Is long-term treatment of Alzheimer's disease with cholinesterase inhibitor therapy justified?

Advancements in Stem Cell Research for Effective Therapies Against Alzheimer's Disease: Current Investigation and Future Insight

Alzheimer's disease (AD) is the most prevalent cause of dementia in the elderly, affecting approximately 50 million individuals globally with significant impose in health and financial burdens. Despite extensive research, no current treatment effectively halts the progression of AD, primarily due to its complex pathophysiology of the disease and the limitations of available therapeutic approaches. In this context, stem cell transplantation has emerged as a promising treatment strategy, harnessing the regenerative capabilities of various stem cell types, including neural stem cells (NSCs), embryonic stem cells (ESCs), and mesenchymal stem cells (MSCs). This review explores the potential of stem cell-based therapies in AD, emphasizing the necessity for continued innovation to overcome existing challenges and enhance therapeutic efficacy. Briefly, NSCs have shown potential in improving cognitive function and reducing AD pathology through targeted transplantation and neuroprotection; however, challenges such as optimizing transplantation protocols and ensuring effective cell integration persist. Concurrently, ESCs, with their pluripotent nature, present opportunities for modulating AD and generating therapeutic neurons, but ethical concerns and immunogenicity present significant obstacles to clinical application. Moreover, MSCs have demonstrated potential in ameliorating AD-related pathology and promoting neurogenesis, offering a more accessible alternative with fewer ethical constraints. The review concludes that the combinatory approaches of different stem cells may provide synergistic benefits in addressing AD-related pathophysiology, warranting further exploration in future research.

Recent Advances in Drug Development for Alzheimer's Disease: A Comprehensive Review

Alzheimer's disease (AD) is a prevalent neurodegenerative disorder characterized by cognitive impairments such as memory loss and executive dysfunction. The primary pathological features of AD include the deposition of amyloid-beta (Aβ) plaques, the hyperphosphorylation of tau proteins leading to neurofibrillary tangles, disruptions of neuronal and synaptic functions, and chronic inflammatory responses. These multifactorial interactions drive disease progression. To date, various therapeutic agents targeting these pathological mechanisms have been developed. This article provides a comprehensive review of the pathogenesis of AD, recent advances in drug development targeting different pathways, current challenges, and future directions, aiming to offer valuable insights for clinical treatment and research.

Protective effects of polydatin amphiphilic chitosan nanocarriers against an aluminum chloride-induced model of Alzheimer's disease in rats: relevance to its anti-inflammatory and antioxidant effects

Alzheimer's disease (AD) is the most frequent cause of dementia. Since there are complex pathophysiological mechanisms behind AD, and there is no effective treatment strategy, it is necessary to introduce novel multi-targeting agents with fewer side effects and higher efficacy. Polydatin (PD) is a naturally occurring resveratrol glucoside employing multiple mechanisms toward neuroprotection. In the current study, the anti-AD mechanisms of a novel amphiphilic chitosan nanocarrier formulation (ACN) of PD (NPD) were studied. After preparing the amphiphilic chitosan nanoformulation (i.e., NPD), physicochemical properties were assessed, including particle size, zeta potential, drug loading, drug release, MTT, Fourier transform infrared spectroscopy (FT-IR), and scanning electron microscopy (SEM). For in vivo analysis, aluminum chloride (AlCl3) was injected intraperitoneally for 14 days to induce AD in male Albino Wistar rats. To examine the anti-AD mechanisms of NPD, a total of 36 rats were divided into six groups of six. Behavioral tests, including open field, Y-maze, elevated plus maze, and shuttle box were done on days 7, 8, 14, and 15. Additionally, zymography, biochemical analysis, and histological studies were done. NPD, as a newly synthesized formulation for PD, potentially improved memory and cognitive behavioral parameters and reduced the activity of inflammatory matrix metalloproteinase 9 (MMP9) and serum nitrite levels, while increasing anti-inflammatory MMP2, antioxidant catalase, and glutathione. NPD also prevented morphological changes and increased neuronal survival in the CA2, CA4, and DG regions of the rat hippocampus. In conclusion, NPD is a novel formulation against AD through anti-inflammatory, antioxidant, and neuroprotective mechanisms.

