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Lanctôt KL, Rivet L, Tumati S, Perin J, Sankhe K, Vieira D, Mintzer J, Rosenberg PB, Shade D, Lerner AJ, Padala PR, Brawman-Mintzer O, van Dyck CH, Porsteinsson AP, Craft S, Levey AI, Padala KP, Herrmann N. Heterogeneity of Response to Methylphenidate in Apathetic Patients in the ADMET 2 Trial. Am J Geriatr Psychiatry 2023; 31:1077-1087. [PMID: 37385898 PMCID: PMC10765607 DOI: 10.1016/j.jagp.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/07/2023] [Accepted: 06/09/2023] [Indexed: 07/01/2023]
Abstract
OBJECTIVE The Apathy in Dementia Methylphenidate Trial 2 (ADMET 2) found that methylphenidate was effective in treating apathy with a small-to-medium effect size but showed heterogeneity in response. We assessed clinical predictors of response to help determine individual likelihood of treatment benefit from methylphenidate. DESIGN Univariate and multivariate analyses of 22 clinical predictors of response chosen a priori. SETTING Data from the ADMET 2 randomized, placebo controlled multi-center clinical trial. PARTICIPANTS Alzheimer's disease patients with clinically significant apathy. MEASUREMENTS Apathy assessed with the Neuropsychiatric Inventory apathy domain (NPI-A). RESULTS In total, 177 participants (67% male, mean [SD] age 76.4 [7.9], mini-mental state examination 19.3 [4.8]) had 6-months follow up data. Six potential predictors met criteria for inclusion in multivariate modeling. Methylphenidate was more efficacious in participants without NPI anxiety (change in NPI-A -2.21, standard error [SE]:0.60) or agitation (-2.63, SE:0.68), prescribed cholinesterase inhibitors (ChEI) (-2.44, SE:0.62), between 52 and 72 years of age (-2.93, SE:1.05), had 73-80 mm Hg diastolic blood pressure (-2.43, SE: 1.03), and more functional impairment (-2.56, SE:1.16) as measured by the Alzheimer's Disease Cooperative Study Activities of Daily Living scale. CONCLUSION Individuals who were not anxious or agitated, younger, prescribed a ChEI, with optimal (73-80 mm Hg) diastolic blood pressure, or having more impaired function were more likely to benefit from methylphenidate compared to placebo. Clinicians may preferentially consider methylphenidate for apathetic AD participants already prescribed a ChEI and without baseline anxiety or agitation.
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Affiliation(s)
- Krista L Lanctôt
- Sunnybrook Research Institute (KLL, LR, ST, KS, DV, NH), University of Toronto, Toronto, Ontario, Canada.
| | - Luc Rivet
- Sunnybrook Research Institute (KLL, LR, ST, KS, DV, NH), University of Toronto, Toronto, Ontario, Canada
| | - Shankar Tumati
- Sunnybrook Research Institute (KLL, LR, ST, KS, DV, NH), University of Toronto, Toronto, Ontario, Canada
| | - Jamie Perin
- Bloomberg School of Public Health (JP, DS), Johns Hopkins University, Baltimore, MD
| | - Krushnaa Sankhe
- Sunnybrook Research Institute (KLL, LR, ST, KS, DV, NH), University of Toronto, Toronto, Ontario, Canada
| | - Danielle Vieira
- Sunnybrook Research Institute (KLL, LR, ST, KS, DV, NH), University of Toronto, Toronto, Ontario, Canada
| | - Jacobo Mintzer
- Ralph H. Johnson VA Medical Center (JM, OB-M), Medical University of South Carolina, Charleston, SC
| | - Paul B Rosenberg
- Department of Psychiatry and Behavioral Sciences (PBR), Johns Hopkins University, Baltimore, MD
| | - David Shade
- Bloomberg School of Public Health (JP, DS), Johns Hopkins University, Baltimore, MD
| | - Alan J Lerner
- University Hospitals Cleveland Medical Center (AJL), Case Western Reserve University School of Medicine, Cleveland, OH
| | - Prasad R Padala
- Central Arkansas Veterans Healthcare System (PRP, KPP), University of Arkansas for Medical Sciences, Little Rock, AR
| | - Olga Brawman-Mintzer
- Ralph H. Johnson VA Medical Center (JM, OB-M), Medical University of South Carolina, Charleston, SC
| | | | | | | | - Allan I Levey
- Emory Goizueta Alzheimer's Disease Research Center (AIL), Atlanta, GA
| | - Kalpana P Padala
- Central Arkansas Veterans Healthcare System (PRP, KPP), University of Arkansas for Medical Sciences, Little Rock, AR
| | - Nathan Herrmann
- Sunnybrook Research Institute (KLL, LR, ST, KS, DV, NH), University of Toronto, Toronto, Ontario, Canada
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Lanctôt KL, Chen C, Mah E, Kiss A, Li A, Shade D, Scherer RW, Vieira D, Coulibaly H, Rosenberg PB, Lerner AJ, Padala PR, Brawman-Mintzer O, van Dyck CH, Porsteinsson AP, Craft S, Levey A, Burke WJ, Mintzer J, Herrmann N. Cost consequence analysis of Apathy in Dementia Methylphenidate Trial 2 (ADMET 2). Int Psychogeriatr 2023; 35:664-672. [PMID: 37066690 PMCID: PMC10579450 DOI: 10.1017/s1041610223000327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/18/2023]
Abstract
