Nonmedical Influences on the Use of Cholinesterase Inhibitors in Dementia Care

Franz, Carol E.; Barker, Judith C.; Kravitz, Richard L.; Flores, Yvette G.; Krishnan, Shankar; Hinton, W Ladson

doi:10.1097/wad.0b013e3181461955

Cited by 23 publications

(22 citation statements)

References 45 publications

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“…70 Family wishes influence the primary care physicians' prescribing attitude. For example, Franz et al 71 found that primary care physicians were influenced by the family's wishes when prescribing cholinesterase inhibitors in patients with dementia.…”

Section: Other Patient-related Influencesmentioning

confidence: 99%

Non-clinical influences on clinical decision-making: a major challenge to evidence-based practice

et al. 2010

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SummaryThis article reviews an aspect of daily clinical practice which is of critical importance in virtually every clinical consultation, but which is seldom formally considered. Non-clinical influences on clinical decision-making profoundly affect medical decisions. These influences include patient-related factors such as socioeconomic status, quality of life and patient's expectations and wishes, physician-related factors such as personal characteristics and interaction with their professional community, and features of clinical practice such as private versus public practice as well as local management policies. This review brings together the different strands of knowledge concerning non-clinical influences on clinical decision-making. This aspect of decision-making may be the biggest obstacle to the reality of practising evidence-based medicine. It needs to be understood in order to develop clinical strategies that will facilitate the practice of evidence-based medicine.

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Section: Other Patient-related Influencesmentioning

confidence: 99%

Non-clinical influences on clinical decision-making: a major challenge to evidence-based practice

et al. 2010

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“…Physician factors include lack of confidence in their dementia assessment skills, ambivalence about the value of a diagnosis 23 or pharmacological treatment. 24 Physician surveys…”

Section: Introductionmentioning

confidence: 99%

Practice Constraints, Behavioral Problems, and Dementia Care: Primary Care Physicians’ Perspectives

Hinton

Franz

Reddy³

et al. 2007

J GEN INTERN MED

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206

238

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OBJECTIVES:To examine how practice constraints contribute to barriers in the health care of persons with dementia and their families, particularly with respect to behavioral aspects of care. DESIGN:Cross-sectional qualitative interview study of primary care physicians. SETTING: Physicians' offices.PARTICIPANTS: Forty primary care physicians in Northern California. MEASUREMENTS:Open-ended interviews lasted 30-60 minutes and were structured by an interview guide covering clinician background and practice setting, clinical care of a particular patient, and general approach to managing patients with AD or dementia. Interviews were transcribed and themes reflecting constraints of practice were identified through a systematic coding process. RESULTS:Recurring themes (i.e., those present in ≥25% of physician interviews) included insufficient time, difficulty in accessing and communicating with specialists, low reimbursement, poor connections with community social service agencies, and lack of interdisciplinary teams. Physician narratives suggest that these constraints may lead to delayed detection of behavior problems, "reactive" as opposed to proactive management of dementia, and increased reliance on pharmacological rather than psychosocial approaches. CONCLUSION:Physicians often feel challenged in caring for dementia patients, particularly those who are more behaviorally complex, because of time and reimbursement constraints as well as other perceived barriers. Our results suggest that more effective educational interventions (for families and physicians) and broader structural changes are needed to better meet the needs of the elderly with dementia and their families now and in the future. Without these changes, dementia care is likely to continue to fall short.KEY WORDS: dementia; quality of care; barriers; qualitative.

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“…ChEIs represent an important group of drugs whose clinical results are, however, not fully satisfactory. According to Franz et al [90] some physicians prescribe them simply to be able to offer "something" to Alzheimer patients and don't expect significant clinical improvements. Nonetheless, ChEIs remain important from a heuristic viewpoint: they are a tool for investigating the role of the cholinergic system in the cognitive processes in health and pathological conditions, may be useful leads for developing new drugs and may have new therapeutic indications.…”

Section: Discussionmentioning

confidence: 98%

Cholinesterase Inhibitors and Beyond

Pepeu¹,

Giovannini²

2009

CAR

180

121

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Cholinesterase inhibitors (ChEIs) were introduced in the therapy of Alzheimer Disease (AD) in the nineteen nineties with great expectations. The hopes and large interest raised by these drugs are well demonstrated by 12,000 references listed by PubMed under 'ChEI' for 1995-2007. The list is reduced to 2500 if we confine ourselves to 'ChEIs and dementia'. Of them, about 500 were published in the last two years. Whereas an increase in brain acetylcholine and an improvement of cognitive deficits have been consistently demonstrated in animal models of AD, from aging rats to transgenic mice, the clinical effectiveness of ChEIs has been and is still a matter of contrasting opinions. These range from the negative conclusions of the AD2000 trial on donepezil, claiming that it is not cost effective, with benefits below a minimally relevant threshold, to the NICE appraisal of 2007 declaring that donepezil, rivastigmine, galantamine are efficacious for mild to moderate AD, irrespective of their different selectivity for acetyl- (AChE) and butyrylcholinesterase (BuChE). The possibility that ChEIs may exert their effects through mechanisms beyond cholinesterase inhibition has been envisaged. However, according to the information presented in this review, the "classical" ChEIs, donepezil, rivastigmine and galantamine, show no pharmacological actions beyond cholinesterase inhibition which may play an important role in their therapeutic efficacy. The diverging opinions on clinical efficacy do not discourage from developing new ChEIs, and particularly the so called multifunctional ChEIs. They represent the future of the cholinergic therapy for AD but other indications for these drugs may be considered, including vascular dementia, mild cognitive impairment, and the ethically sensitive improvement of memory and learning in healthy subjects.

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Nonmedical Influences on the Use of Cholinesterase Inhibitors in Dementia Care

Cited by 23 publications

References 45 publications

Non-clinical influences on clinical decision-making: a major challenge to evidence-based practice

Non-clinical influences on clinical decision-making: a major challenge to evidence-based practice

Practice Constraints, Behavioral Problems, and Dementia Care: Primary Care Physicians’ Perspectives

Cholinesterase Inhibitors and Beyond

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