Long-term effects of rivastigmine treatment on the need for psychotropic medications in nursing home patients with Alzheimer's disease : results of a 52-week open-label study

Do Acetylcholinesterase Inhibitors Prevent or Delay Psychotropic Prescribing in People With Dementia? Analyses of the Swedish Dementia Registry

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.

Unmet Needs in Pharmacological Treatment of Apathy in Alzheimer's Disease: A Systematic Review

Background: Apathy is one of the most prevalent neuropsychiatric symptoms encountered in Alzheimer’s disease (AD) and may be an early sign in the development of dementia persisting over the disease course. It has been associated with poor disease outcome, impaired daily functioning, and significant caregiver distress. Early diagnosis and timely treatment of apathy in AD are of great importance. However, approved agents for apathy are still missing.

Methods: Within this context, we conducted an extensive electronic search in the databases included in the National Library of Medicine, PsychInfo, and Google Scholar for studies that have investigated the effect of pharmacological treatments in apathy in AD. There were no limitations regarding study design and all care settings were considered for inclusion. Structured measures for level of evidence and study quality were employed to evaluate the results.

Results: A total of 1,607 records were identified; 1,483 records remained after the removal of duplicates and were screened; 166 full-text articles were selected and assessed for eligibility and a remaining 90 unique studies and relevant reviews were included in the qualitative synthesis. Acetylcholinesterase inhibitors, gingko biloba, and methylphenidate were found to be successful in reducing apathy in patients with AD. Methodological heterogeneity in the studies and the small amount of studies where apathy was the primary outcome are limiting factors to assess for group effects.

Conclusions: Pharmacological treatment of apathy in AD is an underexplored field. Standardized and systematic efforts are needed to establish a possible treatment benefit. Elucidating the pathophysiology of apathy and its components or subtypes will inform disease models and mechanistic drug studies that can quantify a benefit from specific agents for specific AD groups.

Neuropsychiatric Disturbances in Alzheimer's Disease: What Have We Learned from Neuropathological Studies?

Neuropsychiatric symptoms (NPS) are an integral part of the dementia syndrome and were therefore recently included in the core diagnostic criteria of dementia. The near universal prevalence of NPS in Alzheimer's disease (AD), combined with their disabling effects on patients and caregivers, is contrasted by the fact that few effective and safe treatments exist, which is in part to be attributed to our incomplete understanding of the neurobiology of NPS. In this review, we describe the pathological alterations typical for AD, including spreading and evolution of burden, effect on the molecular and cellular integrity, functional consequences and atrophy of NPS-relevant brain regions and circuits in correlation with specific NPS assessments. It is thereby clearly established that NPS are fundamental expressions of the underlying neurodegenerative brain disease and not simply reflect the patients' secondary response to their illness. Neuropathological studies, moreover, include a majority of end-stage patient samples, which may not correctly represent the pathophysiological environment responsible for particular NPS that may already be present in an early stage, or even prior to AD diagnosis. The burdensome nature and high prevalence of NPS, in combination with the absence of effective and safe pharmacotherapies, provide a strong incentive to continue neuropathological and neurochemical, as well as imaging and other relevant approaches to further improve our apprehension of the neurobiology of NPS.

Pharmacological and Nonpharmacological Treatment for Apathy in Alzheimer Disease : A systematic review across modalities

OBJECTIVE

Apathy is one of the most frequent neuropsychiatric symptoms encountered in Alzheimer disease (AD). Early diagnosis and timely treatment of apathy in AD seem to be of great importance, since apathy has been associated with poor disease outcome, reduced daily functioning, and caregiver distress.

DESIGN

Within this context, we conducted an extensive electronic search from the databases included in the National Library of Medicine as well as PsychInfo and Google Scholar for studies that have investigated the effect of pharmacological and nonpharmacological treatments of apathy in AD.

RESULTS

Acetylcholinesterase inhibitors, gingko biloba, methylphenidate, and a variety of nonpharmacological interventions were found to be successful in reducing apathy in patients with AD. Methodological heterogeneity of the studies and the small amount of studies where apathy was a primary outcome measure are limiting factors to evaluate for group effects.

CONCLUSION

Treatment of apathy in AD is a complicated and an underexplored field. Standardized and systematic efforts primarily focused on the study of apathy in AD may establish a benefit from individualized treatment for specific disease groups that would stem from a combination of both pharmacological and nonpharmacological interventions.

Efficacy of higher-dose 13.3 mg/24 h (15 cm2) rivastigmine patch on the Alzheimer's Disease Assessment Scale-cognitive subscale: domain and individual item analysis

OBJECTIVE

Rivastigmine displays dose-dependent efficacy on cognition in patients with Alzheimer's disease (AD), as measured by the Alzheimer's Disease Assessment Scale-cognitive subscale (ADAS-cog). Subanalysis of the OPTIMA (OPtimising Transdermal Exelon In Mild-to-moderate Alzheimer's disease) study aimed to define ADAS-cog domains by factor analysis of individual items. Efficacy of 13.3 mg/24 h versus 9.5 mg/24 h rivastigmine patch on individual items and newly derived domains was assessed.

