What Is the Economic Impact of Alzheimer's Disease in the United Kingdom

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The key outcome of cost effectiveness studies of medicines for treating AD is the delay time of patients to institutionalisation. The age, cognition and function are the predictors of delay time to institutionalisation. Behaviour is omitted in the study model of mild to moderate AD as it is unlikely to change the output significantly although it is another potential predictor. AD is categorised into mild, moderate and severe stage. AChE inhibitors donepezil, galantamine and rivastigmine are the recommended options for mild to moderate AD. There is insufficient evidence to prove which of these three AChE inhibitors is most cost effective5. The total cost of donepezil (£69,624) is slightly higher than galantamine (£69,592). However, the quality-adjusted life year (QALY) gained from taking galantamine is slightly lower than donepezil (1.616 vs 1.617). At the willingness-to-pay (WTP) threshold which is £30,000 per QALY, AChE inhibitors are considered cost saving (more than 99% probability) if compared to the best supportive care8. Since there is insufficient evidence to prove the most cost effective drug between the three AChE inhibitors, the drug with lowest acquisition cost will be the recommended choice. However, the patients’ adherence, comorbidity, possible drug interaction and adverse reaction profile need to be taken into account while choosing the AChE inhibitors. NMDA receptor blocker memantine is the recommended option in people with moderate AD and have contraindication or intolerant to AChE inhibitors, or in those with severe AD. In moderate AD, memantine is more cost effective than the best supportive care but it generated lower QALY at a higher cost compared with AChE inhibitors. Hence, memantine will be the recommended only if the patient has contraindication or intolerant to AChE inhibitors. In severe AD, the incremental cost effective ratio (ICER) for memantine was £26,500 per QALY gained compare with best supportive care. If the behaviour improvement benefit of memantine is also taken into account, the ICER will be less than £26,500/QALY. Hence, memantine is cost effective in managing severe AD. The cost effectiveness of the drug (AChE inhibitors and memantine) is different at different stage of AD. The assessment scale is important to identify the stage of AD in patient before recommending the medicines5.

In order to obtain the full benefit from a clinically proven medication, the patient adherence to the medication is the first thing to consider by the pharmacists. Patients with AD tend to be forgetful, anxious or depressed. Pharmacists must find an effective way to communicate successfully with the patients. It is important to involve the carers of patients while conveying the information especially the dose of medications. Pharmacists have to make sure that both the patients and carers receive correct information by checking their understanding in the end of consultation. If the patients are still capable of making decision, pharmacists should encourage them to involve in making the decision of treatment option. All these can improve patient adherence to their medicines. Pharmacists can carry out Medicines Use Review (MUR) to identify the efficacy of medicines and tolerability of patients to the medicines. During the MUR, pharmacists may need to enquire the side effects experienced by patients and any new symptoms or comorbidities appear. Because the AD patients might not be able to answer all the questions, pharmacists would need to seek for more information from carers and avoid making assumptions. Side effects are the most common factor to affect the patient adherence. Pharmacists play an important role in advising strategies to reduce the side effects. Furthermore, the appropriateness of current prescribed medicines should be reassessed from time to time. Concern about the self-purchased over-the-counter medicines should be taken to avoid any potential drug interactions. Patients in later stage of AD will encounter swallowing difficulties. Hence, pharmacists are responsible in advising alternative medication with appropriate formulation7.

Reference

- Alzheimer society (2014) What is Alzheimer’s disease? http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=100

- M Bond et al. (2012) Health Technology Assessment 2012 16(21): 1-11

- Dr Tina M. St. John (2015) Livestong.com What Body Systems Are Affected by Alzheimer’s Disease? http://www.livestrong.com/article/177220-what-body-systems-are-affected-by-alzheimers-disease/

- M Bond et al. (2012) Health Technology Assessment 2012 16(21): 271-276

- NICE (2011) Donepezil, galantamine, rivastigmine and memantine for the treatment of Alzheimer’s disease. www.nice.org.uk/guidance/ta217

- NHS (2015) NHS continuing healthcare. http://www.nhs.uk/conditions/social-care-and-support-guide/pages/nhs-continuing-care.aspx

- Karen Liddell. The Pharmaceutical Care of People with Dementia. NHS Education for Scotland. p. 63-141

- M Bond et al. (2012) Health Technology Assessment 2012 Excecutive Summary 16(21): xvi-xviii

- Etters L. et al. (2008) Caregiver Burden among Dementia Patient Caregivers: A Review of the Literature. Journal of the American Academy of Nurse Practitioners. p. 423-428