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Rodriguez-Porcel F, Wyman-Chick KA, Abdelnour Ruiz C, Toledo JB, Ferreira D, Urwyler P, Weil RS, Kane J, Pilotto A, Rongve A, Boeve B, Taylor JP, McKeith I, Aarsland D, Lewis SJG. Clinical outcome measures in dementia with Lewy bodies trials: critique and recommendations. Transl Neurodegener 2022; 11:24. [PMID: 35491418 PMCID: PMC9059356 DOI: 10.1186/s40035-022-00299-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 03/31/2022] [Indexed: 12/28/2022] Open
Abstract
The selection of appropriate outcome measures is fundamental to the design of any successful clinical trial. Although dementia with Lewy bodies (DLB) is one of the most common neurodegenerative conditions, assessment of therapeutic benefit in clinical trials often relies on tools developed for other conditions, such as Alzheimer's or Parkinson's disease. These may not be sufficiently valid or sensitive to treatment changes in DLB, decreasing their utility. In this review, we discuss the limitations and strengths of selected available tools used to measure DLB-associated outcomes in clinical trials and highlight the potential roles for more specific objective measures. We emphasize that the existing outcome measures require validation in the DLB population and that DLB-specific outcomes need to be developed. Finally, we highlight how the selection of outcome measures may vary between symptomatic and disease-modifying therapy trials.
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Affiliation(s)
- Federico Rodriguez-Porcel
- Department of Neurology, Medical University of South Carolina, 208b Rutledge Av., Charleston, SC, 29403, USA.
| | - Kathryn A. Wyman-Chick
- grid.280625.b0000 0004 0461 4886Department of Neurology, Center for Memory and Aging, HealthPartners, Saint Paul, MN USA
| | - Carla Abdelnour Ruiz
- grid.7080.f0000 0001 2296 0625Autonomous University of Barcelona, Barcelona, Spain
| | - Jon B. Toledo
- grid.15276.370000 0004 1936 8091Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL USA
| | - Daniel Ferreira
- grid.4714.60000 0004 1937 0626Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences, and Society, Center for Alzheimer’s Research, Karolinska Institutet, Stockholm, Sweden ,grid.66875.3a0000 0004 0459 167XDepartment of Radiology, Mayo Clinic, Rochester, MN USA
| | - Prabitha Urwyler
- grid.5734.50000 0001 0726 5157ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Rimona S. Weil
- grid.83440.3b0000000121901201Dementia Research Centre, University College London, London, UK
| | - Joseph Kane
- grid.4777.30000 0004 0374 7521Centre for Public Health, Queen’s University, Belfast, UK
| | - Andrea Pilotto
- grid.7637.50000000417571846Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Arvid Rongve
- grid.413782.bDepartment of Research and Innovation, Helse Fonna, Haugesund Hospital, Haugesund, Norway ,grid.7914.b0000 0004 1936 7443Institute of Clinical Medicine (K1), The University of Bergen, Bergen, Norway
| | - Bradley Boeve
- grid.66875.3a0000 0004 0459 167XDepartment of Neurology, Center for Sleep Medicine, Mayo Clinic, Rochester, MN USA
| | - John-Paul Taylor
- grid.1006.70000 0001 0462 7212Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Ian McKeith
- grid.1006.70000 0001 0462 7212Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Dag Aarsland
- grid.13097.3c0000 0001 2322 6764Department of Old Age Psychiatry Institute of Psychiatry Psychology and Neuroscience, King’s College London, London, UK
| | - Simon J. G. Lewis
- grid.1013.30000 0004 1936 834XForeFront Parkinson’s Disease Research Clinic, Brain and Mind Centre, School of Medical Sciences, University of Sydney, 100 Mallett Street, Camperdown, NSW 2050 Australia
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Burley CV, Burns K, Brodaty H. Pharmacological and nonpharmacological approaches to reduce disinhibited behaviors in dementia: a systematic review. Int Psychogeriatr 2022; 34:1-17. [PMID: 35331345 DOI: 10.1017/s1041610222000151] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Disinhibited behaviors in dementia are associated with multiple negative outcomes. However, effective interventions are under-researched. This systematic review aims to provide an overview of intervention studies that report outcome measures of disinhibited behaviors in dementia. DESIGN Systematic searches of the databases MEDLINE, EMBASE, and PsychINFO, Social Work Abstracts and Cochrane Central Register of Controlled Trial databases were conducted for publications published between 2002 and March 2020. We included hand-searched reviews, original articles, case reports, cohort studies, and randomized controlled trials (RCTs). All studies were rated for research quality. Statistical and clinical significance were considered for individual studies. Effect sizes were included where provided or calculated where possible. Mean effect sizes were calculated for RCTs only. PARTICIPANTS The systematic review included studies involving people living with dementia. MEASUREMENTS The Neuropsychiatric Inventory disinhibition subscale was used most often. RESULTS Nine pharmacological and 21 nonpharmacological intervention studies utilized different theoretical/clinical approaches. These included pain management, antidepressants, models of care, education and/or training, music-based approaches, and physical activity. The quality of research in RCTs was strong with a greater effect size in nonpharmacological compared to pharmacological approaches (mean Cohen's d = 0.49 and 0.27, respectively). Disinhibition was a secondary outcome in all studies. CONCLUSION Pharmacological (including pain management and antidepressants) and, more so, nonpharmacological (models of care, education/training, physical activity, and music) approaches were effective in reducing disinhibition.
