Alzheimer's Disease: Differences of Transdermal versus Oral Treatment on Caregiving Time

Translation from Preclinical Research to Clinical Trials: Transdermal Drug Delivery for Neurodegenerative and Mental Disorders

Neurodegenerative diseases (NDs), particularly dementia, provide significant problems to worldwide healthcare systems. The development of therapeutic materials for various diseases has a severe challenge in the form of the blood-brain barrier (BBB). Transdermal treatment has recently garnered widespread favor as an alternative method of delivering active chemicals to the brain. This approach has several advantages, including low invasiveness, self-administration, avoidance of first-pass metabolism, preservation of steady plasma concentrations, regulated release, safety, efficacy, and better patient compliance. Topics include the transdermal method for therapeutic NDs, their classification, and the mechanisms that allow the medicine to enter the bloodstream through the skin. The paper also discusses the obstacles and potential outcomes of transdermal therapy, emphasizing the benefits and drawbacks of different approaches.

Dementia in health claims data: The influence of different case definitions on incidence and prevalence estimates

OBJECTIVES

The epidemiology of dementia subtypes including Alzheimer's disease (AD) and vascular dementia (VD) and their reliance on different case definitions ("algorithms") in health claims data are still understudied.

METHODS

Based on health claims data, prevalence estimates (per 100 persons), incidence rates (IRs, per 100 person-years), and proportions of AD, VD, and other dementias (oD) were calculated. Five algorithms of increasing strictness considered inpatient/outpatient diagnoses (#1, #2), antidementia drugs (#3) or supportive diagnostics (#4, #5).

RESULTS

Algorithm 1 detected 213,409 cases (#2: 197,400; #3: 48,688; #4: 3033; #5: 3105), a prevalence for any dementia of 3.44 and an IR of 1.39 (AD: 0.80/0.21, VD: 0.79/0.31). The prevalence decreased by algorithms for any dementia (#2: 3.19; #3: 0.75; #4: 0.04; #5: 0.05) as did IRs (#2: 1.13; #3: 0.18; #4: 0.05, #5: 0.05). Algorithms 1-2, and 4-5 revealed similar proportions of AD (23.3%-26.6%), VD (19.9%-23.2%), and oD (53.1%-53.8%), algorithm 3 estimated 45% (AD), 12.1% (VD), and 43.0% (oD).

CONCLUSIONS

Health claims data show lower estimates of AD than previously reported, due to markedly lower prevalent/incident proportions of patients with corresponding codes. Using medication in defining dementia potentially improves estimating the proportion of AD while supportive diagnostics were of limited use.

Stability of individual dementia diagnoses in routine care: implications for epidemiological studies

PURPOSE

Epidemiological and health care research frequently rely on diagnoses from routine care, but the intra-individual stability of diagnoses of Alzheimer's disease (AD), vascular dementia (VD) or other forms of dementia (oD) in patients over time is understudied. More data on the diagnostic stability is needed to appraise epidemiological findings from such studies.

METHODS

Using health claims data of the years 2004-2016 from the German Pharmacoepidemiological Research Database, 160 273 patients aged ≥50 with incident dementia were identified and followed for four years. According to the incident ICD-10 codes patients were assigned to the categories AD, VD or oD. Changes between categories during follow-up were calculated.

RESULTS

Overall, 18.8% had incident AD (VD: 21.5%, oD: 59.7%). 15 842 patients had only one dementia diagnosis during four years (AD: 7.4%, VD: 12,4%, oD: 9.8%). Among those with more than one diagnosis, the incident diagnosis matched the last diagnosis in 65.1% (AD), 53.9% (VD) and 73.8% (oD) of patients. Changes in the diagnostic category were higher in patients with AD (mean: 5.1) than in patients with VD (3.6) or oD (3.3). Patients with stable AD diagnoses during the observation period were younger (median: 76 vs. 79 years) and had less inpatient treatment days (median: 14 days) than patients with changes from an AD diagnosis to another category or from another category to AD (27 days).

CONCLUSIONS

While health claims data are feasible for estimating the incidence of dementia in general, the substantial number of changes in dementia diagnoses during the course of the disease warrant caution on the interpretation of epidemiological data on specific dementia types.

How complete is the information on preadmission psychotropic medications in inpatients with dementia? A comparison of hospital medical records with dispensing data

OBJECTIVES

Reliable information on preadmission medications is essential for inpatients with dementia, but its quality has hardly been evaluated. We assessed the completeness of information and factors associated with incomplete recording.

METHODS

We compared preadmission medications recorded in hospital electronic medical records (EMRs) with community-pharmacy dispensations in hospitalizations with discharge code for dementia at the University Hospital of Udine, Italy, 2012-2014. We calculated: (a) prevalence of omissions (dispensed medication not recorded in EMRs), additions (medication recorded in EMRs not dispensed), and discrepancies (any omission or addition); (b) multivariable logistic regression odds ratio, with 95% confidence interval (95% CI), of ≥1 omission.

RESULTS

Among 2,777 hospitalizations, 86.1% had ≥1 discrepancy for any medication (Kappa 0.10) and 33.4% for psychotropics. When psychotropics were recorded in EMR, antipsychotics were added in 71.9% (antidepressants: 29.2%, antidementia agents: 48.2%); when dispensed, antipsychotics were omitted in 54.4% (antidepressants: 52.7%, antidementia agents: 41.5%). Omissions were 92% and twice more likely in patients taking 5 to 9 and ≥10 medications (vs. 0 to 4), 17% in patients with psychiatric disturbances (vs. none), and 41% with emergency admission (vs. planned).

