Outcome of Alzheimer's disease: potential impact of cholinesterase inhibitors

Short-Term Response to Cholinesterase Inhibitors in Alzheimer's Disease Delays Time to Nursing Home Placement

Background:

A varying response to cholinesterase inhibitor (ChEI) treatment has been report-ed among patients with Alzheimer’s disease (AD). Whether the individual-specific response directly af-fects time to nursing home placement (NHP) was not investigated.

Objective:

We examined the relationship between the 6-month response to ChEI and institutionalization.

Methods:

In a prospective, observational, multicenter study, 881 outpatients with a clinical AD diagnosis and a Mini-Mental State Examination score of 10-26 at the start of ChEI therapy (baseline) were included. The participants were evaluated using cognitive, global, and activities of daily living (ADL) scales at base-line and semiannually over 3 years. The date of NHP was recorded.

Results:

During the study, 213 patients (24%) were admitted to nursing homes. The mean ± standard de-viation time from baseline (AD diagnosis) to NHP was 20.8 ± 9.3 months. After 6 months of ChEI treat-ment, the improved/unchanged individuals had longer time to NHP than those who worsened. The pro-longed time to NHP was 3 months for cognitive response (P=0.022), 4 months for global response (P=0.004), 6 months for basic ADL response (P<0.001), and 8 months for response in all three scales (P<0.001). No differences were detected between the improved and unchanged groups in any scales.

Conclusion:

Patients who exhibit a positive short-term response to ChEI can expect to stay in their own home for 3-8 months longer. These findings underline the importance of a comprehensive clinical exami-nation including various assessment scales to evaluate treatment response and provide a more accurate prognosis.

The Alzheimer's Disease Clinical Spectrum: Diagnosis and Management

Alzheimer's disease (AD) care requires timely diagnosis and multidisciplinary management. Evaluation involves structured patient and caregiver history and symptom-function reviews, examination, and testing (laboratory and neuroimaging) to delineate impairment level, determine the cognitive-behavioral syndrome, and diagnose cause. Clinical biomarkers are available to aid high confidence in etiologic diagnosis. Management uses psychoeducation, shared goal setting, and patient-caregiver dyad decision making. When combined, pharmacologic and nonpharmacologic therapies mitigate symptoms and reduce clinical progression and care burden. AD biopathologic processes develop over decades before symptoms manifest; this period is increasingly targeted in research as an opportunity to best delay or prevent AD dementia.

Persistence and adherence to rivastigmine in patients with dementia: Results from a noninterventional, retrospective study using the National Health Insurance research database of Taiwan

Introduction

The objective of the study was to assess adherence and persistence of patients treated with rivastigmine versus donepezil.

Methods

Persistence was calculated as the time from the first prescription date of rivastigmine/donepezil until discontinuation/medication switch/end of available data, whichever occurred first. Adherence was calculated as proportion of days covered and medication possession ratio.

Results

A majority of patients persisted on 4.5 and 6 mg of rivastigmine for 429 and 468 days, respectively, versus 443 and 441 days for patients receiving 5 and 10 mg of donepezil daily, respectively. Patients who initially received 1.5 mg of oral rivastigmine required a shorter time to reach a stable dose compared with those who initiated treatment at a higher dose of rivastigmine. Patients at a stable dose of 4.5 or 6 mg of rivastigmine were observed to persist longer than those at a lower dose of rivastigmine and donepezil.

Discussion

Although results indicate significant difference in persistence between rivastigmine and donepezil groups, clinical significance remains undetermined.

Improving food intake in persons living with dementia

Persons living with dementia have many health concerns, including poor nutritional states. This narrative review provides an overview of the literature on nutritional status in persons diagnosed with a dementing illness or condition. Poor food intake is a primary mechanism for malnutrition, and there are many reasons why poor food intake occurs, especially in the middle and later stages of the dementing illness. Research suggests a variety of interventions to improve food intake, and thus nutritional status and quality of life, in persons with dementia. For family care partners, education programs have been the focus, while a range of intervention activities have been the focus in residential care, from tableware changes to retraining of self-feeding. It is likely that complex interventions are required to more fully address the issue of poor food intake, and future research needs to focus on diverse components. Specifically, modifying the psychosocial aspects of mealtimes is proposed as a means of improving food intake and quality of life and, to date, is a neglected area of intervention development and research.

