1
|
Lapane KL, Ott BR, Hargraves JL, Cosenza C, Liang S, Alcusky M. Changes in Antidementia Medications upon Admission to the Nursing Home: Who Decides and Why? Results From a National Survey of Nursing Home Administrators. J Am Med Dir Assoc 2024; 25:41-46.e5. [PMID: 38173265 PMCID: PMC10783796 DOI: 10.1016/j.jamda.2023.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 09/19/2023] [Accepted: 09/20/2023] [Indexed: 01/05/2024]
Abstract
OBJECTIVE Little is known about who is involved and what factors influence changes in antidementia medications for older adults living in nursing homes. The study sought to describe factors associated with initiation and discontinuation of antidementia medications in nursing home residents with dementia. DESIGN National survey of nursing homes with ≥30 beds; homes with dementia units were oversampled. SETTINGS AND PARTICIPANTS Nursing home administrators [eg, Directors of Nursing (DoNs)]. METHODS In 2022, 1293 homes were surveyed (response rate: 26.6%, n = 340). Weighted analyses provided nationally representative results corrected for nonresponse (n = 14,455). RESULTS DoNs reported that people always/almost always involved in antidementia medication decisions included nursing home prescriber (84.4%), nursing staff (33.2%), family (23.4%), resident (13.8%), community primary care provider (12.1%), and dementia specialist (5.8%). DoNs reported that antidementia medications were much more likely to be initiated if residents (55.8%) and family members (53.2%) wanted antidementia medications, a dementia specialist was involved (51.9%), resident had aggressive behaviors (44.8%), resisted care (31.6%), or had severe physical/cognitive impairment (22.3%). DoNs reported that antidementia medications were much more likely to be discontinued with dementia specialist involvement (46.5%), progression to severe impairment (39.2%), hospice involvement (31.5%), <6 months' prognosis (28.5%), emergence of aggressive behaviors (25.2%), or resisting care (19.0%) and much less likely to be discontinued if residents (30.2%) and family (27.3%) were reluctant to discontinue. One in 6 homes reported that residents had no immediate family/caregivers usually or almost always/always. CONCLUSIONS AND IMPLICATIONS DoNs report that family/caregivers and dementia specialists have significant influence on antidementia medication decisions in nursing homes, but many residents lack their involvement. Real-world evidence on the risks and benefits of antidementia medications in nursing homes is needed to inform clinical guidance about appropriate use of antidementia medications in nursing homes.
Collapse
Affiliation(s)
- Kate L Lapane
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA.
| | - Brian R Ott
- Department of Neurology, Alpert Medical School of Brown University, Providence, RI, USA
| | - J Lee Hargraves
- Center for Survey Research, University of Massachusetts Boston, Boston, MA, USA
| | - Carol Cosenza
- Center for Survey Research, University of Massachusetts Boston, Boston, MA, USA
| | - Shiwei Liang
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Matthew Alcusky
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA
| |
Collapse
|
2
|
Zhao Y, Zhang Y, Meng S, Chen B, Dong X, Guo X, Guo F, Zhang R, Cui H, Li S. Effects of S-Adenosylmethionine on Cognition in Animals and Humans: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Alzheimers Dis 2023; 94:S267-S287. [PMID: 36970898 PMCID: PMC10473070 DOI: 10.3233/jad-221076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND There is increasing evidence that supplementation of S-adenosylmethionine (SAM) can improve cognitive function in animals and humans, although the outcomes are not always inconsistent. OBJECTIVE We conducted a systematic review and meta-analysis to evaluate the correlation between SAM supplementation and improved cognitive function. METHODS We searched studies in the PubMed, Cochrane Library, Embase, Web of Science, and Clinical Trials databases from January 1, 2002 to January 1, 2022. Risk of bias was assessed using the Cochrane risk of bias 2.0 (human studies) and the Systematic Review Center for Laboratory Animal Experimentation risk of bias (animal studies) tools; and evidence quality was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation. STATA software was employed to perform meta-analysis, and the random-effects models was used to evaluate the standardized mean difference with 95% confidence intervals. RESULTS Out of the 2,375 studies screened, 30 studies met the inclusion criteria. Meta-analyses of animal (p = 0.213) and human (p = 0.047) studies showed that there were no significant differences between the SAM supplementation and control groups. The results of the subgroup analyses showed that the animals aged ≤8 weeks (p = 0.027) and the intervention duration >8 weeks (p = 0.009) were significantly different compared to the controls. Additionally, the Morris water maze test (p = 0.005) used to assess the cognitive level of the animals revealed that SAM could enhance spatial learning and memory in animals. CONCLUSION SAM supplementation showed no significant improvement in cognition. Therefore, further studies are needed to assess the effectiveness of SAM supplementation.
Collapse
Affiliation(s)
- Yan Zhao
- Department of Anatomy, Hebei Medical University, Shijiazhuang, China
- Neuroscience Research Center, Hebei Medical University, Shijiazhuang, China
- School of Nursing, Hebei Medical University, Shijiazhuang, China
| | - Yizhou Zhang
- Department of Anatomy, Hebei Medical University, Shijiazhuang, China
- Neuroscience Research Center, Hebei Medical University, Shijiazhuang, China
- Hebei Key Laboratory of Neurodegenerative Disease Mechanism, Shijiazhuang, China
| | - Sijia Meng
- School of Nursing, Hebei Medical University, Shijiazhuang, China
| | - Bingyu Chen
- Department of Anatomy, Hebei Medical University, Shijiazhuang, China
- Neuroscience Research Center, Hebei Medical University, Shijiazhuang, China
| | - Xinyi Dong
- School of Nursing, Hebei Medical University, Shijiazhuang, China
| | - Xiaojing Guo
- School of Nursing, Hebei Medical University, Shijiazhuang, China
| | - Fangzhen Guo
- Department of Anatomy, Hebei Medical University, Shijiazhuang, China
- Neuroscience Research Center, Hebei Medical University, Shijiazhuang, China
| | - Runjiao Zhang
- Department of Anatomy, Hebei Medical University, Shijiazhuang, China
- Neuroscience Research Center, Hebei Medical University, Shijiazhuang, China
| | - Huixian Cui
- Department of Anatomy, Hebei Medical University, Shijiazhuang, China
- Neuroscience Research Center, Hebei Medical University, Shijiazhuang, China
- Hebei Key Laboratory of Neurodegenerative Disease Mechanism, Shijiazhuang, China
| | - Sha Li
- Department of Anatomy, Hebei Medical University, Shijiazhuang, China
- Neuroscience Research Center, Hebei Medical University, Shijiazhuang, China
- Hebei Key Laboratory of Neurodegenerative Disease Mechanism, Shijiazhuang, China
| |
Collapse
|
3
|
Nakai T, Yamada K, Mizoguchi H. Alzheimer's Disease Animal Models: Elucidation of Biomarkers and Therapeutic Approaches for Cognitive Impairment. Int J Mol Sci 2021; 22:ijms22115549. [PMID: 34074018 PMCID: PMC8197360 DOI: 10.3390/ijms22115549] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 05/21/2021] [Indexed: 12/12/2022] Open
Abstract
Alzheimer’s disease (AD) is an age-related and progressive neurodegenerative disorder. It is widely accepted that AD is mainly caused by the accumulation of extracellular amyloid β (Aβ) and intracellular neurofibrillary tau tangles. Aβ begins to accumulate years before the onset of cognitive impairment, suggesting that the benefit of currently available interventions would be greater if they were initiated in the early phases of AD. To understand the mechanisms of AD pathogenesis, various transgenic mouse models with an accelerated accumulation of Aβ and tau tangles have been developed. However, none of these models exhibit all pathologies present in human AD. To overcome these undesirable phenotypes, APP knock-in mice, which were presented with touchscreen-based tasks, were developed to better evaluate the efficacy of candidate therapeutics in mouse models of early-stage AD. This review assesses several AD mouse models from the aspect of biomarkers and cognitive impairment and discusses their potential as tools to provide novel AD therapeutic approaches.
Collapse
Affiliation(s)
- Tsuyoshi Nakai
- Department of Neuropsychopharmacology and Hospital Pharmacy, Nagoya University Graduate School of Medicine, Nagoya 466-8560, Japan; (T.N.); (K.Y.)
| | - Kiyofumi Yamada
- Department of Neuropsychopharmacology and Hospital Pharmacy, Nagoya University Graduate School of Medicine, Nagoya 466-8560, Japan; (T.N.); (K.Y.)
| | - Hiroyuki Mizoguchi
- Department of Neuropsychopharmacology and Hospital Pharmacy, Nagoya University Graduate School of Medicine, Nagoya 466-8560, Japan; (T.N.); (K.Y.)
- Medical Interactive Research and Academia Industry Collaboration Center, Research Institute of Environmental Medicine, Nagoya University, Nagoya 464-8601, Japan
- Correspondence: ; Tel.: +81-52-744-2674; Fax: +81-52-744-2979
| |
Collapse
|
4
|
Saifullah MAB, Komine O, Dong Y, Fukumoto K, Sobue A, Endo F, Saito T, Saido TC, Yamanaka K, Mizoguchi H. Touchscreen-based location discrimination and paired associate learning tasks detect cognitive impairment at an early stage in an App knock-in mouse model of Alzheimer's disease. Mol Brain 2020; 13:147. [PMID: 33183323 PMCID: PMC7664057 DOI: 10.1186/s13041-020-00690-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 10/28/2020] [Indexed: 02/08/2023] Open
Abstract
Alzheimer's disease (AD) is a progressive neurodegenerative disorder characterized by cognitive decline with accumulation of amyloid beta (Aβ) and neurofibrillary tangles that usually begins 15–30 years before clinical diagnosis. Rodent models that recapitulate aggressive Aβ and/or the pathology of neurofibrillary tangles are essential for AD research. Accordingly, non-invasive early detection systems in these animal models are required to evaluate the phenotypic changes, elucidate the mechanism of disease progression, and facilitate development of novel therapeutic approaches. Although many behavioral tests efficiently reveal cognitive impairments at the later stage of the disease in AD models, it has been challenging to detect such impairments at the early stage. To address this issue, we subjected 4–6-month-old male AppNL−G−F/NL−G−F knock-in (App-KI) mice to touchscreen-based location discrimination (LD), different object–location paired-associate learning (dPAL), and reversal learning tests, and compared the results with those of the classical Morris water maze test. These tests are mainly dependent on the brain regions prone to Aβ accumulation at the earliest stages of the disease. At 4–6 months, considered to represent the early stage of disease when mice exhibit initial deposition of Aβ and slight gliosis, the classical Morris water maze test revealed no difference between groups, whereas touchscreen-based LD and dPAL tasks revealed significant impairments in task performance. Our report is the first to confirm that a systematic touchscreen-based behavioral test battery can sensitively detect the early stage of cognitive decline in an AD-linked App-KI mouse model. This system could be applied in future translational research.
