A pilot study evaluating the efficacy and safety of rivastigmine in patients with mixed dementia

Unraveling the role of brain renin angiotensin system in vascular dementia: mechanisms and therapeutic perspectives

Dementia is a heterogeneous syndrome characterized by the progressive deterioration of various brain functions, severely impacting cognitive, emotional, and social abilities. According to a World Health Organization (WHO) report, dementia represents a pressing global health concern, with the number of affected individuals projected to triple by 2050. Among its various subtypes, vascular dementia (VD) stands as the second most common form, following Alzheimer's disease (AD). Despite ongoing efforts in drug development, no pharmaceutical entity has yet received approval from the U.S. Food and Drug Administration (FDA) for the treatment of VD. Emerging evidence underscores the critical involvement of the brain's Renin-Angiotensin System (RAS) in the pathogenesis of multiple neurodegenerative disorders, including VD. The intricate roles of RAS components include regulating vascular tone, neuronal growth and survival, regulating cerebral blood flow and endothelial dysfunction, increasing neuroinflammation (by increasing release of IL-1, IL-6, TNF-α, microglial activation), oxidative stress and destruction of BBB integrity, mainly through Angiotensin II type 1 (AT1) and type 2 (AT2) receptors, are of significant interest in the pathophysiology of VD. However, disruptions in these signaling pathways are believed to contribute substantially to the progression of VD. This review addresses the limitations of current therapeutic approaches for VD while emphasizing the untapped potential of RAS-targeted interventions. We systematically explore the neurophysiological mechanisms of brain RAS, their role in promoting neuronal health, and the factors that compromise these pathways, ultimately leading to cognitive decline. By elucidating these mechanisms and challenges, the review offers novel insights into designing innovative RAS-based therapeutic strategies, paving the way for effective clinical management of VD. This work aspires to stimulate further research and development in this underexplored yet promising domain.

[The efficacy of pharmacological approaches to therapy of the apathy syndrome in dementia disorders (the review)]

The article presents a literature review of psychopharmacological methods of treatment of the apathy syndrome, which is common in neurocognitive disorders. The review provides recommendations for the management of such patients, taking into account evidence-based medicine.

The CITIRIVAD Study: CITIcoline plus RIVAstigmine in Elderly Patients Affected with Dementia Study

BACKGROUND

Acetylcholinesterase inhibitors (AchEIs), such as rivastigmine, coadministered with cholinergic precursors, such as citicoline, could be effective in Alzheimer's disease (AD) and in mixed dementia (MD), because they are able to increase the intrasynaptic levels of acetylcholine more than the single drugs given alone.

OBJECTIVE

The aim of the present study was to show the effectiveness of oral citicoline plus rivastigmine in patients with AD and MD.

METHODS

The CITIRIVAD study was a retrospective case-control study on 174 consecutive outpatients aged ≥65 years, affected with AD or MD, mean age 81.3 ± 4.5 years. Of the 174 patients, 92 had been treated with rivastigmine + citicoline 1000 mg/day given orally (group A); 82 patients had been treated with rivastigmine (group B). In both groups rivastigmine patch had been used for at least six months at the highest tolerated dosage. Group A comprised 62 patients affected with AD and 30 patients with MD. Group B comprised 53 patients affected with AD and 29 with MD. Cognitive functions had been assessed by Mini Mental State Examination (MMSE), daily life functions by activities of daily living (ADL) and instrumental activities (IADL), behavioral symptoms by neuropsychiatric inventory (NPI), comorbidities by the Cumulative Illness Rating Scale and mood by geriatric depression scale (GDS)-short form tests, which had been administered at baseline, 3 and 9 months.

RESULTS AND CONCLUSIONS

Data show the effectiveness of combined administration versus the AchEI alone, mainly in slowing disease progression and consequently in disease management, both in AD and in MD. No differences regarding the combined treatment were found between the two groups. Treatment with citicoline plus rivastigmine was safe and well tolerated.

Alzheimer's disease with cerebrovascular disease: current status in the Asia-Pacific region

BACKGROUND

There is growing awareness of the coexistence of Alzheimer's disease and cerebrovascular disease (AD+CVD), however, due to lack of well-defined criteria and treatment guidelines AD+CVD may be underdiagnosed in Asia.

METHODS

Sixteen dementia specialists from nine Asia Pacific countries completed a survey in September 2014 and met in November 2014 to review the epidemiology, diagnosis and treatment of AD+CVD in Asia. A consensus was reached by discussion, with evidence provided by published studies when available.

RESULTS

AD accounts for up to 60% and AD+CVD accounts for 10-20% of all dementia cases in Asia. The reasons for underdiagnosis of AD+CVD include lack of awareness as a result of a lack of diagnostic criteria, misdiagnosis as vascular dementia or AD, lack of diagnostic facilities, resource constraints and cost of investigations. There is variability in the tools used to diagnose AD+CVD in clinical practice. Diagnosis of AD+CVD should be performed in a stepwise manner of clinical evaluation followed by neuroimaging. Dementia patients should be assessed for cognition, behavioural and psychological symptoms, functional staging and instrumental activities of daily living. Neuroimaging should be performed using computed tomography or magnetic resonance imaging. The treatment goals are to stabilize or slow progression as well as to reduce behavioural and psychological symptoms, improve quality of life and reduce disease burden. First-line therapy is usually an acetylcholinesterase inhibitor such as donepezil.

CONCLUSION

AD+CVD is likely to be under-recognised in Asia. Further research is needed to establish the true prevalence of this treatable and potentially preventable disease.

Recommended measures for the assessment of cognitive and physical performance in older patients with dementia: a systematic review

Aim/Goal

To recommend a set of neuropsychological and physical exercise tests for researchers to assess cognition and physical fitness in clinical trials with older patients with dementia; to create consensus, decrease heterogeneity, and improve research quality.

