DESK REVIEWS | 07.05. Antidementia medication and care products

DESK REVIEW | 07.05. Antidementia medication and care products

Yes. These are: donepezil, galantamine, rivastigmine, and memantine.

Clinical Practice Guidelines (CPGs) for management of dementia published by the Indian Psychiatric Society (Shaji. et al., 2018) lists the following approved anti-dementia drugs (Cholinesterase Inhibitors):

  • Donepezil
  • Rivastigmine
  • Galantamine
  • Rivastigmine Transdermal Patch
  • Donepezil Extended Release
  • NMDA Antagonist Memantine.
References:

Shaji, K.S., Sivakumar, P.T., Rao, G.P., Paul, N., (2018). Clinical Practice Guidelines for Management of Dementia. Indian J. Psychiatry 60, S312–S328. https://doi.org/10.4103/0019-5545.224472

There is coverage for dementia medications according to the National Formulary 2015 (there are amendments in 2017, 2018 but not affecting Alzheimer’s drugs). Covering is only available for donepezil (classified as anticholinesterase). It can only be obtained at health facilities at level 3 (tertiary hospitals/type A hospitals according to BPJS) and can only be prescribed for mild to moderate Alzheimer’s. Coverage is 30 tablets per month for both film-coated tablets 5mg and for dispersible tablets 10mg.

Most drugs are approved by the National Medicines Regulatory Authority but not included on the essential drug list of drugs in Kenya (Ministry of Health, 2016a) and are unavailable in public facilities. For instance, Donepezil is mostly available in private facilities (Mokaya et al., 2016).

References:

Ministry of Health. (2016a). Kenya Essential Medical Supplies List 2016. Nairobi, Kenya. http://publications.universalhealth2030.org/uploads/KEMSL-2016Final-1.pdf

Mokaya, J., Dotchin, C. L., Gray, W. K., Hooker, J., & Walker, R. W. (2016). The accessibility of Parkinson’s disease medication in Kenya: results of a national survey. Movement Disorders Clinical Practice, 3(4), 376–381. https://doi.org/10.1002/mdc3.12294

 

According to the Clinical Guidance[1] for Cognitive Impairment, the recommended medicines are cholinesterase inhibitors for management of dementia and antipsychotic medications for the management of challenging behaviours (CENETEC, 2017).

[1] Diagnóstico y Tratamiento de la Demencia Alzheimer. http://www.cenetec.salud.gob.mx/descargas/gpc/CatalogoMaestro/393_IMSS_10_Demencia_Alzheimer/EyR_IMSS_393_10.pdf

References:

CENETEC. (2017). Diagnóstico y Tratamiento de la Enfermedad de Alzheimer. Guía de Evidencias y Recomendaciones: Guía de Práctica Clínica. Guia de Practica Clinica. http://www.cenetec-difusion.com/CMGPC/IMSS-393-10/RR.pdf

There are multiple generics available for the treatment of dementia.

Table 7.11 Generic brands leading in India of the recommended anti-dementia drugs

Serial No. Drug name Generic names
1 Donepezil

 

Aricep
2 Rivastigmine

 

Exelon, Rivamer
3 Galantamine

 

Galamer
4 Memantine

 

Axura,Mentadem, Mentadem
5 Rivastigmine Transdermal Patch

 

Exelon Patch

Source: (Medindia, 2019)

References:

Medindia, 2019. Medindia – Trusted Information on Health & Wellness Available from: www.medindia.net/index.asp

According to the e-catalogue of the Government Procurement Policy Agency/Lembaga Kebijakan Pengadaan Barang/Jasa Pemerintah (LKPP), Donepezil is available in generic form (Lembaga Kebijakan Pengadaan Barang / Jasa Pemerintah, n.d.). The Ministry of Health stated that the prices of drugs available through the National Health Insurance system are made available in the e-catalogue website to eliminate bidding process (Kementerian Kesehatan Republik Indonesia, 2017).

References:

Kementerian Kesehatan Republik Indonesia. (2017). Upaya Kemenkes Antisipasi Ketimpangan Harga Obat. https://www.kemkes.go.id/article/view/17021300003/upaya-kemenkes-antisipasi-ketimpangan-harga-obat.html

Lembaga Kebijakan Pengadaan Barang / Jasa Pemerintah. (n.d.). Katalog Elektronik.

 

Yes. For example, Donepezil is marketed under the brand name Aricept (Mokaya et al., 2016).

