A report by the AARP has found that most dementia patients—around 70 percent—are kept on prescription drugs much longer than they’ve been found to be effective in potentially helping with symptoms. Does that mean dementia patients should stop taking their prescribed drugs after a year?
Drugs like Aricept, (also known as Donezepil), Galantamine and Rivastigmine (also sold in patch form under the name Exelon) are what’s known as cholinesterase inhibitors, and they work by keeping a chemical called acetylcholine from breaking down. Acetylcholine is neurotransmitter that helps brain cells communicate. Drugs like these can’t slow the progression of the disease but they can boost memory for a period of time. However, dementia patients have varying results when they take this kind of medication. For some, they only work for up to three months.
The only other type of drug approved for dementia symptoms, often prescribed for moderate to severe dementia alongside a cholinesterase inhibitor, is called Memantine, and is also sold under the brand Namenda. Memantine is prescribed for symptoms like hallucination and confusion. It has been studied in patients for up to a year, but is not a disease modifier—it does not change the course of the disease, it only may provide some relief from symptoms.
But a report released by AARP that analyzed data from Medicare Advantage enrollees found that some patients were kept on these medications for up to a decade, with a reported price tag of up to $20,000 per person.
“Our research shows some healthcare providers continue prescribing dementia drugs to patients for much longer than is supported by the clinical evidence,” Elizabeth Carter, senior health services research advisor, AARP Public Policy Institute, and co-author of the study, said in a press release.
“Not only do these drugs carry potential side effects, they are costing both patients and the healthcare system a lot of money,” said Carter.
The data comes from over 36,000 Medicare Advantage participants that received treatment between 2006 and 2015. Seventy percent were on the drugs for 13 months or longer.
Carter wrote that cases of long-term prescriptions for drugs like these with no evidence of success over time come down to how doctors are trained to treat dementia.
“Despite the limited effectiveness of dementia drugs, most clinicians receive little guidance on when and how to de-prescribe them—that is, taper or discontinue the drugs to improve patient outcomes,” wrote Carter. “Further, it is common for physicians to continue prescribing these drugs to patients for considerably longer than the duration supported by clinical evidence. The associated costs can be substantial for both patients and health care payers.”
But not everyone agrees that taking dementia patients off cholinesterase drugs after a year is the right thing to do. In fact, according to William Burke, M.D., director of the Stead Family Memory Center at Banner Alzheimer’s Institute in Phoenix, doing so could result in a sharp decline for patients. “We can see people have a substantial drop off in their cognition if they suddenly stop one of these medications,” said Burke. While he agrees that patients can be tapered off the drugs in the later stages of the disease, doing so too early or too abruptly is the difference between a patient recognizing their family or being able to feed themselves, said Burke.
The report from the AARP was released on the premise that all cholinesterase drugs only work for six to twelve months. But Burke said that’s a misconception based on how long the drugs have been tested in clinical trials, in which the medication has only been tested for up to a year. “Many other approved medications for other uses have similarly short-term research studies supporting their use, but no one suggests stopping those drugs based on how long their initial research studies were,” said Burke. Rather, he said, the six to twelve month figure is a way to describe the kind of improvement a patient can expect on these drugs. “A person’s cognitive tests scores might improve back to the level that they were previously at six to 12 months earlier,” said Burke.
This year, dementia costs in the United States are expected to total $270 billion. By 2050, the total cost of care for Alzheimer’s is projected to hit more than $1.1 trillion in the U.S., according to the report.
This article was updated on August 8, 2018.