BACKGROUND This paper used data from the Apathy in Dementia Methylphenidate Trial 2 (NCT02346201) to conduct a planned cost consequence analysis to investigate whether treatment of apathy with methylphenidate is economically attractive. METHODS A total of 167 patients with clinically significant apathy randomized to either methylphenidate or placebo were included. The Resource Utilization in Dementia Lite instrument assessed resource utilization for the past 30 days and the EuroQol five dimension five level questionnaire assessed health utility at baseline, 3 months, and 6 months. Resources were converted to costs using standard sources and reported in 2021 USD. A repeated measures analysis of variance compared change in costs and utility over time between the treatment and placebo groups. A binary logistic regression was used to assess cost predictors. RESULTS Costs were not significantly different between groups whether the cost of methylphenidate was excluded (F(2,330) = 0.626, ηp2 = 0.004, p = 0.535) or included (F(2,330) = 0.629, ηp2 = 0.004, p = 0.534). Utility improved with methylphenidate treatment as there was a group by time interaction (F(2,330) = 7.525, ηp2 = 0.044, p < 0.001). DISCUSSION Results from this study indicated that there was no evidence for a difference in resource utilization costs between methylphenidate and placebo treatment. However, utility improved significantly over the 6-month follow-up period. These results can aid in decision-making to improve quality of life in patients with Alzheimer's disease while considering the burden on the healthcare system.
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Affiliation(s)
| | - Clara Chen
- Faculty of Health Sciences, Western University, London, ON, Canada
| | - Ethan Mah
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - Alex Kiss
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - Abby Li
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - Dave Shade
- Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA
| | - Roberta W. Scherer
- Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Hamadou Coulibaly
- Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Alan J. Lerner
- University Hospital – Case Western Reserve University, Cleveland, OH, USA
| | - Prasad R. Padala
- University of Arkansas for Medical Science, Central Arkansas Veterans Healthcare System, Little Rock, AR, USA
| | - Olga Brawman-Mintzer
- Medical University of South Carolina and Ralph H. Johnson Veterans Administration Medical Center, Charleston, SC, USA
| | | | | | - Suzanne Craft
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | | | | | - Jacobo Mintzer
- Medical University of South Carolina and Ralph H. Johnson Veterans Administration Medical Center, Charleston, SC, USA
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Clark ED, Perin J, Herrmann N, Brawman‐Mintzer O, Lanctôt KL, Lerner AJ, Mintzer J, Padala PR, Rosenberg PB, Sami S, Shade DM, van Dyck CH, Porsteinsson AP. Effects of methylphenidate on neuropsychiatric symptoms in Alzheimer's disease: Evidence from the ADMET 2 study. Alzheimers Dement (N Y) 2023; 9:e12403. [PMID: 37538343 PMCID: PMC10394740 DOI: 10.1002/trc2.12403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 05/08/2023] [Accepted: 05/25/2023] [Indexed: 08/05/2023]
Abstract
INTRODUCTION Methylphenidate has been shown to improve apathy in patients with Alzheimer's disease (AD). The authors evaluated the impact of methylphenidate on neuropsychiatric symptoms (NPS) of AD, excluding apathy, using data from the Apathy in Dementia Methylphenidate Trial 2 (ADMET 2) study. METHODS A secondary analysis was conducted on data from the ADMET 2 study to determine the effect of methylphenidate on Neuropsychiatric Inventory (NPI) scores outside of apathy. Caregiver scores were compared from baseline to month 6 in 199 participants receiving methylphenidate (20 mg/day) or placebo regarding the presence or absence of individual neuropsychiatric symptoms, emergence of new symptoms, and individual domain scores. RESULTS No clinically meaningful improvement was observed in any NPI domain, excluding apathy, in participants treated with methylphenidate compared to placebo after 6 months. A statistical difference between groups was appreciated in the domains of elation/euphoria (P = 0.044) and appetite/eating disorders (P = 0.014); however, these findings were not considered significant. DISCUSSION Methylphenidate is a selective agent for symptoms of apathy in patients with AD with no meaningful impact on other NPS. Findings from this secondary analysis are considered exploratory and multiple limitations should be considered when interpreting these results, including small sample size and use of a single questionnaire.HIGHLIGHTS: Methylphenidate was not associated with significant improvement on the Neuropsychiatric Inventory in domains outside of apathy.Methylphenidate did not show a statistically significant emergence of new neuropsychiatric symptoms (NPS) throughout the 6-month treatment period compared to placebo.Methylphenidate appears to be a highly selective agent for apathy in Alzheimer's disease, potentially supporting catecholaminergic dysfunction as the driving force behind this presentation of symptoms.