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Affiliation(s)
- Claire V Burley
- Dementia Centre for Research Collaboration, School of Psychiatry, University of New South Wales, Sydney, NSW, Australia
- Centre for Healthy Brain Ageing (CHeBA), School of Psychiatry, University of New South Wales, Sydney, NSW, Australia
| | - Kim Burns
- Dementia Centre for Research Collaboration, School of Psychiatry, University of New South Wales, Sydney, NSW, Australia
- Centre for Healthy Brain Ageing (CHeBA), School of Psychiatry, University of New South Wales, Sydney, NSW, Australia
| | - Henry Brodaty
- Dementia Centre for Research Collaboration, School of Psychiatry, University of New South Wales, Sydney, NSW, Australia
- Centre for Healthy Brain Ageing (CHeBA), School of Psychiatry, University of New South Wales, Sydney, NSW, Australia
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Holmstrand C, Rahm Hallberg I, Saks K, Leino-Kilpi H, Renom Guiteras A, Verbeek H, Zabalegui A, Sutcliffe C, Lethin C. Associated factors of suicidal ideation among older persons with dementia living at home in eight European countries. Aging Ment Health 2021; 25:1730-1739. [PMID: 32223443 DOI: 10.1080/13607863.2020.1745143] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES This study aimed to investigate the occurrence of suicidal ideation and associated factors in older persons with dementia living at home in eight European countries, and its association with quality of life. Furthermore, changes in suicidal ideation over time were investigated. METHODS This cohort study (n = 1,223) was part of the European "RightTimePlaceCare" project conducted in 2010-2013. Participating countries were Estonia, Finland, France, Germany, the Netherlands, Spain, Sweden and the United Kingdom. Baseline and follow-up data were analysed using bivariate and multivariate logistic regression. RESULTS The occurrence of suicidal ideation in the participating countries varied between 6% and 24%. Factors significantly (p < 0.0018) associated with suicidal ideation using bivariate analysis were: nationality, depressive symptoms, delusions, hallucinations, agitation, anxiety, apathy, disinhibition, irritability, night-time behaviour disturbances, anxiolytics and anti-dementia medication. In the multivariate regression analysis, country of origin, moderate stage of the dementia, depressive and delusional symptoms, and anti-dementia medication were significantly associated with suicidal ideation (p < 0.05). Over time, suicidal ideation decreased from severe to mild or became absent in 54% of the persons with dementia. CONCLUSION It is essential that professionals identify older persons with dementia and suicidal ideation and depressive and other psychological symptoms in order to give them appropriate treatment and provide relief for their informal caregivers. We emphasize the importance of identifying suicidal ideation, irrespective of depressive symptoms, and specifically of paying attention to persons with moderate dementia. Living with the informal caregiver seems to be associated with staying stable without suicidal ideation.
