Objective: There are few data still on the patterns and predictors of response to AChEI therapy in routine clinical practice. We investigated clinical variables that may distinguish between responders and non-responders to AChEI therapy.
Design: Retrospective case note review
Materials and Methods: 160 consecutive patients with dementia who had started treatment with an AchEI between Jan 1998 and Dec 2002, were studied. Response was defined in two ways (a) A clinical response was achieved when there was no deterioration or there was improvement in the global clinical condition (CGI) at an efficacy assessment, and (b) A cognitive response when there was an improvement of 2 or more points on the Mini Mental State Examination (MMSE) at efficacy assessment. Frequency data was analyzed using Chi square tests with Yates continuity correction for two by two tables and Fishers’ test was used for cell values less than 5. Group means were compared using the independent sample t test. Correlations were calculated using Pearson’s product moment correlation. All p values were two tailed and significance set at 0.05.
Results: Eight (5%) patients could not tolerate treatment for more than 4 weeks. One died before efficacy assessment and one did not have an efficacy assessment. Of the remaining 150, 125 (83%) achieved a clinical response. Paired MMSE data was available for 137 cases and a total of 62/137 (45%) patients achieved a cognitive response.
A diagnosis of Dementia of Lewy Body type (DLB) and Parkinson’s disease + Dementia (PD +DLB), hallucinations and lower MMSE scores at baseline were associated with a cognitive response. MMSE scores at baseline had a significant moderate negative correlation with improvement in MMSE scores.
There were no predictors of a clinical response.
There was a high incidence of non-cognitive symptoms among the patients, Depression (n=42, 26%), Visual Hallucinations (n=19,12%), Delusions (n=12, 7.5%) and falls (n=17, 10%). The MMSE was frequently conducted at efficacy assessment (86%), but a clinical response was not based solely on changes in MMSE scores.
Donepezil was used in 78% of patients, Rivastigmine in 16% and Galantamine in 6%. There was no difference in rates of response based on the AChEI used. Patients on Rivastigmine were more likely to stop treatment due to intolerance.
Patients with Mixed Alzheimer's Disease + Vascular dementia, (n= 15), experienced similar clinical and cognitive response rates as Alzheimer's disease.
Conclusion: Severity of illness, a diagnosis of DLB, and presence of hallucinations at baseline were predictive of a cognitive response. Non-AD dementia responded equally well to AChEI treatment and results of further randomised, placebo-controlled studies are needed to clarify the role of AChEI in the treatment of these disorders.
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