Harbinger of Hope or Commodity Fetishism: “Re-cognizing” Dementia in an Age of Therapeutic Agents

Abstract

Choices abound while we await that pharmacogenetic fix that will save each one of us from all that is our individual and collective fate, contingent of course upon panopticon surveillance of our genetic susceptibilities and environmental triggers. The past decade has offered hope to those families facing the impenetrable shroud characterizing cognitive decline and dementia. Sufferers and their physicians have a growing compendium of pharmaceutical therapeutic interventions to attempt to stave off the usual, if not necessarily mindful, course of illness progression. In January 2001, the acetylcholinesterase inhibitors donepezil, rivastigmine, and galantamine were made available in the National Health Service in the United Kingdom, and some are on the formulary of five provinces in Canada. Those provincial pharmacare programs still refusing to provide these therapies free to the elderly cite lack of evidence of efficacy, following Cochrane guidelines based upon systematic review of the best evidence available using randomized controlled trials. Advocates for public funding of the pharmaceutical agents, on the other hand, cite a narratively rich, heart felt host of behavioral and affective symptoms stabilized or boosted by these drugs. And so, the two solitudes are drawn between science and humanity, between the cold guardians of the public purse and the caring humanitarians.

Nonmedical Influences on the Use of Cholinesterase Inhibitors in Dementia Care

“…Without such changes, inappropriate reliance on ChEI will represent a medical solution for what is actually a structural problem in health care. 6 It is clear from these analyses that PCPs need to become more familiar with the treatment options for dementia, how to present them to patients and families, and how to manage emotional exchanges during a long, debilitating disease. In addition, better public education about what constitutes normal versus atypical cognitive aging may increase the likelihood that diagnosis and treatment are sought earlier in the disease process when dementia treatments-including treatments for underlying health problems such as cardiovascular diseases, depression, thyroid conditions, vitamin deficiencies, and also ChEI-seem to be most effective.…”

“…5 Physician groups have called for more research on dementia treatment with greater sensitivity to clinically meaningful results. 6 At the time of the study (2002 to 2004), pharmaceutical options for the treatment of mild to moderate Alzheimer disease (AD) and related dementias included 4 cholinesterase inhibitors (ChEI): tacrine, donepezil, rivastigmine, and galantamine. In the course of the study memantine-an N-methyl-D-aspartate receptor agonist-was approved for use in moderate-to-severe AD but was not being prescribed by any of the study physicians.…”

Multigenic Control of Drug Response and Regulatory Decision-Making in Pharmacogenomics: The Need for an Upper-Bound Estimate of Genetic Contributions

“…These issues include and relate to regulatory oversight, confidentiality and privacy, informed consent, availability, access and clinician's changing roles and responsibilities [Graham, 2001;Buchanan et al 2002]. Additionally, consent and responsibility extend beyond the individual to communities in pharmacogenetic and pharmacogenomic research.…”

Where There’s a Web, There’s a Way: Commercial Genetic Testing and the Internet

“…Nor will physicians have the training to evaluate the validity of claims made by industry in their Internet-based resources and public advertising campaigns, about the accuracy and benefits of testing [76]. Physicians may thus be open to the influence of companies’ marketing strategies (invariably pitched as patient/consumer or physician ‘education’) and be unable to effectively evaluate the information they receive, as is arguably the case at the moment with prescription drugs [57, 77]. …”