OscarLopez, Neurologist, University of Pittsburgh Medical Center
Melissa J.Armstrong, Neurologist, University of Florida College of Medicine
Thomas S.D.Getchius, Manager, Heart Rhythm Society
MaryGanguli, Psychiatrist, Department of Psychiatry, University of Pittsburgh
DavidGloss, Neurologist, Charleston Area Medical Center Neurology
Gary S.Gronseth, Neurologist, University of Kansas Medical Center
DanielMarson, Clinical Neuropsychologist, University of Alabama at Birmingham
TamaraPringsheim, Neurologist, Cumming School of Medicine, University of Calgary
Gregory S.Day, Neurologist, Knight Alzheimer Disease Research Center, Washington University School of Medicine
MarkSager, Geriatrician, School of Medicine and Public Health, University of Wisconsin
JamesStevens, Neurologist, Fort Wayne Neurological Center
Alexander D.Rae-Grant, Neurologist, Cleveland Clinic Neurological Institute at Lakewood Hospital
Submitted February 20, 2018
The guideline panel thanks Valenzuela et al. for their thoughtful comments on the recommendations concerning the use of cholinesterase inhibitors for treating mild cognitive impairment (MCI). [1] The “may choose not” language resulted from the AAN guideline modified Delphi voting process. As stated in the rationale, the recommendation reflects the fact that some studies could not exclude an important effect of cholinesterase inhibitors on MCI outcomes. The recommendation is also consistent with the donepezil trial, which stated, “the observed relative reduction in the risk of progression to Alzheimer’s disease of 58 percent at one year and 36 percent at two years in the entire cohort is likely to be clinically significant” and these data “could prompt a discussion between the clinician and the patient about this possibility.” [2] Recommendation B3b reflects the reality that many patients with MCI are receiving cholinesterase inhibitors. [3] Guidelines do not tell clinicians what to do in a specific patient encounter. [4] Individual decisions should be based on shared decision making, which remains relevant in the context of MCI. In this situation, it is critical that clinicians help patients understand the evidence (Recommendation B3b) so that they can make an informed decision consistent with their priorities and preferences.
1. Petersen RC, Lopez O, Armstrong MJ, et al. Practice guideline update summary: Mild cognitive impairment: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology 2018; 90:126-135.
2. Petersen RC, Thomas RG, Grundman M, et al. Vitamin E and donepezil for the treatment of mild cognitive impairment. N Engl J Med 2005; 352:2379-2388, 2465-2468.
3. Schneider LS, Insel PS, Weiner MW. Alzheimer’s Disease Neuroimaging Initiative. Arch Neurol 2011; 68:58-66.
4. Armstrong MJ, Gronseth GS. Approach to assessing and using clinical practice guidelines. Neurol Clin Pract 2018; 8:1-4.
The guideline panel thanks Valenzuela et al. for their thoughtful comments on the recommendations concerning the use of cholinesterase inhibitors for treating mild cognitive impairment (MCI). [1] The “may choose not” language resulted from the AAN guideline modified Delphi voting process. As stated in the rationale, the recommendation reflects the fact that some studies could not exclude an important effect of cholinesterase inhibitors on MCI outcomes. The recommendation is also consistent with the donepezil trial, which stated, “the observed relative reduction in the risk of progression to Alzheimer’s disease of 58 percent at one year and 36 percent at two years in the entire cohort is likely to be clinically significant” and these data “could prompt a discussion between the clinician and the patient about this possibility.” [2] Recommendation B3b reflects the reality that many patients with MCI are receiving cholinesterase inhibitors. [3] Guidelines do not tell clinicians what to do in a specific patient encounter. [4] Individual decisions should be based on shared decision making, which remains relevant in the context of MCI. In this situation, it is critical that clinicians help patients understand the evidence (Recommendation B3b) so that they can make an informed decision consistent with their priorities and preferences.
1. Petersen RC, Lopez O, Armstrong MJ, et al. Practice guideline update summary: Mild cognitive impairment: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology 2018; 90:126-135.
2. Petersen RC, Thomas RG, Grundman M, et al. Vitamin E and donepezil for the treatment of mild cognitive impairment. N Engl J Med 2005; 352:2379-2388, 2465-2468.
3. Schneider LS, Insel PS, Weiner MW. Alzheimer’s Disease Neuroimaging Initiative. Arch Neurol 2011; 68:58-66.
4. Armstrong MJ, Gronseth GS. Approach to assessing and using clinical practice guidelines. Neurol Clin Pract 2018; 8:1-4.
For disclosures, please contact the Editorial office at journal@neurology.org.