Intended for healthcare professionals

Analysis And Comment Controversy

Role of cholinesterase inhibitors in dementia care needs rethinking

BMJ 2006; 333 doi: (Published 31 August 2006) Cite this as: BMJ 2006;333:491
  1. Anthony J Pelosi, consultant psychiatrist (,
  2. Seamus V McNulty, consultant psychiatrist2,
  3. Graham A Jackson, consultant psychiatrist3
  1. 1 Department of Psychiatry, Hairmyres Hospital, East Kilbride G75 8RG
  2. 2 Department of Old Age Psychiatry, Ayrshire Central Hospital, Irvine KA12 8SS
  3. 3 Department of Old Age Psychiatry, Leverndale Hospital, Glasgow G52 7TU
  1. Correspondence to: A J Pelosi
  • Accepted 11 August 2006

The NHS focus on memory clinics driven by drugs that slow cognitive decline is taking resources away from services offering long term integrated care. The role of these clinics needs reconsideration alongside availability of the drugs

The National Institute for Health and Clinical Excellence (NICE) is approaching the end of a controversial consultation process on proposed radical revisions to its guidelines on drugs for dementia. Since 2001 the institute has recommended that the National Health Service in England and Wales should make the licensed cholinesterase inhibitors donepezil, rivastigmine, and galantamine available to people with mild to moderate Alzheimer's disease.1

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NICE guidelines met a hostile reception


The available research in 2001 could not provide guidance on which patients would respond to these drugs.2 However, when compared with placebo these drugs slowed cognitive decline. Over six months there was an average advantage of 2-3 points on the cognitive section of the Alzheimer's disease assessment scale, which has a range of 70 to 0. Rates of progression vary widely, but the expected average annual decline on this scale in placebo treated patients is 5-6 points.12 Outside trials the mean annual rate of change is about 8-9 points.3

Carers often report improvements in behavioural disturbances, neuropsychiatric symptoms, motivation, and activities of daily living when their relatives start taking cognitive enhancers but also when they are prescribed placebo. A combination of these features plus cognitive function influence clinicians' global ratings of change, which have usually favoured the active treatments in controlled trials.2

Unanswered questions

NICE and its main advisers acknowledged shortcomings in their and others' economic analyses. Calculation of quality adjusted life years (QALYs) has been based on cross sectional data from carers of patients with Alzheimer's disease using the health utility index, which was not designed for …

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