Methods

A literature search (2005–2011) yielded 89 randomized controlled trials. To provide information on test recommendations the frequency of test use, effect size of the test outcome, study quality, and psychometric properties of tests were analyzed.

Results

Fifty-nine neuropsychological tests (cognitive domains: global cognition, executive functioning, memory, and attention) and 10 exercise tests (physical domains: endurance capacity, muscle strength, balance, and mobility) were found.

Conclusion

The Severe Impairment Battery, Mini Mental State Examination, and Alzheimer Disease Assessment Scale – cognitive subscale were recommended to measure global cognition. The Verbal Fluency Test Category/Letters, Clock Drawing Test, and Trail Making Test-B were recommended to measure executive functioning. No specific memory test could be recommended. The Digit Span Forward, Digit Span Backward, and Trail Making Test-A were recommended to measure attention. As physical exercise tests, the Timed Up and Go and Six Meter Walk for mobility, the Six Minute Walk Distance for endurance capacity, and the Tinetti Balance Scale were recommended.

Pharmacologic treatment of apathy in dementia

Apathy in patients with dementia is common, underrecognized, and undertreated. We sought to improve understanding of the pharmacologic treatment of apathy in dementia by performing a systematic literature review of studies that used apathy outcome scales to document results of pharmacologic treatments for apathy. There is limited evidence of efficiency of pharmacotherapy for treatment of apathy in dementia. The best results were found for acetylcholinesterase inhibitors. There was some evidence of efficacy for memantine, but less evidence of efficacy for stimulants, calcium antagonists, and antipsychotics. There was no evidence to support the use of antidepressants or anticonvulsants. The research quality of studies was modest. Recommendations for standardizing research and for holistic evaluation and treatment are provided.

Management of mixed dementia

Alzheimer's disease (AD) and vascular dementia (VaD) are the most common causes of dementia in the elderly. Although AD can be diagnosed with a considerable degree of accuracy, the distinction between isolated AD, VaD and mixed dementia (MD) [when both pathologies coexist in the same patient] remains a controversial issue and one of the most difficult diagnostic challenges. MD represents a very common pathology, especially in the elderly, as reported in neuropathological studies. Accurate diagnosis of MD is of crucial significance for epidemiological purposes and for preventive and therapeutic strategies. Until recently, pharmacological studies have generally focused on pure disease, either AD or VaD, and have provided few data on the best therapeutic approach to MD. There is only one original randomized clinical trial on (acetyl)cholinesterase inhibitor therapy (GAL-INT-6, galantamine) for MD; the other studies are post hoc analyses of AD trial subgroups (AD2000, donepezil) or of VaD trial subgroups (VantagE, rivastigmine). Cholinesterase inhibitors have reproducible beneficial effects on cognitive and functional outcomes in patients with MD. These benefits are of a similar magnitude to those previously reported for the treatment of AD. It is likely that the beneficial effects of memantine (an NMDA receptor antagonist) in AD may also apply to MD, but randomized controlled trials are still lacking. Treatment of cardiovascular risk factors, especially hypertension, may protect brain function and should be included in prevention strategies for MD.

Diagnosis and management of vascular cognitive impairment

Accurate diagnosis of vascular cognitive impairment (VCI) is important but may be difficult. VCI diagnoses depend on determinations of the presence of both cognitive impairment and cerebrovascular disease (CVD), temporal causal links between cognitive impairment and CVD, and the presence or absence of other potential contributors to cognitive impairment, such as Alzheimer's disease (AD). Diagnostic criteria differ across currently utilized systems, resulting in widely differing VCI prevalence rates. Also, current systems may not be able to differentiate "pure" VCI from "mixed" AD and CVD. National Institute of Neurological Disorders and Stroke harmonization criteria for VCI have been developed for study and validation to help bridge gaps in our understanding of VCI diagnosis. VCI management begins with atherogenic risk factor control. Current VCI treatment options demonstrate statistical improvement but not consistent global clinical efficacy. Future clinical trials should concentrate on both primary risk factor control and development of new therapeutic agents to treat patients already diagnosed with VCI.

A systematic review of the effectiveness of rivastigmine for the treatment of behavioral disturbances in dementia and other neurological disorders

BACKGROUND

Dementia is frequently associated with behavioral disturbances, some of which have a significant impact on patient quality of life and the likelihood of institutionalization. Cholinergic systems, among other neurotransmitters in the brain, appear to be involved with different behaviors, such as psychosis, depression, agitation, and personality changes.

SCOPE

This paper reviews the clinical data on the effectiveness of rivastigmine, a dual inhibitor of acetylcholinesterase and butyrylcholinesterase, in ameliorating behavioral disturbances in different patient populations. Relevant articles were identified through MEDLINE searches with no date restrictions.

FINDINGS

In particular, rivastigmine has shown efficacy in treating behavioral disturbances in patients with a wide range of dementias - Alzheimer's disease, vascular dementia, fronto-temporal dementia, mixed dementia, Lewy body dementia, Parkinson's disease with dementia, and schizophrenia with dementia. Most of the studies have been open-label clinical trials with behavior as a secondary endpoint. The behavior domains that most consistently showed improvement were apathy/indifference, anxiety, delusions (psychosis), and hallucinations. The major limitation of this review is that the effects on behavioral symptoms were usually secondary endpoints in clinical trials.

CONCLUSION

The efficacious effects of treatment with rivastigmine on various behavioral disturbances provide supporting evidence that cholinergic mechanisms, among other neurotransmitters, are involved in the manifestation of some behavioral and psychological symptoms of dementia.