METHODS

OPTIMA was a 48-week, double-blind (DB) study in patients with mild-to-moderate AD. Patients meeting pre-defined decline criteria during open-label treatment with 9.5 mg/24 h patch were randomized in the DB phase to 13.3 mg/24 h (n = 280) or 9.5 mg/24 h (n = 287) patch. ADAS-cog change from baseline was a co-primary outcome measure. Factor analysis categorized ADAS-cog items into newly derived domains. Change from DB-baseline was calculated for domains and individual items.

RESULTS

Numerically, less decline was displayed with 13.3 mg/24 h versus 9.5 mg/24 h patch in the total ADAS-cog score at all time points (significant at Week 24, p = 0.027). Factor analysis identified two domains: memory and language. Significantly, less decline was observed on the memory domain with 13.3 mg/24 h versus 9.5 mg/24 h patch at Weeks 12, 24, and 48 (p < 0.05; observed cases). Three items (following commands, orientation, and word recognition) displayed numerically less decline with 13.3 mg/24 h versus 9.5 mg/24 h patch at all time points. No significant between-group differences were observed on the language domain.

CONCLUSION

Results suggest that the greater cognitive efficacy of 13.3 mg/24 h versus 9.5 mg/24 h rivastigmine patch is driven primarily by effects on memory, particularly in the areas of following commands, orientation, and word recognition.

NMDA Neurotransmission Dysfunction in Behavioral and Psychological Symptoms of Alzheimer's Disease

Dementia has become an all-important disease because the population is aging rapidly and the cost of health care associated with dementia is ever increasing. In addition to cognitive function impairment, associated behavioral and psychological symptoms of dementia (BPSD) worsen patient's quality of life and increase caregiver's burden. Alzheimer's disease is the most common type of dementia and both behavioral disturbance and cognitive impairment of Alzheimer's disease are thought to be associated with the N-methyl-D-aspartate (NMDA) dysfunction as increasing evidence of dysfunctional glutamatergic neurotransmission had been reported in behavioral changes and cognitive decline in Alzheimer's disease. We review the literature regarding dementia (especially Alzheimer's disease), BPSD and relevant findings on glutamatergic and NMDA neurotransmission, including the effects of memantine, a NMDA receptor antagonist, and NMDA-enhancing agents, such as D-serine and D-cycloserine. Literatures suggest that behavioral disturbance and cognitive impairment of Alzheimer's disease may be associated with excitatory neurotoxic effects which result in impairment of neuronal plasticity and degenerative processes. Memantine shows benefits in improving cognition, function, agitation/aggression and delusion in Alzheimer's disease. On the other hand, some NMDA modulators which enhance NMDA function through the co-agonist binding site can also improve cognitive function and psychotic symptoms. We propose that modulating NMDA neurotransmission is effective in treating behavioral and psychological symptoms of Alzheimer's disease. Prospective study using NMDA enhancers in patients with Alzheimer's disease and associated behavioral disturbance is needed to verify this hypothesis.

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.

Revisiting the cholinergic hypothesis of behavioral and psychological symptoms in dementia of the Alzheimer's type

Behavioral and psychological symptoms of dementia (BPSD) include agitation, aberrant motor behavior, anxiety, elation, irritability, depression, apathy, disinhibition, delusions, hallucinations, and sleep or appetite impairment. These symptoms have adverse consequences for patients and caregivers, such as greater impairment in activities of daily living, worsening quality of life and earlier institutionalization. While the etiology of BPSD has not been clearly delineated, studies assessing the benefits of acetylcholinesterase inhibitors on BPSD suggest that some of the neuropsychiatric symptoms of dementia such as agitation, apathy and psychosis may represent a specific central cholinergic deficiency syndrome. Biochemical and neuroimaging studies of BPSD in Alzheimer's patients support these pharmacological data. This review discusses the literature describing the association between cholinergic deficiency and manifestations of BPSD.

Effect of discontinuing cholinesterase inhibitor therapy on behavioral and mood symptoms in nursing home patients with dementia

BACKGROUND

Cholinesterase inhibitors (CHEIs) ameliorate some types of behavioral symptoms in patients with Alzheimer's disease. However, there has been little previous study of the outcomes associated with discontinuing these medications.

OBJECTIVE

The primary aim of this study was to evaluate the extent to which discontinuing CHEI therapy affected behavioral and mood symptoms in a cohort of nursing home residents with a diagnosis of dementia compared with residents receiving longer-term CHEI therapy.

