Treatment of Alzheimer's disease in the long-term-care setting

Purpose. Pharmacologic treatment for patients with Alzheimer's disease (AD) who reside in long-term-care (LTC) facilities is discussed. Summary. The recognition of AD can be problematic in patients residing in LTC who do not have a preexisting diagnosis of dementia. Residents in LTC facilities generally have fewer day-to-day cognitive demands, and, thus, nursing staff or caregivers may not recognize cognitive deficits until the disease is more advanced. The current therapeutic options for the treatment of AD are the cholinesterase inhibitors (ChEIs) and the N-methyl-D-aspartate receptor antagonist memantine. The ChEIs rivastigmine and galantamine are currently approved for the treatment of mild-to-moderate AD, and memantine is approved for the treatment of moderate-to-severe AD. The ChEI donepezil is presently approved for the treatment of mild, moderate, and severe AD in the United States. Two placebo-controlled trials in nursing-home patients receiving donepezil have been published. In both studies, donepezil appeared to be safe and effective for the treatment of AD in patients residing in LTC facilities. Data from an open-label study suggest that rivastigmine treatment might also provide benefits in nursing-home patients with moderate-to-severe AD. Another study demonstrated that treatment with galantamine might delay the need for transfer from an assisted-living facility to a nursing home. The effectiveness and safety of memantine have been assessed in a subgroup of patients with severe AD residing in LTC facilities. There were no major differences in safety and tolerability between the active treatment group and placebo. The relative and clinical importance of the cognitive, functional, and behavioral changes observed in LTC patients treated with ChEIs and memantine remain to be identified. Conclusion. Pharmacologic treatment should be recommended for most patients with AD who reside in LTC facilities.