Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Anticholinesterase inhibitors would be unhelpful in dementia
- Jeffrey J Clarke (5 March 2005)
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Re: Anticholinesterase inhibitors would be unhelpful in dementia
- Thomas L. Perry (5 March 2005)
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A Pandora's box of policy contradictions?
- Steve Iliffe, Jill Manthorpe (7 March 2005)
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Should NHS secondary care services be the next NICE target?
- Robert Stewart (9 March 2005)
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NICE's evaluation of Alzheimer's disease drugs is fundamentally flawed
- Gill Livingston, Claudia Cooper, Cornelius Katona (10 March 2005)
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NICE and treatments for Alzheimer's Disease
- David J. Jolley, Sasi Willmott (12 March 2005)
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NICE proposes to withdraw Alzheimer's drugs from NHS
- Richard Prettyman (14 March 2005)
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NICE draft guidance on the anti dementia drugs
- Alistair Burns, Rob Howard, David Wilkinson, Sube Banerjee (15 March 2005)
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AD treatment is still at its infancy
- Frederic Calon (15 March 2005)
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Need for Consensus Guidelines
- Nischol K Raval, Kalpana Athavale (16 March 2005)
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Re: Need for Consensus Guidelines
- Dr John Rumbold (17 March 2005)
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Re: Re: Need for Consensus Guidelines
- John J Harley (19 March 2005)
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Withholding drugs for the treatment of Alzheimer’s disease: a question of values
- Suzanne Wait, Baroness Sally Greengross, Co-Chair, Alliance for Health and the Future (19 March 2005)
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Is NICE proposing to withdraw non-existent drugs?
- David Ames (20 March 2005)
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Re: Re: Re: Need for Consensus Guidelines
- Simon R Wright (22 March 2005)
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Can we do better in Alzheimers Disease?
- Jed Rowe (24 March 2005)
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Jeffrey J Clarke, Consultant psychiatrist for the elderly Bootham Park Hospital, Bootham, York, YO30 7BY
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The news item "NICE proposes to withdraw Alzheimer's drugs from NHS" twice incorrectly refers to "anticholinesterase inhibitors". Anticholinesterase inhibitors would reduce the availability of acetylcholine in the brain by working against the inhibition of the enzyme which breaks acetylcholine down. These agents almost certainly would be unhelpful in dementia where it is postulated that cholinergic deficit is linked to cognitive decline. Three of the drugs mentioned in the draft guidance are in fact acetylcholinesterase inhibitors which work to increase the availability of acetylcholine. To those of us who suspect that the needs of elderly people with dementia are a low priority for health planners (a suspicion not allayed by this draft guidance) it is disappointing to see that a similarly low priority is accorded to journalistic accuracy when writing about this vulnerable, disenfranchised patient group. Competing interests: I am a psychiatrist for the elderly and routinely prescribe all three acetylcholinesterase inhibitors |
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Thomas L. Perry, physician/university professor University Hospital, Vancouver, B.C. V6T 2B5
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Dr. Jeffrey J. Clarke points out that the term "anticholinesterase inhibitors", is a non-pharmacologic neologism, used mistakenly in a BMJ news item. Although potent inhibitition of acetylcholinesterase (AChE) can be moderated by "cholinesterase reactivators" (pralidoxime), this could make sense in Alzheimer's Disease only in the context of a huge overdose of a cholinesterase inhibitor (AChE-I) such as donepezil, rivastigmine, or galantamine. Oddly enough, creative (if mischievous) doctors have found easier ways around this pharmacological impasse. I have seen a number of patients treated with both an AChE-I and an anticholinergic drug such as oxybutynin or tolterodine. As Dr. Clarke points out, such agents "almost certainly would be unhelpful in dementia where it is postulated that cholinergic deficit is linked to cognitive decline". This doesn't seem to stop some prescribers from trying to counteract with one drug the predictable pharmacologic effects of the other. Prescribers and consumers of AChE-I might also do well to ask themselves which others of the many drugs that antagonize muscarinic receptors they are taking simultaneously. Thomas L. Perry, M.D., FRCPC Clinical Assistant Professor Dept. of Pharmacology & Therapeutics and Dept. of Medicine University of British Columbia Competing interests: None declared |
