So much to learn from our societies: lockdown whatsapp messages in the UK revealing pure manipulation, the blatant lies of the govts on "get the jab, you will protect yourself and others, the Ivermectin prohibition in some countries, Hydroxychloroquine Feb 2020 sold with no prescription in France, March 2020 forbidden! the social distancing oudoors, helicopters sent in the mountains to yell at solitary climbers to go back home, people on the beach in bikini in Spain, mandatory masked when they walk, etc.... .. please, follow me back on Twitter so we can dm . Thank you
I never understood why donepezil is so widely prescribed without evidence of improvement in clinical outcomes. Just another medicine added on, to be taken indefinitely.
In a similar vein, I never understood why dementia screening became a thing. Why test for a surrogate marker, when the clinical outcome you're interested in (e.g. ability to perform ADLs) is readily measurable? On top of that, there is nothing to prevent progression to dementia, so screening for pre-dementia states is useless.
I mean, first thing - fortunately Donepezil is very well-tolerated in most individuals, and *unlike* *masks* - we don't require or mandate people to take it.
Since the initial FDA studies, there has been some data to show that in select cases, you can occasionally see strong responders to Aricept (e.g., where there's actual, measurable improvement in functioning that lasts beyond six months - not just a delay in decline). For families and patients, though, even just a six-month delay of decline is a welcome thing. Yes, it's a very underwhelming medication overall.
Re your point about mental status screenings, I guess I see your point? Functional status *is* really what matters, sure, but on the other hand, there's a lot of sticky things that can affect ADL functioning other than dementia... like motivational issues, depression, etc. Whether it's mental status screenings, neuropsych testing, ADL surveys, etc. - we're all trying to index the same thing, we're trying to index the underlying neurodegeneration in a dementia patient.... at least this is what I'm thinking?
All medications have potential for super responders. Hard to differentiate based on observational data how much of the benefit came from the drug alone. An extreme example would be case reports of patients with stage 4 cancer with spontaneous remission following something like a coffee enema. The point is, the burden of proof is on drug manufacturers to show us via a proper RCT which selective patients benefit from the drugs. I haven't seen this yet.
But in the end, you're in right. Donepezil is well tolerated, and for a disease that is debilitating and terminal without other options it can be argued for giving it a try. Although I'm cautious about it because harms are typically underreported in trial data. Mostly I'm concerned that patients without mod - advanced dementia (age related forgetfulness, MCI, or even mild dementia) are frequently being prescribed donepezil and it's rarely discontinued.
I hadn't fully considered that these mental status screenings and neuerocog testing can help differentiate pure irreversible neurocognitive disease from other issues that may be reversible and thus improve function. But then I would consider it a diagnostic test for a patient with functional issues, rather than a screening test for a patient who didn't come with a chief complaint of "daughter concerned about dementia because of X". I imagine a test like this would be complex and require a specialist with ample time, rather than a 5 minute visit with the PCP, or by some other provider at a big box pharmacy's minute clinic.
Please, follow me back on Twitter so we can dm, especially on news on this side of the world. Thank you @yendial
So much to learn from our societies: lockdown whatsapp messages in the UK revealing pure manipulation, the blatant lies of the govts on "get the jab, you will protect yourself and others, the Ivermectin prohibition in some countries, Hydroxychloroquine Feb 2020 sold with no prescription in France, March 2020 forbidden! the social distancing oudoors, helicopters sent in the mountains to yell at solitary climbers to go back home, people on the beach in bikini in Spain, mandatory masked when they walk, etc.... .. please, follow me back on Twitter so we can dm . Thank you
I never understood why donepezil is so widely prescribed without evidence of improvement in clinical outcomes. Just another medicine added on, to be taken indefinitely.
In a similar vein, I never understood why dementia screening became a thing. Why test for a surrogate marker, when the clinical outcome you're interested in (e.g. ability to perform ADLs) is readily measurable? On top of that, there is nothing to prevent progression to dementia, so screening for pre-dementia states is useless.
I mean, first thing - fortunately Donepezil is very well-tolerated in most individuals, and *unlike* *masks* - we don't require or mandate people to take it.
Since the initial FDA studies, there has been some data to show that in select cases, you can occasionally see strong responders to Aricept (e.g., where there's actual, measurable improvement in functioning that lasts beyond six months - not just a delay in decline). For families and patients, though, even just a six-month delay of decline is a welcome thing. Yes, it's a very underwhelming medication overall.
Re your point about mental status screenings, I guess I see your point? Functional status *is* really what matters, sure, but on the other hand, there's a lot of sticky things that can affect ADL functioning other than dementia... like motivational issues, depression, etc. Whether it's mental status screenings, neuropsych testing, ADL surveys, etc. - we're all trying to index the same thing, we're trying to index the underlying neurodegeneration in a dementia patient.... at least this is what I'm thinking?
All medications have potential for super responders. Hard to differentiate based on observational data how much of the benefit came from the drug alone. An extreme example would be case reports of patients with stage 4 cancer with spontaneous remission following something like a coffee enema. The point is, the burden of proof is on drug manufacturers to show us via a proper RCT which selective patients benefit from the drugs. I haven't seen this yet.
But in the end, you're in right. Donepezil is well tolerated, and for a disease that is debilitating and terminal without other options it can be argued for giving it a try. Although I'm cautious about it because harms are typically underreported in trial data. Mostly I'm concerned that patients without mod - advanced dementia (age related forgetfulness, MCI, or even mild dementia) are frequently being prescribed donepezil and it's rarely discontinued.
I hadn't fully considered that these mental status screenings and neuerocog testing can help differentiate pure irreversible neurocognitive disease from other issues that may be reversible and thus improve function. But then I would consider it a diagnostic test for a patient with functional issues, rather than a screening test for a patient who didn't come with a chief complaint of "daughter concerned about dementia because of X". I imagine a test like this would be complex and require a specialist with ample time, rather than a 5 minute visit with the PCP, or by some other provider at a big box pharmacy's minute clinic.
Hopefully they all have had hearing screenings prior to testing 🙂