Marjetka Jelenc, PhD, Aleš Korošec, Mercedes Lovrečič, PhD Trends in Prescription of Drugs for the Treatment of Dementia in Slovenia in the Period from 2008 to 2018 Received 10. 2. 2020 / Accepted 27. 4. 2020 Scientific article UDC 616.892.3+615.2 KEYWORDS: dementia, drugs, prescriptions, trends ABSTRACT - Dementia is a clinical syndrome in mo- stly older people that manifests with cognitive functi- on problems. Its consequences represent a growing health, social and economic problem in many cou- ntries. Monitoring drug prescription contributes to better management of treatment. Our aim was to evaluate changes and trends in the prescribing of drugs for the treatment of dementia in Slovenia in the period from 2008 to 2018, by gender and age groups. Therefore, we conducted a retrospective, observa- tional study based on the data from the “Database of prescriptions for outpatients” of the Republic of Slovenia. The analysis showed that the number of prescriptions for anti-dementia drugs increased by 140% between 2008 and 2018. The most commonly prescribed drugs were acetylcholinesterase enzyme inhibitors. Outpatient prescribing increased in both men and women, and the number of recipients of at least one prescription more than doubled in the ob- served period. However, not all dementia patients are treated with appropriate medicines, especially at an early stage of the disease when dementia is not yet recognized or diagnosed. Prejeto 10. 2. 2020 / Sprejeto 27. 4. 2020 Znanstveni članek UDK 616.892.3+615.2 KLJUČNE BESEDE: demenca, zdravila, recepti, trendi POVZETEK - Demenca je klinični sindrom, ki se kaže z motnjami kognitivnih funkcij predvsem pri starejših. Posledice bolezni predstavljajo naraščajoč zdravstveni, socialni in ekonomski problem v mnogih državah. Spremljanje predpisovanja zdravil prispe- va k boljšemu nadzorovanju zdravljenja. Naš cilj je bil oceniti spremembe oz. trende pri predpisovanju zdravil, specifičnih za zdravljenje demence v Slove- niji v obdobju od leta 2008 do leta 2018 po spolu in starostnih skupinah. Zato smo izvedli retrospektiv- no, opazovalno študijo na podlagi podatkov iz Baze ambulantno predpisanih zdravil Republike Slovenije. Analiza je pokazala, da se je število receptov za zdra- vila za zdravljenje demence med letoma 2008 in 2018 povečalo za 140 %. Najpogosteje predpisana zdravi- la za zdravljenje demence v Sloveniji v opazovanem obdobju so bili zaviralci encima acetilholinesteraze. Ambulantno predpisovanje se je povečalo pri moških in ženskah. Število prejemnikov vsaj enega recepta se je v opazovanem obdobju več kot podvojilo. Kljub temu vsi bolniki z demenco niso zdravljeni z ustrezni- mi zdravili, zlasti v zgodnji fazi bolezni, ko demenca še ni prepoznana ali diagnosticirana. 1 Introduction In many European countries, as well as in Slovenia, the population is ageing and the number of chronic non-communicable diseases is increasing with age, including various forms of dementia, which represents a serious problem (Jelenc et al., 2018). There are over 47 million people with dementia in the world, and the number is expected to triple by 2050 (Satizabal et al., 2016). Trends in Prescription of Drugs for the Treatment ... 20 Revija za zdravstvene vede (7, 2020) Dementia is a chronic neurodegenerative disorder that usually develops over many years before it is expressed in the classical clinical form of the dementia syndrome. The most common subtype of dementia is Alzheimer's disease, followed by mixed vascular dementia and dementia with Lewy bodies (Gregorič Kramberger, 2017; Sa- tizabal et al., 2016). The disease develops on average in the period of 8 to 12 years, and its development is divided into three basic stages: early, middle and late. The boundaries between these levels are not sharply defined, and the symptoms are different between individuals (Ministry of Health, 2016; Kogoj, 2011). Population ageing and the increasing number of elderly people who are characte- rized by the disease are not the only two problems connected with dementia. Despite intensive research and testing of many potential active substances, a drug