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Steve Iliffe, Reader in General Practice Royal Free & UCL Medical School, London NW3 2PF, Jill Manthorpe
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The Health Technology Appraisal (HTA) committee of the UK National Institute for Clinical Excellence (NICE) is right to be sceptical about the benefits of medication for Alzheimer’s disease (1). But in recommending that this therapy should no longer be available within the NHS for newly diagnosed patients, the committee may have opened a Pandora’s box of policy contradictions. Clinical concerns at the withdrawal of these drugs will no doubt dominate the professional debate, and expert opinion on the robustness and reliability of the economic modelling will be assembled on both sides in the consultation process. However, the debate will not be confined to the professions and the pharmaceutical industry. Public concern, particularly that of older people, their families, and voluntary sector, may prove to be a major factor in shifting the debate from the technical to the political arena. In the run up to the UK general election, the proposals of the HTA committee may deepen suspicions that troubling and distressing symptoms that may be ameliorated by drug therapy have little priority in the NHS if the patient is old. Since these medicines appear to confer benefit their use will continue, but with the costs transferred to individuals and families in a mockery of equity. What will be the point of early detection and diagnosis of dementia as advocated by the Audit Commission and the National Service Framework for Older People if one of their advantages – early trial of symptom-modifying drugs – is no longer available? What is the value of Standard One of the NSFOP – on rooting out age discrimination - if it is qualified by cost? And what is the purpose of including stakeholders in policy development and implementation if economic formulae trump both powerful professional opinion and user experience when deciding policy? Steve Iliffe, Reader in General Practice at Royal Free University College London Medical School. Jill Manthorpe, Professor of Social Work at King’s College London. (1) Kmietowicz Z NICE proposes to withdraw Alzheimer’s drugs from NHS. BMJ 2005;330:495 Competing interests: Steve Iliffe is a general practitioner who prescribes acetylcholinesterase inhibitors within a shared-care protocol, has received research funding from the pharmaceutical industry and is a member of the NICE/SCIE guidelines development group for dementia. Jill Manthorpe is also a member of the NICE/SCIE guidelines development group for dementia. |
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Robert Stewart, Senior Lecturer and Consultant in Liaison Old Age Psychiatry Institute of Psychiatry (Kings College London), De Crespigny Park, London SE5 8AF
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I suppose we should all be very grateful that the NHS will save so much money through the withdrawal of acetyl cholinesterase inhibitors for people with Alzheimer's disease. Those of us who work in long under-funded mental health services for older adults would perhaps feel slightly more appreciative if there was any NHS interest in people with dementia apart from how much they cost. Apparently there is insufficient evidence that acetyl cholinesterase inhibitors have measurable effects on quality of life and time to admission to nursing care. The irony of the second of these outcomes is staggering as the NHS currently does a very good job of saving itself money through speeding up admission to nursing care. People with dementia who happen to be admitted to secondary care services are already in a vulnerable enough position. Rehabilitation is difficult and takes longer. However, the realities of bed costs and length of stay restrictions mean that there are substantial savings to be made through a quick decision to arrange a nursing home placement. The cost is then passed from the Acute Trust on to Social Services – but in England at least the person’s estate (if any) can be decimated to cover this. It is said that the health of a society is reflected in the way it cares for its older members. It is a shame that our morbidity should be reflected so prominently in our health service. Perhaps NHS secondary care should feature in the next NICE assessment of dementia interventions. Competing interests: The author is a consultant psychiatrist and has supervised the prescription of acetyl cholinesterase inhibitors. The author has received research support from several pharmaceutical companies including some which manufacture acetyl cholinesterase inhibitors. |
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Gill Livingston, Reader in psychiatry of older people Dept of Mental Health Sciences., Claudia Cooper, Cornelius Katona
