Continuation versus discontinuation of treatment for severe dementia: randomized, pragmatic, open-label, clinical trial to evaluate the efficacy of continuing drug treatment in patients with severe dementia (STOP-DEM)

Anti-dementia drugs: what is the evidence in advanced stages?

Dementia is a major public health concern due to its increasing prevalence, substantial caregiver burden, and high financial costs. Currently, the anti-dementia drugs aim only at a symptomatic effect. The subject of prescribing these drugs in advanced stages is a matter of considerable debate, with different countries making distinct recommendations. In this review article, we analyzed the evidence regarding cognitive and functional outcomes, adverse events, health-related costs, and caregiver burden in patients with advanced Alzheimer disease (AD) and mixed dementia. We included 35 studies. Most studies are heterogeneous, focus exclusively on AD, and show small benefits in terms of cognitive and functional scales. The overall evidence seems to suggest a benefit in introducing or maintaining anti-dementia drugs in patients with advanced dementia, but clinical meaningfulness is difficult to ascertain. The issue of costs and caregiver burden is significantly underexplored in this field but also seems to favor treatment continuation, despite a reduced overall effect. The decision of introducing or withdrawing anti-dementia drugs in advanced stages of dementia should be individualized. Future studies with homogeneous designs and outcomes are warranted.

Quality of the Evidence Supporting the Role of Acupuncture Interventions for Vascular Dementia

BACKGROUND

Inflammation is an important pathogenesis of vascular dementia (VaD), and the regulatory effect of acupuncture on neuroinflammation has received extensive attention. There is conflicting evidence regarding the efficacy and safety of acupuncture for postpartum VaD. This overview aims to systematically evaluate systematic reviews/meta-analyses (SRs/MAs) of acupuncture on VaD.

METHODS

From the establishment of the electronic database to August 2022, search and identify SRs/MAs on acupuncture treatment for VaD. The Assessing the Methodological Quality of Systematic Reviews 2 (AMSTAR-2), the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 (PRISMA 2020), and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system were used to evaluate the methodological, reporting, and evidence quality of the included SRs/MAs.

RESULTS

Twelve SRs/MAs were included in this research, and the quality of methodological, reporting, and evidence for these SRs/MAs were not satisfactory. The shortcomings of these SRs/MAs mainly include lack of protocol registration, incomplete literature search, missing list of excluded literature, and high risk of bias of included original clinical trials.

CONCLUSION

VaD patients may benefit from acupuncture therapy. However, the high risk of bias in original clinical trials and the low quality of SRs/MAs make evidence-based decisions less reliable.

The Dose and Duration-dependent Association between Melatonin Treatment and Overall Cognition in Alzheimer's Dementia: A Network Meta- Analysis of Randomized Placebo-Controlled Trials

BACKGROUND

While Alzheimer's dementia (AD) has a prevalence as high as 3-32% and is associated with cognitive dysfunction and the risk of institutionalization, no efficacious and acceptable treatments can modify the course of cognitive decline in AD. Potential benefits of exogenous melatonin for cognition have been divergent across trials.

OBJECTIVE

The current network meta-analysis (NMA) was conducted under the frequentist model to evaluate the potential beneficial effects of exogenous melatonin supplementation on overall cognitive function in participants with AD in comparison to other FDA-approved medications (donepezil, galantamine, rivastigmine, memantine, and Namzaric).

METHODS

The primary outcome was the changes in the cognitive function [measured by mini-mental state examination (MMSE)] after treatment in patients with Alzheimer's dementia. The secondary outcomes were changes in the quality of life, behavioral disturbance, and acceptability (i.e., drop-out due to any reason and rate of any adverse event reported).

RESULTS

The current NMA of 50 randomized placebo-controlled trials (RCTs) revealed the medium-term lowdose melatonin to be associated with the highest post-treatment MMSE (mean difference = 1.48 in MMSE score, 95% confidence intervals [95% CIs] = 0.51 to 2.46) and quality of life (standardized mean difference = -0.64, 95% CIs = -1.13 to -0.15) among all of the investigated medications in the participants with AD. Finally, all of the investigated exogenous melatonin supplements were associated with similar acceptability as was the placebo.

CONCLUSION

The current NMA provides evidence for the potential benefits of exogenous melatonin supplementation, especially medium-term low-dose melatonin, in participants with AD.

Effectiveness of acupuncture for patients with vascular dementia: A systematic review and meta-analysis

OBJECTIVES

This meta-analysis assessed the treatment effectiveness of acupuncture in patients with vascular dementia.

