Ganeshalingam et al (Reference Ganeshalingam, Cooper and Livingston2008) infer that prescribers are making clinical judgements rather than strictly adhering to the Mini-Mental State Examination (MMSE) score when deciding to prescribe acetylcholinesterase inhibitors under the revised National Institute for Health and Clinical Excellence guidance (National Institute for Health and Clinical Excellence, 2006).

We examined this issue in Southern Derbyshire by scrutinising application forms submitted by clinicians to our pharmacy department as a prerequisite to the issuing of these drugs.

In the year 1 June 2007 to 30 June 2008, 227 service users were initiated on acetylcholinesterase inhibitors by 7 clinicians working in old age psychiatry and 32 (14%) initiates scored above 20 on the MMSE, of whom 26 had a recorded diagnosis of Alzheimer's disease. Within this high-scoring group of individuals with Alzheimer's disease, MMSE score did not correlate with Bristol Activities of Daily Living (BADL) or Relative Stress Scale (RSS) scores (Spearman's r=0.06 and 0.16 respectively, P>10%), but BADL did correlate with RSS (Spearman's r=0.79, P<1%) - high functional impairment was associated with more carer stress. Almost half (n=12) of the 26 individuals showed such features of dementia as agitation, aggression or psychosis and 11 were anxious, depressed or apathetic. Only six had no recorded behavioural or psychological features of dementia.

These findings indicate that relying on the MMSE score to guide the prescribing of acetylcholinesterase inhibitors to people with apparently mild Alzheimer's disease is likely to represent poor practice. We propose that all individuals with an MMSE of 20 or above are given an acetylcholinesterase inhibitor unless sufficient evidence can be gathered to justify withholding it.