Real-world evaluation of compliance and preference in Alzheimer's disease treatment

Purpose

Rivastigmine transdermal patch has shown higher caregiver satisfaction and greater preference than oral formulation in patients with Alzheimer’s disease. However, there is limited literature available related to caregiver preference or treatment compliance in real-world clinical settings. To date, no such data are available from Asia and the Middle East, which account for a sizeable proportion of patients with Alzheimer’s disease. The objective of this study was to evaluate treatment preference and compliance with oral and transdermal medications in daily clinical practice in an ethnically diverse patient population from Asia and the Middle East with mild-to-moderate Alzheimer’s disease.

Patients and methods

RECAP (Real-world Evaluation of Compliance And Preference in the treatment of Alzheimer’s disease) was a 24-week, multicenter, prospective, noninterventional study. Two treatment cohorts were observed during the study: oral (cholinesterase inhibitors or memantine) and transdermal (rivastigmine patch). Caregiver preference, physician preference, and patient compliance were evaluated at week 24.

Results

A total of 978 of 1,931 enrolled patients (mean age: 72.8 years; 50.5% female) were in the transdermal cohort. For patients with exposure to both oral and transdermal monotherapy (n=330), a significant caregivers’ preference for the transdermal monotherapy was observed (82.7%; P<0.0001). Of the 89 participating physicians, 71 indicated preference for transdermal monotherapy. Patient compliance was also significantly higher for transdermal than oral monotherapy (P<0.0001).

Conclusion

Our study showed higher caregiver and physician preference and greater patient compliance with transdermal monotherapy in daily practice.

The relationship of weight change trajectory with medial temporal lobe atrophy in patients with mild Alzheimer's disease: results from a cohort study

INTRODUCTION

Weight loss has been described in 20% to 45% of patients with Alzheimer's disease (AD) and has been associated with adverse outcomes. Various mechanisms for weight loss in AD patients have been proposed, though none has been proven. This study aimed to elucidate a mechanism of weight loss in AD patients by examining the hypothesis that weight loss is associated with medial temporal lobe atrophy (MTA).

METHODS

Patients from the Frisian Alzheimer's disease cohort study (a retrospective, longitudinal study of 576 community-dwelling AD patients) were included when a brain MRI was performed on which MTA could be assessed. To investigate the hypothesis that weight loss is associated with MTA, we investigated whether the trajectory of body weight change depends on the severity of MTA at the time of diagnosis (that is baseline). We hypothesized that patients with more severe MTA at baseline would have a lower body weight at baseline and a faster decrease in body weight during the course of the disease. The generalized linear mixed model (GLMM) was used to determine the relationship of weight change trajectory with MTA severity.

RESULTS

In total, 214 patients (median age 79 years, median MMSE 23, mean weight 73.9 kg) were included. Patients with moderate, severe or very severe MTA at baseline weighed 3.2 to 6.8 kg more than patients with no or mild MTA. During the 3.5 years, patients gained on average 1.7 kg in body weight, irrespective of the severity of their MTA at baseline.

CONCLUSIONS

We found no evidence that MTA is associated with weight loss in AD patients. Moreover, contrary to what was expected, AD patients did not lose but gained weight during follow-up.

Risk Factors for Progression of Alzheimer Disease in a Canadian Population: The Canadian Outcomes Study in Dementia (COSID)

OBJECTIVE

To determine risk factors for clinically significant progression during 12 months in patients with mild-to-moderate Alzheimer disease.

