Tolerability of Cholinesterase Inhibitors: A Population-Based Study of Persistence, Adherence, and Switching

Prevalence of treated patients with Alzheimer's disease: current trends and COVID-19 impact

BACKGROUND

There are few updated studies on the prevalence and management of Alzheimer's disease (AD), which could be underdiagnosed or undertreated. The COVID-19 pandemic may have worsened the deficiencies in the diagnosis and treatment of these patients. Electronic medical records (EMR) offer an opportunity to assess the impact and management of medical processes and contingencies in the population.

OBJECTIVE

To estimate AD prevalence in Spain over a 6-year period, based on treated patients, according to usual clinical practice. Additionally, to describe the management of AD-treated patients and the evolution of that treatment during the 2020 COVID-19 pandemic.

METHODS

Retrospective study using the Spanish IQVIA EMR database. Patients treated with donepezil, galantamine, rivastigmine, and/or memantine were included in the study. Annual AD prevalence (2015-2020) was estimated and extrapolated to the national population level. Most frequent treatments and involved specialties were described. To assess the effect of COVID-19, the incidence of new AD cases in 2020 was calculated and compared with newly diagnosed cases in 2019.

RESULTS

Crude AD prevalence (2015-2020) was estimated at 760.5 per 100,000 inhabitants, and age-standardized prevalence (2020) was 664.6 (male 595.7, female 711.0). Monotherapy was the most frequent way to treat AD (86.2%), in comparison with dual therapy (13.8%); rivastigmine was the most prescribed treatment (37.3%), followed by memantine (36.4%) and donepezil (33.0%). Rivastigmine was also the most utilized medication in newly treated patients (46.7%), followed by donepezil (29.8%), although donepezil persistence was longer (22.5 vs. 20.6 months). Overall, donepezil 10 mg, rivastigmine 9.5 mg, and memantine 20 mg were the most prescribed presentations. The incidence rate of AD decreased from 148.1/100,000 (95% confidence interval [CI] 147.0-149.2) in 2019 to 118.4/100,000 (95% CI 117.5-119.4) in 2020.

CONCLUSIONS

The obtained prevalence of AD-treated patients was consistent with previous face-to-face studies. In contrast with previous studies, rivastigmine, rather than donepezil, was the most frequent treatment. A decrease in the incidence of AD-treated patients was observed during 2020 in comparison with 2019, presumably due to the significant impact of the COVID-19 pandemic on both diagnosis and treatment. EMR databases emerge as valuable tools to monitor in real time the incidence and management of medical conditions in the population, as well as to assess the health impact of global contingencies and interventions.

Anti-Dementia Drug Persistence Following Donepezil Initiation Among Alzheimer's Disease Patients in Japan: LIFE Study

BACKGROUND

Donepezil is frequently used to treat Alzheimer's disease (AD) symptoms but is associated with early discontinuation. Determining the persistence rates of anti-dementia drug use after donepezil initiation may inform the development and improvement of treatment strategies, but there is little evidence from Japan.

OBJECTIVE

To determine anti-dementia drug persistence following donepezil initiation among AD patients in Japan using insurance claims data.

METHODS

Insurance claims data for AD patients with newly prescribed donepezil were obtained from 17 municipalities between April 2014 and October 2021. Anti-dementia drug persistence was defined as a gap of ≤60 days between the last donepezil prescription and a subsequent prescription of donepezil, another cholinesterase inhibitor, or memantine. Cox proportional hazards models were used to analyze the association between care needs levels and discontinuation.

RESULTS

We analyzed 20,474 AD patients (mean age±standard deviation: 82.2±6.3 years, women: 65.7%). The persistence rates were 89.1% at 30 days, 79.4% at 90 days, 72.6% at 180 days, 64.5% at 360 days, and 58.3% at 540 days after initiation. Among the care needs levels, the hazard ratio (95% confidence interval) for discontinuation was 1.01 (0.94-1.07) for patients with support needs, 1.12 (1.06-1.18) for patients with low long-term care needs, and 1.31 (1.21-1.40) for patients with moderate-to-high long-term care needs relative to independent patients.

CONCLUSION

Japanese AD patients demonstrated low anti-dementia drug persistence rates that were similar to those of other countries. Higher long-term care needs were associated with discontinuation. Further measures are needed to improve drug persistence in AD patients.