A Novel Donepezil–Caffeic Acid Hybrid: Synthesis, Biological Evaluation, and Molecular Docking Studies

A novel donepezil-caffeic acid (DP-CA) hybrid molecule was designed, synthesis, and investigated by molecular modeling. Its biological activity and protective effect were investigated by the IR spectroscopy, ¹H and ¹³C NMR spectroscopy, and mass spectrometry. DP-CA was highly active against acetylcholine esterase and inhibited it at the micromolar concentrations. Fluorescence and UV-Vis spectroscopy studies showed strong binding of DP-CA to DNA. Moreover, DP-CA exhibited protective effects against H2O2-induced toxicity in U-118 MG glioblastoma cells. Finally, molecular docking showed a high affinity of DP-CA in all concentrations, and the active 4EY7 site exhibited essential residues with polar and apolar contacts. Taken together, these findings indicate that DP-CA could be a prospective multifunctional agent for the treatment of neurodegenerative diseases.

The Function and Expression of ATP-Binding Cassette Transporters Proteins in the Alzheimer's Disease

Despite many years of research, radical treatment of Alzheimer's disease (AD) has still not been found. Amyloid-β (Aβ) peptide is known to play an important role in the pathogenesis of this disease. AD is characterized by three main changes occurring in the central nervous system: (1) Aβ plaque accumulation that prevents synaptic communication, (2) the accumulation of hyperphosphorylated tau proteins that inhibit the transport of molecules inside neurons, and (3) neuronal cell loss of the limbic system. Mechanisms leading to Aβ accumulation in AD are excessive Aβ production as a result of mutations in amyloid precursor protein or genes, and impairment of clearance of Aβ due to changes in Aβ aggregation properties and/or Aβ removal processes. Human ATP-binding cassette (ABC) transporters are expressed in astrocyte, microglia, neuron, brain capillary endothelial cell, choroid plexus, choroid plexus epithelial cell, and ventricular ependymal cell. ABC transporters have essential detoxification and neuroprotective roles in the brain. The expression and functional changes in ABC transporters contribute to the accumulation of Aβ peptide. In conclusion, the review was aimed to summarize and highlight accumulated evidence in the literature focusing on the changing functions of human ABC transporter members, in AD pathogenesis and progression.

A comprehensive review on medicinal herbs and novel formulations for the prevention of Alzheimer's disease

Alzheimer's disease (AD) is one of the most prevalent neurodegenerative diseases reported in the aging population across the globe. About 46.8 million people are reported to have dementia, and AD is mainly responsible for dementia in aged people. Alzheimer's disease (AD) is thought to occur due to the accumulation of β-amyloid (Aβ) in the neocortex portion of the brain, nitric oxide mediated dysfunctioning of blood-brain barrier, reduced activity of serine racemase enzyme, cell cycle disturbances, damage of N-methyl-D-aspartate (NMDA) receptors and glutamatergic neurotransmission. Modern treatment methods target the pathways responsible for the disease. To date, solely symptomatic treatments exist for this disease, all making an attempt to counterbalance the neurotransmitter disturbance. Treatments able to prevent or at least effectively modifying the course of AD, referred to as 'disease-modifying' drugs, are still under extensive research. Effective treatments entail a better indulgence of the herbal bioactives by novel drug delivery systems. The herbal bioactive administered by novel drug delivery systems have proved beneficial in treating this disease. This review provides detailed information about the role of medicinal plants and their formulations in treating Alzheimer disease which will be highly beneficial for the researchers working in this area.

Withdrawal or continuation of cholinesterase inhibitors or memantine or both, in people with dementia

BACKGROUND

Dementia is a progressive syndrome characterised by deterioration in memory, thinking and behaviour, and by impaired ability to perform daily activities. Two classes of drug - cholinesterase inhibitors (donepezil, galantamine and rivastigmine) and memantine - are widely licensed for dementia due to Alzheimer's disease, and rivastigmine is also licensed for Parkinson's disease dementia. These drugs are prescribed to alleviate symptoms and delay disease progression in these and sometimes in other forms of dementia. There are uncertainties about the benefits and adverse effects of these drugs in the long term and in severe dementia, about effects of withdrawal, and about the most appropriate time to discontinue treatment.

