Big Cost, Little Benefit | Amy Alkon on MND

Big Cost, Little Benefit
Nursing home psychologist Ira Rosofsky writes in the LA Times that billions of dollars are being spent on medications that offer only marginal benefits for Alzheimer’s sufferers:

Examine the documents supporting the Food and Drug Administration’s approval of Aricept, and you will see upon what a slim reed this drug’s empire was built. Those taking the drug scored, on average, three points better on a 70-item cognitive assessment scale. That’s about a 4% difference, mostly reflecting a slower decline rather than positive improvement. And the differences disappear when the drug is discontinued — indicating that the drugs “do not represent a change in the underlying disease.” At best, these effects may be only marginally more effective against dementia than garlic was against the Black Death in the 14th century.

…Even on Aricept’s website, the claims are sketchy on the drug’s effectiveness when it comes to cognition: “People who took Aricept did better on thinking tests than those who took a sugar pill.”

How much better? The company doesn’t say.

Many studies of the effects of drugs for dementia also speak about statistical significance, but statistical significance can be highly overrated if the differences aren’t meaningful. Take my extremely nearsighted wife, for example. Suppose a drug enabled her to read the giant E at the top of an eye chart without her glasses, but none of the smaller letters. Her eyesight would show statistically significant enhancement, but — despite her being a much better driver than me — I’d still refuse to ride in a car she was driving if she wasn’t wearing her glasses.

There are similar effects at play with anti-dementia drugs.

In 2004, Richard Gray of the University of Birmingham in Britain compared hundreds of patients with mild to moderate dementia who were taking Aricept or a placebo. The drug did improve mental functioning, but at disappointingly small levels — about one point on a 60-point scale. More important, there was no delay in the dementia’s progression or the rate of patients’ institutionalization. And there were no significant differences in mood, behavior or cost of care.

…Could the thousands of dollars spent annually per patient and the billions overall be better directed?

Yes, says Gray: “Doctors and healthcare funders need to question whether it would be better to invest in more doctors and nurses and better social support rather than spending huge sums of money prescribing these expensive drugs.”

A survey released in 2002 by the Kaiser Foundation found that the staffs in a typical nursing home spend a total of about two hours and 20 minutes a day with each resident. For the remaining 21 hours and 40 minutes, residents are left to their own — mostly medicated — devices.

…But why not admit the failure of medication and instead spend some of those billions of dollars on more staff to hold the hands of both patients and their families? Beyond nurturance, much of the savings from giving up on cost-ineffective medications could be diverted to basic research that might yield not only statistically significant but meaningful and large improvements — even a cure.

There is some comfort in believing, as our medieval ancestors did, that a tangible nostrum — like a pearl-hued donepezil tablet — will do some good, but it may be more comforting simply to comfort.

Instead of drugs, I’d bet many patients are wishing someone would just say the words of another ancient rock anthem: I want to hold your hand.