Collapse
Affiliation(s)
- Md Ali Bin Saifullah
- Research Center for Next-Generation Drug Development, Research Institute of Environmental Medicine, Nagoya University, Nagoya, Aichi, 464-8601, Japan
| | - Okiru Komine
- Department of Neuroscience and Pathobiology, Research Institute of Environmental Medicine, Nagoya University, Nagoya, Aichi, 464-8601, Japan
| | - Yutao Dong
- Research Center for Next-Generation Drug Development, Research Institute of Environmental Medicine, Nagoya University, Nagoya, Aichi, 464-8601, Japan.,Department of Neuropsychopharmacology and Hospital Pharmacy, Nagoya University Graduate School of Medicine, Nagoya, Aichi, 466-8560, Japan
| | - Kazuya Fukumoto
- Research Center for Next-Generation Drug Development, Research Institute of Environmental Medicine, Nagoya University, Nagoya, Aichi, 464-8601, Japan
| | - Akira Sobue
- Department of Neuroscience and Pathobiology, Research Institute of Environmental Medicine, Nagoya University, Nagoya, Aichi, 464-8601, Japan
| | - Fumito Endo
- Department of Neuroscience and Pathobiology, Research Institute of Environmental Medicine, Nagoya University, Nagoya, Aichi, 464-8601, Japan
| | - Takashi Saito
- Department of Neuroscience and Pathobiology, Research Institute of Environmental Medicine, Nagoya University, Nagoya, Aichi, 464-8601, Japan.,Laboratory for Proteolytic Neuroscience, RIKEN Center for Brain Science, Wako, Saitama, 351-0198, Japan.,Department of Neurocognitive Science, Institute of Brain Science, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, 467-8601, Japan
| | - Takaomi C Saido
- Laboratory for Proteolytic Neuroscience, RIKEN Center for Brain Science, Wako, Saitama, 351-0198, Japan
| | - Koji Yamanaka
- Department of Neuroscience and Pathobiology, Research Institute of Environmental Medicine, Nagoya University, Nagoya, Aichi, 464-8601, Japan
| | - Hiroyuki Mizoguchi
- Research Center for Next-Generation Drug Development, Research Institute of Environmental Medicine, Nagoya University, Nagoya, Aichi, 464-8601, Japan. .,Department of Neuropsychopharmacology and Hospital Pharmacy, Nagoya University Graduate School of Medicine, Nagoya, Aichi, 466-8560, Japan.
| |
Collapse
|
5
|
Hampel H, Mesulam MM, Cuello AC, Farlow MR, Giacobini E, Grossberg GT, Khachaturian AS, Vergallo A, Cavedo E, Snyder PJ, Khachaturian ZS. The cholinergic system in the pathophysiology and treatment of Alzheimer's disease. Brain 2019; 141:1917-1933. [PMID: 29850777 DOI: 10.1093/brain/awy132] [Citation(s) in RCA: 862] [Impact Index Per Article: 172.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 03/29/2018] [Indexed: 12/19/2022] Open
Abstract
Cholinergic synapses are ubiquitous in the human central nervous system. Their high density in the thalamus, striatum, limbic system, and neocortex suggest that cholinergic transmission is likely to be critically important for memory, learning, attention and other higher brain functions. Several lines of research suggest additional roles for cholinergic systems in overall brain homeostasis and plasticity. As such, the brain's cholinergic system occupies a central role in ongoing research related to normal cognition and age-related cognitive decline, including dementias such as Alzheimer's disease. The cholinergic hypothesis of Alzheimer's disease centres on the progressive loss of limbic and neocortical cholinergic innervation. Neurofibrillary degeneration in the basal forebrain is believed to be the primary cause for the dysfunction and death of forebrain cholinergic neurons, giving rise to a widespread presynaptic cholinergic denervation. Cholinesterase inhibitors increase the availability of acetylcholine at synapses in the brain and are one of the few drug therapies that have been proven clinically useful in the treatment of Alzheimer's disease dementia, thus validating the cholinergic system as an important therapeutic target in the disease. This review includes an overview of the role of the cholinergic system in cognition and an updated understanding of how cholinergic deficits in Alzheimer's disease interact with other aspects of disease pathophysiology, including plaques composed of amyloid-β proteins. This review also documents the benefits of cholinergic therapies at various stages of Alzheimer's disease and during long-term follow-up as visualized in novel imaging studies. The weight of the evidence supports the continued value of cholinergic drugs as a standard, cornerstone pharmacological approach in Alzheimer's disease, particularly as we look ahead to future combination therapies that address symptoms as well as disease progression.
Collapse
Affiliation(s)
- Harald Hampel
- AXA Research Fund and Sorbonne University Chair, Paris, France.,Sorbonne University, GRC n° 21, Alzheimer Precision Medicine (APM), AP-HP, Pitié-Salpêtrière Hospital, Boulevard de l'hôpital, Paris, France.,Brain and Spine Institute (ICM), INSERM U 1127, CNRS UMR 7225, Boulevard de l'hôpital, Paris, France.,Institute of Memory and Alzheimer's Disease (IM2A), Department of Neurology, Pitié-Salpêtrière Hospital, AP-HP, Boulevard de l'hôpital, Paris, France
| | - M-Marsel Mesulam
- Cognitive Neurology and Alzheimer's Disease Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - A Claudio Cuello
- Department of Pharmacology and Therapeutics, McGill University, Montreal, Canada.,Department of Neurology and Neurosurgery, McGill University, Montreal, Canada.,Department of Anatomy and Cell Biology, McGill University, Montreal, Canada
| | - Martin R Farlow
- Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ezio Giacobini
- Department of Internal Medicine, Rehabilitation and Geriatrics, University of Geneva Hospitals, Geneva, Switzerland
| | - George T Grossberg
- Department of Psychiatry and Behavioral Neuroscience, Saint Louis University School of Medicine, St Louis, MO, USA
| | - Ara S Khachaturian
- The Campaign to Prevent Alzheimer's Disease by 2020 (PAD2020), Potomac, MD, USA
| | - Andrea Vergallo
- AXA Research Fund and Sorbonne University Chair, Paris, France.,Sorbonne University, GRC n° 21, Alzheimer Precision Medicine (APM), AP-HP, Pitié-Salpêtrière Hospital, Boulevard de l'hôpital, Paris, France.,Brain and Spine Institute (ICM), INSERM U 1127, CNRS UMR 7225, Boulevard de l'hôpital, Paris, France.,Institute of Memory and Alzheimer's Disease (IM2A), Department of Neurology, Pitié-Salpêtrière Hospital, AP-HP, Boulevard de l'hôpital, Paris, France
| | - Enrica Cavedo
- AXA Research Fund and Sorbonne University Chair, Paris, France.,Sorbonne University, GRC n° 21, Alzheimer Precision Medicine (APM), AP-HP, Pitié-Salpêtrière Hospital, Boulevard de l'hôpital, Paris, France.,Brain and Spine Institute (ICM), INSERM U 1127, CNRS UMR 7225, Boulevard de l'hôpital, Paris, France.,Institute of Memory and Alzheimer's Disease (IM2A), Department of Neurology, Pitié-Salpêtrière Hospital, AP-HP, Boulevard de l'hôpital, Paris, France
| | - Peter J Snyder
- Department of Neurology, Alpert Medical School of Brown University, Providence, RI USA.,Ryan Institute for Neuroscience, University of Rhode Island, Kingston, RI, USA
| | | |
Collapse
|
6
|
Hampel H, Mesulam MM, Cuello AC, Khachaturian AS, Farlow MR, Snyder PJ, Giacobini E, Khachaturian ZS. WITHDRAWN: Revisiting the cholinergic hypothesis in Alzheimer's disease: Emerging evidence from translational and clinical research. Alzheimers Dement 2017:S1552-5260(17)33719-6. [PMID: 29028480 DOI: 10.1016/j.jalz.2017.08.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 08/04/2017] [Accepted: 08/24/2017] [Indexed: 01/18/2023]
Abstract
This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.
Collapse
Affiliation(s)
- Harald Hampel
- AXA Research Fund & UPMC Chair, Paris, France; Sorbonne Universités, Université Pierre et Marie Curie (UPMC) Paris 06, Inserm, CNRS, Institut du Cerveau et de la Moelle Épinière (ICM), Département de Neurologie, Institut de la Mémoire et de la Maladie d'Alzheimer (IM2A), Hôpital Pitié-Salpêtrière, Paris, France
| | - Marsel M Mesulam
- Cognitive Neurology and Alzheimer's Disease Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - A Claudio Cuello
- Department of Pharmacology and Therapeutics, McGill University, Montreal, Canada; Department of Neurology and Neurosurgery, McGill University, Montreal, Canada; Department of Anatomy and Cell Biology, McGill University, Montreal, Canada
| | - Ara S Khachaturian
- The Campaign to Prevent Alzheimer's Disease by 2020 (PAD2020), Potomac, MD, USA
| | - Martin R Farlow
- Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Peter J Snyder
- Department of Neurology, Rhode Island Hospital & Alpert Medical School of Brown University, Providence RI, USA
| | - Ezio Giacobini
- Department of Internal Medicine, Rehabilitation and Geriatrics, University of Geneva Hospitals, Geneva, Switzerland; Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | | |
Collapse
|
7
|
Wong CW. Pharmacotherapy for Dementia: A Practical Approach to the Use of Cholinesterase Inhibitors and Memantine. Drugs Aging 2017; 33:451-60. [PMID: 27154396 DOI: 10.1007/s40266-016-0372-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Cholinesterase inhibitors and memantine are the only classes of drugs approved for the treatment of dementia due to Alzheimer's disease. This article provides evidence-based recommendations to address the issues regarding the use of cholinesterase inhibitors and memantine in clinical practice. It includes their efficacy, timing, assessment, use in institutionalized patients, combined use, and use in other dementia types. However, most of the studies are of short duration (<1 year) and are mainly focused on cognitive and global improvement, whereas the practical issue of their use in daily practice such as optimal duration of treatment, long-term efficacy and delaying institutionalization are limited.
Collapse
Affiliation(s)
- Chit Wai Wong
- Department of Medicine and Geriatrics, Caritas Medical Centre, Hong Kong, China.
| |
Collapse
|
8
|
Chio OI, Yip PK, Liu YC, Chen LH, Wang PC, Tsai TH, Tang SH. Detection of cognitive impairment using self-rated AD8 and informant-reported AD8. J Formos Med Assoc 2017; 117:42-47. [PMID: 28336001 DOI: 10.1016/j.jfma.2017.02.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 10/22/2016] [Accepted: 02/13/2017] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND/PURPOSE Screening of dementia can help to initiate proper management of the disorder. The use of the Ascertain Dementia 8-item Questionnaire (AD8) in screening has been promoted in Taiwan recently. The purpose of this study was to compare the psychometric properties and appropriateness of informant-reported and self-rated AD8 in cognitive impairment screening in Taiwan. METHODS The AD8 were administered to 153 participants and their informants recruited from two neurology out-patient clinics. The discriminative abilities for early cognitive impairment [Clinical Dementia Rating scale (CDR) 0.5 and 1] of informant-based and self-rating AD8 were determined and compared with their areas under the receiver operating curve. κ coefficients representing the agreement between self-rated and informant-reported AD8 scores were also calculated. RESULTS Participants and their informants were aged 76.9 years and 56.0 years on average, respectively. Only informant-reported AD8 was significantly associated with CDR level (Spearman ρ=0.469, p<0.001) and Cognitive Abilities Screening Instrument score (Spearman ρ=-0.458, p<0.001). The item-by-item agreements between self-rated and informant-reported AD8 were poor (κ coefficients: -0.030 to 0.206). The area under the receiver-operator characteristic curve was 0.59 for self-rated AD8 scores, and 0.77 for informant-reported AD8 scores, indicating that the discriminating ability of AD8 scores between CDR 0 and CDR 0.5 or greater is better when reported by informant than when rated by self. CONCLUSION Informant-rated AD8 gave more accurate screening results than self-reported AD8 in an out-patient clinic setting.