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Editor, NICE’s preliminary guidance (1) is that cholinesterase inhibitors and memantine are not recommended in Alzheimer’s disease (AD). This conclusion is reached on health economic grounds and despite the significant improvements these drugs can achieve in cognition, behaviour and function. The calculation is, however, fundamentally flawed (2)and we will discuss two reasons for this. Firstly, NICE’s cost effectiveness uses the Quality Adjusted Life Years (QALY) measure. QALY calculations are based on the number of years of life expectancy. It is thus inevitable that treatment of older people will appear more expensive, or in other words that younger people are more worthy of treatment than older people. The measure is therefore inherently ageist and inappropriate for use in the context of dementia. Secondly, costs incurred by caregivers are not included in QALYs. NICE acknowledge that there is little quantitative evidence related to carer utilities. Most people with dementia are cared for by family caregivers in the community. Many look after people with severe dementia well beyond the point at which institutional care would otherwise be needed. Our longitudinal study of people with AD and their caregivers (3) has found that 65% of family caregivers under retirement age had either reduced their working hours, missed time from work (on average six hours a week) or stopped work altogether to care. This occurred at all stages of dementia, when people lived in the community and was not prevented by the provision of a care package. NICE invokes evidence that memantine decreases family caregiving time by 1.5 hours a day, sustained for 12 months in those with moderately severe/ severe AD. The drug may therefore be associated with significant improvements for caregivers. This has not been accounted for by NICE in their calculations. We suggest that carer emotional and financial sacrifices should not be discounted because they do not directly cost the health service. Yours faithfully, Claudia Cooper
1. Kmietowicz Z NICE proposes to withdraw Alzheimer's drugs from NHS BMJ 2005;330:495 2. Royal College of Psychiatrists response to the proposal of the National Institute of Clinical excellence (NICE) to withdraw treatment for Alzheimer’s disease from the NHS- college strongly disagrees with preliminary recommendation. http//www.rcpsych.ac.uk/press/prereleases/pr/pr_653.htm. Accessed 10 March 2005 3. Regan C, Katona C, Walker Z and Livingston G (2005). Exercise and depression in Alzheimer’s Disease. The LASER-AD study. Int Journal of Geriatric Psychiatry 20 261-268 Competing interests: All three authors are clinical old age psychiatrists who prescribe cholinesterase inhibitors to their patients and find them helpful. GL and CK have taken part in trials of cholinesterase inhibitors and have been received research funding from Lundbeck and Novartis. CK has provided consultancy and given lectures for Lundbeck and Shire. |
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David J. Jolley, Consultant Psychiatrist, Professor of Old Age Psychiatry Dementiaplus, Warstones Resource Centre, WV44PG, Sasi Willmott
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There is widespread concern that the recommendations emanating from the NICE Assessment Group March 1st (http://www.nice.org.uk/page.aspx?o=245909) will become policy, for no new evidence will be forthcoming within the brief consultation period (March 21st). The need is not for more evidence, at this point, but a reasonable appreciation of that which is available from publications and the witness of patients, families and clinicians who live with Alzheimer’s Disease every day. NICE provided guidance, 2001, which has encouraged the spread of good practice and modest, responsible use of the acetylcholine-esterase inhibitors. The Assessment Group received evidence from respected academics, clinicians and families, confirming the benefits which have accrued. The Group acknowledges that these medicines, and memantine (which is considered, almost by-the-way, for the first time) have significant effects upon the core symptoms of Alzheimer’s Disease. This information in support of the continued prescription of these medicines, for their modest benefits, has been set aside for lack of evidence that expenditure on the drugs will be balanced by cost savings on other modes of care. For this the Group depend upon the AD 2000 study which many have felt was poor in design and implementation. It became catastrophically under-powered, recruiting only 565 subjects of the 3000 calculated to be needed to avoid type 2 errors. Only 40 percent of these entered phase two, 10 percent phase three and 0.8 percent phase four. The main determinant of cost identified as a primary outcome measure, admission to institutional care, is influenced by many factors other than severity of cognitive impairment and usually becomes operative after a period of support at home. By this time the study’s power was hopelessly inadequate to identify or reject meaningful differences with any certainty. Paragraphs 4.2.5, 4.2.6 and 4.2.7 will be bewildering to many who try to understand them (baffled with numerical modelling?). They are, at best, a theoretical exercise making use of flimsy evidence and doubtful assumptions to model possible outcomes and their possible cost- consequences. We are not convinced that these considerations form a sound base to argue for a change in national prescribing practice. It is to be hoped that NICE will step back and make new and balanced appraisal of the materials available, from a proper perspective and with respect for what is important to people who live with Alzheimer’s Disease. Competing interests: DJ has been involved in events sponsored by compaies marketing antidementia medicines and is involved in a Memory Clinic which treats people with Alzheimer's Disease |
