The new era of treatable Alzheimer disease: Ending a dark age in British Columbia

It has been almost a century since Dr Alois Alzheimer first described his patient, a 51-year-old woman who had such unusual symptoms that she could not be diagnosed with any known disease. The careful clinical description of this patient was illuminating: she had a profound and progressive amnestic disorder, aphasia, alexia, and agraphia, accompanied by striking psychobehavioral symptoms that included profound agitation, expressing jealousy toward her husband, and shrieking when touched. Her condition lasted until her death 5 years later, during which time there were no treatments to offer beyond compassionate care—a situation that continued for others similarly affected through the ensuing century. At her post mortem she was found to have significant cerebral atrophy and the neurofibrillary tangles and senile neuritic plaques[1] now recognized as characteristic of Alzheimer disease (AD).

Today, AD affects roughly 5% of the Canadian population older than 65 and is known to double in prevalence every 5 years after age 65. The implications for our graying Canadian society are enormous, not only from the medical but also from the economic and psychosocial perspectives. Thankfully, the scientific community has risen to the challenge of this disease in virtually all ways, and improved management options are now available for patients, families, and their physicians. Many clinicians are unaware of the accelerating pace of discovery into AD, with a generation of clinical trails poised to test definitive strategies against the amyloidosis believed to cause the disease. Clinical and translational research efforts have culminated in the regulatory approval of the first generation of medications for treating AD symptoms, the cholinesterase inhibitors (ChEIs). Efforts regarding vascular and other AD risk factors have provided primary care physicians with clearer targets for reducing these risk factors and the possibility of delaying the onset of this disease—a consequence with huge public health implications. Governments and public policymakers have taken a greater interest in AD, even though they are very apprehensive about the costs of treatment.

This theme issue provides an up-to-date clinical perspective on AD care in BC. Physicians who commit a large part of their clinical activity to the care of patients with AD have commented here on a range of AD issues in a number of care settings. We are grateful for their efforts to provide practical and clinically useful comments.

In this issue we also report on the outcome of the Treatment Efficacy in Alzheimer Disease (TREAD) consensus conference, which was held in January 2003 to address state-of-the-art symptomatic treatment for AD. The TREAD results reflect the consensus of opinion that has developed regarding the efficacy, safety, and indication to use ChEIs as the first licensed treatment for AD and as a standard of care. The systematic reviews of the Cochrane Collaboration[2-4] now recognize converging evidence of efficacy for cognitive and clinical global and functional benefits for ChEIs as a class. The practice parameter of the American Academy of Neurology also expresses the view that ChEIs be considered a standard of care.[5]

Unfortunately, at the time of writing, the Therapeutics Initiative and Pharmacare are tenaciously holding to their view that ChEIs are not useful treatments worth paying for in BC. Their determined line of resistance has left BC as one of only two or three provinces in Canada without pharmacare support for these medications, and has left physicians frustrated and unable to practise according to standards of care proposed through their national and international organizations.[2] Despite the lack of formal acknowledgment of efficacy and the absence of public funding, the use of ChEIs in BC is equal to other provinces. This may be the most telling cost-effectiveness study of all. Nonetheless, some deserving patients are still without this option simply because they cannot pay for medication at a time in their lives when they are most disadvantaged.

We hope that the publication of the TREAD results will eventually allow patients with this devastating disease to receive the necessary government financial support in BC, and will lead to the implementation of other critical strategies (education of caregivers and access to adult day-care centres, homemaking, and other resources) that are required. We also hope that this theme issue will encourage and support physician involvement in the rewarding and promising area of dementia care.

—Howard Feldman, MD, FRCPC
Professor and Head, Division of Neurology, UBC
Director, UBC Alzheimer Clinical Trials Unit, UBC and Vancouver Hospital
—B. Lynn Beattie, MD, FRCPC
Division of Geriatric Medicine, UBC
Director, Clinic for Alzheimer Disease and Related Disorders,
UBC and Vancouver Hospital

Competing interests
See here.

References

1. Wilkins RH, Brody IA. Alzheimer’s disease. Arch Neurol 1969;21:109-110. 
2. Birks JS, Harvey R. Donepezil for dementia due to Alzheimer’s disease. Cochrane Database Syst Rev 2003;3:CD001190. PubMed Abstract 
3. Birks JS, Grimley Evans J, Iakovidou V, et al. Rivastigmine for Alzheimer’s disease. Cochrane Database Syst Rev 2000;4:CD001191. PubMed Abstract 
4. Olin J, Schneider L. Galantamine for Alzheimer’s Disease. Cochrane Database Syst Rev 2002;3:CD001747. PubMed Abstract 
5. Doody RS, Stevens JC, Beck C, et al. Practice parameter: Management of dementia (an evidence-based review). Neurology 2001;56:1154-1166. PubMed Abstract Full Text   Site ©, 2003 | Contact Us