OBJECTIVES

To evaluate the effects of withdrawal or continuation of cholinesterase inhibitors or memantine, or both, in people with dementia on: cognitive, neuropsychiatric and functional outcomes, rates of institutionalisation, adverse events, dropout from trials, mortality, quality of life and carer-related outcomes.

SEARCH METHODS

We searched the Cochrane Dementia and Cognitive Improvement Group's Specialised Register up to 17 October 2020 using terms appropriate for the retrieval of studies of cholinesterase inhibitors or memantine. The Specialised Register contains records of clinical trials identified from monthly searches of a number of major healthcare databases, numerous trial registries and grey literature sources.

SELECTION CRITERIA

We included all randomised, controlled clinical trials (RCTs) which compared withdrawal of cholinesterase inhibitors or memantine, or both, with continuation of the same drug or drugs.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed citations and full-text articles for inclusion, extracted data from included trials and assessed risk of bias using the Cochrane risk of bias tool. Where trials were sufficiently similar, we pooled data for outcomes in the short term (up to 2 months after randomisation), medium term (3-11 months) and long term (12 months or more). We assessed the overall certainty of the evidence for each outcome using GRADE methods.

MAIN RESULTS

We included six trials investigating cholinesterase inhibitor withdrawal, and one trial investigating withdrawal of either donepezil or memantine. No trials assessed withdrawal of memantine only. Drugs were withdrawn abruptly in five trials and stepwise in two trials. All participants had dementia due to Alzheimer's disease, with severities ranging from mild to very severe, and were taking cholinesterase inhibitors without known adverse effects at baseline. The included trials randomised 759 participants to treatment groups relevant to this review. Study duration ranged from 6 weeks to 12 months. There were too few included studies to allow planned subgroup analyses. We considered some studies to be at unclear or high risk of selection, performance, detection, attrition or reporting bias. Compared to continuing cholinesterase inhibitors, discontinuing treatment may be associated with worse cognitive function in the short term (standardised mean difference (SMD) -0.42, 95% confidence interval (CI) -0.64 to -0.21; 4 studies; low certainty), but the effect in the medium term is very uncertain (SMD -0.40, 95% CI -0.87 to 0.07; 3 studies; very low certainty). In a sensitivity analysis omitting data from a study which only included participants who had shown a relatively poor prior response to donepezil, inconsistency was reduced and we found that cognitive function may be worse in the discontinuation group in the medium term (SMD -0.62; 95% CI -0.94 to -0.31). Data from one longer-term study suggest that discontinuing a cholinesterase inhibitor is probably associated with worse cognitive function at 12 months (mean difference (MD) -2.09 Standardised Mini-Mental State Examination (SMMSE) points, 95% CI -3.43 to -0.75; moderate certainty). Discontinuation may make little or no difference to functional status in the short term (SMD -0.25, 95% CI -0.54 to 0.04; 2 studies; low certainty), and its effect in the medium term is uncertain (SMD -0.38, 95% CI -0.74 to -0.01; 2 studies; very low certainty). After 12 months, discontinuing a cholinesterase inhibitor probably results in greater functional impairment than continuing treatment (MD -3.38 Bristol Activities of Daily Living Scale (BADLS) points, 95% CI -6.67 to -0.10; one study; moderate certainty). Discontinuation may be associated with a worsening of neuropsychiatric symptoms over the short term and medium term, although we cannot exclude a minimal effect (SMD - 0.48, 95% CI -0.82 to -0.13; 2 studies; low certainty; and SMD -0.27, 95% CI -0.47 to -0.08; 3 studies; low certainty, respectively). Data from one study suggest that discontinuing a cholinesterase inhibitor may result in little to no change in neuropsychiatric status at 12 months (MD -0.87 Neuropsychiatric Inventory (NPI) points; 95% CI -8.42 to 6.68; moderate certainty). We found no clear evidence of an effect of discontinuation on dropout due to lack of medication efficacy or deterioration in overall medical condition (odds ratio (OR) 1.53, 95% CI 0.84 to 2.76; 4 studies; low certainty), on number of adverse events (OR 0.85, 95% CI 0.57 to 1.27; 4 studies; low certainty) or serious adverse events (OR 0.80, 95% CI 0.46 to 1.39; 4 studies; low certainty), and on mortality (OR 0.75, 95% CI 0.36 to 1.55; 5 studies; low certainty). Institutionalisation was reported in one trial, but it was not possible to extract data for the groups relevant to this review.