Collapse
Affiliation(s)
- Oi-I Chio
- Taiwan Catholic Foundation of Alzheimer's Disease and Related Dementia, Taiwan
| | - Ping-Keung Yip
- School of Medicine, Fu Jen Catholic University, Taiwan; Department of Neurology, Cardinal Tien Hospital, Taiwan
| | - Yi-Chien Liu
- School of Medicine, Fu Jen Catholic University, Taiwan; Department of Neurology, Cardinal Tien Hospital, Taiwan
| | - Li-Hua Chen
- Taiwan Catholic Foundation of Alzheimer's Disease and Related Dementia, Taiwan
| | - Peng-Chih Wang
- Department of Clinical Psychology, Fu Jen Catholic University, Taiwan
| | - Tsung-Hsueh Tsai
- Holistic Healthcare Management Consulting Company Limited, Taiwan
| | - Sai-Hung Tang
- Taiwan Catholic Foundation of Alzheimer's Disease and Related Dementia, Taiwan.
| |
Collapse
|
9
|
Panegyres PK, Berry R, Burchell J. Early Dementia Screening. Diagnostics (Basel) 2016; 6:diagnostics6010006. [PMID: 26838803 PMCID: PMC4808821 DOI: 10.3390/diagnostics6010006] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 12/30/2015] [Accepted: 01/11/2016] [Indexed: 12/20/2022] Open
Abstract
As the population of the world increases, there will be larger numbers of people with dementia and an emerging need for prompt diagnosis and treatment. Early dementia screening is the process by which a patient who might be in the prodromal phases of a dementing illness is determined as having, or not having, the hallmarks of a neurodegenerative condition. The concepts of mild cognitive impairment, or mild neurocognitive disorder, are useful in analyzing the patient in the prodromal phase of a dementing disease; however, the transformation to dementia may be as low as 10% per annum. The search for early dementia requires a comprehensive clinical evaluation, cognitive assessment, determination of functional status, corroborative history and imaging (including MRI, FDG-PET and maybe amyloid PET), cerebrospinal fluid (CSF) examination assaying Aβ1–42, T-τ and P-τ might also be helpful. Primary care physicians are fundamental in the screening process and are vital in initiating specialist investigation and treatment. Early dementia screening is especially important in an age where there is a search for disease modifying therapies, where there is mounting evidence that treatment, if given early, might influence the natural history—hence the need for cost-effective screening measures for early dementia.
Collapse
Affiliation(s)
- Peter K Panegyres
- Neurodegenerative Disorders Research Pty Ltd, 4 Lawrence Avenue, West Perth 6005, Western Australia, Australia.
| | - Renee Berry
- Neurodegenerative Disorders Research Pty Ltd, 4 Lawrence Avenue, West Perth 6005, Western Australia, Australia.
| | - Jennifer Burchell
- Neurodegenerative Disorders Research Pty Ltd, 4 Lawrence Avenue, West Perth 6005, Western Australia, Australia.
| |
Collapse
|
10
|
Time to Treatment Initiation in People With Alzheimer Disease: A Meta-Analysis of Randomized Controlled Trials. J Am Med Dir Assoc 2016; 17:24-30. [DOI: 10.1016/j.jamda.2015.08.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Revised: 08/03/2015] [Accepted: 08/10/2015] [Indexed: 11/19/2022]
|
11
|
Wilding L, Eagles D, Molnar F, O'Brien JA, Dalziel WB, Moors J, Stiell I. Prospective Validation of the Ottawa 3DY Scale by Geriatric Emergency Management Nurses to Identify Impaired Cognition in Older Emergency Department Patients. Ann Emerg Med 2015; 67:157-63. [PMID: 26607333 DOI: 10.1016/j.annemergmed.2015.09.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 08/19/2015] [Accepted: 09/02/2015] [Indexed: 01/12/2023]
Abstract
STUDY OBJECTIVE Assessment of older emergency department (ED) patients with cognitive impairment is challenging because few tools exist that can be quickly administered by front-line practitioners. Our objective is to validate the Ottawa 3DY Scale, a 4-question screening tool for cognitive impairment, in older ED patients and compare its performance with that of the Animal Fluency Test. METHODS We conducted a prospective cohort study in 2 EDs and enrolled a convenience sample of patients aged 75 years or older with no history of cognitive impairment. Eligible patients were assessed by geriatric emergency management nurses who administered the Mini-Mental State Examination, ordered with the Ottawa 3DY Scale questions first, followed by the Animal Fluency Test. Mini-Mental State Examination score less than 25 was our criterion standard for cognitive impairment. RESULTS Study patients (N=238) had a mean age of 81.9 years and were 60.1% women, and 26.5% were admitted to the hospital. The Ottawa 3DY Scale and Mini-Mental State Examination were in agreement for 75.6% of cases, with a sensitivity of 93.8% (95% confidence interval [CI] 77.8% to 98.9%) and specificity of 72.8% (95% CI 66.1% to 78.7%). The Animal Fluency Test score less than 15 and Mini-Mental State Examination score were in agreement for 46.2% of cases, with sensitivity 90.6% (95% CI 73.8% to 97.5%) and specificity 39.3% (95% CI 32.7% to 46.4%). CONCLUSION Both the Ottawa 3DY Scale and the Animal Fluency Test demonstrated excellent sensitivity versus the Mini-Mental State Examination; however, the Animal Fluency Test exhibited poor specificity. The Ottawa 3DY Scale is an effective tool to screen for cognitive impairment in older ED patients, and its use may facilitate improved care in this vulnerable population.
Collapse
Affiliation(s)
- Laura Wilding
- The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada.
| | - Debra Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Frank Molnar
- Regional Geriatric Program of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada; Division of Geriatric Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jo-Anne O'Brien
- The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - William B Dalziel
- Division of Geriatric Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Joy Moors
- The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Ian Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| |
Collapse
|
12
|
Su J, Liu Y, Liu Y, Ren L. Long-term effectiveness of rivastigmine patch or capsule for mild-to-severe Alzheimer’s disease: a meta-analysis. Expert Rev Neurother 2015; 15:1093-103. [DOI: 10.1586/14737175.2015.1068120] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
13
|
Herrmann N. Treatment of Moderate to Severe Alzheimer's Disease: Rationale and Trial Design. Can J Neurol Sci 2014; 34 Suppl 1:S103-8. [PMID: 17469692 DOI: 10.1017/s0317167100005667] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Moderate to severe Alzheimer's disease (AD) is characterized by increasing cognitive, functional, and behavioural dysfunction that results in increased caregiver burden and, eventually, complete dependence. Despite its significance as a societal health problem, there are few treatment trials of cognitive enhancers or disease modifying agents for this stage of illness. Studies suggest the cholinesterase inhibitors, especially donepezil, may provide benefit. Several studies provide support for the use of the NMDA receptor antagonist memantine as monotherapy or added to a cholinesterase inhibitor for moderate to severe AD. While there are no published guidelines for the treatment of moderate to severe AD, these studies do provide guidance for recommendations for study design and outcome measures. Such studies are urgently needed.
Collapse
Affiliation(s)
- Nathan Herrmann
- Department of Psychiatry, Division of Geriatric Psychiatry, Faculty of Medicine, University of Toronto, Sunnybrook & Women's College Health Sciences Centre, Toronto, ON, Canada
| |
Collapse
|
14
|
Kälin AM, Pflüger M, Gietl AF, Riese F, Jäncke L, Nitsch RM, Hock C. Intraindividual variability across cognitive tasks as a potential marker for prodromal Alzheimer's disease. Front Aging Neurosci 2014; 6:147. [PMID: 25071556 PMCID: PMC4081834 DOI: 10.3389/fnagi.2014.00147] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 06/16/2014] [Indexed: 01/09/2023] Open
Abstract
Recent studies have shown that increased cognitive intraindividual variability (IIV) across accuracy scores from tests representing different cognitive domains (across-domain IIV) might indicate prodromal Alzheimer’s disease (AD). Although IIV has been proposed to index cognitive control processes, IIV across accuracy scores from cognitive control tasks (within-domain IIV) has not been examined in healthy controls subjects (HCS), mild cognitive impairment (MCI), and AD patients in a single comparative study. This study examines the discriminative properties of within-domain IIV, and across-domain IIV in 149 HCS, 31 MCI, and 26 AD. Three tasks representing different cognitive domains were identified to calculate across-domain IIV. Three other tasks representing cognitive control were identified to calculate within-domain IIV. The intraindividual standard deviation was calculated across accuracy scores. To compare IIV between groups, ANCOVAs with the covariates age, gender, education, and mean performance were computed. IIV scores in general were higher in AD vs. HCS (p < 0.01). Only across-domain IIV was higher in AD vs. MCI (p = 0.001), and only within-domain IIV was higher in MCI vs. HCS (p = 0.05). Within-domain IIV may constitute a cognitive marker for the detection of prodromal AD at the MCI stage, whereas across-domain IIV may detect beginning AD at the MCI stage.
Collapse
Affiliation(s)
- Andrea M Kälin
- Division of Psychiatry Research and Psychogeriatric Medicine, University of Zurich, Zurich Switzerland
| | - Marlon Pflüger
- Department of Forensic Psychiatry, Psychiatric University Clinics, University of Basel, Basel Switzerland
| | - Anton F Gietl
- Division of Psychiatry Research and Psychogeriatric Medicine, University of Zurich, Zurich Switzerland
| | - Florian Riese
- Division of Psychiatry Research and Psychogeriatric Medicine, University of Zurich, Zurich Switzerland
| | - Lutz Jäncke
- Division of Neuropsychology, Institute of Psychology, University of Zurich, Zurich Switzerland ; International Normal Aging and Plasticity Imaging Center, University of Zurich, Zurich Switzerland ; University Research Priority Program "Dynamics of healthy aging", University of Zurich, Zurich Switzerland
| | - Roger M Nitsch
- Division of Psychiatry Research and Psychogeriatric Medicine, University of Zurich, Zurich Switzerland
| | - Christoph Hock
- Division of Psychiatry Research and Psychogeriatric Medicine, University of Zurich, Zurich Switzerland
| |
Collapse
|
15
|
Ishiwata A, Kitamura S, Nomura T, Nemoto R, Ishii C, Wakamatsu N, Katayama Y. Early identification of cognitive impairment and dementia: Results from four years of the community consultation center. Arch Gerontol Geriatr 2014; 59:457-61. [PMID: 25022712 DOI: 10.1016/j.archger.2014.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Revised: 04/25/2014] [Accepted: 06/18/2014] [Indexed: 10/25/2022]
Abstract
The community consultation center was established as the core facility for a project entitled "Community Support Network for Citizens with Mild Cognitive Impairment (MCI) and Dementia." This study reports on our center's activity and user outcomes. Users consulted with medical staff regarding their memory problems and were self-screened using a touch-panel computer assisted screening tool (TPST). Dementia was suspected when the TPST score was 12 points or below, and the Mini-Mental State Examination (MMSE) was conducted by our onsite clinical psychologists, which served as the gold standard. All reports were provided to user's primary care physicians, or a nearby medical institute if users did not have a primary care physician. Patient outcomes were obtained from participating medical institutes. Informed consent was obtained for all users. In the four-year period, 2802 users visited the center. Of them, 1565 registered (men/women=519/1046; mean age, 74 years). Of 1354 people who used TPST, 622 (45.9%) scored 12 points or below. 409 confirmed diagnoses from the medical institutes revealed MCI in 11.2%, Alzheimer's disease in 37.1%, and vascular dementia in 8.0%. Among the 207 users who had no primary care physicians at consultation, 43 (20.8%) were diagnosed with MCI or dementia. Approximately half of the users who took the TPST were suspected of dementia following interview by a clinical psychologist. Both MCI and dementia were confirmed by the medical institutes in 59.6% of users. We conclude that our consultation center plays a pivotal role in early diagnosis of MCI and dementia.