References:

Mokaya, J., Dotchin, C. L., Gray, W. K., Hooker, J., & Walker, R. W. (2016). The accessibility of Parkinson’s disease medication in Kenya: results of a national survey. Movement Disorders Clinical Practice, 3(4), 376–381. https://doi.org/10.1002/mdc3.12294

Yes, medications are available as generics for memantine (clorhidrato de memantina) and galantamine (bromhidrato de galantamina).

No. These are dependent on the ability or interest of well-wishers to give through NGOs or private organizations, but none is provided or subsidized for persons with dementia.

No, and neither for older adults nor people with disabilities in general, except for sporadic give-aways by local-level institutions, but no specific numbers are reported. Usually, they include it as an activity supporting older adults, but no annual or periodic results of what they give out or the number of older adults covered can be identified.

Yes. Any person who needs assistive technology may receive it for free from SUS as long as a doctor from SUS prescribes it. For example, the person may contact the Municipal Health Secretary with the doctor’s prescription and personal documents to require a wheelchair.

Under the national health insurance JKN scheme, assistive technology for elderly people such as spectacles, wheelchairs, false teeth, walking frames, neck brace, and hearing aids are available free of charge for those who need them. A cut-off value of each item and an annual limit of device purchase apply for each type of medical device or assistive technology. For instance, for hearing aid, JKN will cover only up until IDR 5 million and can only be given once every five years per claimant (Sanchia & Halim, 2019).

References:

Sanchia, N., & Halim, M. S. (2019). Terapi Stimulasi Kognitif untuk Lansia dengan Mild Cognitive Impairment: Studi Eksperimental di Panti Wreda. Neurona, 36(4), 258–264. http://www.neurona.web.id/paper-detail.do?id=1123

The assistive devices and services provided within the National Development Fund for persons with disabilities (rather than just dementia) are free but after submitting a complete request form (National Council for Persons with Disabilities (NCPWD), 2019). The new application handbook is designed to clarify how decisions are made at the fund by providing the method and criteria for approving or rejecting applications. For instance, priority would be given to those who require the device for learning, training, or work related environments and those who have never received an assistive device unless it is worn out or too small for their age (National Council for Persons with Disabilities, 2011).

References:

National Council for Persons with Disabilities (NCPWD). (2019). National Development Fund. https://ncpwd.go.ke/ndfpwd-funding-summary/

National Council for Persons with Disabilities. (2011). National Development Fund for Persons with Disabilities: Application Handbook. https://ncpwd.files.wordpress.com/2011/08/application-handbook-56-pages.pdf

Some programs at local level have provided assistive technology instruments but efforts are isolated; most of the times these are a one-off benefit and not following some continuous programmes.

No, but they may receive advice on what should be done to the house.

The Persons with Disabilities (Amendment) Bill, 2019 Part 2B (2f – iii) states that the county executive committee member in each county shall coordinate the implementation of programmes developed by the Council and the Authority relating to persons with disabilities in the county, in particular coordinate programmes on accessibility and reasonable accommodation (Republic of Kenya, 2019). There is no literature indicating whether persons with dementia or disability should have the housing adjustments for free or not (in their homes). However, the bill states that persons with disabilities should enjoy equal benefits and privileges of employment equal to those enjoyed by an employee without a disability (Republic of Kenya, 2019). This is an indication that working environments or areas of accommodation outside their home should have such adjustments. The owners or employers should pay for such or apply to receive the infrastructure through the National Development Fund for persons with disabilities (National Council for Persons with Disabilities, 2011).

References:

National Council for Persons with Disabilities. (2011). National Development Fund for Persons with Disabilities: Application Handbook. https://ncpwd.files.wordpress.com/2011/08/application-handbook-56-pages.pdf

Republic of Kenya. (2019). The Persons with Disabilities (Amendment) Bill, 2019. Nairobi, Kenya. http://www.parliament.go.ke/sites/default/files/2019-02/The%20Persons%20with%20Disabilities%20%28Amendment%29%20Bill%2C%202019.pdf

No, and neither for older adults nor people with disabilities in general.

Yes, all of them are available for free via SUS (Brazilian Ministry of Health, 2017d).