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Affiliation(s)
- Cecilia Holmstrand
- Faculty of Medicine, Department of Clinical Sciences, Psychiatry, Lund University, Lund, Sweden
| | | | - Kai Saks
- Faculty of Medicine, Department of Internal Medicine, University of Tartu, Tartu, Estonia
| | - Helena Leino-Kilpi
- Department of Nursing Science and Turku University Hospital, University of Turku, Turku, Finland
| | - Anna Renom Guiteras
- Faculty of Health, Department of Nursing Science, University of Witten/Herdecke, Witten, Germany.,Geriatrics Department, University Hospital Parc de Salut Mar, Barcelona, Spain
| | - Hilde Verbeek
- Department of Health Services Research, CAPHRI, Faculty of Health, Medicine and Life Sciences, Maastricht, The Netherlands
| | | | - Caroline Sutcliffe
- Personal Social Services Research Unit, Faculty of Biology, Medicine and Health, Division of Population Health, University of Manchester, Manchester, United Kingdom
| | - Connie Lethin
- Faculty of Medicine, Department of Health Sciences, Lund University, Lund, Sweden.,Faculty of Medicine, Department of Clinical Sciences, Clinical Memory Research Unit, Lund University, Lund/Malmö, Sweden
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Chu CS, Yang FC, Tseng PT, Stubbs B, Dag A, Carvalho AF, Thompson T, Tu YK, Yeh TC, Li DJ, Tsai CK, Chen TY, Ikeda M, Liang CS, Su KP. Treatment Efficacy and Acceptabilityof Pharmacotherapies for Dementia with Lewy Bodies: A Systematic Review and Network Meta-Analysis. Arch Gerontol Geriatr 2021; 96:104474. [PMID: 34256210 DOI: 10.1016/j.archger.2021.104474] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 06/27/2021] [Accepted: 06/27/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION We investigated the efficacy and acceptability of pharmacotherapy for dementia with Lewy bodies (DLB) while simultaneously considering the neuropsychiatric symptoms (NPS), cognitive function, motor symptoms, and acceptability. METHODS Electronic databases were searched from inception through June 5, 2019, for randomized controlled trials (RCTs) and open-label trials (OLTs) in patients with DLB. We performed a pairwise conventional meta-analysis (PWMA) and network meta-analysis (NMA) within a frequentist framework. The main outcomes were mean change scores in NPS, general cognition, motor symptoms and acceptability. The effect sizes and odds ratios with 95% confidence intervals (CIs) were calculated. This study was registered with PROSPERO (CRD42018096996). RESULTS In total, we included 29 studies (9 RCTs and 20 OLTs). In the NMA with 9 RCTs, both high- (mean difference [MD] 2.00, 95% CIs, 0.69 to 3.31) and low-dose (1.86, 0.58 to 3.15) donepezil were associated with a greater cognitive improvement than placebo. High-dose zonisamide was associated with greater motor symptom improvement ( -4.10, -7.03 to -1.17]). No medications reached statistical significance regarding improving neuropsychiatric symptoms or developing intolerable adverse effects as compared to placebo. In the second NMA, with 29 studies as an exploratory analysis, aripiprazole and yokukansan may be effective for neuropsychiatric symptoms, while levodopa may be associated with cognitive impairment. CONCLUSIONS We report the most comprehensive evidence for the selection of pharmacotherapy for treating different clusters of DLB-related symptoms. Due to the limited availability of RCTs on DLB, more well-conducted RCTs are needed for MMA to warrant clinical efficacy in the future.
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Affiliation(s)
- Che-Sheng Chu
- Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Center for Geriatric and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Non-invasive Neuromodulation Consortium for Mental Disorders, Society of Psychophysiology, Taipei, Taiwan; Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Taiwan
| | - Fu-Chi Yang
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Ping-Tao Tseng
- Department of Psychology, College of Medical and Health Science, Asia University, Taichung, Taiwan; Institute of Biomedical Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan; Prospect Clinic for Otorhinolaryngology & Neurology, Kaohsiung, Taiwan
| | - Brendon Stubbs
- Physiotherapy Department, South London and Maudsley NHS Foundation Trust, London, UK; Institute of Psychiatry, King's College London, UK
| | - Aarsland Dag
- Centre for Age-related Medicine, Department of Psychiatry, Stavanger University Hospital, Stavanger, Norway.; Department of Old Age Psychiatry, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, UK
| | - Andre F Carvalho
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Centre for Addiction & Mental Health (CAMH), Toronto, ON, Canada
| | - Trevor Thompson
- School of Human Sciences, University of Greenwich, London, UK
| | - Yu-Kang Tu
- Institute of Epidemiology & Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Ta-Chuan Yeh
- Department of Psychiatry, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Institute of Brain Science, National Yang-Ming Chiao Tung University, Taipei, Taiwan
| | - Dian-Jeng Li
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Taiwan; Department of Addiction Science, Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung, Taiwan
| | - Chia-Kuang Tsai
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Tien-Yu Chen
- Department of Psychiatry, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Institute of Brain Science, National Yang-Ming Chiao Tung University, Taipei, Taiwan
| | - Manabu Ikeda
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Chih-Sung Liang
- Department of Psychiatry, Beitou Branch, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan.
| | - Kuan-Pin Su
- Institute of Psychiatry, King's College London, UK; Department of Psychiatry & Mind-Body Interface Laboratory (MBI-Lab), China Medical University Hospital, Taichung, Taiwan; College of Medicine, China Medical University, Taichung, Taiwan; An-Nan Hospital, China Medical University, Tainan, Taiwan.