Collapse
Affiliation(s)
- Akiko Ishiwata
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School, Tokyo 113-8603, Japan.
| | - Shin Kitamura
- Nippon Medical School, Musashi-Kosugi Hospital, Kawasaki 211-8533, Japan
| | - Toshiaki Nomura
- Department of Psychology, Nippon Medical School, Tokyo 113-8603, Japan
| | - Rumi Nemoto
- The Community Consultation Center for Citizens with MCI and Dementia, Nippon Medical School, Kawasaki 211-8533, Japan
| | - Chika Ishii
- The Community Consultation Center for Citizens with MCI and Dementia, Nippon Medical School, Kawasaki 211-8533, Japan
| | - Naoki Wakamatsu
- Department of Rehabilitation, Niigata University of Rehabilitation, Niigata 958-0053, Japan
| | - Yasuo Katayama
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School, Tokyo 113-8603, Japan
| |
Collapse
|
16
|
Cholinesterase inhibitors for the treatment of Alzheimer's disease:: getting on and staying on. CURRENT THERAPEUTIC RESEARCH 2014; 64:216-35. [PMID: 24944370 DOI: 10.1016/s0011-393x(03)00059-6] [Citation(s) in RCA: 190] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/13/2003] [Indexed: 11/24/2022]
Abstract
BACKGROUND Cholinesterase (ChE) inhibitors currently used in the treatment of Alzheimer's disease (AD) are the acetylcholinesterase (AChE)-selective inhibitors, donepezil and galantamine, and the dual AChE and butyrylcholinesterase (BuChE) inhibitor, rivastigmine. In addition to differences in selectivity for AChE and BuChE, ChE inhibitors also differ in pharmacokinetic and pharmacodynamic properties, and these differences could significantly impact on safety, tolerability, and efficacy. OBJECTIVE The aim of this article was to provide an overview of the ChE inhibitors widely used in AD, focusing on key pharmacologic differences among agents and how these may translate into important differences in safety, tolerability, and efficacy in clinical practice. METHODS Using published literature collected over time by the author, a review was conducted, focusing on the pharmacology and clinical data of donepezil, galantamine, and rivastigmine. RESULTS All ChE inhibitors have the potential to induce centrally mediated cholinergic adverse events (AEs), such as nausea and vomiting, if the dose is increased too rapidly or in increments that are too large. These AEs, which are most likely to occur during the "getting on," or dose-escalation, phase of treatment, may result in patients discontinuing treatment early without achieving optimum therapeutic benefit. To reduce the incidence of these AEs, a slow dose-escalation schedule has been established in clinical practice, consisting of a "start low, go slow" procedure with a minimum of 4 weeks between dose increases. After "getting on" treatment, maintaining treatment in the long term, or "staying on," may be achieved with good safety, tolerability, and sustained symptomatic efficacy across the key symptom domains (activities of daily living, behavior, and cognition). CONCLUSIONS ChE inhibitors provide symptomatic benefit in AD across key symptom domains. Factors influencing the safety, tolerability, and efficacy of these agents in clinical practice include ChE enzymes inhibited, brain and brain-region ChE selectivity, and metabolism route. Class-specific cholinergic AEs can be minimized using slow, flexible dose escalation.
Collapse
|
17
|
Cummings J, Winblad B. A rivastigmine patch for the treatment of Alzheimer’s disease and Parkinson’s disease dementia. Expert Rev Neurother 2014; 7:1457-63. [PMID: 17997695 DOI: 10.1586/14737175.7.11.1457] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Jeffrey Cummings
- UCLA Alzheimer's Center, 10911 Weyburn Avenue, Suite 200, Los Angeles, CA 90095-7226, USA.
| | | |
Collapse
|
18
|
Ferris S, Karantzoulis S, Somogyi M, Meng X. Rivastigmine in moderately severe-to-severe Alzheimer's disease: Severe Impairment Battery factor analysis. ALZHEIMERS RESEARCH & THERAPY 2013; 5:63. [PMID: 24351447 PMCID: PMC3978681 DOI: 10.1186/alzrt229] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 12/06/2013] [Indexed: 11/16/2022]
Abstract
Introduction The Severe Impairment Battery (SIB) is validated for assessing cognition in patients with severe dementia. The current analysis aimed to further investigate the cognitive efficacy of rivastigmine capsules, as assessed by SIB factor scores, in patients with moderately severe-to-severe Alzheimer’s disease (AD). Methods This was a retrospective analysis of a 26-week, multicenter, randomized, double-blind, placebo-controlled study of oral rivastigmine conducted in Spain. Previously reported outcome measures included the full SIB. Current analyses examined calculated scores and effect sizes for the change from baseline at Week 26 on: newly defined SIB subscales (derived by a factor analysis of the 40 SIB items, using the PROC FACTOR function (SAS)); previously defined memory, language and praxis subscales (derived by previous analysis of the nine SIB domains); and the individual SIB items. Treatment differences were assessed. Results SIB data were provided by 104 rivastigmine-treated patients and 106 patients receiving placebo (Intent-To-Treat Last Observation Carried Forward population). Significantly less decline was observed on the previously defined memory and language subscales, and the newly defined working memory/memory subscale in rivastigmine-treated patients (all P < 0.05 versus placebo). Calculation of effect sizes demonstrated numerically greater efficacy of rivastigmine versus placebo on each of the subscales, and a broad range of SIB items; greatest effect sizes were observed on SIB items assessing the current month (effect size = 0.30) and digit span series (effect size = 0.33). Conclusions These data suggest the observed efficacy of rivastigmine in moderately severe-to-severe AD is likely a cumulative effect across a range of tasks. Rivastigmine demonstrates broad cognitive efficacy in this patient population.
Collapse
Affiliation(s)
- Steven Ferris
- Alzheimer's Disease Center, Comprehensive Center on Brain Aging, NYU Langone Medical Center, Room 506, 145 East 32nd Street, New York, NY 10016, USA
| | - Stella Karantzoulis
- Alzheimer's Disease Center, Comprehensive Center on Brain Aging, NYU Langone Medical Center, Room 506, 145 East 32nd Street, New York, NY 10016, USA
| | - Monique Somogyi
- Novartis Pharmaceuticals Corporation, East Hanover, NJ 07936-1080, USA
| | - Xiangyi Meng
- Novartis Pharmaceuticals Corporation, East Hanover, NJ 07936-1080, USA
| |
Collapse
|
19
|
Farlow MR, Grossberg GT, Sadowsky CH, Meng X, Somogyi M. A 24-week, randomized, controlled trial of rivastigmine patch 13.3 mg/24 h versus 4.6 mg/24 h in severe Alzheimer's dementia. CNS Neurosci Ther 2013; 19:745-52. [PMID: 23924050 PMCID: PMC4233957 DOI: 10.1111/cns.12158] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Revised: 07/03/2013] [Accepted: 07/04/2013] [Indexed: 11/28/2022] Open
Abstract
AIMS The 24-week, prospective, randomized, double-blind ACTION study investigated the efficacy, safety, and tolerability of 13.3 versus 4.6 mg/24 h rivastigmine patch in patients with severe Alzheimer's disease (AD). METHODS Patients had probable AD and Mini-Mental State Examination scores ≥3-≤12. Primary outcome measures were as follows: Severe Impairment Battery (SIB) and AD Cooperative Study-Activities of Daily Living scale-Severe Impairment Version (ADCS-ADL-SIV). Secondary outcomes were as follows: ADCS-Clinical Global Impression of Change (ADCS-CGIC), 12-item Neuropsychiatric Inventory (NPI-12), and safety/tolerability. RESULTS Of 1014 patients screened, 716 were randomized to 13.3 mg/24 h (N = 356) or 4.6 mg/24 h (N = 360) patch. Baseline characteristics/demographics were comparable. Completion rates were as follows: 64.3% (N = 229) with 13.3 mg/24 h and 65.0% (N = 234) with 4.6 mg/24 h patch. The 13.3 mg/24 h patch was significantly superior to 4.6 mg/24 h patch on cognition (SIB) and function (ADCS-ADL-SIV) at Week 16 (P < 0.0001 and P = 0.049, respectively) and 24 (primary endpoint; P < 0.0001 and P = 0.025). Significant between-group differences (Week 24) were observed on the ADCS-CGIC (P = 0.0023), not NPI-12 (P = 0.1437). A similar proportion of the 13.3 mg/24 h and 4.6 mg/24 h patch groups reported adverse events (AEs; 74.6% and 73.3%, respectively) and serious AEs (14.9% and 13.6%). CONCLUSIONS The 13.3 mg/24 h patch demonstrated superior efficacy to 4.6 mg/24 h patch on SIB and ADCS-ADL-SIV, without marked increase in AEs, suggesting higher-dose patch has a favorable benefit-to-risk profile in severe AD.
Collapse
Affiliation(s)
- Martin R Farlow
- Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | | | | | | |
Collapse
|
20
|
Farlow MR, Grossberg GT, Meng X, Olin J, Somogyi M. Rivastigmine transdermal patch and capsule in Alzheimer's disease: influence of disease stage on response to therapy. Int J Geriatr Psychiatry 2011; 26:1236-43. [PMID: 22068922 DOI: 10.1002/gps.2669] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2010] [Accepted: 11/03/2010] [Indexed: 11/10/2022]
Abstract
OBJECTIVES The cholinesterase inhibitor rivastigmine is approved for the symptomatic treatment of mild to moderate Alzheimer's disease (AD). This exploratory, hypothesis-forming analysis assessed response to rivastigmine according to severity of dementia at baseline. METHODS This was a retrospective analysis of a large randomized, placebo-controlled trial (ENA713D2320). AD patients treated with 9.5 mg/24 h rivastigmine patch, 17.4 mg/24 h rivastigmine patch, rivastigmine capsule (12 mg/day), or placebo were stratified according to baseline Mini-Mental State Examination (MMSE) scores: ≥7 to ≤12 (severe disease), ≥13 to ≤15 (moderately severe), ≥16 to ≤18 (moderate), or ≥19 to ≤25 (mild to moderate). Changes from baseline at Week 24 on Alzheimer's Disease Assessment Scale-cognitive subscale (ADAS-cog), Alzheimer's Disease Cooperative Study-Clinical Global Impression of Change (ADCS-CGIC), and Alzheimer's Disease Cooperative Study-Activities of Daily Living (ADCS-ADL) were assessed. RESULTS Based on baseline MMSE scores, 141, 228, 333, and 348 patients had severe, moderately severe, moderate, and mild to moderate dementia. Worsening of ADAS-cog, ADCS-CGIC, and ADCS-ADL scores in patients receiving placebo were greater in patients with more severe dementia. Significant improvements versus placebo were seen with rivastigmine patch and/or capsule on ADAS-cog, ADCS-CGIC, and ADCS-ADL scores in patients with severe, moderately severe, and moderate AD (all p < 0.05). However, no significant improvements were seen in rivastigmine-treated patients with mild to moderate AD. CONCLUSIONS Rivastigmine benefits AD patients across dementia stages. Similar to previous cholinesterase inhibitor studies, greatest treatment effects with rivastigmine patch and capsule were seen in patients with more advanced dementia, most likely driven by greater placebo decline in this population.
Collapse
Affiliation(s)
- Martin R Farlow
- Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA.
| | | | | | | | | |
Collapse
|
21
|
Geldmacher DS. Treatment guidelines for Alzheimer's disease: redefining perceptions in primary care. PRIMARY CARE COMPANION TO THE JOURNAL OF CLINICAL PSYCHIATRY 2011; 9:113-21. [PMID: 17607333 PMCID: PMC1896294 DOI: 10.4088/pcc.v09n0205] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2006] [Accepted: 07/05/2006] [Indexed: 10/20/2022]
Abstract
BACKGROUND Current treatment guidelines for Alzheimer's disease (AD) do not reflect more recently collected data on therapeutic outcomes other than cognitive function and memory, and this has led to a limited understanding of the value of drug therapy in AD. OBJECTIVES To evaluate the need to revise treatment guidelines for AD, to review data that have become available since the publication of current guidelines, and to communicate how existing guidelines and relevant new data can be valuable to the primary care provider who assesses and treats patients with AD. DATA SOURCES A MEDLINE search was conducted to identify existing treatment guidelines using the MeSH headings Alzheimer disease-drug therapy AND practice guidelines. The alternative terms treatment guidelines, practice parameter, and practice recommendation were also searched in conjunction with the MeSH term Alzheimer disease-drug therapy. Additionally, MEDLINE was searched using the term dementia and publication type "practice guideline." All searches were limited to articles published within the last 10 years, in English. A total of 116 articles were identified by these searches. Additional publications were identified by manually searching the reference lists of these articles and of published clinical trials of AD therapies. STUDY SELECTION AND DATA EXTRACTION Current AD treatment guidelines and clinical trial results for AD treatment options were extracted, reviewed, and summarized to meet the objectives of this article. DATA SYNTHESIS Current guidelines support the use of cholinesterase inhibitors in patients with mild to moderate AD. More recent clinical research indicates that cholinesterase inhibitor treatment provides effectiveness across a wide range of dementia severity and multiple symptom domains. These medications also significantly decrease caregiver burden and may lower the risk for nursing home placement. CONCLUSIONS The expanding literature on AD medications suggests that treatment guidelines need to be reexamined. Recent data emphasize preservation of abilities and delay of adverse outcomes in AD patients rather than short-term improvements in cognitive test scores. Treatment appears to provide the greatest benefit when it is initiated early in the course of the disease and maintained over the long term. Revised treatment guidelines should address newer medications and more recent outcomes considerations, as well as provide guidance on how long to continue and when to discontinue pharmacotherapy for AD.