METHODS

The PubMed, Embase, Cochrane library, and China National Knowledge Infrastructure were searched to identify eligible randomized controlled trials (RCTs). The odds ratios (ORs) and weighted mean differences (WMDs) with 95 % confidence intervals (CIs) were used to assess the pooled effect estimates using a random-effects model for categorical and continuous outcomes, respectively.

RESULTS

Thirty-four RCTs (2672 patients) were selected for the final meta-analysis. The use of acupuncture showed association with an increased incidence of effective rate (OR: 3.28; 95 % CI: 2.54-4.24; P < 0.001). The pooled WMDs revealed that acupuncture was significantly associated with an improvement in the Hasegawa dementia scale (HDS) (WMD: 4.31; 95 % CI: 3.15-5.47; P < 0.001), and Mini-Mental State Examination scores (MMSE) (WMD: 3.07; 95 % CI: 2.40-3.74; P < 0.001). However, the use of acupuncture showed no association with the level of Activities of daily living (ADL) (WMD: 1.93; 95 % CI: - 2.53 to 6.38; P = 0.397). Finally, acupuncture was associated with lower levels of Scale for the differentiation of syndromes of vascular dementia (SDSVD) (WMD: - 2.15; 95 % CI: - 4.14 to - 0.16; P = 0.034), and National Institutes of Health stroke scale (NIHSS) (WMD: - 3.90; 95 % CI: - 4.87 to - 2.94; P < 0.001).

CONCLUSIONS

Acupuncture is probably helpful in vascular stroke, but strong supportive data are not yet available. Acupuncture should be used cautiously, owing to the analysis of this study based on low to moderate evidence. Further high-quality, large-scale RCTs should be conducted.

CCCDTD5 recommendations on the deprescribing of cognitive enhancers in dementia

INTRODUCTION

Cognitive enhancers (ie, cholinesterase inhibitors and memantine) can provide symptomatic benefit for some individuals with dementia; however, there are circumstances in which the risks of continuing treatment may potentially outweigh benefits. The decision to deprescribe cognitive enhancers must consider each patient's preferences, treatment indications, current clinical status and symptoms, prognosis, and dementia type.

METHODS

The 5th Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD5) established a subcommittee of experts to review current evidence on the deprescribing of cognitive enhancers. The questions answered by this group included: When should cognitive enhancers be deprescribed in persons with dementia and mild cognitive impairment? How should cognitive enhancers be deprescribed? And, what clinical factors should be considered when deprescribing cognitive enhancers?

RESULTS

Patient and care-partner preferences should be incorporated into all decisions to deprescribe cognitive enhancers. Cognitive enhancers should be discontinued in individuals without ongoing evidence of benefit or when the indication for cognitive enhancer use was inappropriate (eg, mild cognitive impairment). Deprescribing should occur gradually and cognitive enhancers should be reinitiated if patients' cognition or function deteriorates. Cognitive enhancers should be continued in individuals whose neuropsychiatric symptoms improve in response to treatment. Clinicians should not deprescribe cognitive enhancers in individuals with significant neuropsychiatric symptoms until symptoms have stabilized.

CONCLUSION

CCCDTD5 deprescribing recommendations provide evidence-informed recommendations related to cognitive enhancer deprescribing that will facilitate shared decision making among patients, care partners, and clinicians.

Participants' written informed consent in low-risk pragmatic clinical trials with medicines

Introduction: An important gap within modern medicine is the lack of enough comparative effectiveness research of marketed medicines. Low-risk pragmatic randomized controlled trials (pRCTs) are those conducted resembling usual clinical practice that poses no or minimal incremental risk compared with normal clinical practice.Areas covered: This review addresses one important hurdle in the conduct of low-risk pRCTs: the need to seek participants' written informed consent.Expert opinion: The CIOMS ethical guidelines consider that any research that (a) would not be feasible or practicable to carry out without the waiver or modification, (b) has important social value, and (c) poses no more than minimal risks to participants, and that is approved by the relevant research ethics committee, could be conducted without participants' consent. It is clear that these provisions are applicable to some low-risk RCTs. Recently a research on the EU-CTR registry showed that only 2% of all ongoing phase 4 RCTs could have fulfilled the CIOMS provisions following the investigators' assessment. The EU clinical trial regulation - and that of other jurisdictions - should be debated on the suitableness of the conduct with an alteration or waiver of participants' consent of those low-risk pRCTs that fulfill the three CIOMS provisions.