Somatic comorbidities and Alzheimer's disease treatment

Adjunctive treatment of behavioral disorders in patients with cognitive deficit

Adjunctive treatment of behavioral disorders in patients with cognitive deficit The article provides an overview of the pharmacotherapy of behavioural and psychological symptoms of dementia (BPSD) in the context of evidence-based medicine. Its goal is to provide readers with a practical and educational overview of managing these symptoms. Cognitive disorders, including dementia, result from the disruption of higher cortical functions of the brain. Dementia often manifests not only through cognitive dysfunction but also through BPSD, such as agitation, aggression, anxiety, psychosis, and sleep disturbances. These symptoms affect up to 97% of patients with dementia and significantly reduce the quality of life for both patients and caregivers. BPSD are often more stressful for patients and caregivers than the cognitive symptoms themselves. Behavioural symptoms include a wide range of manifestations from non-aggressive forms such as pacing and repetitive movements to aggressive and agitated behaviour (verbal and physical). Psychological symptoms can include depression, anxiety, and psychotic symptoms such as paranoia and delusions. The causes of BPSD can be varied, as well as their risk factors (including e.g. co-medication, comorbidities, the patient's personality traits, inappropriate communication by caregivers, and environmental influences). The pharmacotherapy of BPSD is complex and often involves the use of antipsychotics, antidepressants, benzodiazepines, or acetylcholinesterase inhibitors and memantine. Due to the diversity of manifestations and causes of BPSD, a unified pharmacotherapeutic approach cannot be applied. Non-pharmacological approaches should always be preferred, except in cases of severe depression, psychosis, or aggression that may endanger the patient or someone else. In practice, many medications indicated for BPSD therapy are used off-label. The pharmacotherapy of BPSD should only begin after ruling out other causes of BPSD. Furthermore, it should only be initiated after considering all risks and potential benefits, starting with low geriatric doses, monitoring side effects, regularly reassessing effectiveness, and administering medications for the shortest possible duration should be also applied.

Pharmacogenetic studies in Alzheimer disease

INTRODUCTION

Alzheimer disease (AD) is the most common cause of dementia and is considered one of the main causes of disability and dependence affecting quality of life in elderly people and their families. Current pharmacological treatment includes acetylcholinesterase inhibitors (donepezil, galantamine, rivastigmine) and memantine; however, only one-third of patients respond to treatment. Genetic factors have been shown to play a role in this inter-individual variability in drug response.

DEVELOPMENT

We review pharmacogenetic reports of AD-modifying drugs, the pharmacogenetic biomarkers included, and the phenotypes evaluated. We also discuss relevant methodological considerations for the design of pharmacogenetic studies into AD. A total of 33 pharmacogenetic reports were found; the majority of these focused on the variability in response to and metabolism of donepezil. Most of the patients included were from Caucasian populations, although some studies also include Korean, Indian, and Brazilian patients. CYP2D6 and APOE are the most frequently studied biomarkers. The associations proposed are controversial.

CONCLUSIONS

Potential pharmacogenetic biomarkers for AD have been identified; however, it is still necessary to conduct further research into other populations and to identify new biomarkers. This information could assist in predicting patient response to these drugs and contribute to better treatment decision-making in a context as complex as aging.

Conceptualising comorbidity and multimorbidity in dementia: A scoping review and syndemic framework

Background

Older people and people with dementia experience a high prevalence of multiple health conditions. The terms 'comorbidity' and 'multimorbidity' are often used interchangeably to describe this, however there are key conceptual differences between these terms and their definitions. This has led to issues in the validity and comparability of research findings, potentially inappropriate intervention development and differences in quality of health care.

Objective

To review how the terms 'comorbidity' and 'multimorbidity' are defined within peer-reviewed dementia research and propose an operational framework.

Design

A scoping review of definitions within dementia research was carried out. Searches took place across five databases: Academic Search Premier, CINAHL Complete, MEDLINE, PsycARTICLES and PsycINFO. PRISMA-ScR guidelines were followed.

Results

Content analysis revealed five key themes, showing significant overlap and inconsistencies from both within, and between, the comorbidity and multimorbidity definitions; 1. Number of conditions; 2. Type of health conditions; 3. The co-occurrence of conditions; 4. The inclusion of an index disease (or not); 5. Use of medical language. The analysis also revealed gaps in how the underlying concepts of the definitions relate to people with dementia living with multiple health conditions.