Collapse
Affiliation(s)
- David S Geldmacher
- Department of Neurology, University of Virginia Health System, Charlottesville, VA, USA.
| |
Collapse
|
22
|
Schmitt FA, Wichems CH. A systematic review of assessment and treatment of moderate to severe Alzheimer's disease. PRIMARY CARE COMPANION TO THE JOURNAL OF CLINICAL PSYCHIATRY 2011; 8:158-9. [PMID: 16912819 PMCID: PMC1540387 DOI: 10.4088/pcc.v08n0306] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2005] [Accepted: 12/08/2005] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The systematic, large-scale study of therapies for moderate to severe Alzheimer's disease (AD) is a relatively recent advancement in the field. This review describes for the general practitioner the characterization of moderate to severe AD, discusses the development of metrics sensitive to the constellation of symptoms in these patients, and critically evaluates the use of those measures in moderate to severe AD clinical trials. DATA SOURCES Published clinical trials obtained by MEDLINE searches used the following key words: moderate AD, severe AD, donepezil, rivastigmine, galantamine, memantine, and anti-dementia agents. Clinical trials were limited by language (English), study type (clinical trial), and publication dates (1990-2005). STUDY SELECTION Nine clinical trials comprise the studies conducted to date in moderate to severe AD and include 5 prospective randomized clinical trials (3 for memantine, 2 for donepezil) and 4 retrospective subanalyses (2 for galantamine, 2 for rivastigmine) of primary datasets. DATA EXTRACTION Clinical trials are summarized and major findings are reviewed. DATA SYNTHESIS The data reviewed support the decision to initiate and maintain treatment in moderate to severe AD patients. CONCLUSIONS The development and implementation of improved metrics for moderate to severe AD patients has revealed that meaningful benefits are attainable in this patient population by treatment with the N-methyl-D-aspartate receptor antagonist memantine. Evidence also indicates a benefit from cholinesterase inhibitor treatment, although further study of these agents in this patient population is warranted.
Collapse
Affiliation(s)
- Frederick A Schmitt
- Departments of Neurology, Psychiatry, Behavioral Sciences, and Psychology, and the Sanders-Brown Center on Aging, University of Kentucky, Lexington, KY, USA.
| | | |
Collapse
|
23
|
Alvarez XA, Cacabelos R, Sampedro C, Aleixandre M, Linares C, Granizo E, Doppler E, Moessler H. Efficacy and safety of Cerebrolysin in moderate to moderately severe Alzheimer's disease: results of a randomized, double-blind, controlled trial investigating three dosages of Cerebrolysin. Eur J Neurol 2011; 18:59-68. [PMID: 20500802 DOI: 10.1111/j.1468-1331.2010.03092.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND cerebrolysin is a neuropeptide preparation mimicking the effects of neurotrophic factors. This subgroup analysis assessed safety and efficacy of Cerebrolysin in patients with moderate to moderately severe Alzheimer's disease (AD) (ITT data set: N = 133; MMSE: 14-20) included in a dose-finding study (ITT data set: N = 51; MMSE: 14-25). Results of the mild AD subgroup (ITT data set: N = 118; MMSE: 21-25) are also presented. METHODS patients with AD received 100 ml IV infusions of Cerebrolysin (10, 30 or 60 ml diluted in saline; N = 32, 34 and 35, respectively) or placebo (saline; N = 32) over twelve weeks (5 days per week for 4 weeks and 2 days per week for another 8 weeks). Primary efficacy criteria ADAS-cog+ (Alzheimer's Disease Assessment Scale Cognitive Subpart Modified) and CIBIC+ (Clinical Interview-based Impression of Change with Caregiver Input) were assessed 24 weeks after baseline. RESULTS at week 24, Cerebrolysin improved the global clinical function significantly with all three dosages and induced significant improvements in cognition, initiation of activities of daily living (ADL) and neuropsychiatric symptoms at 10-, 30- and 60-ml doses, respectively. Treatment effects on total ADL and other secondary parameters (MMSE, Trail-making test) were not significant. Cerebrolysin was safe and well tolerated. CONCLUSIONS these results demonstrate the efficacy of Cerebrolysin in moderate to moderately severe AD, showing dose-specific effects similar to those reported for patients with mild to moderate AD. The benefits of Cerebrolysin in advanced AD need to be confirmed in larger trials.
Collapse
Affiliation(s)
- X A Alvarez
- EuroEspes Biomedical Research Centre, Santa Maria de Babio, 15166 Bergondo, La Coruna, Spain.
| | | | | | | | | | | | | | | |
Collapse
|
24
|
Delrieu J, Piau A, Caillaud C, Voisin T, Vellas B. Managing cognitive dysfunction through the continuum of Alzheimer's disease: role of pharmacotherapy. CNS Drugs 2011; 25:213-26. [PMID: 21323393 DOI: 10.2165/11539810-000000000-00000] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
It has been shown that, during several years preceding the diagnosis of Alzheimer's disease there is a gradual cognitive decline with a continuum between the pre-dementia stage (still known as the prodromal stage but now included within the general concept of mild cognitive impairment [MCI]) and the other stages of the disease. In MCI, the use of cholinesterase inhibitors (ChEIs) is not associated with any delay in the onset of Alzheimer's disease or dementia. During the dementia stages, the three ChEIs (donepezil, galantamine and rivastigmine) are efficacious for mild to moderate Alzheimer's disease; therefore, monotherapy with a ChEI can be envisaged as initial treatment. Confirmation of the efficacy of ChEIs in the mild dementia stage is essentially based on the results from a single, randomized study carried out specifically among patients at this stage of severity. Memantine can represent an alternative to ChEIs in the moderate stage of Alzheimer's disease. At the severe stage of the disease, memantine and donepezil are currently indicated. Indeed, memantine has been approved by numerous drug regulatory agencies for use in severe stages of the disease, whereas donepezil has only been approved by the US FDA. There is currently insufficient evidence for recommending combination therapy in Alzheimer's disease.
Collapse
Affiliation(s)
- Julien Delrieu
- Alzheimers Disease Clinical Research Centre, Gérontopôle, Toulouse University Hospital, Toulouse, France.
| | | | | | | | | |
Collapse
|
25
|
Gold M, Alderton C, Zvartau-Hind M, Egginton S, Saunders AM, Irizarry M, Craft S, Landreth G, Linnamägi Ü, Sawchak S. Rosiglitazone monotherapy in mild-to-moderate Alzheimer's disease: results from a randomized, double-blind, placebo-controlled phase III study. Dement Geriatr Cogn Disord 2010; 30:131-46. [PMID: 20733306 PMCID: PMC3214882 DOI: 10.1159/000318845] [Citation(s) in RCA: 245] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2010] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND/AIMS A phase II study of the peroxisome proliferator-activated receptor-γ agonist rosiglitazone extended release (RSG XR) in mild-to-moderate Alzheimer's disease (AD) detected a treatment benefit to cognition in apolipoprotein E(APOE)-ε4-negative subjects. The current phase III study with prospective stratification by APOE genotype was conducted to confirm the efficacy and safety of RSG XR in mild-to-moderate AD. An open-label extension study assessed the long-term safety and tolerability of 8 mg RSG XR. METHODS This double-blind, randomized, placebo-controlled study enrolled 693 subjects. Within 2 APOE allelic strata (ε4-positive, ε4-negative), subjects were randomized (2:2:2:1) to once-daily placebo, 2 mg RSG XR, 8 mg RSG XR or 10 mg donepezil (control). Coprimary endpoints were change from baseline to week 24 in the Alzheimer's Disease Assessment Scale-cognitive subscale (ADAS-Cog) score, and week 24 Clinician's Interview-Based Impression of Change plus caregiver input (CIBIC+). RESULTS At week 24, no significant differences from placebo in change from baseline in coprimary endpoints were detected with either the RSG XR dose in APOE-ε4-negative subjects or overall. For donepezil, no significant treatment difference was detected in ADAS-Cog; however, a significant difference was detected (p = 0.009) on the CIBIC+. Peripheral edema was the most common adverse event for 8 mg RSG XR (15%) and placebo (5%), and nasopharyngitis for 2 mg RSG XR (7%). CONCLUSION No evidence of efficacy of 2 mg or 8 mg RSG XR monotherapy in cognition or global function was detected in the APOE-ε4-negative or other analysis populations. The safety and tolerability of RSG XR was consistent with its known pharmacology.
Collapse
Affiliation(s)
- Michael Gold
- Neurosciences Medicines Development Center, GlaxoSmithKline, Stockley Park, Harlow, UK.
| | - Claire Alderton
- Neurosciences Medicines Development Center, GlaxoSmithKline, Stockley Park, UK
| | - Marina Zvartau-Hind
- Neurosciences Medicines Development Center, GlaxoSmithKline, Stockley Park, UK
| | - Sally Egginton
- Neurosciences Medicines Development Center, GlaxoSmithKline, Harlow, UK
| | - Ann M. Saunders
- Deane Drug Discovery Institute, Division of Neurology, Duke University Medical Center, Durham, N.C., USA
| | - Michael Irizarry
- Neurosciences Medicines Development Center, GlaxoSmithKline, Research Triangle Park, N.C., USA
| | - Suzanne Craft
- Geriatric Research, Education and Clinical Center, VA Puget Sound Health Care System and Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Wash., USA
| | - Gary Landreth
- Department of Neurosciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Ülla Linnamägi
- Department of Neurology and Neurosurgery, University of Tartu, Tartu, Estonia
| | - Sharon Sawchak
- Neurosciences Medicines Development Center, GlaxoSmithKline, Research Triangle Park, N.C., USA
| |
Collapse
|
26
|
Delmaire C, Lehéricy S, Dormont D. [Imaging of dementia in clinical routine. Recommendations of SFNR]. J Neuroradiol 2010; 37:122-6. [PMID: 20346511 DOI: 10.1016/j.neurad.2009.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2009] [Accepted: 11/24/2009] [Indexed: 10/19/2022]
|
27
|
Nourhashémi F, Olde Rikkert MG, Burns A, Winblad B, Frisoni GB, Fitten J, Vellas B. Follow-up for Alzheimer patients: European Alzheimer Disease Consortium position paper. J Nutr Health Aging 2010; 14:121-30. [PMID: 20126960 DOI: 10.1007/s12603-010-0023-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND AND PURPOSE Alzheimer disease (AD) is one of the leading causes of dependence in the elderly. Providing care for patients with AD is complex and the type of care required depends on the stage of the disease and varies over time. The aim of this article is to discuss available care strategies once the AD diagnosis has been made and to propose a follow-up plan as standard of care at a European level. METHODS The proposals developed in this article stem from the collaborative work of a panel of multidisciplinary experts involved in the care of AD patients (European Alzheimer Disease Consortium) based on the results of published scientific studies and on their experience from clinical practice. CONCLUSION Suggestions for follow-up frequency and easily administered and scored assessment tools are provided, thereby increasing efficiency and quality of care for patients with Alzheimer disease.
