The economic benefits of acetylcholinesterase inhibitors for patients with Alzheimer disease and associated dementias

Most cost-effectiveness studies using simulation modeling have demonstrated that donepezil, rivastigmine, and galantamine are cost effective for the treatment of mild-to-moderate Alzheimer disease (AD). These conclusions are in large part based on the assumption that improvement in cognitive status, or prevention of cognitive and functional decline, reduces the amount of time patients spend institutionalized or receiving other full-time care. However, as discussed in this article, outcomes besides delay to institutionalization affect the costs of AD. In reviews of utilization data from Medicare and managed care organizations, it was noted that hospitalization and post acute care in skilled nursing facilities accounted for the largest amount of excess direct costs, even among patients with mild or moderate AD. These utilization reviews also suggest that many patients with AD and related dementias require inpatient care because they are not able to self-manage comorbid conditions. The improvements in cognitive status and daily functioning associated with acetylcholinesterase inhibitor (AChEI) therapy are expected to translate into improved management of comorbidities and reduced caregiver burden, thus reducing the total cost of care. To confirm these and other economic benefits of AChEIs, pharmacoeconomic outcomes should be evaluated routinely as part of randomized, controlled trials and through well-controlled observational studies of AD patients in community and institutional settings.