HFHT's Practising Wisely Newsletter
For the whole healthcare team.
Issue 52: Forget the Aricept
May 8, 2018
The American Academy of Neurology recently published an update to their 2001 guideline on treatment of Mild Cognitive Impairment. The conclusion was that "anticholinesterase inhibitors do not improve cognition or protect MCI patients from conversion to dementia". If clinicians continue to offer them, they need to inform patients of the lack of evidence of any efficacy.
In patients with MCI, exercise training (6 months) is likely to improve cognitive measures which was the best of possible nonpharmacological options (see Quick Links for more info).
This is hardly surprising since reviews dating back to 2005 and published by Therapeutics Initiative came to the same conclusion and even questioned whether the small effects on test scores in patients with dementia were clinically relevant. Their conclusion with respect to Donepezil:
 “Donepezil did not reduce the relative risk of entering institutional care; nor the combined risk of progression of disability or institutionalization. No significant differences were seen between donepezil and placebo in behavioural and psychological symptoms, carer psychopathology, formal care costs, unpaid caregiver time, adverse events or deaths, or between 5 mg/d and 10 mg/d doses of donepezil.” (See Quick Links for more).

A Cochrane review in 2006 summarized:
"There is some evidence that use of donepezil is neither more nor less expensive compared with placebo when assessing total health care resource costs. Benefits on the 10 mg/day dose were marginally larger than on the 5 mg/day dose. Taking into consideration the better tolerability of the 5 mg/day donepezil compared with the 10 mg/day dose, together with the lower cost, the lower dose may be the better option. The debate on whether donepezil is effective continues despite the evidence of efficacy from the clinical studies because the treatment effects are small and are not always apparent in practice, and because of the cost of the drug."

Can we consider this as a classic example of a medical problem with no satisfactory treatment or cure – and a desperate desire on the part of patients and family members to do something?

The statement of treatment effects being small and not always apparent rings true...is it worthwhile from the patient’s and caregiver’s perspective to offer a minimally effective treatment that has side effects that can be upsetting?
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