References:

Brazilian Ministry of Health. (2017d). Relação Nacional de Medicamentos Essenciais 2017 (RENAME). http://bvsms.saude.gov.br/bvs/publicacoes/relacao_nacional_medicamentos_rename_2017.pdf

The Indian Department of Pharmaceuticals launched the Jan Aushadhi Scheme (JAS) (Public Medicine Scheme) in 2015 as a direct market intervention to make generic medicine more affordable and accessible to the general public in all Indian states (IES, 2015).

References:

IES, 2015. Jan Aushadhi Scheme – Arthapedia. Available from: http://www.arthapedia.in/index.php?title=Jan_Aushadhi_Scheme

No. While the Clinical Practice for Alzheimer’s Disease & other Dementias (CENETEC, 2017) recommends cholinesterase inhibitors for managing dementia and the use of antipsychotic medications for challenging behaviour (Haloperidol and second generation medications Quetiapine and Risperidone), for all public and private institutions, a review of the Mexican Social Security Institute IMSS basic catalogue of medicines and of the Ministry of Health’s medication catalogue showed that these medications are not included. This means clinics or hospitals are not obliged to stock them or provide them for free.

References:

CENETEC. (2017). Diagnóstico y Tratamiento de la Enfermedad de Alzheimer. Guía de Evidencias y Recomendaciones: Guía de Práctica Clínica. Guia de Practica Clinica. http://www.cenetec-difusion.com/CMGPC/IMSS-393-10/RR.pdf

Not in the public system, but it is available in the private sector via out-of-pocket payments. For example, cognitive training, cognitive stimulation, exergaming, physiotherapy, and psychotherapy.

Some of the dementia centres across the country follow non-pharmacological interventions such as cognitive stimulation therapy for people with dementia (ARDSI, 2010). DEMCARES by SCARF Chennai runs The Centre for Active Ageing (CAA) which provides psychosocial non-pharmacological interventions (DEMCARES, 2019).

Cognitive stimulation therapy, reality orientation, and reminiscence therapy are some of the commonly used non-pharmacological interventions used to reduce the behavioural, cognitive, and emotional symptoms of dementia which have proven to be effective (Tripathi and Tiwari 2009; Shaji et al., 2018).

References:

Alzheimer’s and Related Disorders Society of India. (2010). THE DEMENTIA INDIA REPORT 2010: Prevalence, impact, cost and services for dementia. New Delhi. Available from: https://ardsi.org/pdf/annual%20report.pdf

DEMCARES. (2019). Centre for Active Aging. Available from: https://dementia.scarfindia.org/centre-for-active-aging/

Shaji, K.S., Sivakumar, P.T., Rao, G.P., Paul, N., (2018). Clinical Practice Guidelines for Management of Dementia. Indian J. Psychiatry 60, S312–S328. https://doi.org/10.4103/0019-5545.224472

Tripathi, R.K., Tiwari, S.C., (2009). Psychotherapeutic Approaches in the Management of Elderlies with Dementia: An Overview, DELHI PSYCHIATRY JOURNAL.

So far, Cognitive Stimulation Therapy has been implemented in Indonesia only in research/academic settings. The 2019 study that was conducted in nursing homes shows a significant difference in the cognitive function within attention domain and memory domain measured after participation in the CST intervention (Triestuning & Sipollo, 2019).  Another study published in 2019 also finds significant differences in cognitive functions between the CST group compared to the control group (Komalasari, 2014). However, a pre-post study published in 2014 with a small sample showed no significant impact of CST in improving cognition (Jakarta Smart City, 2015).

References:

Jakarta Smart City. (2015). Laporkan Kinerja Pemerintah Melalui Qlue.

Komalasari, R. (2014). Domain Fungsi Kognitif Setelah Terapi Stimulasi Kognitif. Jurnal Keperawatan Indonesia, 17(1), 11–17.

Triestuning, E., & Sipollo, B. V. (2019). Cognitive Stimulation Therapy on Elderly with Dementia in Panti Werdha Pandaan, Pasuruan. International Conference of Kerta Cendekia Nursing Academy, 1, 139–144.

None. Interventions such as mhGAP-IG have been implemented by the AMHRTF (Africa Mental Health Training and Research Foundation, 2020) using task sharing approaches i.e., the TEAM project (Mutiso et al., 2018). The focus on delivery of interventions by non-mental health specialists (health care workers) after training was on priority mental health problems (including dementia) listed under the mhGAP-IG which includes dementia (World Health Organization, 2016).

