, Volume 21, Issue 14, pp 1025–1037 | Cite as

Pharmacoeconomics of cholinesterase inhibitors in the treatment of Alzheimer’s disease

  • Linus Jönsson
Review Article


Cholinesterase inhibitors constitute one of few treatment options available for Alzheimer’s disease, the most common cause of dementia. The modest effects and relatively high acquisition costs of these drugs make the health economics of dementia an important subject of study.

Simulation models can be used to bring together existing data and make predictions of the long-term cost effectiveness of treatment. Most models have been built around cognitive function as a key parameter based on the observed relationship between cognitive function and costs of care. Patients with more severe disease attain higher total costs of care. Also, these patients have a higher share of formal care costs than do patients with mild disease, who are usually looked after by informal caregivers. The valuation of unpaid care is controversial, and the choice of method may affect results considerably.

Another important issue is the measurement of health-related QOL in patients with Alzheimer’s disease. The few existing studies have used proxy respondents to elicit utility weights in different disease states; however, this methodology has not been validated.

It is likely that the increased drug costs incurred by the use of cholinesterase inhibitors will be offset (at least partly) by savings in other healthcare costs. However, these results should be viewed as preliminary, since we are still awaiting data from long-term follow-up studies. Also, the value of treatment for patients and caregivers in terms of QOL improvements has yet to be established.


Cholinesterase Inhibitor Rivastigmine Tacrine Galantamine Nursing Home Placement 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



No sources of funding were used to assist in the preparation of this manuscript. The author is acting as consultant to Pfizer AB (Sweden) and Janssen-Cilag AB (Sweden).