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Affiliation(s)
- Emily D. Clark
- Alzheimer's Disease Care, Research and Education Program (AD‐CARE), Department of PsychiatryUniversity of Rochester School of Medicine and DentistryRochesterNew YorkUSA
| | - Jamie Perin
- Department of International HealthJohns Hopkins University Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Nathan Herrmann
- Sunnybrook Research InstituteUniversity of TorontoTorontoOntarioCanada
| | - Olga Brawman‐Mintzer
- Ralph H. Johnson VA Medical Center, Department of PsychiatryMedical University of South CarolinaCharlestonSouth CarolinaUSA
| | - Krista L. Lanctôt
- Hurvitz Brain Science Research Program, Sunnybrook Research Institute, Departments of Psychiatry and PharmacologyUniversity of TorontoTorontoOntarioCanada
| | - Alan J. Lerner
- Department of NeurologyUniversity Hospitals Cleveland Medical CenterCase Western Reserve University School of MedicineClevelandOhioUSA
| | - Jacobo Mintzer
- Ralph H. Johnson VA Medical Center, Department of PsychiatryMedical University of South CarolinaCharlestonSouth CarolinaUSA
| | - Prasad R. Padala
- Central Arkansas Veterans Healthcare SystemBaptist Health‐University of Arkansas for Medical SciencesLittle RockArkansasUSA
| | - Paul B. Rosenberg
- Departments of Psychiatry and Behavioral SciencesJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Susie Sami
- Department of NeurologyUniversity Hospitals Cleveland Medical CenterCase Western Reserve University School of MedicineClevelandOhioUSA
| | - David M. Shade
- Department of EpidemiologyJohns Hopkins University Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Christopher H. van Dyck
- Departments of Psychiatry, Neurology, and NeuroscienceYale School of MedicineNew HavenConnecticutUSA
| | - Anton P. Porsteinsson
- Alzheimer's Disease Care, Research and Education Program (AD‐CARE), Department of PsychiatryUniversity of Rochester School of Medicine and DentistryRochesterNew YorkUSA
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Lee D, Clark ED, Antonsdottir IM, Porsteinsson AP. A 2023 update on the advancements in the treatment of agitation in Alzheimer's disease. Expert Opin Pharmacother 2023; 24:691-703. [PMID: 36958727 DOI: 10.1080/14656566.2023.2195539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
INTRODUCTION Neuropsychiatric symptoms (NPS) in Alzheimer's Disease (AD) are associated with negative outcomes for patients and their care partners. Agitation is one of the most common and distressing NPS, yet we lack safe and effective treatment options. While nonpharmacologic interventions are considered first line treatment, these may not be effective or appropriate for every patient. Our current approaches to the pharmacologic treatment of agitation in AD consist of the off-label use of antipsychotics, sedative/hypnotics, anxiolytics, mood-stabilizing anticonvulsants, acetylcholinesterase inhibitors, NMDA receptor antagonists, and antidepressants. Despite their prevalent use, they have questionable efficacy and significant safety concerns. AREAS COVERED Advances in the understanding of neurobiological mechanisms of agitation have fueled recent clinical trials. This article is an update to our 2017 review. A comprehensive search of ClinicalTrials.gov was completed from January 2017 to June 2022 using the search terms "Alzheimer's Disease" and "Agitation". A subsequent scoping review was completed in PubMed and Google Scholar. Several agents were identified for promise in treating agitation, including: brexpiprazole, cannabinoids, dexmedetomidine, dextromethorphan, escitalopram, masupirdine, and prazosin. EXPERT OPINION Clinical trials remain underway utilizing both novel and repurposed agents to address symptoms of agitation in AD. With increasing understanding of the neurobiological mechanisms that fuel the development of agitation in AD, the use of enhanced trial design and conduct, advanced statistical approaches, and accelerated pathways for regulatory approval, we are advancing closer to having safe and efficacious treatment options for agitation in AD.