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Richard Prettyman, Consultant old age psychiatrist Bennion Centre, Glenfield Hospital, Leicester LE3 9DZ
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The rapid responses already published in response to this news item make a number of important observations including the inappropriate use of the QALY model by Nice and its failure to take account of benefit to patients and carers in a broad sense. We should also be concerned that this draft appraisal establishes an expectation that treatments should result in cost savings or at least be cost neutral. The fact that this is patently not the case in most other therapeutic areas serves only to highlight the impression that we are looking at an example of double standards if not intitutionalised ageism. Richard Prettyman Competing interests: I am a consultant old age psychiatrist involved in the treatment of patients with Alzheimer's disease. I have received lecture fees and honoraria from time to time from pharmaceutical companies that manufacture antidementia drugs. |
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Alistair Burns, Professor Of Old Age Psychiatry Wythenshawe Hospital Manchester M23 9LT, Rob Howard, David Wilkinson, Sube Banerjee
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We are writing with regard to the National Institute for Clinical Excellence (NICE) draft guidance on the drugs for Alzheimer’s disease. The guidance states that these should not be available for new patients on the NHS because of a lack of evidence of cost effectiveness. Since the drugs were first introduced in 1997, they have been prescribed to around 50,000 patients in the UK. Clinical experience has shown that response to the drugs is generally good, with improvement in a number of symptoms, including memory loss, activities of daily living, psychiatric symptoms (such as hallucinations) and behavioural disturbances. The moderate yet clinically significant improvements seen have to be set against the backdrop of a deteriorating and devastating disease both for patients and their carers, and the absence of any other specific intervention which improves, as opposed to merely suppresses, symptoms. NICE do not question the safety and efficacy of these drugs but, on a model of cost effectiveness, they conclude that the drugs have failed to meet the level which would justify their prescription on the NHS. However, the model used is largely based on measures that do not have validity in Alzheimer’s disease and did not take into account the effects of the disease on carers nor the specific positive benefits of the medications on psychiatric symptoms and behavioural disturbances. The assessment of quality of life in Alzheimer’s disease and its economic equivalent quality of life years (QALY’s) is not well developed, the model does not do justice to the myriad aspects of the disease and insufficient data are available to support the assumptions presented by NICE. They have carried out a thorough review of the available literature, but what is striking from this is the lack of evidence available on which to base the cost models generated (rather than there being actual evidence of a lack of clinical or cost effectiveness). At a time when safety of other drugs used in mental health is being questioned (e.g. antidepressants and atypical antipsychotics), removal of the anti-dementia drugs will significantly impair our ability to care for people with Alzheimer’s disease. Patients in England and Wales will be disadvantaged compared to those in other countries, we will see a return of ‘post code’ prescribing of these drugs on the NHS and will leave private prescriptions the only recourse available to patients and their families to obtain a licensed and proven treatment. This is not only against the ethos of the NHS but leaves vulnerable patients open to the vagaries of the market place. As clinicians, we believe the conclusions of the draft guidance are wrong and do not do justice to the complex nature of Alzheimer’s disease. Alistair Burns
Rob Howard,
David Wilkinson
Sube Banerjee
On behalf of the following signatories: George Alexopoulos, New York USA
The signatories are all specialists in the diagnosis and management of people with Alzheimer’s disease. Competing interests: The authors have received support from the pharmaceutical industry for research and educational activities. |
