Clinical Update on Alzheimer's Disease: Managed Care Perspectives
Activity Date: April 2007  — Activity Info: Volume 4, (4)
Goals & Objectives | Faculty | Introduction | Full Activity Content | CME Test & Evaluation (CME Expired)

Clinical Update on Alzheimer's Disease: Managed Care Perspectives
W. Nathan Rawls, PharmD*

Alzheimer’s disease (AD) is a progressive and ultimately fatal neurodegenerative disorder that affects close to 5 million people in the United States.1 With the aging of the Baby Boomer generation, AD (as the most common form of dementia) is poised to consume our national attention, not only in terms of healthcare costs but also resources. The annual cost of caring for patients with AD in the United States is estimated at $100 billion (according to the Alzheimer’s Association), and healthcare organizations are being challenged to meet the demands of an aging population in which AD is becoming increasingly prevalent.2 Moreover, the adult children of patients with AD will face difficult decisions in terms of who will care for their loved one as AD progresses and who will pay for the care. Because AD eventually destroys the patient’s persona and ultimately demands full-time, round-the clock care, the emotional and physical costs to patients and caregivers are almost immeasurable.

Although there is no cure for AD, the past decade has seen considerable progress in understanding the disease pathophysiology and development of effective therapies. AD treatment encompasses neuroprotective strategies, including the use of over-the-counter antioxidants and anti-inflammatory agents, in addition to cholinesterase inhibitors and an N-methyl-Daspartate antagonist, which target the underlying neurochemical abnormalities of the disease. Although the latter 2 drugs are approved by the US Food and Drug Administration (FDA) for treatment of AD, there is insufficient evidence to support a formal recommendation of antioxidants or nonsteroidal antiinflammatory drugs as a treatment or preventive measure against AD.3 However, in addition to pharmacotherapy, a variety of pharmacologic and nonpharmacologic interventions address the behavioral disturbances that frequently accompany the loss of memory and language and declines in ability to perform activities of daily living. It is the behavioral disturbances that most often lead to placement of the patient with AD in a nursing home—often an emotionally agonizing decision for the caregiver and a major driver of healthcare costs for AD. However, with both pharmacologic and behavioral treatment strategies, the burden of AD on patients and their caregivers is greatly eased.

Evidence suggests that there are economic benefits to dementia treatment, including a reduction in the costs of common illnesses suffered by patients with AD.4-7 In the United States, the Medicare Part D system has now required the inclusion of all US FDA approved drugs for AD in the formularies of participating healthcare plans. However, in the United Kingdom, the debate regarding the cost effectiveness of these drugs continues on. Within this debate and the body of evidence supporting both clinical and cost effectiveness is the issue of treatment timing. Indeed, the cholinesterase inhibitors, traditionally approved for mild to moderate AD, are now under evaluation for moderate to severe AD. And, clinical studies of combination therapy (a cholinesterase inhibitor + memantine) have been performed, with promising results. Independent expert panels have weighed in with their recommendations for these drugs, mindful of the costs associated with them.8

This issue of University of Tennessee Advanced Studies in Pharmacy provides practical solutions to the challenges of AD pharmacotherapy—cost and timing. In the review articles prepared by our faculty, we review the pathophysiology and manifestations of AD, the efficacy of currently available therapies and the potential of treatments that are still in development, the rationale for combining pharmacologic and behavioral therapies to lessen the burden of AD on patients and their caregivers, and the impact of AD in the managed care setting. Manju T. Beier, PharmD, FASCP, provides an overview of the epidemiology, etiology, and pathophysiology of AD (including the most recent advances in our understanding of these processes), in addition to its clinical manifestations and diagnosis. Howard Fillit, MD, who has published recommendations on the use of the AD drugs with managed care considerations, discusses the AD drugs in terms of clinical efficacy and practical applications. He also introduces some of the AD vaccines and other emerging therapies. Finally, Nicole Brandt, PharmD, CGP, BCPP, FASCP, discusses the economic cost of AD and AD therapy, including Medicare Part D implementation and the role of combination therapy.

Even with the potential for misgivings about cost, the managed care community must be aggressive in advocating for early detection and aggressive therapy, thereby optimizing both patient and healthcare system outcomes. 

1. Hebert LE, Scherr PA, Bienias JL, et al. Alzheimer’s disease in the US population: prevalence and estimated using the 2000 Census. Arch Neurol. 2003;60:1119-1122.
2. The Alzheimer’s Association Web site. Alzheimer’s Disease Statistics. Available at: Accessed March 1, 2007.
3. Kawas CH. Medications and diet: protective factors for AD? Alzheimer Dis Assoc Disord. 2006;20(suppl 2):S89-S96.
4. Fillit H, Hill J. Economics of dementia and pharmacoeconomics of dementia therapy. Am J Geriatr Pharmacother. 2005;3:39-49.
5. Sano M. Economic effect of cholinesterase inhibitor therapy: implications for managed care. Manag Care Interface. 2004;17:44-49.
6. Plosker GL, Lyseng-Williamson KA. Memantine: a pharmacoeconomic review of its use in moderate to-severe Alzheimer's disease. Pharmacoeconomics. 2005;23: 193-206.
7. Fillit H, Hill JW, Futterman R. Health care utilization and costs of Alzheimer's disease: the role of co-morbid conditions, disease stage, and pharmacotherapy. Fam Med. 2002;34:528-535.
8. Fillit HM, Doody RS, Binaso K, et al. Recommendations for best practices in the treatment of Alzheimer’s disease in managed care. Am J Geriatr Psychiatry. 2006;4(suppl A):S9-S24.

The content in this monograph was developed with the assistance of a staff medical writer. Each author had final approval of his/her article and all its contents.

*Professor, Department of Pharmacy, University of Tennessee College of Pharmacy, Clinical Pharmacy Specialist, Veterans Affairs Medical Center, Memphis, Tennessee.
Address correspondence to: W. Nathan Rawls, PharmD, Professor, Department of Pharmacy, University of Tennessee College of Pharmacy, 847 Monroe Avenue, Suite 208, Memphis, TN 38163. E-mail:
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