METHOD

Community-dwelling patients with mild-to-moderate Alzheimer disease were enrolled in a 3-year prospective study, the Canadian Outcomes Study in Dementia (commonly referred to as COSID), at 32 Canadian sites. Assessments included the Global Deterioration Scale (GDS) for disease severity, the Mini-Mental State Examination (MMSE) for cognition, the Functional Autonomy Measurement System (SMAF) for daily functioning, and the NeuroPsychiatric Inventory (NPI) for behaviour, measured at baseline and at 12 months. Logistic regression identified factors associated with GDS decline, and subsequent stepwise regression identified key independent predictors. Area under the curve (AUC) was then calculated for the model.

RESULTS

Among 488 patients (mean age 76.5 years [SD 6.4], MMSE 22.1 [SD4.6], 44.1% male), 225 (46%) showed GDS decline. After adjusting for age, baseline risk factors for deterioration included the following: poorer cognition (lower MMSE score, OR 0.55; 95% CI 0.4 to 0.72 per 5 points, P ≤ 0.001), greater dependence (lower SMAF, OR 0.72; 95% CI 0.63 to 0.83 per 5 points, P ≤ 0.001), and more neuropsychiatric symptoms (higher NPI, OR 1.11; 95% CI 1.02 to 1.2 per 5 points, P = 0.02), with a protective effect of male sex (OR 0.59; 95% CI 0.39 to 0.9, P = 0.02), and higher (worse) GDS score (very mild, compared with mild OR 0.25; 95% CI 0.09 to 0.70, P ≤ 0.01; compared with moderate, OR 0.08; 95% CI 0.03 to 0.23, P < 0.001; compared with moderately severe, OR 0.03; 95% CI 0.01 to 0.11, P < 0.001). The AUC was 73% (P < 0.001) (sensitivity 90% and specificity 33%).

CONCLUSION

The progression of Alzheimer disease in Canada can be predicted using readily available clinical information.

Predictors of rapid cognitive decline in Alzheimer's disease: results from the Australian imaging, biomarkers and lifestyle (AIBL) study of ageing

BACKGROUND

The AIBL study, which commenced in November 2006, is a two-center prospective study of a cohort of 1112 volunteers aged 60+. The cohort includes 211 patients meeting NINCDS-ADRDA criteria for Alzheimer's disease (AD) (180 probable and 31 possible). We aimed to identify factors associated with rapid cognitive decline over 18 months in this cohort of AD patients.

METHODS

We defined rapid cognitive decline as a drop of 6 points or more on the Mini-Mental State Examination (MMSE) between baseline and 18-month follow-up. Analyses were also conducted with a threshold of 4, 5, 7 and 8 points, as well as with and without subjects who had died or were too severely affected to be interviewed at 18 months and after, both including and excluding subjects whose AD diagnosis was "possible" AD. We sought correlations between rapid cognitive decline and demographic, clinical and biological variables.

RESULTS

Of the 211 AD patients recruited at baseline, we had available data for 156 (73.9%) patients at 18 months. Fifty-one patients were considered rapid cognitive decliners (32.7%). A higher Clinical Dementia Rating scale (CDR) and higher CDR "sum of boxes" score at baseline were the major predictors of rapid cognitive decline in this population. Furthermore, using logistic regression model analysis, patients treated with a cholinesterase inhibitor (CheI) had a higher risk of being rapid cognitive decliners, as did males and those of younger age.

CONCLUSIONS

Almost one third of patients satisfying established research criteria for AD experienced rapid cognitive decline. Worse baseline functional and cognitive status and treatment with a CheI were the major factors associated with rapid cognitive decline over 18 months in this population.

Could cholinesterase inhibitors be harmful over the long term?

Given the rather modest clinical effects of cholinesterase inhibitors, an important question is: For how long should they be prescribed? The clinical trials that supported marketing of the drugs were only 3–6 months in duration. A couple of 12-month, placebo-controlled donepezil trials showed some advantage for Mini-Mental State Examination (MMSE) scores and maintaining a level of activities of daily living (ADL) function during that interval (Mohs et al., 2001; Winblad et al., 2001). The controversial AD2000 trial in the UK tended to show MMSE and ADL efficacy over at least two years (Courtney et al., 2004), but the authors questioned whether treatment was worthwhile or cost-effective.

