delusions, agitation/aggression and irritability through anti-dementia drugs. At the same time it was found that cholinesterase inhibitors can help behavioural symptoms by improving attention and concentration. Feldman et al. (2001) showed particular benefits for apathy, anxiety and depression.

Judicious use of antidementia drugs is required by an expert. Doses, best time to start of antidementia drugs are important which can be addressed only with experience. A patient must be free from delirium, his physical problems should be properly taken care of otherwise the patient will be at receiving end of adverse after effects of the antidementia medications. A patient on antidementia drugs would be managed better by the care giver than the patient off the antidementia drug. Clinically there is definite improvement with antidementia drugs on activies of daily living and behavior which is not possible without improvement in cognition.

References:
1. Gauthier S, Loft H and Cummings J (2008) Improvement in behavioural symptoms in patients with moderate to severe Alzheimer’s disease by memantine: a pooled data analysis. Int J GeriatrPsychiatry 23: 537–545.
2. Mecocci P, Bladstro¨m A and Stender K (2009) Effects of memantine on cognition in patients with moderate to severe Alzheimer’s disease: post-hoc analyses of ADAS-cog and SIB total and single-item scores from six randomized, double-blind, placebo controlled studies. Int J Geriatr Psychiatry 24: 532–538.
3. Feldman H, Gauthier S, Hecker J, Vellas B, Subbiah P and Whalen E (2001) A 24-week, randomized, double-blind study of donepezil in moderate to severe Alzheimer’s disease. Neurology 57: 613–620.

My reply, submitted as a BMJ rapid response is here

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