that would stop or significantly slow down the neurodegenerative process of dementia does not exist. Only symptomatic drugs for the treatment of dementia are available that are most effective in the early stages of the disease (Cummings et al., 2016; Gregorič Kramberger, 2017). Currently registered substances – acetylcholinesterase inhibitors donepezil, ri- vastigmine and galantamine – affect cholinergic connections in the central nervous system. All of these drugs have proven anticholinergic activity; galantamine acts also as an allosteric modulator on nicotinic cholinergic receptors. The acetylcholinesterase inhibitors listed are registered for mild to moderate dementia. Memantine, the fourth dementia drug in addition to the three mentioned, is the first registered anti-dementia drug with effect on the N-methyl-D-aspartate (NMDA) receptor and glutamatergic pathways. All of these drugs have beneficial symptomatic effects and are prescribed to slow the decline in the quality of patient’s life (Gregorič Kramberger, 2017). Early detection, diagnose and treatment of dementia are essential. If the family physician in Slovenia determines no reversible signs of the important cognitive impa- irment and recognises that dementia has not emerged rapidly, that forgetfulness and altered behaviour exist without clear neurological cause and signs, this may already indicate Alzheimer's dementia. Given the change in prescribing, adopted by the Slovenian Health Insurance Insti- tute (SHII) in accordance with Slovenian guidelines for the treatment of patients with dementia, a family doctor may prescribe cognitive modulators, both acetylcholineste- rase inhibitors and glutamate receptor antagonists, without waiting for the opinion of a psychiatrist or neurologist (Blejc, 2018). Monitoring drug prescription helps to identify medical, economic and social im- pacts of the disease (Jelenc, 2013; Kostnapfel Rihtar & Korošec, 2014). The purpose of our study was to assess and evaluate changes and trends in the prescribing of neuropsychopharmacological drugs specific for the treatment of de- mentia in Slovenia in the period from 2008 to 2018, by gender and age groups. 21Marjetka Jelenc, PhD, et al.: Trends in Prescription of Drugs for the Treatment ... 2 Methodology 2.1 Data Source The data source for this retrospective observational analysis is the “Database of prescriptions for outpatients” of the Republic of Slovenia available at the National Institute of Public Health (NIPH). The analysis encompassed data on the number of prescriptions for anti-dementia drugs in the period from 2008 to 2018. All prescriptions reported from the pharmacies, except hospital pharmacies, were analysed. Data was collected according to the Healthcare Databases Act (Official Ga- zette of the Republic of Slovenia, 2000). A consent from the National Medical Ethics Committee was not required because the data used had already been anonymised. 2.2 ATC Classification and DDD definition The presented drugs consumption illustration respects the WHO Anatomical-The- rapeutic-Chemical (ATC) classification. The whole ATC group N06D (donepezil, ri- vastigmine, galantamine, memantine) was analysed. In fact, according to the ATC classification system, the drugs for the nervous system (group N) are divided in seven groups (N01-N07). Anti-dementia drugs (N06D) are classified as the subgroup within psychoanaleptics (N06). The defined daily dose (DDD) is a statistical unit of measurement and is defined as the assumed average maintenance dose per day for a drug used for its main indica- tion in adults. Therapeutic doses for individual patients and patient groups are often different, but it is necessary to standardize the reporting of drug utilization data across countries, population groups and years for research purposes. Only one DDD is assi- gned per ATC code and route of administration (WHO, 2000). 