Diagnosis of Alzheimer's disease patients with rapid cognitive decline in clinical practice: interest of the Deco questionnaire

BACKGROUND

Patients with Alzheimer's disease (AD) who deteriorate rapidly are likely to have a poorer prognosis. There is a clear need for a clinical assessment tool to detect such a decline in newly diagnosed patients.

OBJECTIVE

To identify the predictive factors of rapid cognitive decline (RCD) in a cohort of patients with mild to moderate AD ; and to validate a self-questionnaire for caregivers as a diagnostic tool for rapid decline.

DESIGN AND ANALYSIS

An open-label, observational, 12-month, multicenter, French study. Physicians were asked to record data of three eligible rivastigmine naïve (or on rivastigmine for < 1 year) AD patients. Risk factors of RCD and the detection power of the Détérioration Cognitive Observée scale (Deco), a 19 item self-questionnaire for caregivers, were assessed at endpoint using regression analyses.

RESULTS

Out of the 361 patients enrolled in the study, 91 (25.2%) were excluded due to loss of follow-up. Among subjects using cholinesterase inhibitors or memantine, 161 (59.6%) experienced a stabilization (29.2%) or an improvement (30.4%) in global functioning as measured by the CGI-C. Sixty of the remaining 204 patients retained for analysis (29.6%, CI 95% [23.4; 35.8]) lost three or more points on the MMSE score between the inclusion and one of the follow-up visit. In the multivariate logistic regression analysis, institutionalization, higher level of education and the loss of 3 points or more on the MMSE were found to be significant predictors of a rapid cognitive loss in this population. The threshold which maximizes the predictive values of the Deco score as a diagnostic tool of rapid cognitive decline was significantly different according to the age of the patient (below or over 75 years old). A score below 16 for patients < 75 years old and below 14 for patients ≥ 75 years old consistently predicted a RCD within the next year.

CONCLUSION

The Deco test appears to be a simple tool to alert the physician to the possibility of an aggressive course of the disease which warrants particular management.

Efficacy and safety of donepezil in patients with Alzheimer's disease in assisted living facilities

The aim of this 12-week, open-label study was to determine the safety and efficacy of donepezil in participants with Alzheimer's disease (AD) residing in assisted living facilities (ALFs). Participants received 5 mg donepezil daily for 6 weeks followed by 10 mg daily for 6 weeks. Primary and secondary outcomes were change from baseline in Mini-Mental State Examination (MMSE) and Neuropsychiatric Inventory 8 (NPI-8) scores, respectively. Safety was assessed by adverse events (AEs) and laboratory tests. Of the 97 participants, 76 completed the study. Mean MMSE score (18.7 at baseline) improved 1.8 points (P < .0001) at study end. Total NPI-8 score improved 1.8 points (P = .043). The most frequent AEs were nausea and diarrhea. Donepezil improved cognition and behavior and was safe and well tolerated. The results suggest a need for proactive screening and diagnosis of AD and support the value of treatment and use of donepezil in participants residing in ALFs.

Risk factors for nursing home placement in Alzheimer's disease: a longitudinal study of cognition, ADL, service utilization, and cholinesterase inhibitor treatment

PURPOSE OF THE STUDY

To identify risk factors for early nursing home placement (NHP) in Alzheimer's disease (AD), focusing on the impact of longitudinal change in cognition, activities of daily living (ADL), service utilization, and cholinesterase inhibitor treatment (ChEI).

DESIGN AND METHODS

In an open, 3-year, prospective, multicenter study in a routine clinical setting, 880 AD patients were treated with either donepezil, rivastigmine, or galantamine. At baseline and every 6 months, they were assessed with several rating scales including Mini-Mental State Examination, Instrumental Activities of Daily Living scale (IADL), and Physical Self-Maintenance scale. Moreover, the dose of ChEI, the amount of weekly assistance (home help service and adult day care), and the date of NHP were recorded. Cox regression models were constructed to predict the risk of NHP. 

