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Dementia
Clinical Benefits Associated with a Transdermal Patch for Dementia
a report by
Roberto Bernabei
1
and Pablo Martínez Lage
2
1. Department of Gerontology, Catholic University of the Sacred Heart, Rome; 2. Fundación Alzheimer Centre Educational, Barcelona
Medication management, including treatment compliance, is a cognitive decline,
11
may experience fewer admissions to nursing homes and
widespread challenge in many therapeutic areas, particularly in chronic may have reduced healthcare costs.
12
diseases such as hypertension, congestive heart failure, diabetes and
psychiatric illnesses.
1
Older adults particularly, who typically take multiple A great deal of effort has gone into encouraging treatment compliance and
medications for concurrent conditions,
2
tend to have difficulties with developing strategies that make medication management easier. For
treatment compliance due to complex and complicated drug regimens, example, it has been proposed that simplifying drug regimens and using
the extent to which drug regimens interfere with daily living, the lack of more user-friendly modes of drug delivery or compliance packaging may
understanding or misinterpretation of instructions and forgetfulness.
3
The improve treatment compliance.
3,13,14
Recently, the rivastigmine transdermal
most common form of non-compliant behaviour observed in older patch has become widely approved in Europe for the treatment of AD and
individuals following a long-term, chronic care treatment regimen is in the US for AD and PDD, as well as in many other countries worldwide
underdosing.
4
Often this is involuntary, due to forgetfulness or (including Latin America and Asia-Pacific; regional variations apply). Experts
misinterpretation of/confusion with the dosing regimen. However, have proposed that transdermal administration using a patch may enhance
non-compliance may also be intentional in some cases, for example when compliance and thus may have the potential to optimise clinical
patients do not believe in the benefits of treatment or to avoid associated effectiveness in patients with dementia.
7
In this article we review the
adverse events. reasoning underlying these suggestions, and consider how the first
transdermal patch for AD (and PDD) may have the potential to advance the
The incidence of dementia syndromes such as Alzheimer’s disease (AD) or treatment paradigm for patients with these conditions.
Parkinson’s disease dementia (PDD) increases with age: approximately 10%
of people over the age of 65 years may develop AD,
5
and dementia has Improving Treatment Compliance
been reported in as many as 80% of older PD patients (mean age 73 years).
6
Dosing of oral cholinesterase inhibitors (rivastigmine, donepezil,
These dementia syndromes are characterised by a progressive deterioration galantamine) is implemented in two treatment phases: a short-term
of cognition and the emergence of behavioural and psychological symptoms titration phase during which the objective is to reach a therapeutic dose,
and functional decline, which makes conducting everyday tasks increasingly and a maintenance phase during which the therapeutic dose is
challenging. Cholinesterase inhibitors such as rivastigmine, donepezil and administered for longer-term therapy. The rivastigmine patch has the
galantamine – which have been widely available in oral formulations – and potential to change many aspects of medication management in both
memantine form the mainstay of treatment for AD. Currently, rivastigmine treatment phases, potentially addressing some of the concerns associated
is the only treatment approved for the treatment of mild to moderate PDD. with treatment compliance in older patients.
However, due to the multitude of risk factors that individuals with dementia
face, i.e. typically being older, with co-morbidities, high medication burden Starting Treatment
and memory deficits, this patient population is especially vulnerable to All three cholinesterase inhibitors and memantine are always started at low,
treatment non-compliance.
7
For example, despite AD being a long-term, non-effective doses that must be progressively increased in titration regimes,
chronic disease, the average treatment duration for this condition seldom which often become too complex for elderly patients and care-givers to
exceeds even one year.
8–10
Many patients continue taking low, non- understand. It is not rare to see patients remain in the first or second titration
therapeutic doses due to a misunderstanding of complex titration schedules; steps, consequently being undertreated for long periods. Furthermore,
however, patients who stay on AD therapies for longer periods at adequate cholinergic events such as nausea and vomiting are the most common side
doses have a greater chance of slowing or delaying the progression of effects of all oral cholinesterase inhibitors during the titration phase of
treatment. In the clinical setting, these events can form a barrier that
prevents some patients from reaching optimal therapeutic doses. The
Roberto Bernabei is a Professor of Internal Medicine at the Catholic University of the
Sacred Heart, and Chief of the Department of Geriatrics and Rehabilitative Medicine at
cholinergic side effects of cholinesterase inhibitors are most likely related to
the A Gemelli University Hospital in Rome. He is President of the Italian Society of
the high peak plasma drug concentrations that result from each oral dosage
Gerontology and Geriatrics and also Executive Vice President of interRAI. Professor
Bernabei also serves as a Board Member of the European Academy for Medicine of
intake, and large fluctuations in plasma levels.
15
Ageing (EAMA), and is a Visiting Associate Professor in the Department of Community
Health at Brown University School of Medicine. His main research interests are in
Transdermal patches provide smooth and continuous drug delivery across
geriatric assessment, models of health services for elderly care and geriatric
pharmacoepidemiology. He has authored over 200 papers in peer-reviewed journals,
the skin barrier and into the bloodstream. They have the potential to
eight books and 15 book chapters.
provide more gradual rises in maximal plasma concentration (C
max
) and
E:
bernabei@rm.unicatt.it to prolong the time to C
max
(t
max
), thus avoiding the rapid rise and fall of
concentrations seen with oral therapies.
16
Consequently, drug levels may
24 © TOUCH BRIEFINGS 2008
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