2.3 Statistical Analysis ATC data was used to calculate the number of DDD per package for every prop- rietary name and packaging type of drugs in the ATC code N06D. DDD per 1000 in- habitants per day (hereinafter DID) was calculated as the sum of DDD for each active substance, divided by 365 and by the total number of inhabitants in Slovenia on 1 July in each year, multiplied by 1000. The analysis of anti-dementia drugs prescription was performed with regard to gender, age and time period. Statistical software IBM SPSS Statistics, version 25 for Windows (SPSS Inc, Chicago, IL, USA), was used for data analysis. Compiled data was processed by means of descriptive statistics (numbers, percentages …). Data was presented in tabular form and using bar charts and graphs. Age was classified in five year age groups, with the last one as 90 years or more. The age-spe- cific prevalence rate of anti-dementia drug users is calculated as the proportion of anti-dementia drug users among the total number of inhabitants in Slovenia on 1 July, separately for each year, sex and age group. 22 Revija za zdravstvene vede (7, 2020) 3 Results Data analysis showed that the number of patients who received at least one prescription for anti-dementia drugs from the N06D group more than doubled betwe- en 2008 and 2018. The most commonly prescribed drugs for the treatment of dementia in Slovenia in the observed period were acetylcholinesterase enzyme inhibitors. The ATC codes and by the WHO assigned DDDs for donepezil, rivastigmine, galantami- ne and memantine are shown in Table 1. For example, if a drug package contains 28 tablets, each with 10 mg memantine, the package contains 14 DDD of memantine. Table 1: DDD for donepezil, rivastigmine, galantamine and memantine. ATC code Name of the drug DDD N06DA02 donepezil 7.5 mg O N06DA03 rivastigmine 9 mg O / 9.5 mg TD N06DA04 galantamine 16 mg O N06DX01 memantine 20 mg O Note: 'O' stands for oral route of administration and 'TD' stands for transdermal route of administration. Figure 1 shows the number of patients who received at least one prescription for anti-dementia drugs from the N06D group in the period between 2008 and 2018, by gender. The number of women recipients of anti-dementia drugs increased by 126% and the number of men increased by 146% over the same period. However, female to male ratio decreased from 2.30 to 2.11. Figure 1: Number of patients who received at least one prescription for anti-dementia drugs from the group N06D in the period 2008-2018, by gender. The analysis showed that the number of prescriptions for anti-dementia drugs in- creased by 140% between 2008 and 2018. The increase in the number of prescriptions is shown in Figure 2. 23Marjetka Jelenc, PhD, et al.: Trends in Prescription of Drugs for the Treatment ... Figure 2: Increase in the number of prescriptions for anti-dementia drugs in the period from 2008 to 2018. Despite the increase in the prescription of anti-dementia drugs in DDD/1000 inha- bitants per day by 175%, the costs for the described drugs have been decreasing since 2012, as shown in Figure 3. Figure 3: Demonstration of the consumption of anti-dementia drugs in DDD/1000 inhabitantsper day (DID) and costs for these drugs. The number of patients who received at least one prescription for anti-dementia drugs, arranged by age group and by year of prescription, is presented in Figure 4. Most prescriptions for anti-dementia drugs were given to patients older than 80 years. 24 Revija za zdravstvene vede (7, 2020) Figure 4: Number of patients who received at least one prescription for anti-dementia drugs, arranged by age and by year of prescription (years 2008 (●) through 2018 (►)). Figure 5 shows the age-specific rate of recipients of anti-dementia drugs in the time period from 2008 to 2018, arranged by gender. Not only the number of pati- ents but also the rate of recipients of these drugs increased over the reference period. Among men aged 85-89, the age-specific rate rose from 6.6% in 2008 to 12.1%, and among women, from 7.3% to 15.1%. There was a particularly significant increase in age-specific rates among the elderly (85+ years). In women aged 90 years and more, the rate of receiving the prescriptions for the anti-dementia drugs was over 16%. Figure 5: Age-specific prevalence rate of anti-dementia drug users by age and by gen- der in the period from 2008 (●) through 2018 (►). 