RESULTS

During the study, 206 patients (23%) were admitted to nursing homes. Factors that precipitated institutionalization were lower cognitive and functional abilities at baseline, faster rate of decline in IADLs, female gender, solitary living, and a lower mean dose of ChEI. The men living alone and patients with a substantial increase in adult day care also demonstrated shorter time to NHP.

IMPLICATIONS

The rate of functional but not cognitive decline was a strong risk factor for NHP. The results could be used to identify the care recipients that might risk early NHP to ensure that these individuals receive a sufficient level of assistance. Furthermore, higher doses of ChEI might postpone institutionalization in AD.

Rapid cognitive decline in Alzheimer's disease. Consensus paper

The rate of cognitive decline in Alzheimer's disease (AD) varies considerably between individuals, with some subjects showing substantial deterioration and others showing little or no change over the course of the disease. These wide variations support the relatively new concept of Rapid Cognitive Decline (RCD). Patients with an accelerated rate of cognitive decline have showed to present a worse evolution in terms of mortality, loss of autonomy and institutionalisation. The conclusions from RCD studies conducted in the past years remain very heterogeneous and sometimes contradictory. This is possibly due to methodological differences, mainly the different "a priori" definitions of RCD used to identify rapid decliners. Consequently of this, there is considerable variation in reported frequency of patients with RCD which may vary from 9.5% to 54%. The lack of both consensus definition and consensual clinical assessment tools is one of the major barriers for establishing an appropriated management of rapid decliners in clinical practice. Presently, management of rapid decliners in AD remains to be a challenge waiting to better know predictive factors of a RCD. To date no specific guidelines exist to follow-up or to treat patients with this condition. This consensus paper proposes the loss of 3 points or greater in Mini-Mental State Examination (MMSE) during six months as an empirical definition of rapid cognitive decline to be used in routine medical practice and to be relevant for clinical-decision making in patients with mild to moderately-severe AD.

Prognosis of Alzheimer's disease today: a two-year prospective study in 686 patients from the REAL-FR Study

BACKGROUND

The aim of the present study was to describe the long-term evolution of Alzheimer's disease (AD) in a prospective cohort of patients under treatment with a close follow-up.

METHODS

Six hundred eighty-six AD patients from the French Network on AD (REAL-FR) were followed up and assessed every 6 months for 2 years. Cognitive, functional, behavioral, nutritional, and global status were evaluated by using Mini-Mental State Examination (MMSE), cognitive subscale of AD Assessment Scale (ADAS-cog), Activities of Daily Living scale (ADL), Neuropsychiatric Inventory (NPI), Mini-Nutritional Assessment (MNA), and Clinical Dementia Rating (CDR).

RESULTS

There were 85.13% of patients who were specifically treated for AD during their participation in the study. We observed significant changes (P < .0001) on MMSE, -4.57 +/- 0.23; ADAS-cog, 7.11 +/- 0.41; ADL, -1.32 +/- 0.07; NPI, 2.94 +/- 0.77; MNA, -0.81 +/- 0.17; and sum of boxes of the CDR (CDR-SB), 4.17 +/- 0.17. After 2 years, 10.79% (95% confidence interval [CI], 8.47 to 13.11) of the patients evolved twice as rapidly as the mean of the whole cohort on MMSE (loss, > or =9 points), 65.89% (95% CI, 62.34 to 69.44) reported a loss of 3 to 9 points, and 23.32% (95% CI, 20.16 to 26.46) were stable or improved (loss of -2 points maximum). Annual incidences for institutionalization, hospitalization, and death were 11.84% (95% CI, 9.76 to 13.92), 26.13% (95% CI, 22.52 to 29.74), and 5.95% (95% CI, 4.56 to 7.34), respectively.

CONCLUSIONS

In a recent large AD cohort mostly under treatment, AD evolution appeared to be variable, with high incidences for death or institutionalization and with 11.84% of the patients exhibiting a rapid cognitive decline, whereas one fourth of the cohort appeared in relatively stable condition, and two thirds had a moderate but significant evolution of the disease. More studies are needed to better understand these variations in patients' evolution.

