A comprehensive German claims data analysis of care pathways, risk factors and comorbidities among acetylcholinesterase inhibitor initiators in Alzheimer's disease.

Early stages of Alzheimer's Disease (AD), commonly referred to as early AD (eAD), represent a critical phase for timely diagnosis and intervention. However, significant gaps remain in understanding real-world care of individuals initiating first-line treatment such as acetylcholinesterase inhibitors (AChE-I) in Germany. A retrospective study was conducted using the German InGef claims database with a pragmatic proxy approach, identifying de novo AChE-I initiators as individuals suspected of having eAD. Two cohorts were defined: a pre-cohort (2022) capturing eight-years prior to AChE-I initiation, and a post-cohort (2017), analyzing five-years following initiation. Patients were matched 1:1 to controls without AD based on demographic characteristics. Outcomes included comorbidities, risk factors, diagnostics, prescriptions, and survival. The study identified 1,994 (pre-cohort) and 2,051 (post-cohort) AChE-I initiators, and respective controls. Mobility disorders increased significantly (+ 55%) over the eight years preceding treatment. Eight years pre-initiation, 81.9% of initiators exhibited at least one modifiable risk factor compared to 76.2% in controls (p < 0.001). Advanced diagnostic procedures were underutilized (MRI: 39.0%, cerebrospinal fluid analysis: 9.2%, in year -1). Only 78.6% received an AD-specific diagnosis within the first year post-initiation. Extensive use of psycholeptics and psychoanaleptics was observed, with a notable decline in dementia-specific medications post-initiation. Post-initiation, initiators showed higher comorbidity burden (e.g., urinary incontinence: 40.2% vs. 10.7% by year 5) and higher observed, unadjusted mortality (53.3% vs. 21.7%, p < 0.001). This study highlights patterns suggestive of gaps in the management of AChE-I initiators in Germany, including underutilization of guideline-based diagnostics, high comorbidity burden, and higher observed mortality. Improved management strategies and the development of more precise diagnostic coding that reflects disease stages could help to address these issues.