25Marjetka Jelenc, PhD, et al.: Trends in Prescription of Drugs for the Treatment ... 4 Discussion With this retrospective, observational study, we aimed to evaluate changes and trends in the prescribing of dementia-specific drugs in Slovenia in the period from 2008 to 2018, by gender and age groups. Our results show that the number of pati- ents who received at least one prescription for N06D anti-dementia drugs more than doubled in the observed period. The number of prescriptions for anti-dementia drugs increased by 140% in the period from 2008 to 2018, while the number of DDD /1000 inhabitants per day increased by 175%. The increase is observed in both genders, however, it is higher among men (146%) than among women (132%). Age-speci- fic prevalence rates of receiving prescriptions were expectedly higher among women than among men of equal age and increased significantly, especially with age (85 years and older). However, the number of older people also increased during the observed period. For example, in 2008, there were around 330 thousands inhabitants aged over 65 in Slovenia, and in 2018, there were already 407 thousands inhabitants older than 65 years. The slight decrease in the number of patients in the age group 70-74 is due to the lower number of births during the Second World War. A very limited number of studies with a similar aim are available, therefore it is difficult to compare the trends in Slovenia with the trends in other countries, especially countries with similar demo- graphic data. A longitudinal retrospective cohort study was performed in the United Kingdom in the period 2005-2015 with the aim of describing changes in the proporti- on of people diagnosed with dementia and pharmacological treatments prescribed to them over a 10-year period. The authors found that the prescription of anti-dementia drugs more than doubled after the introduction of national dementia strategies (Done- gan et al., 2017). The results of our analysis showed that the costs of the neuropsychopharmacolo- gical drugs for the treatment of dementia increased by 35% in the period from 2008 to 2012, and fell by 40% between 2012 and 2018. This fall in costs from 2012 is attributed to the fall in drug prices in Slovenia due to the entry of cheaper generic manufacturers on the prescription drug market. The population is ageing and the consequences of dementia are becoming a growing health, social and economic problem. Given the demographic trends of the ageing population, an increase in the number of people with dementia is expected in the future. The problem is even greater because anti-dementia drugs do not cure the disease. They can slow its progression and symptoms of the disease may improve over the time. Etiological treatment of dementia that is absolutely necessary does not exist (Cummings, 2017). Currently available treatment is effective when it is prescribed at an earlier stage of the disease. Early detection and diagnose of dementia is therefore essential. However, the diagnosis of dementia is often made in the late stage of the disease. Dementia is currently treated with cognitive modulators, acetylcholinesterase inhibitors and glutamate receptor antagonists, which can slow its progression. There- fore, it is of key importance to improve and accelerate the research and drug develo- pment in the field of dementia (Pankevich et al., 2014). On the other hand, it is also 26 Revija za zdravstvene vede (7, 2020) necessary to recognise and treat many other symptoms of this disease. In fact, especi- ally at an early stage when the disease has not yet been diagnosed, the patient has for example symptoms of depression or insomnia. All these symptoms of unrecognised disease are usually treated without knowing the disease behind them (Sommerlad et al., 2018). This is also one of the limitations of our study. Drugs for the treatment of non-specific symptoms of dementia or for complications were not included in the study. In summary, not all dementia patients are treated with appropriate medicines, especially at an early stage of the disease when dementia is not yet recognized or diagnosed. By identifying and treating these patients, we can make a significant con- tribution to their quality of life, their autonomy and dignity. Furthermore, caregivers of dementia patients are at a high risk of physical and mental illness as a consequence of caring, and they require equal attention and support (Gregorič Kramberger, 2017). 