AUTHORS' CONCLUSIONS

This review suggests that discontinuing cholinesterase inhibitors may result in worse cognitive, neuropsychiatric and functional status than continuing treatment, although this is supported by limited evidence, almost all of low or very low certainty. As all participants had dementia due to Alzheimer's disease, our findings are not transferable to other dementia types. We were unable to determine whether the effects of discontinuing cholinesterase inhibitors differed with baseline dementia severity. There is currently no evidence to guide decisions about discontinuing memantine. There is a need for further well-designed RCTs, across a range of dementia severities and settings. We are aware of two ongoing registered trials. In making decisions about discontinuing these drugs, clinicians should exercise caution, considering the evidence from existing trials along with other factors important to patients and their carers.

Alzheimer's disease; a review of the pathophysiological basis and therapeutic interventions

Alzheimer's disease (AD) is a neurodegenerative disorder and is identified as the most common cause for dementia. Despite huge global economic burden and the impact on the close family of the patients, there is no definitive cure and thus, improved treatment methods are of need. While memory and cognition are severely affected in AD, exact etiology is yet unknown. The β-Amyloid plaque formation and aggregation hypothesis is among the well-known hypotheses used to explain disease pathogenesis. Currently there are five Food and Drug Administration (FDA) approved drugs as treatment options. All these drugs are used for symptomatic treatment of AD. Thus, disease modifying therapies which can directly address the pathological changes in AD, are needed. Such therapies could be designed based on inhibiting key steps of pathogenesis. Currently there are novel AD drug candidates with various therapeutic mechanisms, undergoing different stages of drug development. Extensive research is being done globally to broaden understanding of the exact mechanisms involved in AD and to develop therapeutic agents that can successfully hinder the occurrence and progression of the disease. In this review, a comprehensive approach to understanding AD and suggestions to be considered in the development of therapeutics for it are presented.

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.

Long-term efficacy and toxicity of cholinesterase inhibitors in the treatment of Alzheimer disease

Though the symptoms of Alzheimer disease go on for years, the phase 3 trials of the cholinesterase inhibitors (ChEIs), the current mainstay of symptomatic pharmacotherapy for this condition, were typically of only 3- to 6-months' duration. We have limited data on long-term (that is, a year or more) therapy with these agents. In this review, we explore the available information on the biological and clinical effects of long-term ChEI therapy, what happens when these agents are discontinued, and examine what others have recommended An individualized approach to deciding on whether to carry on with a ChEI should be taken. If continued, treatment goals should be clarified and patients monitored over time, for both drug-related benefits and adverse effects.

A population-based study of dosing and persistence with anti-dementia medications

PURPOSE

Cholinesterase inhibitors and memantine are the mainstay of pharmacological intervention for the cognitive symptoms of Alzheimer's disease (AD). This study assessed the adequacy of dosing and persistence with AD medications and the predictors of these variables in the 'real world' (outside the clinical trial setting).

METHODS

The Health Service Executive-Primary Care Reimbursement Services prescription claims database in the Republic of Ireland contains prescription information for 1.6 million people. Patients aged >70 years who received at least two prescriptions for donepezil, rivastigmine, galantamine and memantine between January 2006 and December 2010 were included in the study. Rates of dose-maximisation were recorded by examining the initiation dose of each AD drug commenced during the study period and any subsequent dose titrations. Non-persistence was defined by a gap in prescribing of more than 63 consecutive days. Predictors of dose-maximisation and non-persistence were also analysed.

