Impact of the 2011 NICE guidance on dementia drugs in a neurology-led memory clinic

The most recent guidance published by the National Institute for Health and Clinical Excellence (NICE) on the use of the anti-dementia drugs cholinesterase inhibitors (ChEI) and memantine in Alzheimer's disease (AD) and other dementias (NICE217)¹ made these drugs available as per licence, effective from 1 June 2011. The guidance made these drugs more easily accessible than had previously been the case following previous NICE guidance published in 2006 (NICE111). It was anticipated that one effect of this liberalisation of drug availability would be that more people who might be candidates for licensed use of these medications (ie mild to moderate AD and Parkinson's disease dementia) would be referred to dementia/memory clinics, with a possible diminution in the recognised dementia ‘diagnosis gap’ resulting from too few people being diagnosed with dementia and too few of those diagnosed being diagnosed early enough.²

The possible impact of NICE217 in a neurology-led memory service was examined by comparing referral numbers, sources, patient diagnoses and candidacy for treatment with cholinesterase inhibitors in the 12-month periods immediately before (1 June 2010–31 May 2011) and after (1 June 2011–31 May 2012) publication of the NICE217 guidance (Table 1).

These data showed no change in the number of new referrals between the two time periods, but did show an increase in the percentage of referrals coming from primary care in the second time period (82.7% vs 73.5%). The null hypothesis that the proportion of new referrals from primary care was the same in the cohorts referred before and after NICE217 (equivalence hypothesis) was rejected (χ² = 5.12, df = 1, p<0.05). However, there was no change in the percentage of patients receiving a diagnosis of dementia (DSM-IV-TR criteria; χ² = 0.17, df = 1, p0.5).

The proportion of patients deemed candidates for treatment with ChEI or memantine was examined. Exclusions included patients with frontotemporal lobar degenerations, vascular dementia or subcortical ischaemic vascular dementia, dementia with Lewy bodies, Huntington's disease, Down syndrome, alcohol-related dementia, and prion disease, since these conditions fall out with the drug licence, although ChEIs have sometimes been used.³ This analysis showed no change in the proportion of patients suitable for these medications, examining either the whole cohort (χ² = 0) or those patients with dementia only (χ² = 0.56, df = 1, p0.5).

Previous UK national dementia directives, NICE and the Social Care Institute for Excellence (SCIE) guidelines of November 2006, and the National Dementia Strategy (NDS) of February 2009, were associated with increased referrals to a neurology-led memory clinic; although much of the increase was due to individuals without evidence of dementia – and hence not candidates for drug treatment – being referred from primary care.^4,5 In the year since NICE217 became effective, no similar increase in referrals to the clinic has been observed, but there has been a continuing increase in referrals from primary care. To date, the increased availability of dementia drugs consequent upon NICE217 has not been associated with any evidence for closure of the dementia diagnosis gap. Although it is too early for definitive conclusions, this study does further highlight the gap between policy intent and what happens in practice.

• © 2012 Royal College of Physicians