4.1 Limitations Only outpatient prescriptions were included in this study. Hospital data was not available at that time. The duration of prescription was not followed up. Drugs for the treatment of non-specific symptoms of dementia or for complications were not included in the study. 5 Conclusion This retrospective, observational study showed that the most commonly prescri- bed drugs for the treatment of dementia in Slovenia from 2008 to 2018 were acetyl- cholinesterase enzyme inhibitors. In the observed period, outpatient prescribing incre- ased in both men and women, and the number of recipients of at least one prescription more than doubled. Access to the treatment has significantly improved since 2018 due to the measures adopted by SHII. However, we estimate that only a fraction of dementia patients is treated with appropriate drugs, and that there are also people with unrecognized dementia in different stages. By better identifying and involving these people in the treatment, we can make a significant contribution to the quality of life of older people with dementia, their dignity and autonomy, and make life easier for caregivers and families. Dr. Marjetka Jelenc, Aleš Korošec, dr. Mercedes Lovrečič Trendi predpisovanja zdravil za zdravljenje demence v Sloveniji v obdobju od leta 2008 do leta 2018 Tako kot v mnogih evropskih državah se tudi v Sloveniji prebivalstvo stara in šte- vilo kroničnih nenalezljivih bolezni narašča s starostjo, vključno z različnimi oblikami demence, ki predstavljajo resen problem (Jelenc, 2018). Na svetu živi več kot 47 mili- 27Marjetka Jelenc, PhD, et al.: Trends in Prescription of Drugs for the Treatment ... jonov ljudi z demenco; pričakuje se, da se bo število do leta 2050 potrojilo (Satizabal idr., 2016). Demenca je kronična nevrodegenerativna motnja, ki se običajno razvija več let, preden se izrazi v obliki sindroma demence. Najpogostejša podvrsta demence je Alzheimerjeva bolezen, ki ji sledita mešana vaskularna demenca in demenca z Lewyje- vimi telesci (Gregorič Kramberger, 2017; Satizabal, 2016). Bolezen se razvija v pov- prečju od 8 do 12 let, razvoj pa je razdeljen na tri osnovne faze: zgodnjo, srednjo in pozno. Meje med fazami niso natančno določene, simptomi pa se pri posamezniku različno izražajo (Ministrstvo za zdravje, 2016; Kogoj, 2011). Za vse večje število starejših ljudi, za katere je bolezen značilna, pa ni edina težava le demenca. Kljub intenzivnim raziskavam in testiranju številnih potencialnih učinkovin zdravila, ki bi ustavilo ali bistveno upočasnilo nevrodegenerativni proces demence, nimamo. Na vo- ljo so le simptomatska zdravila za zdravljenje demence, ki so najbolj učinkovita v zgodnjih fazah bolezni (Cummings idr., 2016; Gregorič Kramberger, 2017). Trenutno registrirane učinkovine – zaviralci acetilholinesteraze donepezil, rivastigmin in ga- lantamin – vplivajo na holinergične povezave v centralnem živčnem sistemu. Vsa na- vedena zdravila imajo dokazano antiholinergično delovanje; galantamin deluje tudi kot alosterični modulator na nikotinske holinergične receptorje. Navedeni inhibitorji acetilholinesteraze so registrirani za blago do zmerno demenco. Memantin, četrto zdravilo za demenco poleg omenjenih treh, je prvo registrirano zdravilo z učinkom na receptor za N-metil-D-aspartat (NMDA) in glutamatergične poti. Vsa navedena zdravila imajo koristne simptomatske učinke in so predpisana za upočasnitev upada kakovosti življenja bolnikov (Gregorič Kramberger, 2017). Bistvenega pomena je zgodnje odkrivanje, diagnosticiranje in zdravljenje demen- ce. Če družinski zdravnik v Sloveniji ugotovi, da ni reverzibilnih znakov za kognitivni upad, da se pri bolniku ni pojavil hitro ter da pozabljivost