RESULTS

Between January 2006 and December 2010, 20,729 patients aged >70 years received a prescription for an AD medication. Despite most patients on donepezil and memantine receiving a prescription for the maximum drug dose, this dose was maintained for 2 consecutive months in only two-thirds of patients. Patients were significantly more likely to have their doses of donepezil and memantine maximised if prescribed in more recent years (2010 vs. 2007). Rates of non-persistence were 30.1 % at 6 months and 43.8 % at 12 months. Older age [75+ vs. <75 years; hazards ratio (HR) 1.16, 95 % confidence interval (CI) 1.06-1.27] and drug type (rivastigmine vs. donepezil; HR 1.15, 95 % CI 1.03-1.27) increased the risk of non-persistence. Non-persistence was lower for those commencing therapy in more recent years (2010 vs. 2007; HR 0.81, 95 % CI 0.73-0.89, p < 0.001) and for those on multiple anti-dementia medications (HR 0.59, 95 % CI 0.54-0.65, p < 0.001). Persistence was significantly higher when memantine was co-prescribed with donepezil (p < 0.0001).

CONCLUSION

Future studies should explore the reasons underlying non-persistence and failure to maintain dose-maximisation in patients on AD medications. There may be scope to improve the dosing and persistence with these medications in the community.

Drug therapy optimization at the end of life

Older people reaching end-of-life status are particularly at risk of adverse effects of drug therapy. Polypharmacy, declining organ function, co-morbidity, malnutrition, cachexia and changes in body composition all sum up to increase the risk of many drug-related problems in individuals who receive end-of-life care. End of life is defined by a limited lifespan or advanced disability. Optimal prescribing for end-of-life patients with multimorbidity, especially in those dying from non-cancer conditions, remains mostly unexplored, despite the increasing recognition that the management goals for patients with chronic diseases should be redefined in the setting of reduced life expectancy. Most drugs used for symptom palliation in end-of-life care of older patients are used without solid evidence of their benefits and risks in this particularly frail population. Appropriate dosing or optimal administration routes are in most cases unknown. Avoiding or discontinuing drugs that aim to prolong life or prevent disability is usually common sense in end-of-life care, particularly when the time needed to obtain the expected benefits from the drug is longer than the life expectancy of a particular individual. However, discontinuation of drugs is not standard practice, and prescriptions are usually not adapted to changes in the course of advanced diseases. Careful consideration of remaining life expectancy, time until benefit, goals of care and treatment targets for each drug seems to be a sensible framework for decision making. In this article, some key issues on drug therapy at the end of life are discussed, including principles of decision making about drug treatments, specific aspects of drug therapy in some common geriatric conditions (heart failure and dementia), treatment of acute concurrent problems such as infections, evidence to guide the choice and use of drugs to treat symptoms in palliative care, and avoidance of some long-term therapies in end-of-life care. Solid evidence is lacking to guide optimal pharmacotherapy in most end-of-life settings, especially in non-cancer diseases and very old patients. Some open questions for research are suggested.

[Pharmacological treatment of dementia: when, how and for how long. Recommendations of the Working Group on Dementia of the Catalan Society of Geriatrics and Gerontology]

Dementia in general--and Alzheimer's disease (AD) in particular--are bound to loom large among the most acute healthcare, social, and public health problems of the 21st century. AD shows a degenerative progression that can be slowed down--yet not halted--by today's most widely accepted specific treatments (those based on cholinesterase inhibitors as well as those using memantine). There is enough evidence to consider these treatments advisable for the mild, moderate and severe phases of the illness. However, in the final stage of the disease, a decision has to be made on whether to withdraw such treatment or not. In this paper, the Working Group on Dementia for the Catalan Society of Geriatrics and Gerontology reviews the use of these specific pharmacological treatments for AD, and, drawing on the scientific evidence thus gathered, makes a series of recommendations on when, how, and for how long, the currently existing specific pharmacological treatments should be used.

ABC Transporters and the Alzheimer's Disease Enigma

Alzheimer's disease (AD) is considered the "disease of the twenty-first century." With a 10-fold increase in global incidence over the past 100 years, AD is now reaching epidemic proportions and by all projections, AD patient numbers will continue to rise. Despite intense research efforts, AD remains a mystery and effective therapies are still unavailable. This represents an unmet need resulting in clinical, social, and economic problems. Over the last decade, a new AD research focus has emerged: ATP-binding cassette (ABC) transporters. In this article, we provide an overview of the ABC transporters ABCA1, ABCA2, P-glycoprotein (ABCB1), MRP1 (ABCC1), and BCRP (ABCG2), all of which are expressed in the brain and have been implicated in AD. We summarize recent findings on the role of these five transporters in AD, and discuss their potential to serve as therapeutic targets.