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Frederic Calon, scientist/pharmacist Laval university, Quebec, CANADA, G1V4G2
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Although I do not fully agree with the proposition of the NICE, we need to debate if the money spent on acetylcholinesterase inhibitors and memantine is the best investment for AD patients and their caregivers. In other words, we should recognize that 120m£ invested in academic research instead might lead to the discovery of disease-modifying therapeutic alternatives. At this day, AD treatment is a realistic hope, but not a reality. Competing interests: Involved in research funded by public money |
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Nischol K Raval, SHO in Psychiatry Pembrokeshire and Derwen NHS Trust, St. David's Hospital, Job's Well Road, Carmarthen, SA31 3HB, UK, Kalpana Athavale
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NICE's preliminary guidance (1) on cholinesterase inhibitors in Alzheimer's disease have rightly pointed out their clinical effectiveness, in keeping with the views already held by most mental health professionals who prescribe these medications. We are pleased that NICE is also using it's resources to assess the cost-effectiveness of cholinesterase inhibitors. There are some issues which will need to be taken into consideration before arriving at the decision that cholinesterase inhibitors should not be used as they are not cost-effective. -The current guidance does not take into consideration the efficacy and/or cost-effectiveness of other forms of treatment. Therefore there is a risk of replacing an effective treatment modality with one which may be cost-effective but not effective. -The guidance does not take into consideration the wishes of an individual patient and his/her carers,thus denying them a chance of benefitting from a proven effective form of treatment. -The calculations of cost effectiveness do not take into account the cost of treating the overburdened carers, who will have to bear the major brunt of these changes. -Implementation of such guidance has a risk of increasing burden and burnout rates in mental health professionals working with patients suffering from Alzheimer's disease. -The money projected to be saved by not prescribing cholinesterase inhibitors may never reach Old Age Psychiatry services for development of non-pharmacological treatment methods. In view of all the above we hope and sincerely wish that this preliminary guidance is reviewed. Another option to avoid such controversial guidelines in future would be development of Expert Consensus guidelines. (1) Kmietowicz Z. NICE proposes to withdraw Alzheimer's drugs from NHS. BMJ 2005; 330 :495. Competing interests: None declared |
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Dr John Rumbold, n/a West Midlands
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Going back to expert consensus would surely be against the whole ethos of NICE which is to institute EBM for the NHS. Experts are part of the process but their recommendations have to based on good evidence rather than just opinion. Competing interests: None declared |
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John J Harley, GP Woodlands FMC 106 Yarm Lane Stockton-on-Tees TS18 1YE
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I could not agree more with Dr Rumbold, 'In God we trust - all others bring data.' Competing interests: Long term advocate of EBM and member of a number of guideline develoment groups |
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Suzanne Wait, Director of Research International Longevity Centre-UK, 22-26 Albert Embankment, London SE1 7TJ, Baroness Sally Greengross, Co-Chair, Alliance for Health and the Future
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Over the past few weeks, patients, carers, physicians and politicians have raised concerns about the preliminary guidance from NICE to withdraw drugs for Alzheimer’s disease from the NHS [1,2]. There is still hope that the Institute may reverse its decision. Regardless, several important issues deserve mention as they will outlast the polemic surrounding the Institute’s proposals. NICE has justified this preliminary guidance on the basis of insufficient demonstration of clinical and cost-effectiveness for the four drugs in question. The draft guidance states that the clinical evidence is imperfect – yet the only change since the time of previous guidance is a single trial which has been highly criticised by expert psychiatrists [3]. The Health Technology Assessment report, which forms the basis for the Appraisals Committee decisions, claims that it is too complicated to gauge the true burden of this disease from existing economic data. Yet it fails to take into account several recent studies that unanimously point to the high cost burden posed by Alzheimer’s disease and the potential for the drugs in question to alleviate some of this burden [4,5]. It also argues that the economic models presented are based on ‘optimistic’ assumptions and are methodologically flawed – yet it exempts its own set of assumptions and modelling approach from such criticism. Finally, the lynchpin in its decision is that the cost-effectiveness ratio for the drugs in question is too high. However, the Institute has granted positive guidance to technologies that had similarly high cost-effectiveness ratios in the past. In short, the decision to reverse the previous positive guidance is based on a single clinical trial and rather speculative economic modelling. For a disease as devastating and complex as Alzheimer’s disease, this conclusion is both irresponsible and short-sighted. It also misses – and, ironically, underscores -- a crucial point: Alzheimer’s disease is much more than a clinical problem. It is a social phenomenon as yet unprecedented, which poses a tremendous burden to patients, their families and society in general. The draft guidance dismisses the claim, reiterated by the Royal College of Psychiatrists [6], that these drugs are the only treatment currently available to patients with Alzheimer’s disease. In fact, that these drugs do anything to improve the quality of life of patients with Alzheimer’s disease should be considered significant. In an early critique of NICE, it was suggested that there the values espoused by the Institute do not concord with those of the clinicians expected to apply NICE guidance in practice [7]. This is evident from the concern raised by professionals in response to this draft guidance. Alzheimer’s disease is the most significant public health problem facing us in years to come. There is alarming evidence that our health care systems, clinical skills, social services, and societies are ill- equipped to address the scale of this problem [8]. In an audit of mental health services for older people in England and Wales conducted in 2000, two-fifths of GPs were reluctant to diagnose dementia early, most of them did not use protocols for diagnosis, less than half of them felt they had sufficient training and over a third felt they did not have easy access to a suitable specialist for their patients. Three-quarters of carers felt they lacked suitable written information about local services available [9]. These problems persist to this day. The social costs linked to Alzheimer’s disease are poorly estimated, mainly because so much care is provided informally by families. Decentralisation of social services means that inequities in the provision of formal care exist throughout the country and that these are poorly documented. Long-term care expenditure in the UK would need to rise by about 315 percent in real terms between 2000 and 2051 to meet current demographic pressures, including those posed by dementia [8]. One may also be informed from the experience of other countries. The Canadian Coordinating Office for Health. Technology Assessment (CCOHTA), which was one of the prototype agencies upon which NICE was modelled, reviewed these same Alzheimer’s drugs in 2001 and recommended their use on the basis of much of the same clinical and economic data that were included in the current NICE appraisal. In France, the tragic death toll amongst older patients during the 2003 summer heat wave prompted the government to develop comprehensive policies to address the needs of its older citizens. In 2004, France launched the ‘Plan Alzheimer’, a strategic plan similar to our National Service Frameworks. In parallel, Social Security added Alzheimer’s disease to the limited list of conditions for which all treatment, including drugs, is reimbursed at 100%. The monthly cost of a donepezil is €100.59; that of rivastigmine is €50.80 per month. The cost of these drugs is dwarfed by that of paid home care, which is not reimbursed by Social Security. French patients and their families may pay €1524 for 8 hours of care per day, and €4573 per month for 24-hour care [10]. Alzheimer's research is severely under-funded in the UK - only £11 is spent on research annually per Alzheimer's patient, compared with £289 for cancer. The care solutions we can offer patients are limited. Most costs are borne by patients and their families. The number of people with cognitive impairment is expected to rise by 66% between 1998-2031. 75% of these are patients with Alzheimer’s disease [8]. 32% of people in nursing care are there because of dementia [11]. The goals set out in the National Service Framework for Older Persons as well as those of the NSF for Mental Health are still far from being achieved. In light of this, one must question how one can even begin to justify withdrawing four drugs from the NHS that offer relief to patients with Alzheimer’s disease and cost all of £2.50 a day. REFERENCES: 1. Minister intervenes in row over drugs to treat Alzheimer’s. The Guardian 14 March 2005. 2. Iliffe S. A Pandora’s box of policy contraindications. BMJ 7 March 2005.; Livingston G. NICE evaluation of Alzheimer’s disease drugs is fundamentally flawed. BMJ 10 March 2005. 