Collapse
|
28
|
&NA;. Few pharmacological options available for treating cognitive impairment associated with severe Alzheimerʼs disease. DRUGS & THERAPY PERSPECTIVES 2009. [DOI: 10.2165/0042310-200925100-00003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
|
29
|
Ferris S, Nordberg A, Soininen H, Darreh-Shori T, Lane R. Progression from mild cognitive impairment to Alzheimer's disease: effects of sex, butyrylcholinesterase genotype, and rivastigmine treatment. Pharmacogenet Genomics 2009; 19:635-46. [PMID: 19617863 PMCID: PMC4114757 DOI: 10.1097/fpc.0b013e32832f8c17] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Evaluate the effect of sex and butyrylcholinesterase (BuChE) genotype on the incidence of Alzheimer's disease (AD), cognitive and functional decline, brain volume changes, and response to rivastigmine treatment in individuals with mild cognitive impairment (MCI). METHODS This retrospective exploratory analysis from a 3-4 year, randomized, placebo-controlled study of rivastigmine in MCI patients included participants who consented to pharmacogenetic testing. RESULTS Of a total of 1018 patients, 490 [253 (52%) female] were successfully genotyped for BuChE. In patients receiving placebo, the BuChE wt/wt genotype was associated with a statistically significant higher incidence of progression to AD and functional decline in women, compared with men with the BuChE wt/wt genotype. In patients with a BuChE-K allele receiving placebo, incidence of progression to AD and rate of functional decline were not significantly different by sex; however, cognitive decline was significantly faster in men. Statistically significant benefits of rivastigmine treatment on incident AD, functional decline, ventricular volume expansion, whole-brain atrophy, and white matter loss were evident in female BuChE wt/wt. CONCLUSION Sex and BuChE genotype seem to differentially influence the type of decline in MCI patients, with more rapid progression of cognitive decline in male BuChE-K, and more incident AD and functional decline in female BuChE wt/wt. Cognitive decline in male BuChE-K and functional decline and incident AD in female BuChE wt/wt were significantly attenuated by rivastigmine. Rivastigmine treatment also significantly reduced ventricular expansion, whole-brain atrophy rate, and white matter loss in female BuChE wt/wt, suggesting a possible disease-modifying effect.
Collapse
Affiliation(s)
- Steven Ferris
- Alzheimer's Disease Center, Center of Excellence on Brain Aging, NYU Langone Medical Center, Orangeburg, New York, USA.
| | | | | | | | | |
Collapse
|
30
|
Emerging hypotheses regarding the influences of butyrylcholinesterase-K variant, APOE epsilon 4, and hyperhomocysteinemia in neurodegenerative dementias. Med Hypotheses 2009; 73:230-50. [PMID: 19359103 DOI: 10.1016/j.mehy.2009.01.050] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2008] [Revised: 12/04/2008] [Accepted: 01/24/2009] [Indexed: 01/20/2023]
Abstract
Non-enzymatic functions of butyrylcholinesterase (BuChE) include prevention of the aggregation of amyloid-beta peptide (A beta) in a concentration-dependent manner. This is mediated by the C-terminus of the protein, distal from the enzymatic site. The BuChE-K variant polymorphism lowers expression of BuChE protein and/or alters C-terminal activity. In combination with factors that increase production or reduce elimination of A beta, and/or increase susceptibility to A beta toxicity - such as the apolipoprotein E (APOE) epsilon 4 allele and/or hyperhomocysteinemia - BuChE-K may accelerate cholinergic synaptic and neuronal damage and cognitive decline. A beta-mediated damage to ascending cholinergic pathways may be further accentuated by Lewy body and/or cerebrovascular disease. As the disease advances and functioning cholinergic synapses disappear, both the rapid cognitive decline and response to cholinesterase inhibitor therapy in individuals with these factors may diminish. Non-enzymatic functions of the BuChE protein, APOE epsilon 4 status and hyperhomocysteinemia influence the progression of pathology, symptom expression, and response to cholinesterase inhibition in a stage-specific manner in neurodegenerative disorders associated with Alzheimer, Lewy body and vascular pathology.
Collapse
|
31
|
Visch Brink EG, Van Rhee Temme W, Rietveld T, Krulder JWM, Van Harskamp F, Van der Cammen TJM. Improvement of spontaneous speech in early stage Alzheimer's with rivastigmine. J Nutr Health Aging 2009; 13:34-8. [PMID: 19151906 DOI: 10.1007/s12603-009-0007-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Placebo-controlled trials have shown that rivastigmine can delay cognitive deterioration in patients with mild to moderate Alzheimer's disease (AD). Benefits on cognitive functioning, as measured with the ADAS-Cog, occur on a daily dose of 6-12 mg when used for at least 6 months. The effect of rivastigmine on the adequacy of spontaneous speech is unknown. This study aimed to (i) compare the spontaneous speech of AD patients with the spontaneous speech of persons with normal cognition, (ii) compare the spontaneous speech of the same group of AD patients before and after treatment with rivastigmine. METHODS Spontaneous speech of AD patients (n=9) was compared with that of healthy elderly volunteers (n=8). In the patient group, spontaneous speech was analysed before and after treatment with rivastigmine. RESULTS Before treatment, 100% discrimination was found between the spontaneous speech of AD patients and of healthy volunteers based on two linguistic parameters: empty words and compound sentences. After treatment with rivastigmine the spontaneous speech of the AD patients improved on these two variables, while the ADAS-Cog scores decreased. Mean interval between the two spontaneous speech samples was 8.89 months. CONCLUSION Assessment of spontaneous speech might be a valid parameter to discriminate between normal cognition and AD, and to evaluate the effects of anti-AD medication.
Collapse
Affiliation(s)
- E G Visch Brink
- Section of Geriatric Medicine, Department of Internal medicine, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | | | | | | | | | | |
Collapse
|
32
|
|
33
|
Gorus E, De Raedt R, Lambert M, Lemper JC, Mets T. Reaction times and performance variability in normal aging, mild cognitive impairment, and Alzheimer's disease. J Geriatr Psychiatry Neurol 2008; 21:204-18. [PMID: 18838743 DOI: 10.1177/0891988708320973] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study evaluated whether reaction times (RT) and performance variability are potential markers for the early detection of Alzheimer's disease (AD). Cognitively healthy elderly (n = 218), persons with amnestic MCI (a-MCI) (n = 29) and patients with AD (n = 50) were examined with RT tasks with increasing complexity, subdividing RT into a decision and a movement component. Persons with cognitive deterioration demonstrated more intra-individual variability and more slowing than cognitively healthy elderly. The slowing in AD affects both the cognitive and the motor component, while performance variability mainly affects the cognitive component of the RT. Although in a-MCI not all differences reached statistical significance, primarily the cognitive component of the RT is affected in a-MCI. Intra-individual variability and RT of the complex tasks are the best predictors for a-MCI and AD status, respectively. We conclude that performance variability can be regarded as a useful preclinical marker for AD.
Collapse
Affiliation(s)
- Ellen Gorus
- Gerontology Department, Vrije Universiteit Brussel, Brussels, Belgium
| | | | | | | | | |
Collapse
|
34
|
Pelton GH, Harper OL, Tabert MH, Sackeim HA, Scarmeas N, Roose SP, Devanand DP. Randomized double-blind placebo-controlled donepezil augmentation in antidepressant-treated elderly patients with depression and cognitive impairment: a pilot study. Int J Geriatr Psychiatry 2008; 23:670-6. [PMID: 18088076 PMCID: PMC3104294 DOI: 10.1002/gps.1958] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To assess combined antidepressant and cognitive enhancer treatment in elderly patients presenting with depression plus cognitive impairment. METHODS Twenty-three elderly (>50 years old) depressed, cognitively impaired (DEP-CI) patients participated in a pilot study. We evaluated whether, after 8 weeks of open antidepressant treatment, donepezil HCl (Aricept) would afford added cognitive benefit compared to placebo in a randomized 12-week trial. A subsample continued in an 8-month extension phase of open treatment with donepezil. Neuropsychological testing (NPT) was performed and antidepressant response monitored at baseline and the 8, 20, and 52-week time points. RESULTS At 8-weeks, the antidepressant response rate was 61% (14/23). Improvement in SRT immediate recall (SRT-IR; e.g. episodic verbal memory) was observed in responders compared to non-responders. During the 12-week, placebo-controlled, donepezil add-on trial, patients on donepezil showed further improvement in SRT-IR versus patients on placebo. In the open extension phase, patients who continued open donepezil treatment (n = 6) maintained improvement in memory and tended to show an advantage over patients who never received donepezil and were evaluated at the 52-week time point (n = 6). There were no observed significant donepezil effects on non-memory cognitive domains. CONCLUSION These preliminary findings suggest that addition of a cholinesterase inhibitor (AChEI) following antidepressant medication treatment in elderly Dep-CI patients may improve cognition, and support the need for a confirmatory, larger randomized placebo-controlled trial.
Collapse
Affiliation(s)
- Gregory H. Pelton
- Late Life Depression Clinic, The Memory Disorders Center, and The Division of Geriatric Psychiatry, New York State Psychiatric Institute, NY, USA,The College of Physicians and Surgeons of Columbia University, New York, NY, USA,*Correspondence to: Dr G. H. Pelton, New York State Psychiatric Institute, 1051 Riverside Drive, Unit 126, New York, NY 10032, USA.
| | - Oliver L. Harper
- Late Life Depression Clinic, The Memory Disorders Center, and The Division of Geriatric Psychiatry, New York State Psychiatric Institute, NY, USA
| | - Matthias H. Tabert
- Late Life Depression Clinic, The Memory Disorders Center, and The Division of Geriatric Psychiatry, New York State Psychiatric Institute, NY, USA,The College of Physicians and Surgeons of Columbia University, New York, NY, USA
| | - Harold A. Sackeim
- The College of Physicians and Surgeons of Columbia University, New York, NY, USA
| | - Nikolaos Scarmeas
- The College of Physicians and Surgeons of Columbia University, New York, NY, USA
| | - Steven P. Roose
- Late Life Depression Clinic, The Memory Disorders Center, and The Division of Geriatric Psychiatry, New York State Psychiatric Institute, NY, USA,The College of Physicians and Surgeons of Columbia University, New York, NY, USA
| | - D. P. Devanand
- Late Life Depression Clinic, The Memory Disorders Center, and The Division of Geriatric Psychiatry, New York State Psychiatric Institute, NY, USA,The College of Physicians and Surgeons of Columbia University, New York, NY, USA
| |
Collapse
|
35
|
Homma A, Imai Y, Tago H, Asada T, Shigeta M, Iwamoto T, Takita M, Arimoto I, Koma H, Ohbayashi T. Donepezil treatment of patients with severe Alzheimer's disease in a Japanese population: results from a 24-week, double-blind, placebo-controlled, randomized trial. Dement Geriatr Cogn Disord 2008; 25:399-407. [PMID: 18391486 DOI: 10.1159/000122961] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/20/2007] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS A 24-week, randomized, parallel-group, double-blind placebo-controlled study was conducted to evaluate the efficacy and tolerability of donepezil in severe Alzheimer's disease (AD). METHODS Patients with severe AD (Mini-Mental State Examination score 1-12; modified Hachinski Ischemic Score < or =6; Functional Assessment Staging > or =6) were enrolled in this study in Japan. A total of 325 patients were randomized to donepezil 5 mg/day (n = 110), donepezil 10 mg/day (n = 103) or placebo (n = 112). Primary outcome measures were change from baseline to endpoint in the Severe Impairment Battery (SIB) and Clinician's Interview-Based Impression of Change-plus caregiver input (CIBIC-plus) at the endpoint visit. RESULTS Donepezil 5 mg/day and 10 mg/day were significantly superior to placebo on the SIB, with a least-squares mean treatment difference of 6.7 and 9.0, respectively (p < 0.001 compared with placebo). CIBIC-plus analyses showed significant differences in favor of donepezil 10 mg/day over placebo at endpoint (p = 0.003). A statistically significant dose-response relationship was demonstrated with the SIB and CIBIC-plus. Donepezil was well tolerated. CONCLUSION This study confirmed the effectiveness of donepezil 10 mg/day in patients with severe AD and demonstrated a significant dose-response relationship. Donepezil at dosages of both 5 mg/day and 10 mg/day is safe and well tolerated in Japanese patients with severe AD.