Analysis of treatment pattern of anti-dementia medications in newly diagnosed Alzheimer's dementia using OMOP CDM

Anti-dementia medications are widely prescribed to patients with Alzheimer's dementia (AD) in South Korea. This study investigated the pattern of medical management in newly diagnosed patients with AD using a standardized data format-the Observational Medical Outcome Partnership Common Data Model from five hospitals. We examined the anti-dementia treatment patterns from datasets that comprise > 5 million patients during 2009-2019. The medication utility information was analyzed with respect to treatment trends and persistence across 11 years. Among the 8653 patients with newly diagnosed AD, donepezil was the most commonly prescribed anti-dementia medication (4218; 48.75%), followed by memantine (1565; 18.09%), rivastigmine (1777; 8.98%), and galantamine (494; 5.71%). The rising prescription trend during observation period was found only with donepezil. The treatment pathways for the three cholinesterase inhibitors combined with N-methyl-D-aspartate receptor antagonist were different according to the drugs (19.6%; donepezil; 28.1%; rivastigmine, and 17.2%; galantamine). A 12-month persistence analysis showed values of approximately 50% for donepezil and memantine and approximately 40% for rivastigmine and galantamine. There were differences in the prescribing pattern and persistence among anti-dementia medications from database using the Observational Medical Outcome Partnership Common Data Model on the Federated E-health Big Data for Evidence Renovation Network platform in Korea.

Discontinuation Rate of Newly Prescribed Donepezil in Alzheimer's Disease Patients in Asia

Background and Purpose

The rate of donepezil discontinuation and the underlying reasons for discontinuation in Asian patients with Alzheimer's disease (AD) are currently unknown. We aimed to determine the treatment discontinuation rates in AD patients who had newly been prescribed donepezil in routine clinical practice in Asia.

Methods

This 1-year observational study involved 38 institutions in seven Asian countries, and it evaluated 398 participants aged 50–90 years with a diagnosis of probable AD and on newly prescribed donepezil monotherapy. The primary endpoint was the rate of donepezil discontinuation over 1 year. Secondary endpoints included the reason for discontinuation, treatment duration, changes in cognitive function over the 1-year study period, and compliance as assessed using a clinician rating scale (CRS) and visual analog scale (VAS).

Results

Donepezil was discontinued in 83 (20.9%) patients, most commonly due to an adverse event (43.4%). The mean treatment duration was 103.67 days in patients who discontinued. Among patients whose cognitive function was assessed at baseline and 1 year, there were no significant changes in scores on the Mini-Mental State Examination, Montreal Cognitive Assessment, and Trail-Making Test–Black and White scores, whereas the Clinical Dementia Rating score increased significantly (p<0.001). Treatment compliance at 1 year was 96.8% (306/316) on the CRS and 92.6±14.1% (mean±standard deviation) on the VAS.

Conclusions

In patients on newly prescribed donepezil, the primary reason for discontinuation was an adverse event. Cognitive assessments revealed no significant worsening at 1 year, indicating that continuous donepezil treatment contributes to the maintenance of cognitive function.

Sirtuins, brain and cognition: A review of resveratrol effects

Sirtuins (SIRTs) are a protein family with high preservation degree among evolutionary scale. SIRTs are histone deacetylases regulatory enzymes of genetic material deeply involved in numerous physiological tasks including metabolism, brain function and aging. Mammals sirtuins comprise seven enzymatic components (SIRT1–SIRT7). The highest studied sirtuin is SIRT1, which plays an essential position in the prevention and evolution of neuro-disorders. Resveratrol (3,5,4-trihydroxystylbene) (RSV) is a polyphenol, which belongs to a family compounds identified as stilbenes, predominantly concentrated in grapes and red wine. RSV is the must studied Sirtuin activator and is used as food supplementary compound. Resveratrol exhibits strong antioxidant activity, reducing free radicals, diminishing quinone-reductase-2 activity and exerting positive regulation of several endogenous enzymes. Resveratrol is also able to inhibit pro-inflammatory factors, reducing the stimulation of the nuclear factor kB (NF-kB) and the release of endogenous cytokines. Resveratrol treatment can modulate multiple signaling pathway effectors related to programmed cell death, cell survival, and synaptic plasticity. In this context, the present review looks over news and the role of Sirtuins activation and resveratrol effects on modulating target genes, cognition and neurodegenerative disorders.

Risk of rhabdomyolysis with donepezil compared with rivastigmine or galantamine: a population-based cohort study

BACKGROUND

Donepezil, rivastigmine and galantamine are popular cholinesterase inhibitors used to manage the symptoms of Alzheimer disease and other dementias; regulatory agencies in several countries warn about a possible risk of rhabdomyolysis with donepezil, based on information from case reports. Our goal was to investigate the 30-day risk of admission to hospital with rhabdomyolysis associated with initiating donepezil versus other cholinesterase inhibitors.

