Research article
- Elke Jeschke,
- Thomas OstermannEmail author,
- Horst C Vollmar,
- Manuela Tabali,
- Friedemann Schad and
- Harald Matthes
BMC Neurology201111:99
DOI: 10.1186/1471-2377-11-99
© Jeschke et al; licensee BioMed Central Ltd. 2011
Received: 17 January 2011
Accepted: 8 August 2011
Published: 8 August 2011
Abstract
Background
Dementia is a major and increasing
health problem worldwide. This study aims to investigate dementia
treatment strategies among physicians specialised in complementary and
alternative medicine (CAM) by analysing prescribing patterns and
comparing them to current treatment guidelines in Germany.
Methods
Twenty-two primary care physicians in
Germany participated in this prospective, multicentre observational
study. Prescriptions and diagnoses were reported for each consecutive
patient. Data were included if patients had at least one diagnosis of
dementia according to the 10th revision of the International
Classification of Diseases during the study period. Multiple logistic
regression was used to determine factors associated with a prescription
of any anti-dementia drug including Ginkgo biloba.
Results
During the 5-year study period
(2004-2008), 577 patients with dementia were included (median age: 81
years (IQR: 74-87); 69% female). Dementia was classified as unspecified
dementia (57.2%), vascular dementia (25.1%), dementia in Alzheimer's
disease (10.4%), and dementia in Parkinson's disease (7.3%). The
prevalence of anti-dementia drugs was 25.6%. The phytopharmaceutical Ginkgo biloba
was the most frequently prescribed anti-dementia drug overall (67.6% of
all) followed by cholinesterase inhibitors (17.6%). The adjusted odds
ratio (AOR) for receiving any anti-dementia drug was greater than 1 for
neurologists (AOR = 2.34; CI: 1.59-3.47), the diagnosis of Alzheimer's
disease (AOR = 3.28; CI: 1.96-5.50), neuroleptic therapy (AOR = 1.87;
CI: 1.22-2.88), co-morbidities hypertension (AOR = 2.03; CI: 1.41-2.90),
and heart failure (AOR = 4.85; CI: 3.42-6.88). The chance for a
prescription of any anti-dementia drug decreased with the diagnosis of
vascular dementia (AOR = 0.64; CI: 0.43-0.95) and diabetes mellitus (AOR
= 0.55; CI: 0.36-0.86). The prescription of Ginkgo biloba
was associated with sex (female: AOR = 0.41; CI: 0.19-0.89), patient
age (AOR = 1.06; CI: 1.02-1.10), treatment by a neurologist (AOR = 0.09;
CI: 0.03-0.23), and the diagnosis of Alzheimer's disease (AOR = 0.07;
CI: 0.04-0.16).
Conclusions
This study provides a comprehensive
analysis of everyday practice for treatment of dementia in primary care
in physicians with a focus on CAM. The prescribing frequency for
anti-dementia drugs is equivalent to those found in other German
studies, while the administration of Ginkgo biloba is significantly higher.
Background
The
management of dementia is a key challenge in modern health systems. The
prevalence of dementia within people aged 65 years or older is 6.8% [1, 2]. It increases with patient age and doubles every 5 years [3].
As the proportion of people aged 65 years or older rises from 16.8% in
2010 to 23.5% in 2050, the number of dementia cases will also increase
from 1.21 million people today to 2.62 million people in 2050 in Germany
alone [2].
It is estimated that the number of sufferers from dementia worldwide
will increase from 35.6 million today to 65.7 million by 2030 and 115.4
million by 2050 [3].
The raise in dementia patients is directly correlated with increasing
costs in the health care systems. While 7.1 million euros were expended
in Germany for treatment and care of dementia in 2002, the costs
increased to 7.8 million euros in 2004, 8.6 million euros in 2006, and
finally 9.4 million euros in 2008 [4].
Alzheimer's
disease and vascular dementia are the two most common types of
age-related dementia. Alzheimer's disease accounts for more than 65% of
dementia in the elderly [1].
At present no curative treatment is available. Interventions focus on
slowing the course of the disease. Compared with placebo,
pharmacological treatment with cholinesterase inhibitors and memantine
has shown improvements in outcomes such as cognition and global
functioning in Alzheimer's disease [5, 6]. However, the clinical relevance of these treatment effects seems marginal [7, 8].
Some
studies have indicated that complementary and alternative medicine
(CAM) from the areas of phytotherapy, traditional Chinese medicine, or
homoeopathy has potential in the treatment of dementia [9–11]. In particular the phytopharmaceutical Ginkgo biloba is traditionally used quite frequently [12, 13]. In Germany, in contrast to some other countries, Ginkgo biloba
is available as prescription drug for the therapy of mild to moderate
dementia. Although there is acceptable physiological compatibility and
sufficiently proven safety, there is still an unclear picture of
evidence [14, 15]. According to the meta-analysis of Weinmann et al. the change of scores for cognition were in favour of Ginkgo biloba compared to placebo, but they did not show a statistically significant difference from placebo for activities in daily living [16].
The German Institute for Quality and Efficiency in Health Care (IQWIG)
found only a small benefit for the 240 mg preparation and criticised the
heterogeneity of the study results [17]. In fact, Ginkgo biloba is not yet included in evidence-based dementia guidelines published in Germany.
The
development, dissemination, and implementation of these dementia
guidelines are a key strategy for improving the care of persons with
dementia. In Germany one guideline from the German Society of General
Physicians (DEGAM) with a focus on family medicine was published in 2008
while another one from the German Society of Neurology and German
Society of Gerontopsychiatry (DGN and DGPPN) mainly for specialists was
finalised in 2009 [18, 19].
Unfortunately both guidelines reveal different recommendations for the
treatment of dementia, which might be due to the abovementioned
inconsistent appraisal of clinical relevance from study results. The
DEGAM guideline is much more cautious in the recommendation of
cholinesterase inhibitors than the guideline of the DGN/DGPPN, and while
memantine is recommended for Alzheimer's disease in the guideline of
the DGN/DGPPN, the DEGAM only recommends it as an individual approach
for therapy [20].
In
therapy for vascular dementia, recommended therapies focus on the
treatment of cardio-vascular risk factors, e.g. the prevention of
prospective strokes. The treatment of vascular dementia with
anti-dementia drugs, until now, did not produce a reliable portfolio of
evidence and thus the DEGAM does not give any recommendations where the
DGN/DGPPN allows for a selective therapeutic attempt in single cases.
However, with respect to the high amount of elderly patients, guidelines
mainly discuss the problems occurring with age-related co-morbidity and
poly-pharmacy.
Apart
from two concurrent German guidelines, an additional barrier to
guideline adherence is the difficulty faced by physicians in reconciling
patient preferences with guideline recommendations [21].
According to studies in a variety of primary care settings, patient
expectations and preferences can influence the health care provided to
them [22–24].
This issue may be particularly salient in the setting of CAM, as
patients seeking treatment from physicians specialised in this field are
likely to expect to receive some form of alternative therapy.
Furthermore, one should not underestimate the impact of the physician's
conviction on the prescription practice. In a survey of German GPs,
ginkgo preparations for dementia were voted to be equally as effective
as cholinesterase inhibitors and memantine [25].
The
present study thus aims (a) to analyse prescribing patterns among
primary care physicians specialised in CAM, b) to investigate conformity
and variations in prescriptions according to the German dementia
guidelines (DEGAM and DGN/DGNPP), c) to identify different treatment
strategies in GPs and neurologists and d) provide information of
co-morbidities of patients with dementia visiting primary health care
physicians specialised in CAM.