References:

Africa Mental Health Training and Research Foundation. (2020). Welcome to AMHRTF. https://africamentalhealthresearchandtrainingfoundation.org

Mutiso, V. N., Gitonga, I., Musau, A., Musyimi, C. W., Nandoya, E., Rebello, T. J., … Ndetei, D. M. (2018). A step-wise community engagement and capacity building model prior to implementation of mhGAP-IG in a low-and middle-income country: a case study of Makueni County, Kenya. International Journal of Mental Health Systems, 12(1), 1–13.  https://doi.org/10.1186/s13033-018-0234-y

World Health Organization. (2016). mhGAP Intervention Guide version 2.0. Geneva, Switzerland. https://www.who.int/publications/i/item/9789241549790

At the moment, these are not available at large scale through public health services.

No. In Brazil technology for dementia is still very incipient. Some initiatives might exist in the private sector.

There are GPS tracking devices, such as the GPS SmartSole, which is a sole insert for shoes that uses GPS and cellular technology to provide regular data updates (every 10 minutes) on the user’s location (Kim et al., 2017). Likewise, SafeWander is a bed exit alarm sensor that detects changes in body position and alerts caregivers if the person with dementia is about to leave his or her bed (Kim et al., 2017). Similar assistive technologies are available for dementia care on the Indian market. The devices are generally expensive and require maintenance and administration by family members/caregivers.

Nevertheless, technology plays a vital role in dementia care. The portal for old age solutions is a part of the Technology Initiative for Disabled and Elderly, an initiative of the Ministry of Science and Technology and created by All India Institute of Medical Sciences (AIIMS), Delhi (Portal on Technology Initiative for Disabled and Elderly, n.d.). This portal provides significant information on various aspects such as health, nutritional requirements, recreation, environment, networking and assistive devices for the ageing (Portal on Technology Initiative for Disabled and Elderly, n.d.). In addition, DemClinic launched by Nightingales Medical Trust (NMT) in association with ARDSI Bangalore, is the first of its kind offering a telemedicine expert-led cognitive assessment platform for the elderly to increase access to dementia screening, diagnosis, and care (Nightingales Medical Trust, n.d.). Also, the DemLink App by NMT aims to educate families of loved ones with dementia and provides access to care and support via a mobile app (Nightingales Medical Trust, n.d.). Furthermore, caregiver support is provided through platforms such as WhatsApp. The ARDSI Hyderabad ZBCHA WhatsApp group is one such example.

References:

Kim, S., B, Toloui, B.O., Jain, S. (2017). Enhancing Dementia Care Through Digital Health. Available from: https://www.ajmc.com/journals/ajac/2017/2017-vol5-n4/enhancing-dementia-care-through-digital-health

NIGHTINGALES MEDICAL TRUST. (n.d.). DemClinic and DemLink. Available from: https://nightingaleseldercare.com/demclinic.html

Portal on Technology Initiative for Disabled and Elderly, (n.d.). Old Age Solutions. Available from: https://www.oldagesolutions.org/category/old-age-solutions-en/

In 2016, the DKI Jakarta Provincial Government has launched the “Missing Older People” feature in the Qlue online application (Jakarta Resmikan Pasukan Ungu Bantu Penderita Demensia, 2016). The application can be accessed via smart phones by the public to facilitate and accelerate the handling of lost older people in the DKI Jakarta area. Through these features, the community can play an active role in reporting when they find older people who got lost. The report is then forwarded to the “lurah” through the Qlue application and can be followed up by the closest Purple Troops members (BPOM RI, n.d.; Shopee, n.d.).

References:

BPOM RI. (n.d.). Statistik Produk yang Mendapatkan Persetujuan Izin Edar.

Jakarta Resmikan Pasukan Ungu Bantu Penderita Demensia. (2016). BeritaSatu. https://www.beritasatu.com/kesehatan/387342/jakarta-resmikan-pasukan-ungu-bantu-penderita-demensia

Shopee. (n.d.). Hasil Pencarian Untuk “Pegagan”.

Not within the public and social security services. Technology support services could be available within the private sector, but they are only accessible to very few people.

The prices of the medicines vary per state according to federal/state taxation rates (as shown in the table below), and per laboratory. They are available for free in the SUS, but there is a bureaucratic and specific place where they can be obtained. Private patients may buy medication in pharmacies.

