Diagnosis of Alzheimer’s disease is particularly challenging in the early phases when patients may have subtle or mild symptoms (e.g. subjective cognitive decline or MCI). In the primary care setting, more than half of patients with cognitive impairment are not recognized or correctly diagnosed; this can result in suboptimal treatment and care, incorrect or delayed treatment initiation and inaccurate prognostic information.

Abbreviation

MCI, mild cognitive impairment.

Reference

Angioni D, et al. J Prev Alzheimers Dis. 2022;9:569–79.

Guidelines emphasize the importance of input from a reliable informant (who knows the patient well) to support objective assessment of changes in cognition, daily living activities and behaviour where Alzheimer’s disease is suspected.^1,2 History from a reliable informant should be obtained in the presence of the patient, and with their consent.³ There are a number of informant-based interview tools available that are designed to identify cognitive decline over time.⁴

References

1. McKhann GM, et al. Alzheimers Dement. 2011;7:263–9.
2. Albert MS, et al. Alzheimers Dement. 2011;7:270–9.
3. Briggs R, O’Neill D. QJM. 2016;109:301–2.
4. Taylor-Rowan M, et al. Syst Rev. 2020;9:271.

Non-inferiority trials have compared oral formulation versus transdermal patch for both rivastigmine and donepezil.^1,2, Change in ADAS-Cog score from baseline to Week 24 was used as measurement of efficacy.

Compared with placebo, rivastigmine achieved comparable differences in ADAS-Cog in both once-daily 10 cm² transdermal patch and oral 3–12 mg capsule formulations (mean change in ADAS-Cog score was -0.6; p=0.005 and -0.6; p=0.003 respectively).¹ Donepezil once-weekly transdermal patch (25 cm² and 50 cm²) demonstrated non-inferiority to donepezil oral tablet (mean change in ADAS-Cog score was -0.47 and -0.93; p=0.8975 respectively).²

Abbreviation

ADAS-Cog, Alzheimer’s Disease Assessment Scale–Cognitive.

References

1. Winblad B, et al. Int J Geriatr Psychiatry. 2007;22:456–67.
2. Han HJ, et al. J Clin Neurol. 2022;18:428–36.

Choice of treatment with oral or transdermal symptomatic therapy should be based on patient and caregiver preference, ease of use and tolerability.¹ The reduced frequency with once-weekly of dosing with transdermal medications in patients who already have a high medication burden could also increase adherence to treatment.² Once-daily oral galantamine extended-release formulation is indicated in mild and moderate Alzheimer’s disease.³ Once-daily oral donepezil plus memantine extended-release formulation is indicated in moderate to severe Alzheimer’s disease stabilized on 10 mg of donepezil once daily.⁴

References

1. Cummings JL, et al. Ann Clin Transl Neurol. 2015;2:307–23.
2. Citrome L, et al. J Clin Psychiatry. 2019;80:18nr12554.
3. FDA. Galantamine PI. 2021.
4. FDA. Memantine and donepezil PI. 2014.

FDA Prescribing information searchable by agent at www.accessdata.fda.gov/scripts/cder/daf/ (accessed 6 December 2022).

Donepezil and rivastigmine transdermal patch formulations are both indicated for the management of mild, moderate and severe Alzheimer’s disease.^1,2 Transdermal patches are easy to administer and to check for adherence.³ Real-world data show care partner preference for (and greater satisfaction with) transdermal patches compared with oral formulations of symptomatic therapy (rivastigmine) for ease of administration, scheduling and less interference with daily activities.^4,5 Patient adherence was reported as significantly higher with transdermal patches compared with oral formulations.⁵

References

1. FDA. Donepezil transdermal system PI. 2022.
2. FDA. Rivastigmine transdermal system PI. 2018.
3. Citrome L, et al. J Clin Psychiatry. 2019;80:18nr12554.
4. Winblad B, et al. Int J Geriatr Psychiatry. 2007;22:485–91.
5. Pai MC, et al. Clin Interv Aging. 2015;10:1779–87.

FDA Prescribing information searchable by agent at www.accessdata.fda.gov/scripts/cder/daf/ (accessed 6 December 2022).