Introduction
Globally, there are over 47 million people are living with dementia,
with this figure set to reach 135.46 million by 2050 [1]. As of
2019, a total of 472,890 people in England have a coded diagnosis of
dementia [2].
The National Institute of Clinical Excellence (NICE) guideline on
Dementia in England recommends acetylcholinesterase (AChE) inhibitors:
donepezil, galantamine and rivastigmine as recommended monotherapies for
the management of mild to moderate Alzheimer’s disease (AD) [3]. The
NICE guideline recommend that the N-methyl-D-aspartate (NMDA) receptor
antagonist, memantine, should be used to treat moderate AD in patients
who are intolerant or have a contraindication to AChE inhibitors.
Memantine is also recommended to be used in patients with an established
diagnosis of AD when AChE inhibitors are already being used. The NICE
guidelines also recommend AChE inhibitors for the treatment of
non-Alzheimer’s dementia; however, they do not have a UK marketing
authorisation for this purpose and therefore must be prescribed
off-label [3].
In addition to AChE inhibitors and memantine, antipsychotics are
recommended for the management of non-cognitive symptoms of dementia.
These symptoms of dementia include agitation, aggression, distress and
psychosis. Currently in the UK, risperidone and haloperidol are the only
antipsychotics with a UK marketing authorisation for the treatment of
non-cognitive symptoms associated with dementia [3].
In the last decade, there has been an increased emphasis on the
diagnoses and management of dementia in primary care, prior to any
psychiatric referrals. The National Dementia Strategy (NDS) published in
2009 in England emphasised the need to improve public and professional
awareness and understanding of dementia as well as early diagnosis and
treatment [4]. The Quality and Outcomes Framework (QoF) is a
voluntary annual reward and incentive programme for all general
practices in England. This incorporates better diagnosis and management
of dementia, including a follow-up care plan in primary care, as one of
the key quality indicators [5].
Evaluation of prescribing practices in dementia have predominantly
focused on minimising the potentially inappropriate use of
antipsychotics for treatment of non-cognitive symptoms [6-9].
However, a time trend analysis of prescribing of drugs used in the
management of dementia, in the context of recent policy emphases on
better diagnosis and management of dementia in primary care, have not
been investigated to a similar extent. In addition, the link between
deprivation, prevalence and prescribing for dementia remains poorly
understood. Geographical and deprivation level variations in prescribing
practices can inform stratification of targeted interventions to
identify linked co-morbidities and reduce health inequalities. The aim
of this study was to analyse the trends in prescribing of anti-dementia
drugs in primary care in England from 2009 to 2019 and to investigate
the impact of deprivation and regional demography on prescribing
practices.