Conclusion

This scoping review found that current definitions of comorbidity and multimorbidity are heterogeneous, reductionist and disease-focussed. Recommendations are made on the design of research studies including transparency and consistency of any terms and definitions used. A syndemic framework could be a useful tool for researchers, clinicians and policy makers to consider a more holistic picture of a person with dementia's health and wellbeing.

A Retrospective Study on the Benefits of Combined Citicoline, Memantine, and Acetylcholinesterase Inhibitor Treatments in Older Patients Affected with Alzheimer's Disease

BACKGROUND

Background: Citicoline has been proven to have beneficial effects in patients with cognitive impairment. In previous studies, combined treatment with memantine and acetylcholinesterase inhibitors (AChEIs) maintained cognitive function in patients with Alzheimer's disease (AD) better than memantine or AChEIs alone.

OBJECTIVE

To evaluate the effectiveness and safety of a combination therapy of oral citicoline, memantine, and an AChEI in AD when compared with memantine and an AChEI without citicoline.

METHODS

This was a retrospective multi-centric case-control study, conducted in Italian Centers for Cognitive Impairment and Dementia. Overall, 170 patients were recruited (34.11%of men, mean age 76,81±4.93 years): 48.8%treated with memantine and donepezil; 48.2%with memantine and rivastigmine; 2.9%with memantine and galantamine. 89 patients (control-group) were treated with memantine and an AChEI, whereas 81 patients (case-group) were treated with oral citicoline 1000 mg/day added to memantine and an AChEI given orally. Cognitive functions, activities of daily living, instrumental activities of daily living, comorbidities, mood and behavioral disturbances were assessed at baseline, month 6, and month 12.

RESULTS

In the case group, MMSE score had a statistically significant increasing trend between T0 and T2 (14.88±2.95 versus 15.09±3.00; p = 0.040), whereas in the control group, MMSE score showed a statistically significant decrease trend (14.37±2.63 versus 14.03±2.92 p = 0.024).

CONCLUSION

In older patients with AD, a triple therapy with citicoline, memantine, and AChEI was more effective than memantine and AChEI without citicoline in maintaining the MMSE total score after 12 months.

Revisiting social MPE: an integration of molecular pathological epidemiology and social science in the new era of precision medicine

INTRODUCTION

Molecular pathological epidemiology (MPE) is an integrative transdisciplinary area examining the relationships between various exposures and pathogenic signatures of diseases. In line with the accelerating advancements in MPE, social science and its health-related interdisciplinary areas have also developed rapidly. Accumulating evidence indicates the pathological role of social-demographic factors. We therefore initially proposed social MPE in 2015, which aims to elucidate etiological roles of social-demographic factors and address health inequalities globally. With the ubiquity of molecular diagnosis, there are ample opportunities for researchers to utilize and develop the social MPE framework.

AREAS COVERED

Molecular subtypes of breast cancer have been investigated rigorously for understanding its etiologies rooted from social factors. Emerging evidence indicates pathogenic heterogeneity of neurological disorders such as Alzheimer's disease. Presenting specific patterns of social-demographic factors across different molecular subtypes should be promising for advancing the screening, prevention, and treatment strategies of those heterogeneous diseases. This article rigorously reviewed literatures investigating differences of race/ethnicity and socioeconomic status across molecular subtypes of breast cancer and Alzheimer's disease to date.

EXPERT OPINION

With advancements of the multi-omics technologies, we foresee a blooming of social MPE studies, which can address health disparities, advance personalized molecular medicine, and enhance public health.

Efficacy and safety of pharmacotherapy for Alzheimer's disease and for behavioural and psychological symptoms of dementia in older patients with moderate and severe functional impairments: a systematic review of controlled trials

BACKGROUND

Many patients with Alzheimer's disease (AD) are physically frail or have substantial functional impairments. There is growing evidence that such patients are at higher risk for medication-induced adverse events. Furthermore, frailty seems to be more predictive of poor clinical outcomes than chronological age alone. To our knowledge, no systematic review of clinical trials examining drug therapy of AD or behavioural and psychological symptoms of dementia (BPSD) has specifically focused on the topic of physical frailty. Our objective was to evaluate the efficacy and safety of pharmacotherapy in AD patients with frailty or significant functional impairments.

