Cholinergic therapy for neuropsychiatric symptoms in neurologic disorders

[The efficacy of pharmacological approaches to therapy of the apathy syndrome in dementia disorders (the review)]

The article presents a literature review of psychopharmacological methods of treatment of the apathy syndrome, which is common in neurocognitive disorders. The review provides recommendations for the management of such patients, taking into account evidence-based medicine.

Pharmacologic treatment of apathy in dementia

Apathy in patients with dementia is common, underrecognized, and undertreated. We sought to improve understanding of the pharmacologic treatment of apathy in dementia by performing a systematic literature review of studies that used apathy outcome scales to document results of pharmacologic treatments for apathy. There is limited evidence of efficiency of pharmacotherapy for treatment of apathy in dementia. The best results were found for acetylcholinesterase inhibitors. There was some evidence of efficacy for memantine, but less evidence of efficacy for stimulants, calcium antagonists, and antipsychotics. There was no evidence to support the use of antidepressants or anticonvulsants. The research quality of studies was modest. Recommendations for standardizing research and for holistic evaluation and treatment are provided.

An open-label pilot study of acetylcholinesterase inhibitors to promote functional recovery in elderly cognitively impaired stroke patients

BACKGROUND

Impairments in cognition and motivation are common after stroke and predict poor functional recovery. Pharmacological agents that enhance cognition and/or diminish apathy may, when combined with traditional rehabilitative efforts, improve functional recovery. We investigated the feasibility of using acetylcholinesterase inhibitors in older patients with acute post-stroke cognitive impairment and examined their effects on functional recovery.

METHODS

This 12-week open-label study prospectively treated ischemic stroke survivors aged > or =60 years who were undergoing inpatient rehabilitation and who had cognitive impairment in one or more domains (memory, attention or executive function). Participants received galantamine (maximum dose 24 mg/day) or donepezil (maximum dose 10 mg/day). Physical function was assessed using the Functional Independence Measure-motor subscale (FIM-motor); participants' functional gains were compared to those of a matched historical comparator group. Changes in cognition and apathy were also assessed. Since donepezil and galantamine have different pharmacologic profiles, they were examined separately.

RESULTS

Forty participants started study medication; 14 participants terminated prematurely. Donepezil-treated participants experienced a 14-point greater improvement in the FIM-motor score compared to either galantamine-treated participants or the historical comparator group (repeated measures mixed model, group x time interaction p < 0.0001). Change in apathy, but not in cognition, was also associated with change in the FIM-motor score.

CONCLUSIONS

In this open-label study, participants receiving donepezil had better functional recovery than participants receiving galantamine or the historical comparators. This improvement may reflect efficacy at the starting dose for donepezil but not galantamine. A randomized trial is in progress.

Do lesions involving the cortical cholinergic pathways help or hinder efficacy of donepezil in patients with Alzheimer's disease?

AIMS

To investigate the influences of vascular lesions detected by MRI, lesions involving the cortical cholinergic pathways and hippocampal thickness on therapeutic responsiveness to donepezil in patients with Alzheimer's disease (AD).

METHODS

The study cohort contained 67 patients with probable AD. We used the revised Hasegawa Dementia Rating (HDS-R) and the Clock Drawing Test (CDT) to evaluate drug efficacy for 24 months. The Cholinergic Pathways Hyperintensities Scale (CHIPS), a newly developed visual scale, was used to semiquantify lesions on the cholinergic pathways.

RESULTS

Over the 24-month period, the results of the CDT showed more apparent and constant association with white matter hyperintensities (WMH) and lesions on the cholinergic pathways than the HDS-R. WMH may enhance, while lesions on the cholinergic pathways may attenuate sensitivity to donepezil treatment when judged by the CDT. No apparent association between the thicknesses of hippocampi with baseline cognition or therapeutic responsiveness to donepezil was found.

CONCLUSION

Donepezil may be more efficacious when further executive dysfunction caused by WMH is added to AD dementia and less so when cholinergic reserves are further impinged upon by lesions involving the cortical cholinergic pathways.

Treating Dementia Patients With Vascular Lesions With Donepezil: A Preliminary Analysis

Sixteen patients with Alzheimer's disease (AD) and 15 patients with vascular dementia (VaD) associated with subcortical white matter lesions or subcortical cardiovascular accidents (CVAs) were treated with donepezil for 16 weeks. Within-group analyses for the AD group revealed significant improvement on some tests of working memory, and marginal improvement on the Mini-Mental State Examination and on tests of immediate free recall from a serial list-learning task. Identical analyses for the VaD group revealed substantial gains on tests of working memory and delayed recognition memory. These data suggest that medication such as donepezil may act to improve the working memory deficits known to be associated with dementia patients with subcortical vascular lesions. The clinical implications of these findings are discussed.

Mild cognitive impairment is associated with characteristic neuropsychiatric symptoms

Mild cognitive impairment (MCI) has emerged as an identifiable condition and in many cases is a transitional state preceding diagnosable Alzheimer disease (AD). Neurobiological and neuroimaging characteristics of amnestic-type MCI have been investigated, but few comprehensive neuropsychiatric studies have been reported. The aim of this preliminary study was to define the neuropsychiatric features of the amnestic-type MCI and compare them with those of mild AD and normal controls. The Neuropsychiatric Inventory (NPI) was used to assess the neuropsychiatric symptoms in three age and education comparable groups, i.e., 28 MCI, 124 mild AD, and 50 normal subjects. Individual subscores of the 10 NPI symptoms and total NPI scores were compared between the MCI patients and the other 2 groups. The results of this preliminary investigation showed that MCI patients frequently manifested neuropsychiatric symptoms. The most common symptoms in the MCI group were dysphoria (39%), apathy (39%), irritability (29%), and anxiety (25%). There were significant differences in apathy, dysphoria, irritability, anxiety, agitation, and aberrant motor behavior between the MCI and control groups; in contrast, only delusions were significantly less common in MCI compared with mild AD. There was a significant difference between the MCI and control groups on total NPI scores (p = 0.001), but not between the MCI and mild AD groups (p = 0.304). Amnestic MCI is associated with significant neuropsychiatric symptoms, especially mood disturbances and apathy. Psychotic symptoms are significantly more common in the early stage of AD than in MCI. These results are derived from a limited clinical sample and require confirmation in longitudinal community-based investigations.