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Affiliation(s)
- Daniel Lee
- Alzheimer's Disease Care, Research and Education (AD-CARE), Department of Psychiatry, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Rochester, NY 14642
| | - Emily D Clark
- Alzheimer's Disease Care, Research and Education (AD-CARE), Department of Psychiatry, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Rochester, NY 14642
| | - Inga M Antonsdottir
- Johns Hopkins School of Nursing, 525 N. Wolfe Street, 21205, Baltimore, MD, USA
- Richman Family Precision Medicine Center of Excellence in Alzheimer's Disease, Department of Psychiatry and Behavioral Sciences, Johns Hopkins Bayview, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Anton P Porsteinsson
- Alzheimer's Disease Care, Research and Education (AD-CARE), Department of Psychiatry, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Rochester, NY 14642
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Turnbull A, Anthony M, Tadin D, Porsteinsson AP, Heffner K, Lin FV. Effect of online tDCS to left somatomotor cortex on neuropsychiatric symptoms among older adults at risk for dementia. Cortex 2023; 159:131-141. [PMID: 36623419 PMCID: PMC9931675 DOI: 10.1016/j.cortex.2022.10.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 09/28/2022] [Accepted: 10/19/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Neuropsychiatric symptoms (NPS) in mild cognitive impairment (MCI) cause distress to patients and caregivers, and accelerate progression to dementia. Transcranial direct current stimulation (tDCS) is a promising non-invasive treatment for NPS. OBJECTIVE/HYPOTHESIS This pilot study assessed behavioral and neural effects of a 4-week anodal tDCS intervention targeting left sensorimotor cortex (LSMC: left precentral/postcentral gyri) during visual attention (compared to online sham tDCS), in 40 older adults (24 females, mean age = 71) with MCI. METHODS A phase 0 double-blinded randomized control trial was conducted. NPS (patient-reported mood symptoms plus a caregiver-reported questionnaire) and fMRI were measured at baseline and immediately post-intervention. RESULTS Generalized Estimating Equations found no significant group by time interactions for either NPS measure. However, there was evidence of decreased patient-reported NPS (Wald's χ2 = 3.80, p = .051), decreased LSMC activation during visual attention (Wald's χ2 = 2.93, p = .087), and increased LSMC-amygdala resting-state functional connectivity (rsFC; Wald's χ2 = 3.13, p = .077) in intervention group from pre-to post-intervention. Decrease in LSMC activation (Wald's χ2 = 9.20, p = .002) and increase in LSMC-amygdala rsFC (Wald's χ2 = 4.72, p = .030) related to decreased patient-reported NPS. Increased positive valence across sessions was significantly associated with intervention-related NPS improvement (Wald's χ2 = 22.92, p < .001). There were no findings for caregiver-reported NPS. Effects were stronger for left postcentral compared to left precentral gyrus. CONCLUSION We found tentative evidence that tDCS applied to LSMC during visual attention in older adults with MCI improved NPS via changes in LSMC activation and LSMC-amygdala rsFC, suggesting improved emotion regulation. Patient-reported NPS was more sensitive to these changes than caregiver-reports, and effects were strongest for left postcentral gyrus. Follow-up studies should perform precise mechanistic investigation and efficacy testing.
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Affiliation(s)
- Adam Turnbull
- CogT Lab, Department of Psychiatry and Behavioral Sciences, Stanford University, CA, USA; Departments of Brain and Cognitive Sciences, Neuroscience and Ophthalmology, University of Rochester, NY, USA.