METHODS

We conducted a retrospective cohort study in Ontario, Canada, from 2002 to 2017. Participants were adults aged 66 years or older with a newly dispensed prescription for donepezil compared with rivastigmine or galantamine. The primary outcome was hospital admission with rhabdomyolysis (assessed using hospital diagnostic codes) within 30 days of a new prescription of a cholinesterase inhibitor. Odds ratios were estimated using logistic regression, with inverse probability of treatment weights calculated from propensity scores.

RESULTS

The average age in our 2 groups was 81.1 years, and 61.4% of our population was female. Donepezil was associated with a higher risk of hospital admission with rhabdomyolysis compared with rivastigmine or galantamine (88 events in 152 300 patients [0.06%] v. 16 events in 68 053 patients [0.02%]; weighted odds ratio of 2.21, 95% confidence interval [CI] 1.52-3.22). Most hospital admissions with rhabdomyolysis after donepezil use were not severe, and no patient was treated with acute dialysis or mechanical ventilation.

INTERPRETATION

Initiating donepezil is associated with a higher 30-day risk of admission to hospital with rhabdomyolysis compared with initiating rivastigmine or galantamine. The proportion of patients who develop severe rhabdomyolysis within 30 days of initiating donepezil is very low.

Comparison of cholinesterase inhibitor safety in real-world practice

Introduction

Cholinesterase inhibitors (ChEIs) are widely used to treat mild to moderate Alzheimer's disease and related dementia. Clinical trials have focused on placebo comparisons, inadequately addressing within-class comparative safety.

Methods

New users of ChEIs in British Columbia were categorized into five study cohorts: low-dose donepezil, high-dose donepezil, galantamine, rivastigmine patch, and oral rivastigmine. Comparative safety of ChEIs assessed hazard ratios using propensity score adjusted Cox regression.

Results

Compared with low-dose donepezil, galantamine use was associated with a lower risk of mortality (adjusted hazard ratio: 0.84, 95% confidence interval: 0.60–1.18), cardiovascular serious adverse events (adjusted hazard ratio: 0.78, 95% confidence interval: 0.62–0.98), and entry into a residential care facility (adjusted hazard ratio: 0.72, 95% confidence interval: 0.59–0.89).

Discussion

Given the absence of randomized trial data showing clinically meaningful benefit of ChEI therapy in Alzheimer's disease, our study suggests preferential use of galantamine may at least be associated with fewer adverse events than treatment with donepezil or rivastigmine.

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Galantamine was associated with fewer adverse events than donepezil or rivastigmine.

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Galantamine users experienced longer independent living.

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The 3-year risk of cardiovascular events and mortality was lowest with galantamine.

Smartphone-Based Interventions to Foster Simple Activity and Personal Satisfaction in People With Advanced Alzheimer's Disease

OBJECTIVES

This study assessed a smartphone-based program to promote practical and mildly demanding arm responses and personal satisfaction and increase physical exertion (heart rates) in people with advanced Alzheimer's disease.

METHODS

The program relied on a Samsung Galaxy A3 smartphone with Android 6.0 operating system. Two groups of 10 and 11 participants, respectively, were assigned different responses (ie, placing cards into an elevated box and moving bottles with water from a table into a container). Responses activated the smartphone, which produced brief periods of preferred stimulation. Lack of responding led the smartphone to produce a verbal prompt.

RESULTS

All participants had significant increases in independent response frequencies, level of personal satisfaction, and heart rates during program sessions as opposed to baseline or control sessions.

CONCLUSION

A smartphone-based program may help people with advanced Alzheimer's disease increase independent occupation with possible benefits in terms of satisfaction and physical condition.

The effects of medication adherence on study outcomes in randomized clinical trials: A role for cognitive dysfunction?

Medication nonadherence is common and has been associated with poor health outcomes. Older adults are especially likely to be non-adherent to their medications, as they often have more medications to manage and are at greater risk for cognitive dysfunction. Though less frequently examined, the association between cognitive dysfunction and nonadherence also likely extends to clinical trials research. The current study used archival data to examine the potential impact of cognitive dysfunction on adherence to a nutritional supplement as part of a 90-day randomized clinical trial in neurologically healthy middle-aged and older adults. Results showed overall cognitive performance was predictive of adherence to capsule intake when controlling for polypharmacy [F(1,157) = 6.53, p < .01]. These results suggest that cognitive dysfunction may impact findings from RCTs through its adverse impact on adherence to study protocol, possibly leading to greater treatment variance, artificially reduced treatment effects, lower study power, and distorted study outcomes and conclusions. A better understanding of methodological and statistical approaches to account for these unwanted effects are needed.