TAX Federal State Initials
20% RJ
18% AM, AP, BA, CE, MA, MG, PB, PE, PI, PR, RN, RS, SE, SP, TO and RJ
17.5% RO
17% Other states
12% Generic medicines in SP and MG

The Brazilian Health Regulatory Agency (ANVISA) establishes the maximum price a costumer can pay for each medicine. It may happen that a laboratory sells the same drug with different “brand names” which may impact on the final price of the medication. People living with dementia can get all these medications free of charge through the SUS.

Table 7.12. Cost per dose of generics as per the Clinical practice guideline management for dementia

Name of the medication Dose as per guidelines No. of brands/trades name  available Range of cost
Usual starting dose in mg/day Maximum recommended dose (mg/day)
Donepezil 5 10 28 Rs 105 – Rs 171 5Mg (10 tablets)

Rs 145- Rs 244 10 mg (10 tablets)

Rivastigmine 3 12 19 Rs 22 – Rs 710 1.5mg (10 capsules)
Galantamine 8 24   Rs 131- Rs 220 4 mg/ 10s
Rivastigmine Transdermal Patch 4.6/24 hours patch 9.5/24 hours patch 19 Rs 5497 / 30 pcs
Donepezil extended release 11.5 23 Rs 121- Rs 172 (10 tablets)
NMDA Antagonist Memantine 10 20 3 Rs 88- Rs 798 (10 tablets)

Source: (Medindia, 2019; Shaji et al., 2018)

References:

Medindia, 2019. Medindia – Trusted Information on Health & Wellness Available from: www.medindia.net/index.asp

Shaji, K.S., Sivakumar, P.T., Rao, G.P., Paul, N., (2018). Clinical Practice Guidelines for Management of Dementia. Indian J. Psychiatry 60, S312–S328. https://doi.org/10.4103/0019-5545.224472

Only donepezil is approved on the national formulary for dementia and Alzheimer’s. For donepezil film-coated tablet 5mg, the price varies according to province with higher prices seen in eastern regions of Indonesia, but the price range is around Rp. 1,700 to Rp. 2,200. There are other products registered at BPOM (Badan Pengawas Obat dan Makanan) as traditional supplements without specific dementia indication but can be found on locally popular e-commerce websites advertised as dementia medication at a much higher price. For example, Kapsul Esktrak Pegagan priced at Rp 250,000, citicoline 500mg (Rp 165,000), and Lycozein Softgel (Rp 450,000) (Wu, 2014).

References:

Wu, T. (2014). The Asian Family, the State and Care for Urban Older Adults: A Comparison of Singapore, China, and Indonesia. July.

Since they are not included on the essential drug list of drugs in Kenya (Ministry of Health, 2016a) and are unavailable in public facilities, the cost in private facilities is dependent on the distributor.

References:

Ministry of Health. (2016a). Kenya Essential Medical Supplies List 2016. Nairobi, Kenya. http://publications.universalhealth2030.org/uploads/KEMSL-2016Final-1.pdf

There was no publicly available information regarding prices within the public health services or social security institutions, as these are not included in the public sector medicine catalogues.

A rapid search of prices among private sector pharmacies (Metropolitan Area of Mexico City), where most people purchase them, given they are not usually covered by health or social security institutions, shows an average price for the main presentations of these four medications as follows:

  1. Clorhidrato de donepezilo: a) PEZZIL (torrent): 5mg / 28 tablets: $1,450.- MXN (around $74 USD)  b) Eranz (Pfizer) 5 mg / 28 tablets $2,150.- (around $113.- USD),
  2. Bromhidrato de galantamina: a) Reminyl ER (Jannsen-CILAG) 20.508 mg (equivalent to 16 mg of galantamine) / 14 capsules: 14: $1420 MXN (around $70.- USD),
  3. Clorhidrato de memantina a) Menural (Apopharma) 10 mg / 28 tablets: $640.- MXN (around $32.- USD), b) Ebixa (Lundbeck) 20 mg / 28 tablets: $1,500.- MXN; c) Akatinol (Merz) 20 mg / 28 tablets: $1650.- MXN ($83.- USD),
  4. Rivastigmina: Exelon patches (Novartis) 9.5 mg / 24 hours / 30 patches: $2,900.- MXN ($145.- USD).

Some pharmacies offer a discount of 5% for older adults if they are registered with INAPAM, the national older adults’ institute. In addition, some private insurance companies have agreements with pharmacies and so they offer discount for some medicines of 10% on average.