Naturalistic audit of NICE criteria for the use of cholinesterase inhibitors

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Abstract
Aims and Method In 2001 the National Institute for Clinical Excellence (NICE) produced guidance for the treatment of Alzheimer's disease. NICE encourages the withdrawal of medication when the Mini-Mental State Examination (MMSE) score reaches 12 and advises against the treatment of patients with cholinesterase inhibitors if the MMSE score is below 12. Most health authorities have rigorously enforced these guidelines, which has put old age psychiatrists in a difficult position. Our prospective 12 week audit of consecutive patients examines the response to treatment of patients treated both in accordance with and outside of NICE criteria. We also investigated the effect of stopping the medication according to NICE's recommendation. Results Our results suggest that patients outside the NICE criteria respond better than those within the criteria. More disturbingly, when the medication was stopped owing to the MMSE score falling below 12, we found a very high mortality rate (5 out of 25, 20%) or acute deterioration (12 out of 25, 48%). This suggests that the medication is beneficial in the later stages and should not be stopped purely because of the stage of dementia. Clinical Implications If we are to prevent unnecessary suffering, greater freedom is needed by old age psychiatrists in the use of these antidementia drugs. Patients with severe dementia may benefit from acute treatment. The withdrawal of medication in line with NICE guidance is poor clinical practice and likely to have adverse outcomes in a large proportion of cases.

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