Alzheimer's Disease: A Primer For Pharmacists
W. Nathan Rawls, PharmD*
The diagnosis and treatment of Alzheimer's disease (AD) has advanced significantly over the past 20 years, evolving from a little- known disorder often merely attributed to "old age" to becoming a household term and receiving unprecedented federal funds for research (growing from $20 million in 1982 to $663 million in 2004).1 The Alzheimer's Association is now advocating $1 billion as its federal funding goal.2 The Alzheimer's Association was formed approximately 25 years ago, and the need for this resource is best exemplified by a simple letter to Dear Abby in 1980 that mentioned AD and resulted in more than 25 000 inquires to the Alzheimer's Association.1 President George H. W. Bush declared the 1990s the Decade of the Brain, "to enhance public awareness of the benefits to be derived from brain research."3 With President Ronald Reagan's announcement to the world in 1994 of his diagnosis, AD became a topic of conversation in nearly every American household. In 1983, fewer than 250 scientific articles on AD and dementia had been published. By 2003, the number of peer-reviewed scientific articles on AD surpassed 3000.1 The first-ever dementia prevention conference was held just this year (June 18Ð21, 2005), announcing the most recent advances in pathophysiology, diagnosis, and treatment of AD. More than 1000 clinicians, physicians, researchers, and policy advocates attended.4
We are now able to diagnose AD with approximately 90% confidence based on clinical presentation alone. We can offer our patients at least 4 treatments for the early symptoms of AD, with several other treatments currently under investigation. We also have a growing body of evidence on the possible causes and risk factors for AD, although the complexity of this disease will make prevention and treatment a challenge, necessitating multifaceted approaches.
This first in a series of 3 monographs is designed to present the world of AD to you—the current prevalence rates and how they are expected to change, the economic burden of AD, the current criteria for diagnosis and recommendations for the diagnostic process, and the pathophysiologic processes that inflict devastating clinical consequences.
Manju Beier, PharmD, FASCP, reviews the currently known and emerging possible risk factors for AD and prevalence rates. She also provides an important discussion on the costs of AD from many perspectives—patients, families, the healthcare system, and society—in addition to the challenges in determining accurate cost and cost-effectiveness estimates. Importantly, the imminent retirement of "baby boomers" is going to stress the already stretched Medicare and Medicaid systems. Cost and cost-outcome data are critical as we struggle with the best use of our healthcare resources and optimizing the way AD is managed.
Jeanne Jackson-Siegal, MD, walks us through the complex pathophysiologic processes of AD. Many of these processes are involved in normal aging and in other types of dementia. She explains the characteristics that are unique to AD and the areas in which many questions still remain, the relationship between pathology and symptomology of AD, and current and potential therapeutic targets.
Gary M. Levin, PharmD, BCPP, FCCP, describes the current diagnostic criteria from leading medical organizations and reviews the tools that are used in the diagnostic process. He also offers specific and practical information on recognizing dementia symptoms in pharmacy patients, including a case study. Also discussed is the role the pharmacist plays in working with primary care practitioners to not only alert them to possible signs of dementia but also to eliminate medication side effects as a possible cause.
With a comprehensive, current understanding of AD and dementia, possible reversible causes can be identified and eliminated and treatments for AD symptoms can begin as early as possible, improving quality of life for patient and family. The pharmacist plays a critical role in providing information to patients and primary care practitioners.
This series of 3 monographs provides a compendium of information on AD in primary care. Part 2 of this monograph series will focus on pharmacologic treatments for AD and the associated neurobehavioral and psychiatric symptoms. Emerging treatments and treatment strategies will also be reviewed, including the latest information on AD vaccines and combination treatment approaches. In Part 3 of this series, we focus on the patient's family and caregiver—the burdens they bear and the decisions they will have to make (preferably in conjunction with the patient before the development of severe cognitive decline) about long-term and end-of-life care, in addition to nonpharmacologic treatments for symptoms and the role of the pharmacist as an information resource and support structure for the family.
1. Alzheimer's Association. Alzheimer's disease—then and now. Advances. 2003;23.
2. Library of Congress. Project on decade of the brain. Available at: http://www.loc.gov/loc/brain/. Accessed June 23, 2005.
3. Alzheimer's Association, New York City Chapter. Public policy update: federal and state Alzheimer's advocacy. Available at: http://www.alznyc.org/newsletter/2005-S/08.htm. Accessed June 23, 2005.
4. Alzheimer's Association Web site. Available at: http://www.alz.org/preventionconference/pc2005/over-view.asp. Accessed June 23, 2005.
*Clinical Pharmacy Specialist, Veterans Affairs Medical Center, Professor, Department of Pharmacy, University of Tennessee College of Pharmacy, Memphis, Tennessee.
Address correspondence to: W. Nathan Rawls, PharmD, Clinical Pharmacy Specialist, Veterans Affairs Medical Center, Professor, Department of Pharmacy, University of Tennessee College of Pharmacy, 847 Monroe Avenue, Suite 208, Memphis, TN 38163. E-mail: firstname.lastname@example.org.