George Provenzano

Donepezil Is Associated with Delayed Nursing Home Placement in Patients with Alzheimer's Disease

OBJECTIVES: To assess the relationship between donepezil treatment and time to nursing home placement (NHP) for patients with Alzheimers disease (AD).

Outcomes of surgical management of total HIP replacement in patients aged 65 years and older: cemented versus cementless femoral components and lateral or anterolateral versus posterior anatomical approach

This observational study compared the outcomes of 271 cases of hip osteoarthritis receiving primary total hip replacement (patients 65 years of age and older) from numerous surgeons in 12 Baltimore region hospitals from 1991–1993. The independent variables studied were: (a) totally non‐cemented prostheses (non‐cemented femoral component, non‐cemented acetabular component) versus hybrid prostheses (cemented femoral component, non‐cemented acetabular component), and (b) lateral or anterolateral surgical approach versus posterior surgical approach. Outcomes included complications during the initial hospitalization, hospital length of stay, hospital cost, readmission, and reported and/or observed physical, instrumental, neuromuscular and affective functioning and pain at 2, 6, and 12 months post surgery.

RESPONSE TO DR. FINUCANE

To the Editor: Lopez et al. report that ‘‘cholinesterase inhibitor (CEI) use had a clinically meaningful effect on the natural history of Alzheimer Disease (AD),’’ slowing disease progression and lowering risk of nursing home admission after 2 years. The design of the study is worrisome. Of 1,139 patients who enrolled in the AD Research Center over 7 years, 270 were selected; 135 began taking CEIs ‘‘immediately after enrollment, and continued to take them throughout the following 12 months,’’ and 135 never took the drug. How these individuals were selected is not otherwise described. They were matched on a few characteristics, such as age, Mini-Mental State Examination score, and education. This study resembles a study by Dr. Geldmacher et al. that showed that patients who took a CEI faithfully (80% of pills or more) had a significant delay in nursing home placement (NHP). Both of these nonrandomized studies failed to report important baseline characteristics of the groups being studied. In the Geldmacher article, for example, nonadherent patients were far less likely to have a spouse caregiver than faithful users, yet the authors, who claimed it was the donepezil that ‘‘resulted in significant delays in NHP,’’ omitted this fact. Both papers are easily distinguished from AD 2000, a properly randomized, controlled trial with the largest number of placebo-controlled patient-years of any cholinesterase study. In AD 2000, ‘‘no significant benefits were seen with donepezil compared with placebo in institutionalization or progression of disability . . . [or] in behavioral and psychological symptoms, carer psychopathology, formal care costs, unpaid caregiver time, adverse events, or death or between 5 mg and 10 mg of donepezil.’’ In the United Kingdom, the National Institute for Clinical Excellence Appraisal Committee has recently issued the following preliminary recommendation: ‘‘Donepezil, rivastigmine and galantamine are not recommended for use in the treatment of mild to moderate Alzheimer’s disease (AD).’’ Would Dr. Lopez modify the discussion of his paper, where he emphasizes the important benefits of donepezil, in view of the results from AD 2000, a larger, better-designed trial that failed to show any meaningful difference at all?