Strategies for Continued Successful Treatment in Patients with Alzheimer's Disease: An Overview of Switching Between Pharmacological Agents

Introduction:

Alzheimer’s disease (AD) is the most common cause of dementia, characterized by a progressive decline in cognition and function. Current treatment options for AD include the cholines-terase inhibitors (ChEIs) donepezil, galantamine, and rivastigmine, as well as the N-methyl-D-aspartate receptor antagonist memantine. Treatment guidelines recommend the use of ChEIs as the standard of care first-line therapy. Several randomized clinical studies have demonstrated the benefits of ChEIs on cogni-tion, global function, behavior and activities of daily living. However, patients may fail to achieve sus-tained clinical benefits from ChEIs due to lack/loss of efficacy and/or safety, tolerability issues, and poor adherence to the treatment. The purpose of this review is to explore the strategies for continued successful treatment in patients with AD.

Methods:

Literature search was performed for articles published in PubMed and MEDLINE, using pre-specified search terms. Articles were critically evaluated for inclusion based on their titles, abstracts, and full text of the publication.

Results and Conclusion:

The findings of this review indicate that dose up-titration and switching between ChEIs may help to improve response to ChEI treatment and also address issues such as lack/loss of effica-cy or safety/tolerability in patients with AD. However, well-designed studies are needed to provide robust evidence.

Resveratrol and cognitive decline: a clinician perspective

Resveratrol (3,5,4'-trihydroxystilbene) belongs to a family of polyphenolic compounds known as stilbenes, particularly concentrated in grape and red wine. The aim of our review was to critically review the available evidence of resveratrol effects on brain function and its potential impact on therapy. In preclinical models of cognitive decline, resveratrol displays potent antioxidant activity by scavenging free radicals, reducing quinone reductase 2 activity and upregulating endogenous enzymes. Resveratrol also inhibits pro-inflammatory enzyme expression, reduces nuclear factor-κB activation and cytokine release. Treatment with resveratrol can affect multiple signaling pathway effectors involved in cell survival, programmed cell death and synaptic plasticity. Direct and/or indirect activation of the deacetylase sirtuins by resveratrol has also been suggested. In humans, clinical evidence derived from randomized clinical trials suggests that resveratrol is able to improve cerebral blood flow, cerebral vasodilator responsiveness to hypercapnia, some cognitive tests, perceived performances, and the Aβ₄₀ plasma and cerebrospinal fluid level.

Tablet-based intervention to foster music-related hand responses and positive engagement in people with advanced Alzheimer’s disease

Purpose

Music stimulation is considered beneficial for people with advanced Alzheimer’s disease. The purpose of this paper is to assess a tablet-based program to promote music-related hand responses and positive engagement (e.g. singing or moving the body with the music) in people with advanced Alzheimer’s disease.

Design/methodology/approach

The program was implemented with 20 participants according to a non-concurrent multiple baseline design across participants. The participants were provided with a tablet whose screen worked as a sensor. During the intervention, sensor activations by hand responses led the tablet to present 10 s segments of preferred songs; an absence of sensor activation led the tablet to produce a prompt.

Findings

The participants’ mean frequencies of hand responses (i.e. sensor activations) per 5 min session increased from mostly zero during baseline to between about 9 and 20 during the intervention. The mean percentages of observation intervals with participants’ positive engagement increased from 0 to 12 during the baseline to between 13 and 55 during the intervention. The differences between baseline and intervention data were statistically significant for all participants.

Originality/value

A tablet-based program, such as that used in this study, may help people with advanced Alzheimer’s disease develop specific music-related responses and positive engagement.

Persistence and adherence to the new oral disease-modifying therapies for multiple sclerosis: A population-based study

OBJECTIVE

To examine persistence and adherence to the oral disease-modifying therapies (DMTs) for multiple sclerosis (MS).

METHODS

Population-based health administrative databases in British Columbia, Canada were accessed to identify all individuals filling an oral DMT prescription for MS (fingolimod, dimethyl fumarate, teriflunomide) between January 2011 and December 2015. Predictors of persistence and adherence at 6 and 12 months were assessed using logistic regression, with estimates expressed as adjusted odds ratios (aORs), and 95% confidence intervals (CIs).