Collapse
Affiliation(s)
- Akira Homma
- Dementia Interventional Research Group, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Onor ML, Trevisiol M, Aguglia E. Rivastigmine in the treatment of Alzheimer's disease: an update. Clin Interv Aging 2008; 2:17-32. [PMID: 18044073 PMCID: PMC2684084 DOI: 10.2147/ciia.2007.2.1.17] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Alzheimer's disease is the most common form of dementia in industrialized countries. In the European Union, about 54% of dementia cases are believed to be due to Alzheimer's disease. The condition is an age-related neurodegenerative disorder characterized by multiple cognitive deficiencies, including loss of memory, judgment, and comprehension. These manifestations are accompanied by behavioral and mood disturbances. Although no cure has yet been discovered for Alzheimer's disease, symptomatic therapies are now widely available and offer significant relief to patients and benefits to caregivers in terms of reduced care burden. At the start of the 21st century, health technology assessments recommended three agents for the symptomatic treatment of mild to moderate Alzheimer disease: rivastigmine, donepezil, and galantamine. Rivastigmine (Exelon, Novartis Basel-Switzerland) is a slowly reversible inhibitor of acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE), while donepezil (Aricept, Pfizer, New York, USA) and galantamine (Reminyl, Janssen, New Jersey, USA) show no functional inhibition of BuChE, and are considered AChE-selective, rapidly-reversible inhibitors. The efficacy of all three agents has been evaluated in large, double-blind, placebo-controlled clinical trials of up to 6 months' duration. Rivastigmine treatment in mild to moderate Alzheimer's disease improves cognition, activities of daily living, and global function.
Collapse
Affiliation(s)
- Maria Luisa Onor
- Department of Clinical, Morphological and Technological Sciences, UCO of Clinical Psychiatry, University of Trieste, Trieste, Italy.
| | | | | |
Collapse
|
37
|
Herrmann N, Gauthier S, Lysy PG. Clinical practice guidelines for severe Alzheimer's disease. Alzheimers Dement 2007; 3:385-97. [DOI: 10.1016/j.jalz.2007.07.007] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2007] [Accepted: 07/12/2007] [Indexed: 11/28/2022]
Affiliation(s)
- Nathan Herrmann
- Department of PsychiatrySunnybrook Health Sciences CentreUniversity of TorontoTorontoOntarioCanada
| | - Serge Gauthier
- Alzheimer's Disease Research UnitMcGill Center for Studies in AgingDepartment of NeurologyMcGill UniversityMontrealQuebecCanada
| | - Paul G. Lysy
- Department of Family MedicineMcGill UniversityMontrealQuebecCanada
| |
Collapse
|
38
|
Argimón Pallàs JM, Riu Subirana S, Lizán Tudela L, Badia Llach X, Martínez Lage JM. [Initial treatment of patients with subjective memory complaints and/or cognitive impairment in primary care: ISSEA Study]. Aten Primaria 2007; 39:171-7. [PMID: 17428419 PMCID: PMC7664581 DOI: 10.1016/s0212-6567(07)70871-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2005] [Accepted: 05/24/2006] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To describe the initial treatment of patients >60 years who had subjective memory complaints and/or cognitive impairment for at least 6 months. DESIGN Observational, longitudinal, multicentre, and naturalistic study, with a follow-up period of 12 months. SETTING A total of 105 primary care centres. PARTICIPANTS The study included 921 patients who attended a clinic. MAIN MEASUREMENTS In the baseline visit, the social demographic characteristics, diagnosis, treatment, and the health care referrals were recorded, and in the next 2 (6 and 12 months) the diagnostic change, treatment, and referrals. RESULTS The majority of subjects were female (66.9%) and the mean age was 74.3+/-6.8 years. In the initial visit, 50.5% (95% confidence interval [CI], 47.3-53.7) of the diagnoses were classed as syndromic and 33.3% (95% CI, 30.3-36.3), aetiological. The primary care doctor modified an unconfirmed initial diagnosis in 22% (95% CI, 19.3-24.7) of the patients during the 12 months follow-up study. A diagnosis was made in 63.8% (95% CI, 60.7-66.9) of patients by anamnesis, physical examination, the screening test, and laboratory data. In the initial visit, el 52.6% (95% CI, 49.4-55.8) received treatment of mainly nootropics and neuroprotectors, and later, the percentage of patients on cholinesterase inhibitors increased. The primary care doctor referred 54.9% (95% CI, 51.7-58.1) of the patients during the 12 months of the study. CONCLUSIONS The primary care doctor diagnoses the majority of patients with the means available, mainly based on anamnesis, examination, the screening test, and laboratory data. They prescribe drugs that lack efficacy for this disease and few of those that have been shown to be effective.
Collapse
Affiliation(s)
| | | | - Luis Lizán Tudela
- Health Economics and Outcomes Research. IMS Health. Barcelona. España
- Unidad Docente de Medicina de Familia. Castellón. España
| | - Xavier Badia Llach
- Health Economics and Outcomes Research. IMS Health. Barcelona. España
- Departamento de Epidemiología Clínica y Salud Pública. Hospital de la Santa Creu i Sant Pau. Barcelona. España
| | - José Manuel Martínez Lage
- Unidad de Trastornos de Memoria. Departamento de Neurología y Neurocirugía. Clínica Universitaria de la Universidad de Navarra. Pamplona. Navarra. España
| |
Collapse
|
39
|
Burns A, O'Brien J, Auriacombe S, Ballard C, Broich K, Bullock R, Feldman H, Ford G, Knapp M, McCaddon A, Iliffe S, Jacova C, Jones R, Lennon S, McKeith I, Orgogozo JM, Purandare N, Richardson M, Ritchie C, Thomas A, Warner J, Wilcock G, Wilkinson D. Clinical practice with anti-dementia drugs: a consensus statement from British Association for Psychopharmacology. J Psychopharmacol 2006; 20:732-55. [PMID: 17060346 DOI: 10.1177/0269881106068299] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The British Association for Psychopharmacology (BAP) coordinated a meeting of experts to review the evidence on the drug treatment for dementia. The level of evidence (types) was rated using a standard system: Types 1a and 1b (evidence from meta-analysis of randomised controlled trials or at least one controlled trial respectively); types 2a and 2b (one well-designed study or one other type of quasi experimental study respectively); type 3 (non-experimental descriptive studies); and type 4 (expert opinion). There is type 1a evidence for cholinesterase inhibitors (donepezil, rivastigmine and galantamine) for mild to moderate Alzheimer's disease; memantine for moderate to severe Alzheimer's disease; and for the use of bright light therapy and aromatherapy. There is type 1a evidence of no effect of anti inflammatory drugs or statins. There is conflicting evidence regarding oestrogens, with type 2a evidence of a protective effect of oestrogens but 1b evidence of a harmful effect. Type 1a evidence for any effect of B12 and folate will be forthcoming when current trials report. There is type 1b evidence for gingko biloba in producing a modest benefit of cognitive function; cholinesterase inhibitors for the treatment of people with Lewy body disease (particularly neuropsychiatric symptoms); cholinesterase inhibitors and memantine in treatment cognitive impairment associated with vascular dementia; and the effect of metal collating agents (although these should not be prescribed until more data on safety and efficacy are available). There is type 1b evidence to show that neither cholinesterase inhibitors nor vitamin E reduce the risk of developing Alzheimer's disease in people with mild cognitive impairment; and there is no evidence that there is any intervention that can prevent the onset of dementia. There is type 1b evidence for the beneficial effects of adding memantine to cholinesterase inhibitors, and type 2b evidence of positive switching outcomes from one cholinesterase inhibitor to another. There is type 2a evidence for a positive effect of reminiscence therapy, and type 2a evidence that cognitive training does not work. There is type 3 evidence to support the use of psychological interventions in dementia. There is type 2 evidence that a clinical diagnosis of dementia can be made accurately and that brain imaging increases that accuracy. Although the consensus statement dealt largely with medication, the role of dementia care in secondary services (geriatric medicine and old age psychiatry) and primary care, along with health economics, was discussed. There is ample evidence that there are effective treatments for people with dementia, and Alzheimer's disease in particular. Patients, their carers, and clinicians deserve to be optimistic in a field which often attracts therapeutic nihilism.
Collapse
|
40
|
Brodaty H, Low LF, Gibson L, Burns K. What is the best dementia screening instrument for general practitioners to use? Am J Geriatr Psychiatry 2006; 14:391-400. [PMID: 16670243 DOI: 10.1097/01.jgp.0000216181.20416.b2] [Citation(s) in RCA: 156] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to review existing dementia screening tools with a view to informing and recommending suitable instruments to general practitioners (GPs) based on their performance and practicability for general practice. METHOD A systematic search of pre-MEDLINE, MEDLINE, PsycINFO, and the Cochrane Library Database was undertaken. Only available full-text articles about dementia screening instruments written in English or with an English version were included. Articles using a translation of an English language instrument were excluded unless validated in a general practice, community, or population sample. RESULTS The General Practitioner Assessment of Cognition (GPCOG), Mini-Cog, and Memory Impairment Screen (MIS) were chosen as most suitable for routine dementia screening in general practice. The GPCOG, Mini-Cog, and MIS were all validated in community, population, or general practice samples, are easy to administer, and have administration times of 5 minutes or less. They also have negative predictive validity and misclassification rates, which do not differ significantly from those of the Mini-Mental Status Examination. CONCLUSIONS It is recommended that GPs consider using the GPCOG, Mini-Cog, or MIS when screening for cognitive impairment or for case detection.
Collapse
Affiliation(s)
- Henry Brodaty
- Academic Department for Old Age Psychiatry, Euroa Centre, Prince of Wales Hospital, Randwick, Australia.
| | | | | | | |
Collapse
|
41
|
Forchetti CM. Treating patients with moderate to severe Alzheimer's disease: implications of recent pharmacologic studies. PRIMARY CARE COMPANION TO THE JOURNAL OF CLINICAL PSYCHIATRY 2005; 7:155-61. [PMID: 16163398 PMCID: PMC1192433 DOI: 10.4088/pcc.v07n0403] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2004] [Accepted: 05/02/2005] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND OBJECTIVE As the prevalence of Alzheimer's disease (AD) continues to rise, physicians will be challenged to manage increasing numbers of patients with moderate to severe AD. Despite the need for active treatment and management, the growing AD population has been overlooked in the primary care setting. Currently, the approved treatments for AD are the cholinesterase inhibitors donepezil, riva-stigmine, and galantamine and the N-methyl-D-aspartate receptor antagonist memantine. The objective of this article is to review recent pharmacologic studies and discuss implications for treatment of moderate to severe AD. DATA SOURCES AND STUDY SELECTION A PubMed search was performed for publications from 1995 to 2004 using the search terms moderate or severe, efficacy, and Alzheimer. The search was limited to randomized, controlled trials published in English. The search was further restricted to prospective studies of pharmacologic agents that included patients with severe dementia (Mini-Mental State Examination score < 10). A total of 96 citations were retrieved. Of these, 5 met the inclusion criteria. DATA EXTRACTION AND SYNTHESIS Randomized, double-blind, placebo-controlled studies in patients with moderate to severe AD have been conducted for donepezil and memantine. Patients treated with donepezil monotherapy showed improved cognition, stabilized function, and improved behavioral symptoms. Patients treated with memantine monotherapy showed less than expected decline in cognition, function, and behavioral symptoms. Patients who received memantine treatment adjunctive to stable, long-term donepezil treatment derived cognitive, functional, and behavioral benefits from add-on therapy. CONCLUSION Overall, published studies of donepezil and memantine report treatment benefits.