  1. 1.
    Gonzalez-Salvador MT, Arango C, Lyketsos CG, et al. The stress and psychological morbidity of the Alzheimer patient caregiver. Int J Geriatr Psychiatry 1999; 14 (9): 701–10PubMedCrossRefGoogle Scholar
  2. 2.
    Bell CM, Araki SS, Neumann PJ. The association between caregiver burden and caregiver health-related quality of life in Alzheimer disease. Alzheimer Dis Assoc Disord 2001; 15 (3): 129–36PubMedCrossRefGoogle Scholar
  3. 3.
    Winslad D, Karlsson G, Winblad B, et al. A proposed health economics research agenda for dementia. In: Wimo A, Winblad B, Jonsson B, editors. Health economics of dementia. London: John Wiley & Sons, 1998: 563–5Google Scholar
  4. 4.
    Wimo A, Karlsson G, Sandman PO, et al. Cost of illness due to dementia in Sweden. Int J Geriatr Psychiatry 1997; 12 (8): 857–61PubMedCrossRefGoogle Scholar
  5. 5.
    Ernst RL, Hay JW. The US economic and social costs of Alzheimer’s disease revisited. Am J Public Health 1994; 84 (8): 1261–4PubMedCrossRefGoogle Scholar
  6. 6.
    Souetre E, Thwaites RM, Yeardley HL. Economic impact of Alzheimer’s disease in the United Kingdom: cost of care and disease severity for non-institutionalised patients with Alzheimer’s disease. Br J Psychiatry 1999; 174: 51–5PubMedCrossRefGoogle Scholar
  7. 7.
    Hux MJ, O’Brien BJ, Iskedjian M, et al. Relation between severity of Alzheimer’s disease and costs of caring. CMAJ 1998; 159 (5): 457–65PubMedGoogle Scholar
  8. 8.
    Jonsson L, Lindgren P, Wimo A, et al. Costs of Mini Mental State Examination-related cognitive impairment. Pharmacoeconomics 1999; 16 (4): 409–16PubMedCrossRefGoogle Scholar
  9. 9.
    Kronborg Andersen C, Sogaard J, Hansen E, et al. The cost of dementia in Denmark: the Odense Study. Dement Geriatr Cogn Disord 1999; 10 (4): 295–304PubMedCrossRefGoogle Scholar
  10. 10.
    Kavanagh S, Knapp M. Cognitive disability and direct care costs for elderly people. Br J Psychiatry 1999; 174: 539–46PubMedCrossRefGoogle Scholar
  11. 11.
    Kane RL, Atherly A. Medicare expenditures associated with Alzheimer disease. Alzheimer Dis Assoc Disord 2000; 14 (4): 187–95PubMedCrossRefGoogle Scholar
  12. 12.
    Gutterman EM, Markowitz IS, Lewis B, et al. Cost of Alzheimer’s disease and related dementia in managed-Medicare. J Am Geriatr Soc 1999; 47 (9): 1065–71PubMedGoogle Scholar
  13. 13.
    Taylor Jr DH, Sloan FA. How much do persons with Alzheimer’s disease cost Medicare? J Am Geriatr Soc 2000; 48 (6): 639–46PubMedGoogle Scholar
  14. 14.
    Fillenbaum G, Heyman A, Peterson BL, et al. Use and cost of outpatient visits of AD patients: CERAD XXII. Neurology 2001; 56 (12): 1706–11PubMedCrossRefGoogle Scholar
  15. 15.
    Fillenbaum G, Heyman A, Peterson BL, et al. Use and cost of hospitalization of patients with AD by stage and living ar-rangement: CERAD XXI. Neurology 2001; 56 (2): 201–6PubMedCrossRefGoogle Scholar
  16. 16.
    McCormick WC, Hardy J, Kukull WA, et al. Healthcare utilization and costs in managed care patients with Alzheimer’s disease during the last few years of life. J Am Geriatr Soc 2001; 49 (9): 1156–60PubMedCrossRefGoogle Scholar
  17. 17.
    Fastbom J, Giron M. Drug costs in dementia care. In: Wimo A, Winblad B, Jönsson B, editors. Health economics of dementia. London: John Wiley & Sons, 1998: 285–98Google Scholar
  18. 18.
    Rice D, Fox PJ, Max W, et al. The economic burden of Alzheimer’s disease care. Health Affairs 1993; 12: 164–76PubMedCrossRefGoogle Scholar
  19. 19.
    Ostbye T, Crosse E. Net economic costs of dementia in Canada. CMAJ 1994; 151 (10): 1457–64PubMedGoogle Scholar
  20. 20.
    Ernst RL, Hay JW, Fenn C, et al. Cognitive function and the costs of Alzheimer disease: an exploratory study. Arch Neurol 1997; 54 (6): 687–93PubMedCrossRefGoogle Scholar
  21. 21.
    Drummond M, O’Brien BJ, Stoddart GL, et al. Methods for the economic evaluation of health care programmes. 2nd ed. Oxford: Oxford University Press, 1997Google Scholar