RESULTS

Of 858 individuals with ≥6 months of follow-up, the mean age at first prescription was 43.0 (SD:10.3) years; 74.2% were women. By 6 months 11.0% (94/858) had discontinued their initial oral DMT; by 12 months the proportion was 19.6% (113/577). Over 6 and 12 months, among those persisting with their oral DMT, 82.5% (630/764) and 81.7% (379/464) exhibited optimal adherence (proportion of days covered ≥80%). Age, sex, calendar year and comorbidity were not associated with persistence or adherence. Individuals with higher neighbourhood-level socioeconomic status had higher odds of discontinuation within 6 months (aOR = 2.2; 95%CI:1.3-3.7). Those who had previously used another DMT had higher odds of optimal adherence (6 months aOR = 2.4;95%CI:1.6-3.6, and 12 months aOR = 2.4; 95%CI:1.5-3.9).

CONCLUSION

Approximately 1 in 10 individuals discontinued their first oral DMT within 6 months, and 1 in 5 did so within one year. However, among those who did continue drug, a high proportion (>80%) exhibited optimal adherence. Predictors of persistence or adherence with immediate practical application were lacking; this highlights the challenges in optimizing drug therapy.

Predictors of Cholinesterase Discontinuation during the First Year after Nursing Home Admission

OBJECTIVES

For persons with dementia, the appropriate duration of cholinesterase inhibitor (ChEI) use remains unclear. We examined patterns of ChEI use during nursing home (NH) transition and the factors associated with discontinuation following admission.

DESIGN

Population-based retrospective cohort study using linked health administrative and Resident Assessment Instrument Minimum Dataset, version 2.0 databases.

SETTING AND PARTICIPANTS

A total of 47,851 older adults (mean age = 84.8 years, standard deviation = 6.8) with dementia newly admitted to a NH in Ontario, Canada between 2011 and 2015.

MEASUREMENTS

ChEI use at admission and during the following year was identified from prescription claims. Resident sociodemographic and health characteristics at admission, including a 72-item frailty index, were derived from the Resident Assessment Instrument Minimum Dataset 2.0. Additional resident and prescriber characteristics were derived from administrative data. Discontinuation was defined as a 30+-day gap in ChEI supply. Multivariable subdistribution hazard models were used to estimate the independent effect of resident frailty and other factors on ChEI discontinuation.

RESULTS

Approximately one-third (17,560) of residents with dementia were on a ChEI at admission. Among this group, 17.7% (3110) discontinued use over follow-up. Incidence of discontinuation was significantly higher among residents with syncope [subdistribution hazard ratio, sHR = 2.21, 95% confidence interval, CI (1.52, 3.22)], more severe behavioral symptoms [sHR = 1.79, 95% CI (1.57, 2.05)], cognitive impairment [sHR = 1.26, 95% CI (1.07, 1.48)], higher frailty, [sHR = 1.19, 95% CI (1.04, 1.36)], and a primary prescriber active in the NH [sHR = 1.28, 95% CI (1.14, 1.45)]. A significantly lower incidence was observed for older and unmarried residents and those with a longer duration of use.

CONCLUSIONS/IMPLICATIONS

Less than one-fifth of residents on a ChEI at admission discontinued use during the following year. Although some of the predictors of discontinuation align with past research and current clinical recommendations, others were unexpected and point to novel drivers of ChEI use. Future investigations should explore the varied reasons underlying these associations and resident outcomes associated with ChEI discontinuation.

Technology-Based Behavioral Interventions for Daily Activities and Supported Ambulation in People With Alzheimer's Disease

OBJECTIVES

These 2 studies evaluated technology-based behavioral interventions for promoting daily activities and supported ambulation in people with mild-to-moderate and moderate-to-severe Alzheimer's disease, respectively.

METHODS

Study 1 included 8 participants who were taught to start and carry out daily activities on their own using a tablet or smartphone device, which provided activity reminders, step instructions, and praise. Study 2 included 9 participants who were taught to engage in brief periods of ambulation using a walker combined with a tilt microswitch and a notebook computer, which monitored step responses and provided stimulation and prompts.

RESULTS

The participants of study 1 succeeded in starting the activities independently and carrying them out accurately. The participants of study 2 largely increased their ambulation levels and also showed signs of positive involvement (eg, smiles and verbalizations).

CONCLUSION

The aforementioned technology-based interventions may represent practical means for supporting people with Alzheimer's disease.