| | - Mia Anthony
- CogT Lab, Department of Psychiatry and Behavioral Sciences, Stanford University, CA, USA; Departments of Brain and Cognitive Sciences, Neuroscience and Ophthalmology, University of Rochester, NY, USA
| | - Duje Tadin
- Departments of Brain and Cognitive Sciences, Neuroscience and Ophthalmology, University of Rochester, NY, USA
| | - Anton P Porsteinsson
- Departments of Brain and Cognitive Sciences, Neuroscience and Ophthalmology, University of Rochester, NY, USA; Department of Psychiatry, University of Rochester Medical Center, NY, USA
| | - Kathi Heffner
- Department of Psychiatry, University of Rochester Medical Center, NY, USA; Elaine Hubbard Center for Nursing Research on Aging, School of Nursing, University of Rochester Medical Center, NY, USA; Division of Geriatrics & Aging, Department of Medicine, University of Rochester Medical Center, NY, USA
| | - Feng V Lin
- CogT Lab, Department of Psychiatry and Behavioral Sciences, Stanford University, CA, USA
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Lanctôt KL, Perin J, Vieira D, Rosenberg PB, Herrmann N, Shade D, Lerner AJ, Padala PR, Brawman‐Mintzer O, van Dyck CH, Porsteinsson AP, Craft S, Levey AI, Mintzer JE. Heterogeneity of response to methylphenidate in apathetic patients in the ADMET 2 Trial. Alzheimers Dement 2022. [DOI: 10.1002/alz.066932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Krista L. Lanctôt
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute Toronto ON Canada
| | | | | | | | - Nathan Herrmann
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute Toronto ON Canada
| | - David Shade
- Johns Hopkins University School of Medicine Baltimore MD USA
| | - Alan J. Lerner
- Department of Population and Quantitative Health Sciences, Case Western Reserve University Cleveland OH USA
| | - Prasad R Padala
- University of Arkansas for Medical Sciences Little Rock AR USA
| | | | | | | | | | - Allan I. Levey
- Emory Goizueta Alzheimer’s Disease Research Center Atlanta GA USA
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Rabinovici GD, Rafii MS, Apgar C, An N, Barakos J, Brangman SA, Daffner KR, Edelmayer RM, Gatsonis C, Hakim R, Hanna L, Jicha GA, Jordan J, Lingler JH, Lopez OL, March A, Porsteinsson AP, Possin KL, Romero K, Salloway SP, Sano M, Sivakumaran S, Snyder HM, Stebbins P, Vukmir RB, Whitlow CT, Carrillo MC. ALZ‐NET: Using Real World Evidence to Inform the Future of Alzheimer’s Treatment and Care. Alzheimers Dement 2022. [DOI: 10.1002/alz.069542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Gil D. Rabinovici
- Department of Radiology and Biomedical Imaging University of California, San Francisco San Francisco CA USA
| | - Michael S Rafii
- Alzheimer’s Therapeutic Research Institute University of Southern California San Diego CA USA
| | | | - Na An
- Brown University School of Public Health Providence RI USA
| | | | | | | | | | | | | | | | | | - John Jordan
- American College of Radiology / American Society of Neuroradiology / Providence Little Company of Mary Medical Center‐Torrance Torrance CA USA
| | - Jennifer H Lingler
- University of Pittsburgh Alzheimer’s Disease Research Center (ADRC) Pittsburgh PA USA
| | | | | | | | | | | | | | - Mary Sano
- Mount Sinai School of Medicine New York NY USA
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Porsteinsson AP, Rangaraju S, Spires-Jones TL, O'Banion MK. Alzheimer's disease and related dementias: From risk factors to disease pathogenesis. Eur J Neurosci 2022; 56:5337-5341. [PMID: 36324230 DOI: 10.1111/ejn.15857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 10/27/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Anton P Porsteinsson
- Department of Psychiatry and Del Monte Institute for Neuroscience, University of Rochester School of Medicine & Dentistry, Rochester, New York, USA
| | - Srikant Rangaraju
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Tara L Spires-Jones
- UK Dementia Research Institute and Centre for Discovery Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - M Kerry O'Banion
- Department of Neuroscience and Del Monte Institute for Neuroscience, University of Rochester School of Medicine & Dentistry, Rochester, New York, USA
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Mintzer JE, Scherer R, Drye LT, Lanctôt KL, Rosenberg PB, Herrmann N, Padala PR, Brawman‐Mintzer O, Lerner AJ, Levey AI, Porsteinsson AP, van Dyck CH. Apathy in Dementia Methylphenidate Trial 2 (ADMET2): Results of a phase III, placebo‐controlled, double‐blind, 6‐month, multi‐center, randomized clinical trial. Alzheimers Dement 2021. [DOI: 10.1002/alz.051489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Jacobo E. Mintzer
- Roper St. Francis Hospital The Clinical Biotechnology Research Institute Charleston SC USA
- Ralph H. Johnson VA Medical Center Charleston SC USA