  22. 22.
    Baladi IF, Bailey PA, Black S, et al. Rivastigmine for Alzheimer’s disease: Canadian interpretation of intermediate outcome measures and cost implications. Clin Ther 2000; 22 (12): 1549–61PubMedCrossRefGoogle Scholar
  23. 23.
    Fenn P, Gray A. Estimating long term cost savings from treatment of Alzheimer’s disease: a modelling approach. Pharmacoeconomics 1999; 2 (16): 165–74CrossRefGoogle Scholar
  24. 24.
    Fillit H, Gutterman EM, Lewis B. Donepezil use in managed Medicare: effect on health care costs and utilization. Clin Ther 1999; 21 (12): 2173–85PubMedCrossRefGoogle Scholar
  25. 25.
    Hauber AB, Gnanasakthy A, Mauskopf JA. Savings in the cost of caring for patients with Alzheimer’s disease in Canada: an analysis of treatment with rivastigmine. Clin Ther 2000; 22 (4): 439–51PubMedCrossRefGoogle Scholar
  26. 26.
    Hauber AB, Gnanasakthy A, Synder EH, et al. Potential savings in the cost of caring for Alzheimer’s disease: treatment with rivastigmine. Pharmacoeconomics 2000; 17 (4): 351–60PubMedCrossRefGoogle Scholar
  27. 27.
    Henke CJ, Burchmore MI. The economic impact of the tacrine in the treatment of Alzheimer’s disease. Clin Ther 1997; 19 (2): 330–45PubMedCrossRefGoogle Scholar
  28. 28.
    Small GW, Donohue JA, Brooks RL. An economic evaluation of donepezil in the treatment of Alzheimer’s disease. Clin Ther 1998; 20 (4): 838–50PubMedCrossRefGoogle Scholar
  29. 29.
    Lanctôt K, Risebrough N, Oh P. Factors affecting the economic attractiveness of cognitive enhancers in Alzheimer’s disease [abstract]. J Clin Pharmacol 1998; (38): 870Google Scholar
  30. 30.
    Neumann PJ, Hermann RC, Kuntz KM, et al. Cost-effectiveness of donepezil in the treatment of mild or moderate Alzheimer’s disease [see comments]. Neurology 1999; 52 (6): 1138–45PubMedCrossRefGoogle Scholar
  31. 31.
    Jönsson L, Lindgren W, Wimo A, et al. The cost-effectiveness of donepezil therapy in Swedish patients with Alzheimer’s disease: a Markov model. Clin Ther 1999; 21 (7): 1230–40PubMedCrossRefGoogle Scholar
  32. 32.
    O’Brien BJ, Goeree R, Hux M, et al. Economic evaluation of donepezil for the treatment of Alzheimer’s disease in Canada. J Am Geriatr Soc 1999; 47 (5): 570–8PubMedGoogle Scholar
  33. 33.
    Stewart A, Phillips R, Dempsey G. Pharmacotherapy for people with Alzheimer’s disease: a Markov-cycle evaluation of five years’ therapy using donepezil. Int J Geriatr Psychiatry 1998; 13 (7): 445–53PubMedCrossRefGoogle Scholar
  34. 34.
    Salek SS, Walker MD, Bayer AJ. A review of quality of life in Alzheimer’s disease. Part 2: issues in assessing drug effects. Pharmacoeconomics 1998; 14 (6): 613–27PubMedCrossRefGoogle Scholar
  35. 35.
    Walker MD, Salek SS, Bayer AJ. A review of quality of life in Alzheimer’s disease. Part 1: issues in assessing disease impact. Pharmacoeconomics 1998; 14 (5): 499–530PubMedCrossRefGoogle Scholar
  36. 36.
    Neumann PJ, Kuntz KM, Leon J, et al. Health utilities in Alzheimer’s disease: a cross-sectional study of patients and caregivers. Med Care 1999; 37 (1): 27–32PubMedCrossRefGoogle Scholar
  37. 37.
    Neumann PJ, Sandberg EA, Araki SS, et al. A comparison of HUI2 and HUI3 utility scores in Alzheimer’s disease. Med Decis Making 2000; 20 (4): 413–22PubMedCrossRefGoogle Scholar
  38. 38.
    Caro J, Getsios D, Migliaccio-Walle K, et al. Assessment of health economics in Alzheimers Disease (AHEAD) based on need for full-time care. Neurology 2001; 57: 964–71PubMedCrossRefGoogle Scholar
  39. 39.
    Sonnenberg F, Leventhal E. Modeling disease progression with Markov models. In: Wimo A, Musson B, Karlsson G, et al., editors. Health economics of dementia. Chichester: John Wiley & Sons, 1998Google Scholar
  40. 40.
    Rogers SL, Farlow MR, Doody RS, et al. A 24-week, doubleblind, placebo-controlled trial of donepezil in patients with Alzheimer’s disease. Donepezil Study Group. Neurology 1998; 50 (1): 136–45PubMedCrossRefGoogle Scholar