3. Jolley DJ. NICE and treatments for Alzheimer’s disease. BMJ 12 March 2005. 4. Fillit H, Hill J. The economic benefits of acetylcholinesterase inhibitors for patients with Alzheimer disease and associated dementias. Alzheimer Dis Assoc Disord. 2004 Apr-Jun;18 Suppl 1:S24-9. 5. Sano M. Economic effect of cholinesterase inhibitor therapy: implications for managed care. Managed Care Interface 2004 August; 17(8): 44-9. 6. Royal College of Psychiatrists response to the proposal of the National Institute of Clinical Excellence (NICE) to withdraw treatment for Alzheimer’s disease from the NHS – college strongly disagrees with preliminary recommendation. 7. Dent THS, Sadler M. From guidance to practice: why NICE is not enough. BMJ 2002; 324: 842-5. 8. Raphael Wittenberg R., Comas-Herrera A., Pickard L. and Hancock R. Future demand for long-term care in the UK. A summary of projections of long-term care finance for older people to 2051. Joseph Rowntree Foundation 2004. 9. Forget me not: mental health services for older people. Audit Commission 2000. 10. http://www.doctissimo.fr/html/dossiers/alzheimer/sa_4575_cout_social.htm. 11. Clive Bowman. Continuing Care Conference, International Longevity Centre-UK, February 2004. Competing interests: The International Longevity Centre-UK benefits from a research grant from Pfizer and the Pfizer Foundation for its work on the Alliance for Health and the Future. However, none of the monies received are explictly linked to research on Alzheimer's disease. |
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David Ames, Associate Professor of Psychiatry of old Age University of Melbourne, 1 North, Royal Melbourne Hospital, Parkville, Victoria, 3050, Australia
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Dear Sir It was odd to read Zosia Kmietowicz's report (BMJ 2005, 330, 495)about the proposed withdrawal of a non-existent class of drugs. Of course cholinesterase inhibitors (also known as anticholinesterases) are used to treat some patients with Alzheimer's disease. However the article referred to "anti-cholinesterase inhibitors" , which while it might describe the attitude of NICE rather well, does not refer to any class of drugs in current use. Doesn't anyone at the BMJ proofread this stuff? David Ames dames@unimelb.edu.au 20/3/05 Competing interests: Consultancies, research support, conference attendance supported by Pfizer, Janssen and Novartis |
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Simon R Wright, Consultant Psychiatrist for Older People, Honorary Senior Clinical Lecturer Rotherham General Hospital, South Yorks, S60 2UD
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Dear Sir, I must comment on the advocates of EBM with reference to this debate. I like many others who oppose the draft guidelines on drugs for dementia do not oppose evidence based medicine, rather oppose it being a bedfellow of what appears to be a flawed economic analysis and a somewhat biased selection of the evidence. EBM also must be placed in the context of experienced and expert clinical opinion. It seems to be the case with this guidance, very few if any, of the NICE committee members are experienced dementia clinicians and this is evident in their lack of understanding of the good effect of these drugs in clinical practice. I have read this and recent NICE guidance on mental health technology with interest. Some seem to be at best no more than what experienced clinicians have been practicing for years, and at worse exhibit a clinical naivety divorced from everyday clinical practice. It is time I believe NICE was counter-balanced by a peer group selected expert consensus committee perhaps appointed through the Royal College's with equal resources and decision making powers. For me NICE guidance is now synonymous with an onerous hurdle to pass for busy clinicians trying to do best for patients, not a helpful resource and addition to our scientific understanding of the use of new medical technology. Competing interests: I prescribe all four anti-dementia drugs and have received sponsorships and honorarium from Eisai/Pfizer, Novartis, Shire Pharmaceuticals and Lundbeck Ltd. |
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Jed Rowe, Consultant Geriatrician Moseley Hall Hospital, B13 8JL
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There is a treatment for Alzheimers disease which delays institutionalisation by an average of 10 months [1] and produces sustained psychological benefit for carers [2]. It isn't a drug. Shouldn't we be fighting harder for good supportive care? 1. Mittelman MS, Ferris SH, Shulman E, Steinberg G, Levin B.A family intervention to delay nursing home placement of patients with Alzheimer disease. A randomized controlled trial. JAMA. 1996;276(21):1725-31. 2. Mittelman MS, Roth DL, Coon DW, Haley WE. Sustained benefit of supportive intervention for depressive symptoms in caregivers of patients with Alzheimer's disease. Am J Psychiatry. 2004;161(5):850-6. Competing interests: None declared |
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