- Medical University of South Carolina Charleston SC USA
| | | | - Lea T. Drye
- Johns Hopkins Bloomberg School of Public Health Baltimore MD USA
| | | | | | | | - Prasad R Padala
- University of Arkansas for Medical Sciences Little Rock AR USA
- Central Arkansas Veterans Healthcare System North Little Rock AR USA
| | | | - Alan J. Lerner
- Case Western Reserve University School of Medicine Cleveland OH USA
| | - Allan I Levey
- Emory Goizueta Alzheimer's Disease Research Center Atlanta GA USA
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Cohen S, He P, Benea ML, Miller R, Forrestal F, Pang M, Castrillo‐Viguera C, Harrison JE, Jaeger J, Mummery CJ, Porsteinsson AP, Cummings JL, Tian Y, Yang L, Haeberlein SB. Item‐level analysis of clinical measures in patients with early symptomatic Alzheimer’s disease following treatment with high‐dose aducanumab in the phase 3 study EMERGE. Alzheimers Dement 2021. [DOI: 10.1002/alz.057619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
| | | | | | | | | | | | | | - John E Harrison
- King's College ‐ Institute of Psychiatry Psychology & Neuroscience London United Kingdom
| | - Judy Jaeger
- Cognition Metrics, Inc Wilmington DE USA
- Albert Einstein College of Medicine New York NY USA
| | | | | | - Jeffrey L. Cummings
- Center for Transformative Neuroscience Department of Brain Health School of Integrated Health Sciences University of Nevada Las Vegas (UNLV) Las Vegas NV USA
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11
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Mintzer J, Lanctôt KL, Scherer RW, Rosenberg PB, Herrmann N, van Dyck CH, Padala PR, Brawman-Mintzer O, Porsteinsson AP, Lerner AJ, Craft S, Levey AI, Burke W, Perin J, Shade D. Effect of Methylphenidate on Apathy in Patients With Alzheimer Disease: The ADMET 2 Randomized Clinical Trial. JAMA Neurol 2021; 78:1324-1332. [PMID: 34570180 PMCID: PMC8477302 DOI: 10.1001/jamaneurol.2021.3356] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance Apathy, characterized by diminished will or initiative and one of the most prevalent neuropsychiatric symptoms in individuals with Alzheimer disease, is associated with significant caregiver burden, excess disability, increased medical costs, and mortality. Objective To measure whether methylphenidate compared with placebo decreases the severity of apathy in individuals with Alzheimer disease. Design, Setting, and participants This multicenter randomized placebo-controlled clinical trial was conducted from August 2016 to July 2020 in 9 US clinics and 1 Canadian clinic specializing in dementia care. A total of 307 potential participants were screened. Of those, 52 did not pass screening and 55 were not eligible. Participants with Alzheimer disease, mild to moderate cognitive impairment, and frequent and/or severe apathy as measured by the Neuropsychiatric Inventory (NPI) were included. Interventions Ten milligrams of methylphenidate, twice daily, vs matching placebo. Main Outcomes and Measures The coprimary outcomes included (1) change from baseline to 6 months in the NPI apathy subscale or (2) improved rating on the Alzheimer's Disease Cooperative Study Clinical Global Impression of Change. Other outcomes include safety, change in cognition, and quality of life. Results Of 200 participants, 99 were assigned to methylphenidate and 101 to placebo. The median (interquartile range) age of study participants was 76 (71-81) years; 68 (34%) were female and 131 (66%) were male. A larger decrease was found from baseline to 6 months in the NPI apathy score in those receiving methylphenidate compared with placebo (mean difference, -1.25; 95% CI, -2.03 to -0.47; P = .002). The largest decrease in the NPI apathy score was observed in the first 100 days, with a significant hazard ratio for the proportion of participants with no apathy symptoms receiving methylphenidate compared with placebo (hazard ratio, 2.16; 95% CI, 1.19-3.91; P = .01). At 6 months, the odds ratio of having an improved rating on the Alzheimer's Disease Cooperative Study Clinical Global Impression of Change for methylphenidate compared with placebo was 1.90 (95% CI, 0.95-3.84; P = .07). The difference in mean change from baseline to 6 months estimated using a longitudinal model was 1.43 (95% CI, 1.00-2.04; P = .048). Cognitive measures and quality of life were not significantly different between groups. Of the 17 serious adverse events that occurred during the study, none were related to the study drug. No significant differences in the safety profile were noted between treatment groups. Conclusions and Relevance This study found methylphenidate to be a safe and efficacious medication to use in the treatment of apathy in Alzheimer disease. Trial Registration ClinicalTrials.gov Identifier: NCT02346201.
