Central  South  Dakota  Medical News
The Clinical View
by Phillip Hoffsten,M.D.
17 March 04

A NEW MEDICATION FOR ALZHEIMER’S DISEASE

     It is estimated that approximately 4½ million people in the United States have Alzheimer’s disease.  This amounts to about 2% of our population.  Alzheimer’s disease is a wastebasket term that we apply to elderly individuals whose minds progressively deteriorate.  The name would not indicate that all of these patients have the same disease process although they all seem to have the same result of a progressive decrease in the ability to remember and carry on activities of daily living.  As the disease progresses, the person becomes less and less able to manage simple daily tasks such as hygiene, feeding oneself, dressing oneself, and being able to do daily chores.  Eventually many of these individuals need care in a nursing facility which can be very expensive at $3,000-$5,000 per month.  Thus any steps that will help preserve an individual’s function and ability to stay in their own home would provide a tremendous saving in both expense and comfort.

     Several years ago a medication called donepezil (Aricept) was introduced with the expectation that it would slow the progression of Alzheimer’s disease.  Subsequently two additional medications in the same class called Exelon and Reminyl were released onto the market.  These three preparations all seemed to work in the same manner.  They were designed to maintain communication between brain cells (neurotransmission) with a chemical called acetylcholine.  Scientists have hypothesized that one of the basic problems in patients with Alzheimer’s disease was a deficiency of the neurotransmitter acetylcholine.  The theory suggested that the amount of acetylcholine in the brain got so low that nerve cells were no longer able to communicate with each other.  Therefore, the person was not able to communicate from one nerve cell to the next and lost their ability to think.  The use of Aricept (Reminyl or Exelon) was designed to increase acetylcholine concentration and enhance neurotransmission.  These three drugs slowed the progression of Alzheimer’s disease but really did not reverse the basic disease process.  Patients seemed to progress more slowly with the use of these drugs, perhaps maintaining an additional six months to one year in their home before a more supportive environment was required.

     The question of cost of any medication always enters into consideration.  Aricept costs approximately $150.00 a month using the 10 mg tablet once a daily.  At $5.00 a pill, many individuals felt that this was more than could be afforded and especially considering the fact that it did not prevent the progression of the disease.  If one balances that $150.00 a month vs the $3,000-$5,000 a month expense of a nursing home perhaps the expense seems more reasonable for every month a person can stay out of the nursing home.

     In October of 2003, a new class of anti-Alzheimer’s medications was introduced onto the market.  This medication was called memantine (trade name Namenda).  It worked in an entirely different way than the three drugs mentioned above.  Instead of enhancing acetylcholine neurotransmission, Namenda affected an entirely different neurotransmitter system.  This drug had been released in Europe in the past and had been felt to be effective there.  The FDA in the United States finally released the drug to the market in the United States in October 2003.

     Namenda is started at 5 mg daily and then increased slowly over the first month eventually using 10 mg twice a day. The cost of this drug is about $140.00 a month.  It may be as effective or more effective than Aricept although in individual patients the results are going to vary.  A major advantage of Namenda is the very low side effect profile.

     As might be expected when two different drugs work on two different systems, somebody suggests that the combination of both together might work better than either one alone.  That study was recently published in the Journal of the American Medical Association in January of this year.  Indeed, the use of both Aricept and Namenda seemed to work better than giving the person Aricept alone.  Now one faces the prospect of approximately $300.00 a month for medications to slow the progression of Alzheimer’s disease.  Fortunately, the side effect profile for Namenda is meager although for some individuals a side effect profile of Aricept can be significant with nausea and vomiting.  Thus if a person is having difficulty with progressive dementia and facing the prospect of entering a nursing facility, the use of one or both of these medications is a consideration and certainly substantially cheaper than the care of being in a nursing facility.

    It is my personal belief (not proven) that much of the Alzheimer’s disease in our country comes from a combination of multiple degenerative processes such as high blood pressure, high cholesterols, smoking, alcohol, poor diet and long-term stress.  Unfortunately, once a person loses mental function from Alzheimer’s disease, it is very unusual that that function is regained and thus prevention is the major step in avoiding this problem in the future.  For those in whom the condition is already present and progressing, the use of one or both of the above medications may be worth a trial in order to preserve function at home.

     Family members often ask me whether an individual already in the nursing home should be treated with one or both of these medications.  These medications may add some “good days” to the person’s course but neither of them prevents the progression of the disease.  Thus it becomes a very subjective individual consideration as whether to spend an extra $300.00 a month to prevent the progression of this dreaded condition.  The healthcare professionals at your local clinics have to deal with this type of consideration very frequently and can help regarding the various decisions that have to be made.