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cholinesterase inhibitors

Assessing the Response of Patients with Alzheimer Disease to Cholinesterase Inhibitors

Assessing the Response of Patients with Alzheimer Disease to Cholinesterase Inhibitors

Teaser: 

Serge Gauthier, MD, FRCPC, Neurologist, McGill Centre for Studies in Aging, McGill University, Montreal, QC.

Introduction
The advent of cholinesterase inhibitors (CI) as regular prescription drugs for the treatment of Alzheimer disease (AD) in mild to moderate stages has created opportunities for a proactive role among primary care practitioners with interest in a geriatric practice. The Canadian Consensus Conference on Dementia original report,1 and its update,2 clearly support the role of primary care physicians in the diagnosis and treatment of AD. A new challenge is the assessment of response to CI in individual patients. This review will examine the evolving expectations of response to treatment since 1986, when tacrine was first described as an effective drug,3 and will conclude with current realistic goals at therapeutic doses of donepezil, rivastigmine and galantamine--improvement in apathy peaking after three months of therapy and one year of stability for cognitive, functional and behavioural symptoms, followed by a decline parallel to natural history.4

Responders in Randomized Clinical Studies
The early descriptions of the response to CIs such as tacrine, included 'return to playing golf,'3 which set treatment expectations to a return to previous complex activities. A Canadian double-blind multicentre study did not find such dramatic effects.

Cholinesterase Inhibitors in the Treatment of Vascular Dementia

Cholinesterase Inhibitors in the Treatment of Vascular Dementia

Teaser: 

Chris MacKnight, MD, MSc, FRCPC, Division of Geriatric Medicine, Dalhousie University, Halifax, NS.

Introduction
Vascular dementia is common, and currently there is no accepted therapy aimed at the cognitive symptoms. Prevention of further strokes is, of course, well established.1 Evidence is accumulating that the cholinesterase inhibitors, proven therapy in Alzheimer disease (AD), may also be of use in vascular dementia (VaD). This paper will summarize that evidence.

Epidemiology of Vascular Dementia
Vascular dementia can be diagnosed when there is a high degree of suspicion that cognitive impairment and stroke are related. Various criteria exist, which unfortunately do not overlap to any great extent, but all share several features.2 These include: the presence of stroke, either clinical or found on neuroimaging; the presence of focal neurologic signs, such as asymmetric power or a positive Babinski response; and a characteristic course, with a sudden onset or stepwise progression. For the highest degree of confidence in the diagnosis, a temporal relationship between the stroke and the dementia is required.

In most surveys of older adults, vascular dementia is the second most common cause of dementia in the community, after AD. In Canada, the prevalence of VaD is 1.5% in people 65 and over, and 5.1% for AD.3 Other surveys have found similar values.

Therapeutic Approaches for Treatment of Alzheimer’s Disease

Therapeutic Approaches for Treatment of Alzheimer’s Disease

Teaser: 


Reviewing the Benefits and Limitations of Psychotropics and Cholinesterase Inhibitors

Wafa Harrouk, PharmD

The following are brief summaries of salient points from presentations in the session on Therapeutic Approaches for the Treatment of Alzheimer's disease, Sunday July 9th, 2000.

Clinical Status of Therapy for Behavioral Disturbances
Dr. Jeffrey L. Cummings, MD, from the Alzheimer's Disease Center, University of California, highlighted some of the most salient therapeutic interventions that are currently available for treatment of behavioural disturbances associated with AD. Alzheimer's disease (AD) is associated with a variety of neuro-psychiatric disturbances, including delusions, hallucinations, anxiety, depression, apathy, irritability, disinhibition, and agitation. Patients may also suffer from aberrant motor behaviours such as rummaging, pacing and wandering. These behavioural disturbances are stressful to the patient as well as to their caregivers. Appropriate treatment of these disturbances would improve the patients' quality of life, alleviate their caregiver's stress, and delay their placement in a nursing home. Relatively few double blind, placebo control trials of psychotrophic medications have been conducted on patients with AD.