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Affiliation(s)
- Jacobo Mintzer
- Ralph H. Johnson VA Medical Center, Medical University of South Carolina, Charleston
| | - Krista L. Lanctôt
- Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Roberta W. Scherer
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | | | - Nathan Herrmann
- Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | | | - Prasad R. Padala
- Central Arkansas Veterans Healthcare System, University of Arkansas for Medical Sciences, Little Rock
| | - Olga Brawman-Mintzer
- Ralph H. Johnson VA Medical Center, Medical University of South Carolina, Charleston
| | | | - Alan J. Lerner
- University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Suzanne Craft
- Wake Forest University, Winston-Salem, North Carolina
| | - Allan I. Levey
- Emory Goizueta Alzheimer’s Disease Research Center, Atlanta, Georgia
| | | | - Jamie Perin
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - David Shade
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
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12
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Spira AP, Zipunnikov V, Raman R, Choi J, Di J, Bai J, Carlsson CM, Mintzer JE, Marshall GA, Porsteinsson AP, Yaari R, Wanigatunga SK, Kim J, Wu MN, Aisen PS, Sperling RA, Rosenberg PB. Brain amyloid burden, sleep, and 24-hour rest/activity rhythms: screening findings from the Anti-Amyloid Treatment in Asymptomatic Alzheimer's and Longitudinal Evaluation of Amyloid Risk and Neurodegeneration Studies. Sleep Adv 2021; 2:zpab015. [PMID: 34661109 PMCID: PMC8519157 DOI: 10.1093/sleepadvances/zpab015] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 09/08/2021] [Indexed: 04/16/2023]
Abstract
STUDY OBJECTIVES To examine in a subsample at the screening phase of a clinical trial of a β-amyloid (Aβ) antibody whether disturbed sleep and altered 24-hour rest/activity rhythms (RARs) may serve as markers of preclinical Alzheimer's disease (AD). METHODS Overall, 26 Aβ-positive (Aβ+) and 33 Aβ-negative (Aβ-) cognitively unimpaired participants (mean age = 71.3 ± 4.6 years, 59% women) from the Anti-Amyloid Treatment in Asymptomatic Alzheimer's (A4) and the Longitudinal Evaluation of Amyloid Risk and Neurodegeneration (LEARN) studies, respectively, wore actigraphs for 5.66 ± 0.88 24-hour periods. We computed standard sleep parameters, standard RAR metrics (mean estimating statistic of rhythm, amplitude, acrophase, interdaily stability, intradaily variability, relative amplitude), and performed a novel RAR analysis (function-on-scalar regression [FOSR]). RESULTS We were unable to detect any differences between Aβ+ and Aβ- participants in standard sleep parameters or RAR metrics with our sample size. When we used novel FOSR methods, however, Aβ+ participants had lower activity levels than Aβ- participants in the late night through early morning (11:30 pm to 3:00 am), and higher levels in the early morning (4:30 am to 8:30 am) and from midday through late afternoon (12:30 pm to 5:30 pm; all p < .05). Aβ+ participants also had higher variability in activity across days from 9:30 pm to 1:00 am and 4:30 am to 8:30 am, and lower variability from 2:30 am to 3:30 am (all p < .05). CONCLUSIONS Although we found no association of preclinical AD with standard actigraphic sleep or RAR metrics, a novel data-driven analytic method identified temporally "local" RAR alterations in preclinical AD.
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Affiliation(s)
- Adam P Spira
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins Center on Aging and Health, Baltimore, MD, USA
| | - Vadim Zipunnikov
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Rema Raman
- Alzheimer’s Therapeutic Research Institute, University of Southern California, San Diego, CA, USA
| | - Jiyoon Choi
- Alzheimer’s Therapeutic Research Institute, University of Southern California, San Diego, CA, USA
| | - Junrui Di
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jiawei Bai
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Cynthia M Carlsson
- Wisconsin Alzheimer’s Disease Research Center, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jacobo E Mintzer
- Ralph H. Johnson VA Medical Center, Charleston, SC, USA
- Lowcountry Center for Veterans Research, South Carolina Institute for Brain Health, Charleston, SC, USA
| | - Gad A Marshall
- Center for Alzheimer Research and Treatment, Brigham and Women’s Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Roy Yaari
- Eli Lilly and Company, Indianapolis, IN, USA
| | | | - John Kim
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mark N Wu
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Paul S Aisen
- Alzheimer’s Therapeutic Research Institute, University of Southern California, San Diego, CA, USA
| | - Reisa A Sperling
- Center for Alzheimer Research and Treatment, Brigham and Women’s Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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13
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Porsteinsson AP, Isaacson RS, Knox S, Sabbagh MN, Rubino I. Diagnosis of Early Alzheimer's Disease: Clinical Practice in 2021. J Prev Alzheimers Dis 2021; 8:371-386. [PMID: 34101796 DOI: 10.14283/jpad.2021.23] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Alzheimer's disease is a progressive, irreversible neurodegenerative disease impacting cognition, function, and behavior. Alzheimer's disease progresses along a continuum from preclinical disease, to mild cognitive and/or behavioral impairment and then Alzheimer's disease dementia. Recently, clinicians have been encouraged to diagnose Alzheimer's earlier, before patients have progressed to Alzheimer's disease dementia. The early and accurate detection of Alzheimer's disease-associated symptoms and underlying disease pathology by clinicians is fundamental for the screening, diagnosis, and subsequent management of Alzheimer's disease patients. It also enables patients and their caregivers to plan for the future and make appropriate lifestyle changes that could help maintain their quality of life for longer. Unfortunately, detecting early-stage Alzheimer's disease in clinical practice can be challenging and is hindered by several barriers including constraints on clinicians' time, difficulty accurately diagnosing Alzheimer's pathology, and that patients and healthcare providers often dismiss symptoms as part of the normal aging process. As the prevalence of this disease continues to grow, the current model for Alzheimer's disease diagnosis and patient management will need to evolve to integrate care across clinical disciplines and the disease continuum, beginning with primary care. This review summarizes the importance of establishing an early diagnosis of Alzheimer's disease, related practical 'how-to' guidance and considerations, and tools that can be used by healthcare providers throughout the diagnostic journey.