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Ortner M, Stange M, Schneider H, Schroeder C, Buerger K, Müller C, Dorn B, Goldhardt O, Diehl-Schmid J, Förstl H, Steimer W, Grimmer T. Serum Concentrations of Cholinesterase Inhibitors in Patients With Alzheimer's Dementia Are Frequently Below the Recommended Levels. Front Pharmacol 2020; 11:691. [PMID: 32508640 PMCID: PMC7253642 DOI: 10.3389/fphar.2020.00691] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 04/27/2020] [Indexed: 01/14/2023] Open
Abstract
Background Acetylcholinesterase inhibitors (AChE-I) are recommended for the treatment of cognitive symptoms but also of behavioral and psychological symptoms in dementia. They are widely used not only in Alzheimer's disease, but also in other forms of dementia. Efficacy of treatment might depend on serum concentration of the respective AChE-I. Objective In patients with mild to moderate Alzheimer's dementia, we measured serum concentrations of hepatically metabolized donepezil and renally excreted rivastigmine and investigated possible modifiers. Additionally, we looked at correlations between serum concentrations and efficacy for both drugs. Methods Serum concentrations of donepezil and rivastigmine were measured by liquid chromatography – tandem mass spectrometry (LC-MS/MS). Real-time quantitative polymerase chain reaction (PCR). Allele specific PCR were performed to determine CYP2D6 genotype and gene dose. Clinical efficacy was assessed by changes of the subtest wordlist delayed recall of the Consortium to Establish a Registry for Alzheimer's Disease-Neuropsychological Assessment Battery (CERAD-NAB). Results Sixty-seven patients treated with a stable dosage of donepezil 10 mg (n=41) or rivastigmine 9.5 mg (n=26) were included. Mean serum concentration of donepezil and rivastigmine were 41.2 and 6.5 ng/ml, respectively. Serum concentrations were below the recommended range in 73% of the subjects in the donepezil group and in 65% of the participants in the rivastigmine group. When applying a dose-related reference, ranges 63% of patients in the donepezil group and 32% in the rivastigmine group had concentrations below the expected range. Gene dose, sex, and duration of treatment significantly predicted donepezil serum concentration (p=0.046, p=0.001, p=0.030 respectively). Only for rivastigmine did the serum concentration significantly contribute to the regression model predicting changes on the subtest word list delayed recall (β=0.472; p=0.019). Conclusions Serum concentrations of about two thirds of the patients were below the recommended range. When not looking at absolute values but at the dose-related reference ranges, these numbers improved but still 32%, respectively 63% of patients had low serum concentrations. High serum concentrations of rivastigmine predicted clinical response to cognition. Therapeutic drug monitoring might help to identify the cause of poor clinical response to cognition and behavioral and psychological symptoms in patients with AChE-I treatment.
