I recently read a British Geriatrics Society (BGS) blog which was titled:
“Antidementia medication may improve survival in Alzheimer’s disease”.
Having read this blog several times I wrote to the author on the 22nd September 2017 with some questions that arose for me:
Dear Dr Mueller,
I am wondering why you have chosen not to use the term dementia (the clinical syndrome) in this blog – instead you talk about “Alzheimer’s disease” ?
The BNF, section 4.11 is entitled “DRUGS FOR DEMENTIA” and the indications for use of acetylcholinesterase inhibitors are described as:
“mild to moderate dementia in Alzheimer’s disease” [bolding mine]
I am wondering if you may be asking (or encouraging) professionals to diagnose Alzheimer’s disease out-with the clinical criteria for dementia (DSM and ICD) ? If so what criteria should clinicians follow (research criteria being quite different to internationally standardised clinical criteria).
Might you be able to provide me more details of the evidence that supports this robust conclusion:
“Acetylcholinesterase inhibitors are not only helpful for memory, psychiatric symptoms and functioning, but may also improve survival. They should be strongly considered in every patient diagnosed with Alzheimer’s disease.”
Are you saying that acetylcholinesterase inhibitors are disease modifying? The scientific advisors for Alzheimer’s Society state quite emphatically that they are not and that they do not improve overall outcome? The World Health Organisation say likewise.
Mixed messages can be confusing to the public and professionals alike. The public are already confused about the loose (and unhelpful) use of language by professionals and the media: such that “Alzheimers” is often synonymously misunderstood as dementia.
A few years ago I debated in an RCPsych Congress advocating a timely approach to the diagnosis of dementia. Prof Ballard advocated diagnosing “early Alzheimers disease”. He lost the debate and was not able to give the audience necessary clinical guidelines on how to diagnose “early Alzheimer’s disease” without risking false-positive or false-negative diagnoses of dementia.
Prof Ballard has also stated in a Lancet publication that plaques and tangles may not be “paradigmatic” (the exact quote is below).
I would welcome any thoughts you may have.
With kindest wishes,
Dr Peter Gordon
Footnote: The 2008 - 2012 period that forms the data for this retrospective survival analysis was the period when early diagnosis was encouraged and in some instances, financially incentivised. Might it be that this resulted in a higher number of false positive diagnoses of "dementia"? Thus, a potential explanation of this "reduced mortality in Alzheimer's disease" is that it may actually relate to misdiagnosis of non-progressive mild cognitive impairment?