CONCLUSION

Psychotropics, commonly used in dementia, were often incompletely recorded. To enhance information completeness, both EMRs and dispensations should be used.

[Users and utilization of support groups among caregivers of dementia patients : Results of a naturalistic observational study]

BACKGROUND

Caring for patients with Alzheimer's disease (AD) is frequently associated with an increased burden for the caregiving relatives (CG). While therapeutic options and low threshold assistance offers for a reduction of the burden have become well established, data on the utilization of support groups (SG) are still lacking.

MATERIAL AND METHODS

In the outpatient neurological and psychiatric routine treatment, AD patients were enrolled with their accompanying CG in a 2-stage study. Firstly, each patient was clinically documented by the treating physician and each CG was asked to fill out a questionnaire on the current care situation at the patient's home. In stage two, each CG was additionally assessed with a standardized interview and screened for depression with the depression screening questionnaire (DSQ). Each CG also rated the current CG burden, life satisfaction and health condition on a visual analogue scale (VAS).

RESULTS

Overall, 14.8 % of CGs attended an SG. The CGs who visited an SG showed a tendency to report a severe CG burden more often than CGs who did not (71.9 % vs. 56.3 %, p = 0.060) and more frequently a lower satisfaction with life (33.3 vs. 17.2 %, p < 0.01). They also reported higher rates of verbal and physical aggression by the patients (51.5 % vs. 34.0 %, p < 0.05 and 39.4 % vs. 12.7 %, p < 0.01, respectively) and appraised their health condition to be lower (VAS score 66.0 % vs. 54.0, p < 0.01). Depressive disorders occurred in both groups at similar rates (54.1 % and 42.1 %, p = 0.317).

CONCLUSION

The data suggest that the decision to join an SG is influenced more by behavioral and non-cognitive symptoms of the AD rather than its duration or severity.

Alpha rhythm oscillations and MMSE scores are differently modified by transdermal or oral rivastigmine in patients with Alzheimer's disease

BACKGROUND

Alzheimer's disease (AD) is the most common cause of dementia in older patients. Rivastigmine, a reversible cholinesterase inhibitor, has been shown to improve the clinical manifestations of AD by delaying the breakdown of acetylcholine (ACh) released into synaptic clefts. Moreover, there is evidence that ACh modulates EEG alpha frequency.

OBJECTIVES

the objectives of this pilot study in patients with AD were to determine the effects of two formulations of RV (transdermal and oral) on Mini-Mental State Examination (MMSE) scores and on alpha frequency in particular the posterior dominant rhythm.

METHODS

twenty subjects with AD were randomly assigned to receive either RV transdermal patch (RV-TDP, n=10) or RV capsules (RV-CP, n=10) according to the standard recommended dosage regimen. All patients were driven to the maximum drug dosage. Diagnosis of AD was made according to NINCDS-ADRDA criteria and the Diagnostic and Statistical Manual of Mental Disorders IV. All patients underwent EEG recordings at the beginning and at the end of the 18-month study period using P3, P4, O1 and O2 electrodes each at high (10.5-13.0 Hz) and low (8.0-10.5 Hz) frequency. MMSE scores were determined at the start of the study and at three successive 6-month intervals (T0, T1, T2, and T3).

RESULTS

administration of RV-DP increases the spectral power of alpha waves in the posterior region and is associated with improved cognitive function as evidenced by significant changes in MMSE scores.

CONCLUSION

RV-DP provides an effective and long-term management option in patients with AD.

Comparison of the effects of transdermal and oral rivastigmine on cognitive function and EEG markers in patients with Alzheimer's disease

BACKGROUND

Alzheimer's disease (AD) is the most common cause of dementia in older patients. Rivastigmine (RV, Exelon, Novartis), a reversible cholinesterase inhibitor, improves clinical manifestations of AD and may enhance ACh-modulated electroencephalogram (EEG) alpha frequency. This pilot study aimed to determine the effects of two formulations of RV [transdermal patch (RV-TDP) and oral capsules (TV-CP)] on alpha frequency, in particular the posterior dominant rhythm, and cognitive function [assessed by the Mini-Mental State Examination (MMSE)] in patients with AD.

METHODS

Subjects with AD were assigned to receive either RV-TDP 10 cm(2) or RV-CP 12 mg/day. All patients underwent EEG recordings at the beginning and end of the 18-month study period using P3, P4, O1, and O2 electrodes, each at high (10.5-13.0 Hz) and low (8.0-10.5 Hz) frequency. MMSE scores were determined at the start of the study (T0) and at three successive 6-month intervals (T1, T2, and T3).

RESULTS

RV-TDP administration (n = 10) maintained cognitive function as evidenced by stable MMSE scores from baseline to 18 months (21.07 ± 2.4-21.2 ± 3.1) compared with a decrease in MMSE score with RV-CP (n = 10) over 18 months [18.3 ± 3.6-13.6 ± 5.06 (adjusted for covariates p = 0.006)]. MMSE scores were significantly different between treatment groups from 6 months (p = 0.04). RV-TDP also increased the spectral power of alpha waves in the posterior region measured with electrode P3 in a significantly great percentage of patients than TV-CP from baseline to 18 months; 80% vs 30%, respectively [p = 0.025 (χ (2) test)].

CONCLUSIONS

RV-TDP was associated with a greater proportion of patients with increased posterior region alpha wave spectral power and significantly higher cognitive function at 18 months, compared with RV-CP treatment. Our findings suggest that RV-TDP provides an effective long-term management option in patients with AD compared with oral RV-CP. This study is a pilot, open-label study with a clear explorative purpose and with a small number of patients. Further randomized, double-blind, placebo-controlled trial studies with a bigger sample size as well as healthy controls are needed to support these initial results.