Cognitive Enhancers in Moderate to Severe Alzheimer's Disease

The treatment of moderate to severe Alzheimer's disease is reviewed with regard to mechanisms of action, pharmacokinetics, metabolism, safety/tolerability, and efficacy in reducing cognitive, behavioral/psychiatric, functional and global symptoms. The cholinesterase inhibitors donepezil, rivastigmine and galantamine and the N-methyl-d-aspartate receptor channel blocker memantine are moderately beneficial. Small improvements over a few months are followed by slowed mental decline. Concerning cognitive, functional and global functions, these drugs are similarly effective. Cholinesterase inhibitors also reduce apathy, memantine counteracts agitation and aggression. Serious adverse effects are rare with all four drugs. Cholinesterase inhibitors bear a risk for patients with cardiac diseases. Adverse emetic events are typical for oral formulations of these drugs, but less for rivastigmine transdermal patches. Other routes of administration and use of a galantamine prodrug are currently investigated. The superiority of combination therapies over monotherapies requires further support. Promising investigational drugs include the copper/zinc ionophore PBT2 and multifunctional hybrid molecules.

Galantamine: an update

SUMMARY Alzheimer’s disease (AD) is a progressive neurodegenerative disorder that impairs cognitive function. Currently, the main purpose of pharmacological treatment is to slow down the progression by relieving its symptoms. Galantamine is one of the three cholinesterase inhibitors that are commonly used, either alone or in conjunction with memantine, to treat AD. Four fixed-dose pivotal trials with the immediate-release form and one with the extended-release form established its effectiveness in treating mild-to-moderate AD, without causing excessive adverse events. Both forms possess similar efficacy, but the extended-release form has better compliance.

Discontinuing cholinesterase inhibitors: results of a survey of Canadian dementia experts

BACKGROUND

Cholinesterase inhibitors (ChEIs) are being used for increasingly long periods of time, even in patients with severe Alzheimer's disease. Because there is little data to help clinicians to decide on when it is safe and appropriate to discontinue ChEIs after long-term use, practices may vary widely.

METHODS

An internet-based survey was undertaken of Canadian dementia experts (geriatric psychiatrists, neurologists, geriatricians) involved in clinical trial research. Recommendations for ChEI discontinuation were determined based on responses to questions dealing with patient/caregiver preference, administrative considerations, effectiveness, and adverse events.

RESULTS

There was reasonable consensus that ChEIs should be discontinued based on patient and caregiver preference, and in the presence of severe bothersome adverse events. There was much less consensus on issues related to effectiveness - in particular, what constitutes greater than expected decline. There was a general reluctance to rely on any single measure of cognition, function and/or behavior, and in particular, the MMSE was seen as unhelpful for making decisions about discontinuation.

CONCLUSION

Recommendations for discontinuing ChEIs after long-term use from a survey of dementia experts are presented. Ideally, clinical practice guidelines based on controlled discontinuation trials are needed.

Yokukansan inhibits neuronal death during ER stress by regulating the unfolded protein response

BACKGROUND

Recently, several studies have reported Yokukansan (Tsumura TJ-54), a traditional Japanese medicine, as a potential new drug for the treatment of Alzheimer's disease (AD). Endoplasmic reticulum (ER) stress is known to play an important role in the pathogenesis of AD, particularly in neuronal death. Therefore, we examined the effect of Yokukansan on ER stress-induced neurotoxicity and on familial AD-linked presenilin-1 mutation-associated cell death.

METHODS

We employed the WST-1 assay and monitored morphological changes to evaluate cell viability following Yokukansan treatment or treatment with its components. Western blotting and PCR were used to observe the expression levels of GRP78/BiP, caspase-4 and C/EBP homologous protein.