METHODS

We performed a systematic literature search in MEDLINE, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL) for randomized controlled trials (RCTs) of drug therapy of AD and BPSD in patients with significant functional impairments according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and Cochrane research criteria. Significant functionally impaired patient populations were identified using the recommendations of the Medication and Quality of Life in frail older persons (MedQoL) Research Group. Screening, selection of studies, data extraction and risk of bias assessment were performed independently by two reviewers. Outcomes including functional status, cognitive function, changes in BPSD symptoms, clinical global impression and quality of life were analysed. For assessing harm, we assessed adverse events, drop-outs as a proxy for treatment tolerability and death. Results were analysed according to Cochrane standards and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

Of 45,045 search results, 38,447 abstracts and 187 full texts were screened, and finally, 10 RCTs were included in the systematic review. Selected articles evaluated pharmacotherapy with acetylcholinesterase-inhibitors (AChEI), anticonvulsants, antidepressants and antipsychotics. Studies of AChEIs suggested that patients with significant functional impairments had slight but significant improvements in cognition and that AChEIs were generally well tolerated. Studies of antidepressants did not show significant improvements in depressive symptoms. Antipsychotics and anticonvulsants showed small effects on some BPSD items but also higher rates of adverse events. However, due to the very small number of identified trials, the quality of evidence for all outcomes was low to very low. Overall, the small number of eligible studies demonstrates that significantly functional impaired older patients have not been adequately taken into consideration in most clinical trials investigating drug therapy of AD and BPSD.

CONCLUSION

Due to lack of evidence, it is not possible to give specific recommendations for drug therapy of AD and BSPD in frail older patients or older patients with significant functional impairments. Therefore, clinical trials focussing on frail older adults are urgently required. A standardized approach to physical frailty in future clinical studies is highly desirable.

Relationship between chewing tobacco, smoking, consuming alcohol and cognitive impairment among older adults in India: a cross-sectional study

BACKGROUND

Physical aging increases the sensitivity to the effects of substance use, elevating the risk for cognitive impairment among older adults. Since studies on the association of substance use with cognitive ability in later years are scant in India, we aimed to explore the factors associated with cognitive impairment especially, alcohol consumption, smoking, and chewing tobacco later in life.

METHODS

The present research used nationally representative data from Building a Knowledge Base on Population Aging in India (BKPAI) that was conducted in 2011, across seven states of India (N=9,453). Sample distribution along with percentage distribution was calculated for cognitive impairment over explanatory variables. For finding the association between cognitive impairment over explanatory variables, binary logistic regression models were estimated.

RESULTS

About 16.5 percent of older adults in rural areas consumed smoked tobacco compared to 11.7 percent in urban areas. Nearly, 23.7 percent of rural older adults consumed smokeless tobacco in comparison to 16 percent in urban areas. Alcohol consumption was high among rural residents (7.9%) than urban counterparts (6.7%). The prevalence of cognitive impairment was 62.8% and 58% among older adults from rural and urban areas respectively. Older adults who smoked tobacco had a 24 percent significantly higher likelihood to have cognitive impairment with reference to older adults who did not smoke [OR: 1.24, CI: 1.02-1.49]. Moreover, older adults who consumed alcohol had a 30 percent significantly higher likelihood to have cognitive impairment [OR: 1.02, 1.65]. It was also found that older adults who had smoked along with consuming alcohol were at risk of worse cognitive outcomes than those who neither smoke nor drink alcohol [OR: 1.56, CI: 1.21-2.00] or consumed either of them unlike consuming smokeless tobacco only.

CONCLUSION

The encouragement of older people to stop smoking and smokeless tobacco use could be considered as part of a strategy to reduce the incidence of cognitive impairment. Further, appropriate measures should be taken for the detection of early stages of cognitive decline in older individuals and efforts should be made to improve the availability and quality of care for dementing older adults.

Effects of kidney function, serum albumin and hemoglobin on dementia severity in the oldest old people with newly diagnosed Alzheimer's disease in a residential aged care facility: a cross-sectional study

Background

Chronic kidney disease (CKD), low serum albumin, and anemia are known risk factors for cognitive decline in older people. We investigated the association between kidney function and cognitive impairment severity in oldest-old people with a diagnosis of Alzheimer’s disease (AD).

Methods

A cross-sectional study of patients aged 80 years and older was conducted at a veterans’ home in Taiwan between 2012 and 2016. Their estimated glomerular filtration rate (eGFR) was determined using the Modification of Diet in Renal Diseases (MDRD) equation. Cognitive function was evaluated with the Mini-Mental State Examination (MMSE) and Clinical Dementia Rating (CDR).