Endpoints for trials in Alzheimer's disease: a European task force consensus

Harmful consequences in health status caused by disease are referred to as outcomes, and in clinical studies the measures of these outcomes are called endpoints. A major challenge when deciding on endpoints is to represent the outcomes of interest accurately, and the accuracy of such representation is assessed through validation. Complex diseases like Alzheimer's disease have many different and interdependent outcomes. We present a consensus for endpoints to be used in clinical trials in Alzheimer's disease, agreed by a European task force under the auspices of the European Alzheimer Disease Consortium. We suggest suitable endpoints for primary and secondary prevention trials, for symptomatic and disease-modifying trials in very early, mild, and moderate Alzheimer's disease, and for trials in severe Alzheimer's disease. A clear and consensual definition of endpoints is crucial for the success of further clinical trials in the field and will allow comparison of data across studies.

Trends in the prevalence and mortality of cognitive impairment in the United States: is there evidence of a compression of cognitive morbidity?

BACKGROUND

Recent medical, demographic, and social trends might have had an important impact on the cognitive health of older adults. To assess the impact of these multiple trends, we compared the prevalence and 2-year mortality of cognitive impairment (CI) consistent with dementia in the United States in 1993 to 1995 and 2002 to 2004.

METHODS

We used data from the Health and Retirement Study (HRS), a nationally representative population-based longitudinal survey of U.S. adults. Individuals aged 70 years or older from the 1993 (N = 7,406) and 2002 (N = 7,104) waves of the HRS were included. CI was determined by using a 35-point cognitive scale for self-respondents and assessments of memory and judgment for respondents represented by a proxy. Mortality was ascertained with HRS data verified by the National Death Index.

RESULTS

In 1993, 12.2% of those aged 70 or older had CI compared with 8.7% in 2002 (P < .001). CI was associated with a significantly higher risk of 2-year mortality in both years. The risk of death for those with moderate/severe CI was greater in 2002 compared with 1993 (unadjusted hazard ratio, 4.12 in 2002 vs 3.36 in 1993; P = .08; age- and sex-adjusted hazard ratio, 3.11 in 2002 vs 2.53 in 1993; P = .09). Education was protective against CI, but among those with CI, more education was associated with higher 2-year mortality.

CONCLUSIONS

These findings support the hypothesis of a compression of cognitive morbidity between 1993 and 2004, with fewer older Americans reaching a threshold of significant CI and a more rapid decline to death among those who did. Societal investment in building and maintaining cognitive reserve through formal education in childhood and continued cognitive stimulation during work and leisure in adulthood might help limit the burden of dementia among the growing number of older adults worldwide.

Acetylcholinesterase inhibitors for Alzheimer’s disease

Acetylcholinesterase inhibitor drugs are now a mature treatment approach for Alzheimer’s disease, although they remain controversial. This review addresses the available data on acetylcholinesterase inhibitor treatment in patients with Alzheimer’s disease across multiple outcome types. It addresses rational and evidence-based expectations for treatment in this population.

Commentary on "Health economics and the value of therapy in Alzheimer's disease." Value therapy for Alzheimer's disease--a European perspective

The overall goal of value therapy is to provide the most efficient use of resources, taking into account both the cost and the value derived from a given technology or drug, and to assist in healthcare decision-making, because both cost and effectiveness are considered. After a short review of European Medicines Agency (EMEA) Committee for Medicinal Products for Human Use (CHMP) recommendations for the development of medications for Alzheimer's disease, we focus on the evidence with respect to cost and benefits obtained so far with acetylcholinesterase inhibitor (AChEI) and Memantine in the treatment of Alzheimer's disease. We then analyze the recommendations developed by professionals for the treatment of Alzheimer's disease at the national level in European countries, and finally we discuss how to utilize this process more homogenously in the future to assess value therapeutic values in Alzheimer's disease.