Introduction
Globally, there are over 47 million people are living with dementia, with this figure set to reach 135.46 million by 2050 [1]. As of 2019, a total of 472,890 people in England have a coded diagnosis of dementia [2].
The National Institute of Clinical Excellence (NICE) guideline on Dementia in England recommends acetylcholinesterase (AChE) inhibitors: donepezil, galantamine and rivastigmine as recommended monotherapies for the management of mild to moderate Alzheimer’s disease (AD) [3]. The NICE guideline recommend that the N-methyl-D-aspartate (NMDA) receptor antagonist, memantine, should be used to treat moderate AD in patients who are intolerant or have a contraindication to AChE inhibitors. Memantine is also recommended to be used in patients with an established diagnosis of AD when AChE inhibitors are already being used. The NICE guidelines also recommend AChE inhibitors for the treatment of non-Alzheimer’s dementia; however, they do not have a UK marketing authorisation for this purpose and therefore must be prescribed off-label [3].
In addition to AChE inhibitors and memantine, antipsychotics are recommended for the management of non-cognitive symptoms of dementia. These symptoms of dementia include agitation, aggression, distress and psychosis. Currently in the UK, risperidone and haloperidol are the only antipsychotics with a UK marketing authorisation for the treatment of non-cognitive symptoms associated with dementia [3].
In the last decade, there has been an increased emphasis on the diagnoses and management of dementia in primary care, prior to any psychiatric referrals. The National Dementia Strategy (NDS) published in 2009 in England emphasised the need to improve public and professional awareness and understanding of dementia as well as early diagnosis and treatment [4]. The Quality and Outcomes Framework (QoF) is a voluntary annual reward and incentive programme for all general practices in England. This incorporates better diagnosis and management of dementia, including a follow-up care plan in primary care, as one of the key quality indicators [5].
Evaluation of prescribing practices in dementia have predominantly focused on minimising the potentially inappropriate use of antipsychotics for treatment of non-cognitive symptoms [6-9]. However, a time trend analysis of prescribing of drugs used in the management of dementia, in the context of recent policy emphases on better diagnosis and management of dementia in primary care, have not been investigated to a similar extent. In addition, the link between deprivation, prevalence and prescribing for dementia remains poorly understood. Geographical and deprivation level variations in prescribing practices can inform stratification of targeted interventions to identify linked co-morbidities and reduce health inequalities. The aim of this study was to analyse the trends in prescribing of anti-dementia drugs in primary care in England from 2009 to 2019 and to investigate the impact of deprivation and regional demography on prescribing practices.