Results

A total of 84 patients (age mean ± SD, 86.6 ± 3.9 years) had MMSE scores of 10.1 ± 6.7, and CDR scores of 1.6 ± 0.7. The average eGFR was 61.7 ± 21.5 mL/min/1.73m². The mean hemoglobin concentration was 12.7 ± 1.7 g/dl, and the mean albumin concentration was 4.5 ± 4.8 g/dl. Multivariate regression analyses showed that scores of CDR were significantly correlated with eGFR after adjustment for potential confounders. The scores of MMSE were significantly correlated with serum albumin and hemoglobin after adjustment for potential confounders.

Conclusions

We found dementia severity was significantly associated with kidney function, serum albumin, and hemoglobin in the oldest-old with AD. We recommend that oldest-old people with a diagnosis of AD be evaluated to determine kidney function, as well as nutritional and hematological status. Further study is needed to establish whether prevention of CKD deterioration, and correction of malnutrition and anemia may help to slow cognitive decline in oldest-old people with dementia.

The Impact of Pharmacologic and Nonpharmacologic Interventions to Improve Physical Health Outcomes in People With Dementia: A Meta-Review of Meta-Analyses of Randomized Controlled Trials

OBJECTIVES

We summarized and compared meta-analyses of pharmacologic and nonpharmacologic interventions targeting physical health outcomes among people with dementia.

DESIGN

This is a systematic review and meta-analysis.

SETTING AND PARTICIPANTS

People with dementia, confirmed through validated assessment measures.

METHODS

Major databases were searched until October 21, 2019. Effect sizes [standardized mean difference (SMD)/Hedges g or risk ratio (RR)] were compared separately.

RESULTS

Of 3773 search engine hits, 4 meta-analyses were included, representing 31 meta-analyzed trials and 10,054 study participants. Although meta-analyses were generally of adequate high quality, meta-analyzed studies were less so. Nutritional supplements were the only one to show a weight-increasing effect [SMD 0.53, 95% confidence interval (CI) 0.38-0.68, ie, medium effect; N = 12, n = 748]. Acetylcholinesterase inhibitors are associated with an increased risk for weight loss (RR 2.1, 95% CI 1.5‒3.0; N = 9, n = 7010). For the treatment of pain, sensory stimulation has a medium effect (SMD -0.58, 95% CI -0.99 to -0.17; N = 6, n = 199), whereas physical activity has a small effect (SMD -0.24, 95% CI -1.06 to 0.59; N = 2, n = 75). When exploring the characteristics of the psychosocial interventions, group-based interventions demonstrated a medium (SMD -0.55, 95% CI -1.02 to -0.09; N = 6, n = 157) and individual psychosocial interventions a small effect (SMD -0.27, 95% CI -1.06 to 0.53; N = 2, n = 55).

CONCLUSIONS AND IMPLICATIONS

Despite frequent physical comorbidities, the current evidence for pharmacologic and nonpharmacologic interventions in people with dementia to prevent and treat these conditions is still in its infancy, and larger trials targeting a wide range of physical health outcomes are urgently needed. Based on the SMDs and RRs, nutritional supplements can be recommended as an intervention to treat malnutrition. Clinicians should be careful in treating patients with acetylcholinesterase inhibitors, as it shows medium weight reducing effects. For the treatment of comorbid pain, sensory stimulation and psychosocial interventions are recommended.

Cholinesterase Inhibitors for Alzheimer's Disease: Multitargeting Strategy Based on Anti-Alzheimer's Drugs Repositioning

In the brain, acetylcholine (ACh) is regarded as one of the major neurotransmitters. During the advancement of Alzheimer's disease (AD) cholinergic deficits occur and this can lead to extensive cognitive dysfunction and decline. Acetylcholinesterase (AChE) remains a highly feasible target for the symptomatic improvement of AD. Acetylcholinesterase (AChE) remains a highly viable target for the symptomatic improvement in AD because cholinergic deficit is a consistent and early finding in AD. The treatment approach of inhibiting peripheral AChE for myasthenia gravis had effectively proven that AChE inhibition was a reachable therapeutic target. Subsequently tacrine, donepezil, rivastigmine, and galantamine were developed and approved for the symptomatic treatment of AD. Since then, multiple cholinesterase inhibitors (ChEIs) have been continued to be developed. These include newer ChEIs, naturally derived ChEIs, hybrids, and synthetic analogues. In this paper, we summarize the different types of ChEIs which are under development and their respective mechanisms of actions.