in spremenjeno vedenje obstajata brez jasnih nevroloških vzrokov in znakov, lahko to kaže na Alzheimerjevo demenco. Glede na administrativno spremembo predpisovanja, ki jo je sprejel Zavod za zdravstveno zavarovanje Slovenije (ZZZS) v skladu s slovenskimi smernicami za zdravljenje bolnikov z demenco, lahko družinski zdravnik predpiše kognitivne modu- latorje, tako zaviralce acetilholinesteraze kot antagoniste receptorjev glutamata – ne da bi čakal na specialistični pregled in izvid psihiatra oz. nevrologa (Blejc, 2018). Spremljanje predpisovanja zdravil pomaga ugotavljati zdravstvene, ekonomske in socialne posledice bolezni (Jelenc, 2013; Kostnapfel Rihtar in Korošec, 2014). Namen naše študije je bil oceniti spremembe oz. trende pri predpisovanju zdravil, specifičnih za zdravljenje demence v Sloveniji od leta 2008 do leta 2018 po spolu in starostnih skupinah. Vir podatkov za to retrospektivno opazovalno analizo je bila Baza ambulantno predpisanih zdravil na Nacionalnem inštitutu za javno zdravje (NIJZ) Re- publike Slovenije. V analizo so bili zajeti podatki o številu izdanih receptov za zdravila za zdravljenje demence v obdobju od leta 2008 do leta 2018. Analizirani so bili vsi recepti ambulantno predpisanih zdravil, pridobljenih iz lekarn, razen iz bolnišničnih lekarn. Podatki so bili zbrani v skladu z Zakonom o zbirkah podatkov na področju 28 Revija za zdravstvene vede (7, 2020) zdravstva (Uradni list, 2000). Soglasje Republiške etične komisije ni bilo potrebno, ker so bili uporabljeni podatki že anonimizirani. Raziskava temelji na anatomsko-terapevtsko-kemijski (ATC) klasifikaciji Svetovne zdravstvene organizacije (SZO). Analizirali smo celotno ATC-skupino N06D (done- pezil, rivastigmin, galantamin, memantin). Po klasifikacijskem sistemu ATC so zdra- vila za živčni sistem (skupina N) razdeljena v sedem skupin (N01-N07). Zdravila za zdravljenje demence (N06D) so razvrščena med podskupine psihoanaleptikov (N06). Definirani dnevni odmerek zdravila (DDD) je statistična mera in je opredeljen kot pričakovan povprečni dnevni vzdrževalni odmerek zdravila za njegovo glavno indika- cijo pri odraslih. Dejanski terapevtski odmerki pri individualnih bolnikih in skupinah bolnikov so pogosto lahko različni, vendar je potrebno standardizirati porabo zdravil v raziskovalne namene med državami, skupinami ljudi in leti (WHO, 2000). Podatki ATC so bili uporabljeni za izračun števila DDD za vsako lastniško ime zdravila in njegovo pakiranje znotraj ATC-skupine N06D. Število DDD na 1.000 pre- bivalcev na dan (v nadaljevanju DID) se izračuna kot vsota števila definiranih dnev- nih odmerkov za vsako posamezno učinkovino, deljeno s 365 in celotnim številom prebivalcev v Sloveniji na dan 1. 7. posameznega leta, pomnoženo s 1000. Analiza podatkov je pokazala, da se je število bolnikov, ki so prejeli vsaj en recept za zdravila za zdravljenje demence iz skupine N06D, med letoma 2008 in 2018 več kot podvojilo. Najpogosteje predpisana zdravila za zdravljenje demence v Sloveniji v opazovanem obdobju so bili zaviralci encima acetilholinesteraze. Posledice demence so vse večji zdravstveni, socialni in gospodarski problem. Glede na demografska gibanja oz. staranje prebivalstva se v prihodnosti pričakuje povečanje števila oseb z demenco. Težava je še večja, ker zdravila za zdravljenje de- mence bolezni ne pozdravijo, ampak lahko le upočasnijo njeno napredovanje. Simp- tomi bolezni se lahko sčasoma izboljšajo. Etiološko zdravljenje demence, ki je nujno potrebno, ne obstaja (Cummings, 2017). Trenutno razpoložljivo zdravljenje je bolj učinkovito, kadar ga začnemo v zgodnejši fazi bolezni, zato je zgodnje odkrivanje in diagnosticiranje bolezni nujno. Pogosto se diagnoza demenca postavi v napredoval- nih oblikah bolezni (Sommerlad, 2016). Demenco trenutno zdravimo s kognitivnimi modulatorji, zaviralci acetilholinesteraze in antagonisti receptorjev glutamata. Zato je ključnega pomena, da izboljšamo in pospešimo raziskave in razvoj zdravil na po- dročju demence (Pankevich idr., 2014). Po drugi strani pa je treba zdraviti tudi številne nespecifične simptome te bolezni, še posebej v zgodnji