Scenarios

1. SA form for initial coverage in a patient with a diagnosis of AD with co-morbid vascular component

Mrs. L.H. is an 84-year-old Mandarin-speaking Asian woman who resides in Vancouver with her husband and eldest daughter. She has a 10-year history of hypertension and a 6-year history of Type II diabetes mellitus. Her family reports that over the last 2 years she has had a progressive loss of short-term memory and some difficulty in finding words and remembering the names of her grandchildren and great-grandchildren.

Her memory seemed to get worse several months ago when she had an episode of confusion and aphasia thought to represent a small stroke or transient ischemic attack. A CT head scan at that time showed evidence of a small lacune and moderate leukoaraiosis in the periventricular and deep white matter.

Her family members assist her with some of her instrumental activities of daily living including managing her finances and monitoring her medication administration, but she continues to be fully independent for her own personal care.

Mrs. H. weighs 58 kg. She has some mild visual and hearing impairment but not enough to interfere with the examination. She is literate, having completed Grade 9 in China. Though she is unable to conduct the full SMMSE in English, with her daughter’s help the exam is completed in Mandarin and she scores 23/30. Her GDS score is 5. A medication history rules out drug-induced causes of her cognitive decline.

Question: Is she eligible for the ADTI?

Response: The doctor completes the SA form for initiation of therapy and prescribes her the starting dose of a cholinesterase inhibitor, then titrates up to the therapeutic dose after four weeks with no side effects.

2. A patient with Alzheimer’s disease who has already received coverage, continues to meet eligibility criteria, and requires SA form for renewal of coverage

Mr. M.F. is a 78-year old widower who lives alone on his acreage in rural B.C. Mr. F.’s two sons reside in close proximity and continue to actively involve Mr. F. in the day-to-day operations of the family-run grain and cattle farm. Mr. F. has been unable to oversee the farming accounts for the past several years and no longer operates any of the heavy machinery, but he continues to regularly accompany his sons into the fields. Mr. F. has a known family history of Alzheimer’s Disease and began to recognize a decline in his mental “sharpness” 18 months ago. Mr. F. saw his family doctor about these concerns five months ago and was educated about the use of cholinesterase inhibitors and their potential benefit in slowing the progression of mild Alzheimer’s disease. Mr. F. completed a SMMSE with his GP and scored 23/30. His GDS score was 4. A SA form for initial coverage of a cholinesterase inhibitor was completed and Special Authority approval granted.

Mr. F. was initiated on a trial of a cholinesterase inhibitor at the starting dose. He saw his GP for follow-up two weeks later to ensure he was tolerating the medication. Four weeks thereafter he was seen for a medication review and the dosage was increased to the mid-range for a further four weeks before being increased to the maximum therapeutic dose.

Mr. F. has now been on this cholinesterase inhibitor for the past five and a half months and comes into the office today, accompanied by his daughter-in-law, to complete the necessary Special Authority request for renewal of ongoing coverage. His SMMSE is repeated and Mr. F. scores 23/30. On review of his functioning, Mr. F.’s daughter-in-law indicates that the family is now more actively assisting Mr. F. with meal preparation and housekeeping, but he continues to be independent for his own ADLs. There have been no specific safety concerns and no significant behavioural changes as noted by the family. His GDS score is 4 and he is considered minimally worse.

Question: Is the patient eligible for continued coverage?

Response: Yes, the patient is eligible for another six-months. There is no indication for consideration of medication switching at this time.

3. An appeal process in the continuation phase

Mr. A.S. is an 80-year old married, retired long-haul truck driver who lives with his 68-year old wife in their apartment in Duncan. Mr. S. was initially started on a cholinesterase inhibitor 12 months ago at which time his SMMSE was 12 and his GDS score 6. His wife is his primary caregiver, but he receives regular homecare support to assist with his ADLs, including dressing and weekly bathing. Their daughter resides in the same apartment complex and provides significant support and assistance to both parents.

Since his initial eligibility for coverage, Mr. S.’s SMMSE scores have shown a gradual decline from 12 to 10, and today on repeat testing he scores 9/30. Despite the decline in his SMMSE score, his GDS score remains 6. He is considered to be minimally worse in the past six months.

The SA for renewal of coverage is completed and faxed to Pharmacare. One week later, Pharmacare contacts you indicating Mr. S. was denied ongoing coverage as his SMMSE score of 9 no longer meets the eligibility criteria of SMMSE 10-26 inclusive.

You and the family both believe that Mr. S. continues to derive some benefit from the medication and you feel remiss to discontinue the same. Mr. and Mrs. S. are unable to assume the medication costs themselves.

Question: What can be done in this situation?

Response: Unfortunately, he does not meet the ADTI criteria and the only alternative is to have the patient’s family support payment. If they are unable to, then he will not be able to access the medication.

4. Patient who meets eligibility criteria shows no benefit from the first cholinesterase inhibitor trial. SA for renewal/switching of a cholinesterase inhibitor must be completed prior to a second agent being considered and initiated.

Mrs. H.B. is a 79-year old widow residing in a seniors’ apartment in Vernon. She was diagnosed with Alzheimer’s disease two and a half years ago and was started on a cholinesterase inhibitor 12 months ago, following the announcement of the Alzheimer’s Drug Therapy Initiative. Following Special Authority approval for initiation of coverage, she was gradually titrated up from the daily starting dose to the therapeutic dose. She was tolerating her cholinesterase inhibitor well with no significant adverse effects at the time of her last follow-up appointment 3 months ago. A family friend, who was unaware of any new concerns, accompanied her at that time.

Mrs. B. has another follow-up appointment today to complete the necessary paperwork to enable her to continue to receive another 6 months of medication coverage. She is accompanied by her eldest son who indicates that the family has grown increasingly concerned about her welfare in recent months. The family has received several reports from the building manager that Mrs. B. has been disoriented in the community and has required assistance to find her way home. In addition, she has been struggling with food preparation and has been eating increasingly basic meals. She now receives Meals on Wheels, as well as having a private companion for four hours a day, five days a week. Her companion provides some housekeeping and laundry service, in addition to accompanying her on short outings into the community. Mrs. B’s laundry shows evidence that she has difficulties with incontinence. Her son calls her every morning to remind her to take her medications, which he organizes weekly into a dosette box. The family is actively looking at alternative living accommodations where Mrs. B. can receive increased support and regular medication monitoring.

On repeat cognitive testing, Ms. B. scores 14/30 on the SMMSE (19/30 and 17/30 were her scores 12 and 6 months ago, respectively). Her GDS score has increased from 4 to a current score of 5. She is considered to be much worse clinically.

Reading through the SA for renewal/switching of a cholinesterase inhibitor, you recognize that you should consider switching to another medication given her clinical non-response. You discuss the situation with Mrs. B. and her son and together you agree to switch her medication to a different cholinesterase inhibitor.

Question: What should be done to effectively make the switch?

Response: Complete the SA for renewal/switching of a cholinesterase inhibitor and switch to a second cholinesterase inhibitor.

To safely taper Mrs. B off her first cholinesterase inhibitor while simultaneously initiating and titrating up the dose of her second cholinesterase inhibitor, please follow the switching guidelines outlined in the ADTI materials at www.health.gov.bc.ca/pharme/adti/clinician/pdf/SECTION%204%20-%20Reference%20Guide%20to%20Prescribing%20ChEIs.pdf

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