A Focused Library of Psychotropic Analogues with Neuroprotective and Neuroregenerative Potential

Overcoming the lack of effective treatments and the continuous clinical trial failures in neurodegenerative drug discovery might require a shift from the prevailing paradigm targeting pathogenesis to the one targeting simultaneously neuroprotection and neuroregeneration. In the studies reported herein, we sought to identify small molecules that might exert neuroprotective and neuroregenerative potential as tools against neurodegenerative diseases. In doing so, we started from the reported neuroprotective/neuroregenerative mechanisms of psychotropic drugs featuring a tricyclic alkylamine scaffold. Thus, we designed a focused-chemical library of 36 entries aimed at exploring the structural requirements for efficient neuroprotective/neuroregenerative cellular activity, without the manifestation of toxicity. To this aim, we developed a synthetic protocol, which overcame the limited applicability of previously reported procedures. Next, we evaluated the synthesized compounds through a phenotypic screening pipeline, based on primary neuronal systems. Phenothiazine 2Bc showed improved neuroregenerative and neuroprotective properties with respect to reference drug desipramine (2Aa). Importantly, we have also shown that 2Bc outperformed currently available drugs in cell models of Alzheimer's and Parkinson's diseases and attenuates microglial activation by reducing iNOS expression.

Comorbidity and polypharmacy in people with dementia: insights from a large, population-based cross-sectional analysis of primary care data

Background

The care of older people with dementia is often complicated by physical comorbidity and polypharmacy, but the extent and patterns of these have not been well described. This paper reports analysis of these factors within a large, cross-sectional primary care data set.

Methods

Data were extracted for 291,169 people aged 65 years or older registered with 314 general practices in the UK, of whom 10,258 had an electronically recorded dementia diagnosis. Differences in the number and type of 32 physical conditions and the number of repeat prescriptions in those with and without dementia were examined. Age–gender standardised rates were used to calculate odds ratios (ORs) of physical comorbidity and polypharmacy.

Results

People with dementia, after controlling for age and sex, had on average more physical conditions than controls (mean number of conditions 2.9 versus 2.4; P < 0.001) and were on more repeat medication (mean number of repeats 5.4 versus 4.2; P < 0.001). Those with dementia were more likely to have 5 or more physical conditions (age–sex standardised OR [sOR] 1.42, 95% confidence interval (CI) 1.35–1.50; P < 0.001) and were also more likely to be on 5 or more (sOR 1.46; 95% CI 1.40–1.52; P < 0.001) or 10 or more repeat prescriptions (sOR 2.01; 95% CI 1.90–2.12; P < 0.001).

Conclusions

People with dementia have a higher burden of comorbid physical disease and polypharmacy than those without dementia, even after accounting for age and sex differences. Such complex needs require an integrated response from general health professionals and multidisciplinary dementia specialists.

The Citicholinage Study: Citicoline Plus Cholinesterase Inhibitors in Aged Patients Affected with Alzheimer's Disease Study

BACKGROUND

Citicoline can have beneficial effects both in degenerative and in vascular cognitive decline in a variety of ways (apoptosis inhibition, neuroplasticity potentiation, phospholipid, and acetylcholine (ACh) synthesis). Acetylcholinesterase inhibitors (AChEIs) have been used for treatment of Alzheimer's disease (AD). When co-administered with cholinergic precursors, they are able to increase the intrasynaptic levels of ACh more than when the single drugs given alone.

OBJECTIVE

The aim of the present study was to show the effectiveness of oral citicoline plus AChEIs in patients affected with AD.

METHODS

This was a retrospective multi-centric case-control study, involving seven Centers for Cognitive Impairment and Dementia in Italy, on 448 consecutive patients aged 65 years old or older affected with AD. 197 patients were treated with an AChEI while 251 were treated with an AchEI + citicoline 1000 mg/day given orally. Cognitive functions were assessed by MMSE, daily life functions by ADL and IADL, behavioral symptoms by NPI, comorbidities by CIRS, and mood by GDS-short form. Tests were administered at baseline (T0), after 3 (T1), and 9 months (T2). The primary outcomes were effects of combined administration versus AChEIs given alone on cognitive functions assessed by MMSE. The secondary outcomes were possible side effects or adverse events of combination therapy versus AChEIs alone.

RESULTS

Patients treated with citicoline plus an AChEI showed a statistically significant increase in MMSE between T0 and T1 (16.88±3.38 versus 17.62±3.64; p = 0.000) and between T1 and T2 (17.62±3.64 versus 17.89±3.54; p = 0.000).

CONCLUSION

The present study encourages the role of combined administration in disease management by slowing disease progression.