Collapse
Affiliation(s)
- Concetta M Forchetti
- Memory Disorders Center, Alexian Neurosciences Institute, Hoffman Estate, Illinois 60194, USA.
| |
Collapse
|
42
|
Grossberg GT. Effect of rivastigmine in the treatment of behavioral disturbances associated with dementia: review of neuropsychiatric impairment in Alzheimer's disease. Curr Med Res Opin 2005; 21:1631-9. [PMID: 16238903 DOI: 10.1185/030079905x65402] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Cognitive decline is conventionally regarded as the defining clinical symptom of Alzheimer's disease (AD), but behavioral and neuropsychiatric symptoms are also present throughout the course of the disease. In fact, behavioral symptoms may appear before cognitive decline is diagnosed. The presence of these symptoms may predict an increasing need for community-based services or even nursing home placement. The characteristic behavioral and neuropsychiatric symptoms associated with AD may be related to the same pathophysiology that underlies the cognitive abnormalities. AD is characterized by a loss of cholinergic neurons as well as by the presence of neurofibrillary tangles (NFTs) and senile plaques in brain regions with cholinergic deficits, resulting in a deficiency in acetylcholine (ACh) in areas of the brain that modulate cognition, behavior, and emotion. Cholinesterase inhibitors are thought to augment or maximize the concentration of ACh in the synaptic cleft. Rivastigmine is a dual inhibitor of both acetylcholin esterase (AChE) and butyrylcholinesterase (BuChE), enzymes involved in hydrolysis of ACh. Literature searches using MEDLINE and EMBASE databases were performed to identify studies of rivastigmine (through August 2005) that assessed neuropsychiatric aspects of AD. Rivastigmine has been demonstrated to be safe and effective in stabilizing or improving the cognitive symptoms of AD in 3 large, well-controlled, randomized clinical trials, which also demonstrated that rivastig mine improves overall global functioning. Smaller studies and meta-analyses of pooled data from the 3 large trials have suggested that rivastigmine may improve the behavioral and neuropsychiatric symptoms associated with AD.
Collapse
Affiliation(s)
- George T Grossberg
- Division of Geriatric Psychiatry, Saint Louis University School of Medicine, St. Louis, MO 63104, USA
| |
Collapse
|
43
|
Abstract
In addition to strategies designed to decrease amyloid beta (A beta) levels, it is likely that successful Alzheimer's disease (AD) therapeutic regimens will require the concomitant application of neuroprotective agents. Elucidation of pathophysiological processes occurring in AD and identification of the molecular targets mediating these processes point to potential high-yield neuroprotective strategies. Candidate neuroprotective agents include those that interact specifically with neuronal targets to inhibit deleterious intraneuronal mechanisms triggered by A beta and other toxic stimuli. Strategies include creating small molecules that block A beta interactions with cell surface and intracellular targets, down-regulate stress kinase signaling cascades, block activation of caspases and expression of pro-apoptotic proteins, and inhibit enzymes mediating excessive tau protein phosphorylation. Additional potential neuroprotective compounds include those that counteract loss of cholinergic function, promote the trophic state and plasticity of neurons, inhibit accumulation of reactive oxygen species, and block excitotoxicity. Certain categories of compounds, such as neurotrophins or neurotrophin small molecule mimetics, have the potential to alter neuronal signaling patterns such that several of these target actions might be achieved by a single agent.
Collapse
Affiliation(s)
- Frank M Longo
- Department of Neurology, University of North Carolina, Chapel Hill, North Carolina 27599, USA.
| | | |
Collapse
|
44
|
Feldman H, Gauthier S, Hecker J, Vellas B, Xu Y, Ieni JR, Schwam EM. Efficacy and safety of donepezil in patients with more severe Alzheimer's disease: a subgroup analysis from a randomized, placebo-controlled trial. Int J Geriatr Psychiatry 2005; 20:559-69. [PMID: 15920715 DOI: 10.1002/gps.1325] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND There have been very limited investigations of cholinesterase inhibitor therapy in more advanced stages of Alzheimer's disease (AD). The efficacy and safety of donepezil were evaluated in post hoc analyses of a subgroup of patients with more severe AD (standardized Mini-Mental State Examination [sMMSE] score 5-12) within a randomized, placebo-controlled trial in moderate to severe AD (MSAD study). Additional analyses examined whether donepezil's treatment effects were consistent across the full range of baseline AD severity studied (sMMSE score 5-17). METHODS Patients with moderate to severe AD (n = 290) who were living in the community or in assisted living facilities received donepezil or placebo for 24 weeks; n = 145 in the more severe AD subgroup. The primary outcome measure was the Clinician's Interview-Based Impression of Change (CIBIC-plus) with secondary outcomes including the sMMSE, Severe Impairment Battery, Neuropsychiatric Inventory, and Disability Assessment for Dementia. Analysis of Variance and Analysis of Covariance models tested for treatment x disease severity interaction in the full MSAD study sample. RESULTS CIBIC-plus scores for donepezil patients were significantly improved compared with placebo for each time-point, with a 0.70 mean treatment difference at Week 24 last observation carried forward (LOCF; p = 0.0002). Significant differences favoring donepezil were noted at Week 24 LOCF for all secondary measures. There were no treatment x severity interactions for any of the efficacy measures. CONCLUSIONS In this analysis, donepezil had significant benefits over placebo on global, cognitive, functional, and behavioral measures in a subgroup of patients with more severe AD. Furthermore, the treatment effects of donepezil were not driven by a particular stratum within the moderate to severe dementia range.
Collapse
Affiliation(s)
- Howard Feldman
- Division of Neurology, University of British Columbia, Clinic for Alzheimer's Disease and Related Disorders, Vancouver, BC, Canada.
| | | | | | | | | | | | | |
Collapse
|
45
|
Fernandez HH, Crucian GP, Okun MS, Price CC, Bowers D. Mild cognitive impairment in Parkinson's disease: the challenge and the promise. Neuropsychiatr Dis Treat 2005; 1:37-50. [PMID: 18568128 PMCID: PMC2426819 DOI: 10.2147/nedt.1.1.37.52295] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
This review addresses the literature surrounding Parkinson's disease (PD) and mild cognitive impairment (MCI). It discusses the neuropsychological, pharmaceutical, and pathological overlap, the socioeconomic impact of PD and MCI, and the value of recognizing, understanding, and treating MCI in PD. It is concluded from this review that MCI in PD does exist and should be considered in clinical and research investigations. Due to the lack of accepted clinical criteria, an inclusive operating definition of MCI in PD is proposed. Research guidelines for studying the presence of MCI in PD and evaluating the efficacy of pharmaceutical interventions are also suggested.
Collapse
|
46
|
Abstract
Dementia, a diagnostic syndrome that includes Alzheimer's disease (AD) and vascular dementia, affects more than 4 million Europeans. Its prevalence will increase as the population ages, even though half of cases remain undiagnosed. Dementia has a marked impact on the general health economy. The direct costs of caring for persons with AD alone exceed the cost of heart disease, cancer and stroke combined, primarily because of the need for expensive care in the later stages of the disease. Yet research spending for AD remains disproportionately small. Effective planning for the public health issues posed by AD mandates reduction of either the dependency or the prevalence of the disease. Some drug treatments have alleviated the symptoms of AD and improved the quality of life for patients and their families. However, many countries have introduced inappropriately stringent regulations for the use of medical therapy. These and related issues were addressed during the recent Facing Dementia Forum, in which 175 experts in dementia care discussed results of an extensive international survey. The experts identified three main barriers to effective care: (i) dementia is not considered a health care priority; (ii) there is a mistaken belief that nothing can be done about dementia; and (iii) early dementia is difficult to recognise. These observations provided a basis for the Agenda for Change, a series of strategies to overcome these barriers. The specific findings of the survey, as well as the Agenda for Change, will be reviewed in subsequent articles in this supplement.
Collapse
Affiliation(s)
- D Wilkinson
- Memory Assessment and Research Centre, Moorgreen Hospital, Southampton, UK.
| |
Collapse
|
47
|
Kurz A, Farlow M, Quarg P, Spiegel R. Disease stage in Alzheimer disease and treatment effects of rivastigmine. Alzheimer Dis Assoc Disord 2004; 18:123-8. [PMID: 15494617 DOI: 10.1097/01.wad.0000127445.00442.a1] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The efficacy and tolerability of the cholinesterase inhibitor rivastigmine in the treatment of Alzheimer disease (AD) have been demonstrated in several clinical trials, which included patients with a wide range of dementia severities. To investigate the association between severity of disease and treatment response, the combined data from three large randomized, placebo-controlled trials were analyzed. The pooled patient population was stratified into three cohorts showing moderately severe (Mini-Mental State Examination score [MMSE] < or = 15), moderate (MMSE 16-22), and mild (MMSE > or = 22) dementia. In each cohort, the effects of rivastigmine 6 to 12 mg/day versus placebo were evaluated using the cognitive subscale of the Alzheimer Disease Assessment Scale (ADAS-cog) and the Progressive Deterioration Scale. Rivastigmine 6 to 12 mg/day maintained ADAS-cog scores at or above placebo levels in all cohorts, while cognitive deterioration with placebo was progressive and severity dependent. Activities of daily living showed statistically significant benefits with rivastigmine across all severity cohorts.
Collapse
|
48
|
Masterman D. Cholinesterase inhibitors in the treatment of Alzheimer's disease and related dementias. Clin Geriatr Med 2004; 20:59-68. [PMID: 15062487 DOI: 10.1016/j.cger.2003.11.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Donna Masterman
- Department of Neurology, David Geffen School of Medicine at UCLA, 710 Westwood Plaza, Box 951769, Los Angeles, CA 90095-1769, USA.
| |
Collapse
|
49
|
Wilkinson D, Stave C, Keohane D, Vincenzino O. The Role of General Practitioners in the Diagnosis and Treatment of Alzheimer's Disease: A Multinational Survey. J Int Med Res 2004; 32:149-59. [PMID: 15080018 DOI: 10.1177/147323000403200207] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Alzheimer's disease (AD) is a growing healthcare problem. Early diagnosis and effective treatment would benefit patients and caregivers, as well as having economic implications. We conducted a survey of 741 caregivers of patients with AD in Australia, France, Italy, Spain and the UK to assess the current situation regarding the diagnosis and treatment of AD in routine clinical practice. The average time from when symptoms were first noticed by the caregiver to making the first doctor's appointment was 4 months, but 22% of caregivers waited more than 1 year before consulting a doctor. Although the majority of patients (74%) consulted their general practitioner first, the diagnosis was more likely to be made by a specialist; on average, there was a 1-year delay from when symptoms were first noticed by the caregiver to diagnosis. Access to AD care is restricted by many national healthcare systems. The delay in diagnosis imposed by such restrictions impacts on access to early and effective treatment.
Collapse
Affiliation(s)
- D Wilkinson
- Memory Assessment and Research Centre, Southampton, UK.
| | | | | | | |
Collapse
|
50
|
Longo FM, Massa SM. Neuroprotective strategies in Alzheimer’s disease. Neurotherapeutics 2004. [DOI: 10.1007/bf03206572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
|