METHODS

This was a retrospective cohort study using Rhode Island Medicaid prescription claims and the Minimum Data Set (MDS). Participants were Rhode Island nursing home residents aged > or =60 years with a diagnosis of Alzheimer's disease or non-Alzheimer's dementia, treated with CHEI monotherapy, and enrolled in the Medicaid program between January 1, 2004, and December 31, 2005. The discontinuation cohort (CHEI-DC) was selected by identifying residents who received 3 to 9 months of uninterrupted CHEI therapy. The continuation cohort (CHEI-CONT) was prescribed continuous CHEI therapy for >9 months. Changes in scores on the Aggressive Behavior Scale (ABS) and the Depression Rating Scale (DRS) for CHEI-DC residents were compared with changes in scores for CHEI-CONT residents. Secondary outcomes included change over time for individual behavioral symptoms and indicators of cognitive and functional status coded on the MDS.

RESULTS

The final matched sample (N = 178) included 62 CHEI-DC cases and 116 CHEI-CONT controls. More than half of the cohort was aged > or =85 years, and the sample was predominantly female. A diagnosis of Alzheimer's disease was documented in 40.3% of the CHEI-DC patients and in 46.5% of the CHEI-CONT patients. Behavioral worsening, indicated by an increase in the estimated mean monthly point change in ABS score, occurred in the CHEI-DC group (0.08; 95% CI, 0.01 to 0.16) but not in the CHEI-CONT group (-0.01; 95% CI, -0.06 to 0.04), and the between-group difference was significant (0.09; 95% CI, 0.01 to 0.18). There were no significant between-group differences in the mean monthly point change in mood symptoms on the DRS (0.04; 95% CI, -0.03 to 0.12). For the secondary outcomes, the mean monthly MDS point change for frequency of repetitive verbal behaviors indicated that CHEI-DC patients exhibited significantly more episodes of repetitive questioning (0.17; 95% CI, 0.05 to 0.29) and repetitive health complaints (0.16; 95% CI, 0.04 to 0.27) compared with CHEI-CONT residents. Continued use of CHEIs was associated with more time spent in leisure-related activities over the study period (-0.26; 95% CI, -0.50 to -0.02), with the CHEI-DC group spending less time in activities (0.11; 95% CI, 0 to 0.23); the between-group difference was also significant (0.37; 95% CI, 0.10 to 0.65).

CONCLUSION

Results of this retrospective analysis suggest that, compared with longer duration of CHEI therapy, discontinuation of CHEIs in these nursing home residents with dementia was associated with some adverse behavioral changes and decreased time spent engaging in leisure-related activities.

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.

Pharmacologic management of neuropsychiatric symptoms of Alzheimer disease

OBJECTIVE

To systematically review published clinical trials of the pharmacotherapy of neuropsychiatric symptoms of Alzheimer disease (AD).

METHOD

We searched MEDLINE and EMBASE for published English-language medical literature. Our review focused on randomized controlled trials (RCTs) and corresponding metaanalyses.

RESULTS

The pharmacotherapy of neuropsychiatric symptoms of AD has been studied with numerous RCTs. The largest number of studies has focused on antipsychotics. Data are of reasonably high quality and indicate that risperidone and olanzapine are more effective than placebo for institutionalized patients with severe agitation, aggression, and psychosis. The efficacy of antipsychotics is counterbalanced by safety concerns that include cerebrovascular adverse events and mortality. Cholinesterase inhibitors and memantine appear to have modest benefits for patients with mildly to moderately severe symptoms. Antidepressants are effective for treating depression in AD, but more data are required to determine the efficacy of trazodone and citalopram for agitation and aggression. Carbamazepine appears to be efficacious, although side effects and concerns about drug-drug interactions limit its use. The data do not support the use of valproate. Benzodiazepines should only be used for short-term, as-needed use. There are insufficient data on other pharmacologic interventions, such as beta blockers, buspirone, and estrogen preparations.

CONCLUSIONS

Although there have been numerous well-designed studies of the pharmacotherapy of neuropsychiatric symptoms in AD, safer and more effective treatments are urgently needed.

Treatment of Cognitive Decline and Psychiatric Disturbances Associated With Alzheimer's Dementia

Alzheimer's dementia (AD) is the most common type of dementia. In addition to the cognitive and functional disturbances that happen as the disease progresses, other psychological disturbances may manifest. Depression, insomnia, anxiety, and psychosis are among several psychological conditions which can occur concomitantly with AD. These changes can result in decreased quality of life for both patients and caregivers, increase caregiver burden, and impact the decision to place a patient with AD into a long-term care facility. An evidence-based review of the literature was performed to ascertain if a specific recommendation for pharmacotherapy can be made based on current research in this specific patient population.