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Affiliation(s)
- Marion Ortner
- Department of Psychiatry and Psychotherapy, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Marion Stange
- Department of Psychiatry and Psychotherapy, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Heike Schneider
- Institute for Clinical Chemistry and Pathobiochemistry, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Charlotte Schroeder
- Institute for Clinical Chemistry and Pathobiochemistry, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Katharina Buerger
- Institut for Stroke and Dementia Research, University of Munich, Munich, Germany.,DZNE - German Center for Neurodegenerative Diseases, Munich, Germany
| | - Claudia Müller
- Institut for Stroke and Dementia Research, University of Munich, Munich, Germany
| | - Bianca Dorn
- Department of Psychiatry and Psychotherapy, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Oliver Goldhardt
- Department of Psychiatry and Psychotherapy, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Janine Diehl-Schmid
- Department of Psychiatry and Psychotherapy, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Hans Förstl
- Department of Psychiatry and Psychotherapy, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Werner Steimer
- Institute for Clinical Chemistry and Pathobiochemistry, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Timo Grimmer
- Department of Psychiatry and Psychotherapy, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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Tan ECK, Johnell K, Bell JS, Garcia-Ptacek S, Fastbom J, Nordström P, Eriksdotter M. Do Acetylcholinesterase Inhibitors Prevent or Delay Psychotropic Prescribing in People With Dementia? Analyses of the Swedish Dementia Registry. Am J Geriatr Psychiatry 2020; 28:108-117. [PMID: 31331724 DOI: 10.1016/j.jagp.2019.06.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 06/19/2019] [Accepted: 06/20/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To investigate whether acetylcholinesterase inhibitor (AChEI) use prevents or delays subsequent initiation of psychotropic medications in people with Alzheimer's disease (AD) and Lewy body dementia (LBD). METHODS Cohort study of 17,763 people with AD and LBD, without prior psychotropic use at time of dementia diagnosis, registered in the Swedish Dementia Registry from 2007 to 2015. Propensity score-matched regression models were used to compute hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between time-dependent AChEI use and risk of psychotropic initiation. RESULTS Compared with matched comparators, AChEI users had a lower risk of antipsychotic (HR: 0.85, 95%CI: 0.75-0.95) and anxiolytic (HR: 0.76, 95%CI: 0.72-0.80) initiation. In subanalyses, this association remained significant at higher AChEI doses, and in AD but not LBD. There were no associations between AChEI use and initiation of antidepressants or hypnotics. CONCLUSION AChEI use may be associated with lower risk of antipsychotic and anxiolytic initiation in AD, particularly at higher doses. Further investigation into aceytylcholinesterase inhibitors in behavioral and psychological symptoms of dementia management in LBD is warranted.
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Affiliation(s)
- Edwin C K Tan
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences (ECKT, JSB), Monash University, Parkville, Australia; The University of Sydney, Faculty of Medicine and Health, School of Pharmacy (ECKT), NSW, Australia; Aging Research Centre, Department of Neurobiology, Care Sciences and Society (ECKT, JF), Karolinska Institutet and Stockholm University, Stockholm, Sweden.
| | - Kristina Johnell
- Department of Medical Epidemiology and Biostatistics (KJ), Karolinska Institutet, Stockholm, Sweden
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences (ECKT, JSB), Monash University, Parkville, Australia
| | - Sara Garcia-Ptacek
- Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society (SGP, ME), Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden; Department of Internal Medicine, Section for Neurology (SGP), Södersjukhuset, Stockholm, Sweden
| | - Johan Fastbom
- Aging Research Centre, Department of Neurobiology, Care Sciences and Society (ECKT, JF), Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Peter Nordström
- Department of Community Medicine and Rehabilitation (PN), Umeå University, Umeå, Sweden
| | - Maria Eriksdotter
- Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society (SGP, ME), Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden; Theme Aging (ME), Karolinska University Hospital, Huddinge, Sweden
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Abstract
Purpose of Review Agitation is common among older adults with dementia; its origin may be multi-factorial, and it is often difficult to treat. In this paper, we summarize current knowledge and offer considerations on pharmacologic management of behavioral and psychological symptoms of dementia (BPSD). Recent Findings We reviewed human studies published from 2013 to 2018 evaluating pharmacologic management of BPSD manifestations including depressive symptoms, mania, psychosis, and other BPSD, as well as severe agitation without determination of underlying cause. After non-pharmacological management is exhausted, the choice of pharmacological options depends on patient comorbidities, specific BPSD presentation, and patient tolerance of medications. Summary Depending on manifestations of BPSD, low- to moderate-quality evidence supports the use of anti-depressants, anti-psychotics, or anti-epileptics in conjunction with cholinesterase inhibitors. The current evidence base needs to be augmented with future research that focuses on real-world medication use alongside head-to-head evaluation of medication effectiveness rather than comparison to placebo.