  41. 41.
    van Hout BA, Al MJ, Gordon GS, et al. Costs, effects and C/Eratios alongside a clinical trial. Health Econ 1994; 3 (5): 309–19PubMedCrossRefGoogle Scholar
  42. 42.
    Claxton K, Neumann PJ, Araki S, et al. Bayesian value-of-information analysis. An application to a policy model of Alzheimer’s disease. Int J Technol Assess Health Care 2001; 17 (1): 38–55PubMedCrossRefGoogle Scholar
  43. 43.
    Lubeck DP, Mazonson PD, Bowe T. Potential effect of tacrine on expenditures for Alzheimer’s disease. Med Interface 1994; 7 (10): 130–8PubMedGoogle Scholar
  44. 44.
    Knapp MJ, Knopman DS, Solomon PR, et al. A 30-week randomized controlled trial of high-dose tacrine in patients with Alzheimer’s disease. The Tacrine Study Group. JAMA 1994; 271 (13): 985–91PubMedCrossRefGoogle Scholar
  45. 45.
    Wimo A, Karlsson G, Nordberg A, et al. Treatment of Alzheimer disease with tacrine: a cost-analysis model. Alzheimer Dis Assoc Disord 1997; 4 (11): 191–200Google Scholar
  46. 46.
    Henke C, Burchmore M. The economic impact of tacrine in the treatment of Alzheimer’s disease. Clin Ther 1996; Suppl. A (18): 29–30CrossRefGoogle Scholar
  47. 47.
    British national formulary. London: British Medical Association & Royal Pharmaceutical Society, 2000Google Scholar
  48. 48.
    Brooks E, Deal L. The effect of rivastigmine on the direct and indirect costs of Alzheimer’s disease [abstract no. PMH5 + poster]. Value Health 2000; 3 (2): 79CrossRefGoogle Scholar
  49. 49.
    2000 drug topics red book. Montvale (NJ): Medical Economics Company, 2000Google Scholar
  50. 50.
    Lyseng-Williamson KA, Plosker GL, Galantamine: a pharmacoeconomic review of its use in Alzheimer’s disease. Pharmacoeconomics 2002; 20 (13): 919–42PubMedCrossRefGoogle Scholar
  51. 51.
    Migliaccio-Walle K, Getsios D, Caro JJ, et al., for the AHEAD Study Group. Economic evaluation of galantamine for the treatment of mild to moderate Alzheimer’s disease in the United States. Clin Ther. In pressGoogle Scholar
  52. 52.
    Ward A, Caro JJ, Getsios D, et al., for the AHEAD Study Group. Assessment of health economics in Alzheimer’s disease (AHEAD): treatment with galantamine in the UK. Int J Geriatric Psych. In pressGoogle Scholar
  53. 53.
    Caro JJ, Salas M, Ward A, et al. Economic analysis of galantamine, a cholinesterase inhibitor, in the treatment of patients with mild to moderate Alzheimer’s disease in the Netherlands. Dement Geriatr Cogn Disord 2002; 14 (2): 84–9PubMedCrossRefGoogle Scholar
  54. 54.
    Garfield FB, Getsios D, Caro JJ, et al. Assessment of health economics in Alzheimer’s disease (AHEAD): treatment with galantamine in Sweden. Pharmacoeconomics 2002; 20 (9): 629–37PubMedCrossRefGoogle Scholar
  55. 55.
    Getsios D, Caro JJ, Caro G, et al. Assessment of health economics in Alzheimer’s disease (AHEAD): galantamine treatment in Canada. Neurology 2001; 57 (6): 972–8PubMedCrossRefGoogle Scholar
  56. 56.
    Areosa SA, Sherriff F. Memantine for dementia. The Cochrane Library, issue 3, 2003. Oxford; updated software; CDO03154Google Scholar
  57. 57.
    Feldman H, Gauthier S, Hecker J, et al. Efficacy of donepezil on maintenance of activities of daily living in patients with moderate to severe Alzheimer’s disease and the effect on caregiver burden. J Am Geriatr Soc 2003; 51 (6): 737–44PubMedCrossRefGoogle Scholar
  58. 58.
    Gauthier S, Feldman H, Hecker J, et al. Efficacy of donepezil on behavioral symptoms in patients with moderate to severe Alzheimer’s disease. Int Psychogeriatr 2002; 14 (4): 389–404PubMedCrossRefGoogle Scholar

Copyright information

© Adis Data Information BV 2003

Authors and Affiliations

  1. 1.Department of NeuroscienceOccupational Therapy and Elderly Care Research (NEUROTEC), Karolinska InstitutetStockholmSweden

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