RESULTS

Yokukansan inhibited neuronal death during ER stress, with Cnidii Rhizoma (Senkyu), a component of Yokukansan, being particularly effective. We also showed that Yokukansan and Senkyu affect the unfolded protein response following ER stress and that these drugs inhibit the activation of caspase-4, resulting in the inhibition of ER stress-induced neuronal death. Furthermore, we found that the protective effect of Yokukansan and Senkyu against ER stress could be attributed to the ferulic acid content of these two drugs.

CONCLUSIONS

Our results indicate that Yokukansan, Senkyu and ferulic acid are protective against ER stress-induced neuronal cell death and may provide a possible new treatment for AD.

A pilot study for the effects of donepezil therapy on cerebral and optic nerve head blood flow, visual field defect in normal-tension glaucoma

PURPOSE

To evaluate the effect of donepezil hydrochloride, an agent for the treatment of Alzheimer's disease (AD), on the cerebral and optic nerve head (ONH) blood flow, visual field defect in normal-tension glaucoma (NTG) patients with decreased cerebral blood flow (CBF) that demonstrates an AD-like perfusion pattern.

METHODS

The subjects were 5 NTG patients who exhibited AD-like decreased CBF upon (123)I-iodoamphetamine single photon emission computed tomography ((123)I-IMP SPECT). Donepezil hydrochloride (5 mg/day) was prescribed for each patient during a period of 12 months. Intraocular pressure (IOP), mean deviation (MD) of the Humphrey visual field, ONH blood flow determined by a laser speckle flowgraphy, and regional CBF (rCBF) determined by (123)I-IMP SPECT were measured before and every 6 months during the treatment.

RESULTS

MD, ONH blood flow, and rCBF were improved significantly after 6 months of the treatment, although IOP did not change significantly. No deterioration of NTG morbidity was found in any of the measured parameters after 12 months of the treatment.

CONCLUSIONS

Oral administration of donepezil hydrochloride in NTG patients might prevent deterioration of visual field defect, ONH blood flow, and rCBF in the temporal, parietal, and posterior lobes. This pilot study suggested the possibility that donepezil hydrochloride might ameliorate glaucomatous optic neuropathy in NTG.

Withholding, discontinuing and withdrawing medications in dementia patients at the end of life: a neglected problem in the disadvantaged dying?

Recent years have seen a growing recognition that dementia is a terminal illness and that patients with advanced dementia nearing the end of life do not currently receive adequate palliative care. However, research into palliative care for these patients has thus far been limited. Furthermore, there has been little discussion in the literature regarding medication use in patients with advanced dementia who are nearing the end of life, and discontinuation of medication has not been well studied despite its potential to reduce the burden on the patient and to improve quality of life. There is limited, and sometimes contradictory, evidence available in the literature to guide evidence-based discontinuation of drugs such as acetylcholinesterase inhibitors, antipsychotic agents, HMG-CoA reductase inhibitors (statins), antibacterials, antihypertensives, antihyperglycaemic drugs and anticoagulants. Furthermore, end-of-life care of patients with advanced dementia may be complicated by difficulties in accurately estimating life expectancy, ethical considerations regarding withholding or withdrawing treatment, and the wishes of the patient and/or their family. Significant research must be undertaken in the area of medication discontinuation in patients with advanced dementia nearing the end of life to determine how physicians currently decide whether medications should be discontinued, and also to develop the evidence base and provide guidance on systematic medication discontinuation.

Persistence with cholinesterase inhibitor therapy for dementia: an observational administrative health database study

OBJECTIVE

To determine if choice of drug and ease of administration affect persistence of therapy with cholinesterase inhibitors (ChEIs) for treatment of dementia.

METHODS

An observational administrative health database study was conducted in 5622 patients aged >or=65 years who received a new prescription for donepezil (DON), rivastigmine (RIV) or galantamine (GAL) from February to May 2006. Patients were followed for 1 year from initiation of therapy to determine percentage persistence and days of therapy. Once-daily galantamine extended release (GAL-ER) was compared with twice-daily galantamine immediate release (GAL-IR) to determine if ease of administration affected persistence. Previous treatment with ChEIs was also documented.

