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