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8
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Meng YH, Wang PP, Song YX, Wang JH. Cholinesterase inhibitors and memantine for Parkinson's disease dementia and Lewy body dementia: A meta-analysis. Exp Ther Med 2018; 17:1611-1624. [PMID: 30783428 PMCID: PMC6364145 DOI: 10.3892/etm.2018.7129] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 11/30/2018] [Indexed: 12/01/2022] Open
Abstract
Recently, several randomized controlled trials on the use of cholinesterase inhibitors or memantine as treatments for cognitive impairment in Parkinson's disease (CIND-PD), Parkinson's disease with dementia (PDD) and dementia with Lewy bodies (DLB) were completed. The present study provided a meta-analysis of these studies to evaluate the efficacy of cholinesterase inhibitors and memantine on CIND-PD, PDD and DLB. The Cochrane Library, Pubmed, Embase and Web of Science databases were searched to retrieve eligible studies. As primary efficacy outcomes, cognitive function, global impression, behavioral symptoms and motor function were selected, while falling and adverse events were regarded as safety outcomes. Of note, domain-specific cognitive function was assessed as a primary efficacy outcome and falling as a safety outcome, which, to the best of our knowledge, has not been studied previously in CIND-PD, PDD and DLB. A total of 15 trials were included in the present meta-analysis. The results revealed that treatment with cholinesterase inhibitors resulted in improvements in cognitive function, the clinician's global impression, behavioral symptoms and motor function, in accordance with the results of previous studies. Furthermore, it was revealed that cholinesterase inhibitors had a significant effect on attention, processing speed, executive functions, memory and language; however, they did not improve visuospatial cognition compared with placebos. Memantine had a significant effect on attention, processing speed and executive functions. In addition, cholinesterase inhibitors and memantine did not significantly reduce falling. It was demonstrated that an increased number of adverse events occurred in the pooled cholinesterase inhibitors and memantine group, compared with that in the placebo group (risk ratio (RR)=1.09; 95% confidence interval (CI): 1.04–1.16; P=0.001); however, in the subgroup analysis, only the rivastigmine group experienced significantly more adverse events than the placebo group (85 vs. 73%; RR=1.18; 95% CI: 1.08–1.29; P=0.0001), but donepezil and memantine did not produce any significant adverse events. In conclusion, cholinesterase inhibitors and memantine have an effect not only on global cognitive function and motor function, but also on attention, processing speed, executive functions, memory and language. However, careful monitoring of the side effects of rivastigmine may be required. Further clinical trials are required to verify these conclusions.
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Affiliation(s)
- Yan-Hong Meng
- Department of Graduate School, Hebei Medical University, Shijiazhuang, Hebei 050017, P.R. China.,Department of Neurology, Hebei General Hospital, Shijiazhuang, Hebei 050051, P.R. China
| | - Pan-Pan Wang
- Department of Graduate School, Hebei Medical University, Shijiazhuang, Hebei 050017, P.R. China.,Department of Neurology, Hebei General Hospital, Shijiazhuang, Hebei 050051, P.R. China
| | - Ya-Xue Song
- Department of Neurology, Hebei General Hospital, Shijiazhuang, Hebei 050051, P.R. China.,Department of Graduate School, Hebei North University, Zhangjiakou, Hebei 075000, P.R. China
| | - Jian-Hua Wang
- Department of Neurology, Hebei General Hospital, Shijiazhuang, Hebei 050051, P.R. China
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9
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Cummings J, Lai TJ, Hemrungrojn S, Mohandas E, Yun Kim S, Nair G, Dash A. Role of Donepezil in the Management of Neuropsychiatric Symptoms in Alzheimer's Disease and Dementia with Lewy Bodies. CNS Neurosci Ther 2016; 22:159-66. [PMID: 26778658 DOI: 10.1111/cns.12484] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 10/19/2015] [Accepted: 10/23/2015] [Indexed: 12/20/2022] Open
Abstract
Alzheimer's disease (AD) is a progressive condition that affects cognition, function, and behavior. Approximately 60-90% of patients with AD develop neuropsychiatric symptoms (NPS) such as hallucinations, delusions, agitation/aggression, dysphoria/depression, anxiety, irritability, disinhibition, euphoria, apathy, aberrant motor behavior, sleep disturbances, appetite and eating changes, or altered sexual behavior. These noncognitive behavior changes are thought to result from anatomical and biochemical changes within the brain, and have been linked, in part, to cholinergic deficiency. Cholinesterase inhibitors may reduce the emergence of NPS and have a role in their treatment. These agents may delay initiation of, or reduce the need for, other drugs such as antipsychotics. This article summarizes the effects of donepezil, a cholinesterase inhibitor, on the NPS of dementia with emphasis on AD and dementia with Lewy bodies.
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Affiliation(s)
- Jeffrey Cummings
- Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, NV, USA
| | - Te-Jen Lai
- Department of Psychiatry, Chung Shan Medical University Hospital, Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Solaphat Hemrungrojn
- Department of Psychiatry, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - E Mohandas
- Department of Psychological Medicine, Sun Medical and Research Centre, Thrissur, Kerala, India
| | - Sang Yun Kim
- Department of Neurology, Seoul National University College of Medicine & Seoul National University Bundang Hospital, Seoul, Korea
| | - Girish Nair
- Department of Neurology, Fortis Hospital Mahim, Mumbai, India
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