RESULTS

One-year persistence rates were significantly different among the ChEIs: GAL-ER 54% (95% CI 51, 57), DON 46% (95% CI 43, 49) and RIV 40% (95% CI 37, 43). Average days of therapy were greater for GAL-ER (293) than for RIV (272), but there were no differences between DON (287) and GAL-ER or DON and RIV. One-year persistence was significantly greater for GAL-ER 54% (95% CI 48, 59) than for GAL-IR 44% (95% CI 39, 50), although there was no significant difference in days of therapy (293 vs 286, respectively). More patients currently treated with RIV (40.5%) or GAL-ER (32.3%) had received previous treatment with a different ChEI than with DON (21.9%).

CONCLUSION

Among possible factors affecting persistence of ChEI therapy for dementia, choice of drug, ease of administration and previous treatment appear to be important.

Report of ten years' activity in an Alzheimer's disease assessment unit

BACKGROUND AND AIMS

After ten years' treatment with cholinesterase inhibitors (AcheI) in Alzheimer's disease (AD), we report here the activity of the Alzheimer's Disease Assessment Unit of IRCCS C. Mondino, Pavia, Italy.

METHODS

From September 2000 to December 2007, 794 out-patients (of 2236 referred to our Assessment Unit for cognitive disturbances) with AD of mild to moderate degree were treated with cholinesterase inhibitors (M/F: 273/521, mean age 73.6+/- 8.4 yrs, range 52-85 yrs). Outcome measures were scores on Mini Mental State Examination (MMSE), ADL, IADL and Neuropsychiatric Inventory (NPI).

RESULTS

Mean treatment duration was 36.9+/-16.1 months. After three months' treatment, MMSE scores remained stable (responders) in 60% of cases and improved (increase of 3 or more points - good responders) in 15%, with good preservation of autonomy. After 15 months, the percentage of "good responders" decreased to 7%, while after 15, 27 and 39 months the percentage of responders progressively decreased to 40%, 30% and 8%, respectively; greater impairment in instrumental with respect to basic everyday activities was noted. No variables capable of predicting the response to treatment were detected. The onset of behavioral disturbances caused significant (p<0.02) worsening of both cognition and function and, in 12% of cases, suspension of treatment.

CONCLUSIONS

Our results therefore confirm the efficacy of AcheI in AD of mild to moderate degree even in a nonselected population; efficacy also seems to persist in long-term treatment. This report, although brief and mainly descriptive, can make a contribution to better knowledge of the usefulness of these drugs in AD of mild to moderate extent in everyday clinical practice.

Diagnosis and treatment of dementia: 5. Nonpharmacologic and pharmacologic therapy for mild to moderate dementia

BACKGROUND

Practising physicians frequently seek advice on the most effective interventions for dementia. In this article, we provide practical guidance on nonpharmacologic and pharmacologic interventions for the management of mild to moderate dementia based on recommendations from the Third Canadian Consensus Conference on the Diagnosis and Treatment of Dementia.

METHODS

We developed evidence-based guidelines using systematic literature searches, with specific criteria for the selection and quality assessment of articles, and a clear and transparent decision-making process. We selected articles published from January 1996 to December 2005 that dealt with the management of mild to moderate stages of Alzheimer disease and other forms of dementia. Recommendations based on the literature review were drafted and voted on. Consensus required 80% or more agreement by participants. Subsequent to the conference, we searched for additional articles published from January 2006 to April 2008 using the same major keywords and secondary search terms. We graded the strength of the evidence using the criteria of the Canadian Task Force on Preventive Health Care.

RESULTS

We identified 1615 articles, of which 954 were selected for further study. From a synthesis of the evidence in these studies, we made 48 recommendations for the management of mild to moderate dementia (28) and dementia with a cerebrovascular component (8) as well as recommendations for addressing ethical issues (e.g., disclosure of the diagnosis) (12). The updated literature review did not change these recommendations. An exercise program is recommended for patients with mild to moderate dementia. Physicians should decide whether to prescribe a cholinesterase inhibitor on an individual basis, balancing anticipated benefits with the potential for harm. For mild mood and behavioural concerns, nonpharmacologic approaches should be considered first.

INTERPRETATION

Although the available therapies for dementia can help with the management of symptoms, there is a need to develop more effective interventions.