Alec Logan is wise to warn against collusion with commercial interests and misplaced hopes in the benefits of medication.1 But what about avoiding the risks of a highly selective review of the scientific evidence about medication? By citing only AD2000 and the Petersen study of mild cognitive impairment he confuses two issues. There are many trials of cholinesterase inhibitors in Alzheimer's disease, all of which are methodologically limited (AD2000 included), and MCI is not the same as Alzheimer's disease — some would argue that it does not really exist.
The NICE technology appraisal committee reached the judgement that the cholinesterase inhibitors do ‘work’ — that is, they produce visible and measurable short-term benefits for some individuals with dementia. The controversy that the NICE technology committee triggered arose because it concluded in its preliminary report that the cholinesterase inhibitors were not cost effective, using a method of economic analysis (Quality Adjusted Life Years) that is itself controversial and contested.
The NICE clinical guidelines development group, working in parallel with the technology appraisal committee, is conducting its own analysis of medication benefits and the economics of the cholinesterase inhibitors, including a systematic review of patient perceptions of benefit. Two important scientific issues are: How can we measure and cost the deferment of disability in a progressive neurodegenerative disorder? What are the characteristics of those who appear to benefit from these medicines, which might allow targeting of treatment in a difficult-to-diagnose pathology?
General practitioners may be able to contribute something useful to the answers, through our close engagement with people with dementia, and with the emerging research networks focussed on neurodegenerative disorders. We also have the ability to influence spending on social care, through joint budgets at PCT level, but we do not need to polarise medication versus social support in a simplistic and counterproductive way.
Our viewpoints are influenced by what we do, creating much scope for hidden agendas and conflicts of interest, so confession is in order. I am a member of the Medical & Scientific Advisory Committee of the Alzheimer's Society, and of the NICE dementia clinical guidelines development group. I have received unrestrictive funding from the pharmaceutical industry to carry out non-drug research in the dementia field, and I am associate director of the National Coordinating Centre for Neurodegenerative Disease and Dementias research networks.
- © British Journal of General Practice, 2005.