Donepezil for Severe Alzheimer's Patients in Long-term Care
Donepezil for Severe Alzheimer's Patients in Long-term Care
The number of Alzheimer's disease (AD) patients continues to increase worldwide and thus the establishment of an appropriate therapeutic approach including drug, psychosocial intervention, and rehabilitation is necessary. For drug treatment, cholinesterase inhibitors (ChEIs), such as donepezil, have clinically positive effects, leading to improvements in cognitive function for a certain duration and delaying the progression of the disease. The drug can delay the deterioration of daily function, thus decreasing the caregivers' burden. Indeed, the severity of the daily functional disability is the most critical factor in keeping AD patients living in their homes prior to placement in nursing homes.
Most AD patients residing in nursing homes have severe stage of disease characterized by a profound cognitive loss as well as deterioration in functional abilities. Thus, the treatment of severe AD is expected to improve or stabilize such symptoms. Several clinical trials of ChEIs in moderate to severe AD have consistently reported such effects. Jelic et al. studied the efficacy of donepezil for severe AD patients in 248 nursing homes, and demonstrated that donepezil treatment showed stabilization or improvement across multiple outcome measures.
Since ChEIs are not "curative" drugs, the addition of psychosocial interventions are also considered in order to optimize the function of patients. The reminiscence approach seeks to facilitate the recall of past experiences and thereby improve well-being or quality of life (QOL). Relatively well preserved remote memory in AD can provide a neurological basis to support this approach. The reality orientation (RO) technique is also used, which stimulates time and place orientation, usually by providing information regarding orientation. It is usually used in combination with the reminiscence approach.
We have previously reported a positive effect of combined donepezil and psychosocial intervention, including the RO with the reminiscence approach, on the patients' QOL. However, such positive effects of the drug are not always recognized by the patients and caregivers; thus, leading them to discontinue the drug treatment easily. Umegaki et al. surveyed the persistence of donepezil therapy and found that only 50% of AD patients remained on treatment after one year. The main reason for drug withdrawal was the perceived "ineffectiveness" of the drugs by the patients and caregivers, which may contrast with their unrealistic expectations, such as "improving" memory function.
Although benefit of psychosocial intervention such as RO and physical reactivation program in combination with donepezil for mild to moderate AD has been reported, no such studies have been performed for patients with severe stage of disease. Such a combined therapeutic approach especially for severe AD patients would be better performed at the institutes, since caregivers are also getting old and even suffering from mild cognitive impairment in Japan, and high-quality psychosocial intervention is not frequently possible at home.
According to the Long-Term Care Insurance, three kinds of institutes are available in Japan, i.e., the Long-Term Care Health Facilities (LTCHF), Special Elderly Nursing Homes, and Group Homes. The situations of drug treatment are different: patients living in the latter two institutes are able to consult doctors at other clinics to receive prescriptions. However, after placement in the LTCHF, by law the patients can only take medicines provided by the institute, and unfortunately expensive drugs, such as ChEIs, are not always provided. Managers of the LTCHFs decide independently whether or not the ChEIs are provided for economic reasons. We believe that this is a second reason for drug withdrawal.
However, we actually experienced patients with severe AD who experienced a positive effect by the combination of donepezil and psychosocial intervention. It may be due to the introduction of rehabilitation that was reported to improve ADL. The aim of the study is to investigate whether ChEIs together with psychosocial interventions have clinically positive effects for patients with severe AD. We hypothesized that even for LTCHF-replacement patients with severe AD, ChEIs together with psychosocial interventions have such effects. This effect included improving daily activities and promoting rehabilitation, as well as decreasing the incidence of accidental fall. Data was collected prospectively from the two types of LTHCFs.
Background
The number of Alzheimer's disease (AD) patients continues to increase worldwide and thus the establishment of an appropriate therapeutic approach including drug, psychosocial intervention, and rehabilitation is necessary. For drug treatment, cholinesterase inhibitors (ChEIs), such as donepezil, have clinically positive effects, leading to improvements in cognitive function for a certain duration and delaying the progression of the disease. The drug can delay the deterioration of daily function, thus decreasing the caregivers' burden. Indeed, the severity of the daily functional disability is the most critical factor in keeping AD patients living in their homes prior to placement in nursing homes.
Most AD patients residing in nursing homes have severe stage of disease characterized by a profound cognitive loss as well as deterioration in functional abilities. Thus, the treatment of severe AD is expected to improve or stabilize such symptoms. Several clinical trials of ChEIs in moderate to severe AD have consistently reported such effects. Jelic et al. studied the efficacy of donepezil for severe AD patients in 248 nursing homes, and demonstrated that donepezil treatment showed stabilization or improvement across multiple outcome measures.
Since ChEIs are not "curative" drugs, the addition of psychosocial interventions are also considered in order to optimize the function of patients. The reminiscence approach seeks to facilitate the recall of past experiences and thereby improve well-being or quality of life (QOL). Relatively well preserved remote memory in AD can provide a neurological basis to support this approach. The reality orientation (RO) technique is also used, which stimulates time and place orientation, usually by providing information regarding orientation. It is usually used in combination with the reminiscence approach.
We have previously reported a positive effect of combined donepezil and psychosocial intervention, including the RO with the reminiscence approach, on the patients' QOL. However, such positive effects of the drug are not always recognized by the patients and caregivers; thus, leading them to discontinue the drug treatment easily. Umegaki et al. surveyed the persistence of donepezil therapy and found that only 50% of AD patients remained on treatment after one year. The main reason for drug withdrawal was the perceived "ineffectiveness" of the drugs by the patients and caregivers, which may contrast with their unrealistic expectations, such as "improving" memory function.
Although benefit of psychosocial intervention such as RO and physical reactivation program in combination with donepezil for mild to moderate AD has been reported, no such studies have been performed for patients with severe stage of disease. Such a combined therapeutic approach especially for severe AD patients would be better performed at the institutes, since caregivers are also getting old and even suffering from mild cognitive impairment in Japan, and high-quality psychosocial intervention is not frequently possible at home.
According to the Long-Term Care Insurance, three kinds of institutes are available in Japan, i.e., the Long-Term Care Health Facilities (LTCHF), Special Elderly Nursing Homes, and Group Homes. The situations of drug treatment are different: patients living in the latter two institutes are able to consult doctors at other clinics to receive prescriptions. However, after placement in the LTCHF, by law the patients can only take medicines provided by the institute, and unfortunately expensive drugs, such as ChEIs, are not always provided. Managers of the LTCHFs decide independently whether or not the ChEIs are provided for economic reasons. We believe that this is a second reason for drug withdrawal.
However, we actually experienced patients with severe AD who experienced a positive effect by the combination of donepezil and psychosocial intervention. It may be due to the introduction of rehabilitation that was reported to improve ADL. The aim of the study is to investigate whether ChEIs together with psychosocial interventions have clinically positive effects for patients with severe AD. We hypothesized that even for LTCHF-replacement patients with severe AD, ChEIs together with psychosocial interventions have such effects. This effect included improving daily activities and promoting rehabilitation, as well as decreasing the incidence of accidental fall. Data was collected prospectively from the two types of LTHCFs.
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