fazi, ko bolezen še ni diagnosticirana in ima bolnik na primer simptome depresije ali nespečnosti. Vsi ti nespecifični simptomi nediagnosticirane osnovne bolezni se običajno zdravijo z zdravili. Na to dejstvo se navezuje tudi ena izmed pomanjkljivosti naše raziskave, ki ni vključevala zdravil za zdravljenje spre- mljevalnih simptomov nediagnosticirane bolezni. S to retrospektivno, opazovalno študijo smo želeli oceniti trende predpisovanja zdravil za zdravljenje demence v Sloveniji v obdobju od leta 2008 do leta 2018. Ugo- tovili smo, da se je število bolnikov, ki so prejeli vsaj en recept za zdravila iz skupi- 29Marjetka Jelenc, PhD, et al.: Trends in Prescription of Drugs for the Treatment ... ne N06D, v opazovanem obdobju več kot podvojilo. Povišanje je večje med moškimi (146 %) kot med ženskami (132 %). Število receptov za zdravila za zdravljenje de- mence se je v obdobju od leta 2008 do leta 2018 povečalo za 140 %, medtem ko se je število DDD/1000 prebivalcev na dan povečalo za 175 %. Stroški teh zdravil so se v obdobju od 2008 do 2012 zvišali za 35 % in med letoma 2012 in 2018 padli za 40 %, kar je posledica padca cen zdravil zaradi vstopa cenejših proizvajalcev generičnih izdelkov na trg. Vendar pa se je v opazovanem obdobju povečalo tudi število starejših. Na primer, leta 2008 je bilo v Sloveniji okrog 330 tisoč prebivalcev starejših od 65 let, v letu 2018 pa je bilo starejših od 65 let že 407 tisoč prebivalcev. Rahlo zmanjšanje števila bolnikov v starostni skupini 70–74 let je posledica manjšega števila rojstev med drugo svetovno vojno. Na voljo je zelo omejeno število študij s podobnim ciljem, zato je težko primerjati trende v Sloveniji s trendi v drugih državah, zlasti ne z državami s podobnimi demografskimi podatki. V Veliki Britaniji je bila v obdobju 2005–2015 opravljena longitudinalna retrospektivna kohortna študija, katere cilj je bil opisati spremembe v deležu ljudi z diagnozo demenca in zdravil, ki so jim bila predpisana v desetletnem obdobju. Avtorji so ugotovili, da se je predpisovanje zdravil proti demenci po uvedbi nacionalnih strategij za demenco več kot podvojilo (Donegan idr., 2017). Naša raziskava je imela tudi nekaj pomanjkljivosti. Vanjo so bili vključeni le am- bulantni recepti, bolnišnični podatki še niso bili na voljo. Študija tudi ni vključevala zdravil za zdravljenje spremljevalnih simptomov nediagnosticirane bolezni. Ocenju- jemo, da se le del bolnikov z demenco zdravi z ustreznimi zdravili in da obstajajo tudi osebe z neprepoznano demenco v različnih fazah. Z boljšo identifikacijo in vključitvijo teh ljudi v zdravljenje lahko bistveno prispevamo h kakovosti življenja starejših z de- menco, njihovemu dostojanstvu in samostojnosti ter olajšamo življenje skrbnikom in družinam. Negovalci pacientov z demenco so zaradi zahtevnega dela zelo izpostav- ljeni telesnim in duševnim boleznim, zato potrebujejo enako pozornost in podporo (Gregorič Kramberger, 2017). Pričujoča retrospektivna opazovalna študija je pokazala, da so bila najpogosteje predpisana zdravila za zdravljenje demence v Sloveniji od leta 2008 do leta 2018 zaviralci encimov acetilholinesteraze. V opazovanem obdobju se je ambulantno pred- pisovanje zdravil za zdravljenje te bolezni povečalo pri moških in ženskah, število pre- jemnikov vsaj enega recepta pa se je kar več kot podvojilo. Dostopnost do zdravljenja je od leta 2018 zaradi ukrepov ZZZS bistveno boljša. Predvidevamo pa, da nekateri bolniki z demenco še vedno niso ustrezno zdravljeni, predvsem zaradi neprepoznane bolezni v zgodnji fazi. Zgodnja diagnoza bolezni in takojšnje ustrezno zdravljenje sta ključna za bolnika, njegove svojce in skrbnike. LITERATURE 1. Blejc, U. (2018). Ob demenci ne smemo izgubljati časa. Pharmonia, 42. 2. Cummings, J. (2017). Disease modification and neuroprotection in neurodegenerative disorders. Translational Neurodegeneration, 6, p. 25. 3. Cummings, J., Morstorf, T. and Lee, G. (2016). 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E-mail: ales.korosec@nijz.si Mercedes Lovrečič, PhD, Assist. Prof, National Institute of Public Health, Slovenija. E-mail: mercedes.lovrecic@nijz.si