Use of cholinesterase inhibitors in dementia

Alzheimer’s disease is the most common cause of dementia in older people, with about half a million people affected in the UK. Its effects are devastating and far-reaching for sufferers, their carers and society in general – the Audit Commission estimated the annual cost of dementia care for 1998–1999 at £6.1 billion (Audit Commission, 2000). There is no cure and it is terminal within 3 to 7 years of diagnosis. Given an estimated doubling of dementia cases over the next 50 years (Melzer et al, 1997), the burden of care is set to increase substantially. In April 1997 donepezil hydrochloride, the first of several symptomatic drugs, was licensed in the UK. Since many health authorities refused to fund prescription of these products, the National Institute for Clinical Excellence (NICE) reviewed the evidence of their efficacy and issued formal guidance for their use (NICE, 2001). Medication aimed at the amelioration of the underlying pathophysiology of Alzheimer ’s disease, with resultant improvements in the core cognitive deficits of the disorder, has, understandably, generated enthusiasm in both clinicians and patient representatives. Does the current best evidence support this, and if so, how might these new drugs be incorporated into clinical practice?