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Affiliation(s)
- A P Porsteinsson
- Sean Knox, MBChB. Biogen International GmBH, Neuhofstrasse 30, 6340 Baar, Switzerland. Phone: +41413921976;
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14
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Lanctôt KL, Scherer RW, Li A, Vieira D, Coulibaly H, Rosenberg PB, Herrmann N, Lerner AJ, Padala PR, Brawman-Mintzer O, van Dyck CH, Porsteinsson AP, Craft S, Levey A, Burke WJ, Mintzer JE. Measuring Apathy in Alzheimer's Disease in the Apathy in Dementia Methylphenidate Trial 2 (ADMET 2): A Comparison of Instruments. Am J Geriatr Psychiatry 2021; 29:81-89. [PMID: 32565008 PMCID: PMC7704818 DOI: 10.1016/j.jagp.2020.05.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 05/10/2020] [Accepted: 05/15/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Diagnostic criteria for apathy have been published but have yet to be evaluated in the context of clinical trials. The Apathy in Dementia Methylphenidate Trial 2 (ADMET 2) operationalized the diagnostic criteria for apathy (DCA) into a clinician-rated questionnaire informed by interviews with the patient and caregiver. OBJECTIVE The goal of the present study was to compare the classification of apathy using the DCA with that using the Neuropsychiatric Inventory-apathy (NPI-apathy) subscale in ADMET 2. Comparisons between NPI-Apathy and Dementia Apathy Interview Rating (DAIR) scale, and DCA and DAIR were also explored. METHODS ADMET 2 is a randomized, double-blind, placebo-controlled phase III trial examining the effects of 20 mg/day methylphenidate on symptoms of apathy over 6 months in patients with mild to moderate Alzheimer's disease (AD). Participants scoring at least 4 on the NPI-Apathy were recruited. This analysis focuses on cross-sectional correlations between baseline apathy scale scores using cross-tabulation. RESULTS Of 180 participants, the median age was 76.5 years and they were predominantly white (92.8%) and male (66.1%). The mean (±standard deviation) scores were 7.7 ± 2.4 on the NPI-apathy, and 1.9 ± 0.5 on the DAIR. Of those with NPI-defined apathy, 169 (93.9%, 95% confidence interval [CI] 89.3%-96.9%) met DCA diagnostic criteria. The DCA and DAIR overlapped on apathy diagnosis for 169 participants (93.9%, 95% CI 89.3%-96.9%). CONCLUSION The measurements used for the assessment of apathy in patients with AD had a high degree of overlap with the DCA. The NPI-apathy cut-off used to determine apathy in ADMET 2 selects those likely to meet DCA criteria.
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Affiliation(s)
| | - Roberta W. Scherer
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD. USA
| | - Abby Li
- Sunnybrook Research Institute, Toronto, ON, Canada
| | | | - Hamadou Coulibaly
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD. USA
| | | | | | - Alan J Lerner
- University Hospital – Case Western Reserve University, Cleveland, OH, USA
| | - Prasad R Padala
- University of Arkansas for Medical Science, Central Arkansas Veterans Healthcare System, Little Rock, AR, USA
| | - Olga Brawman-Mintzer
- Medical University of South Carolina and Ralph H. Johnson Veterans Administration Medical Center, Charleston, SC, USA
| | | | | | - Suzanne Craft
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | | | | | - Jacobo E. Mintzer
- Medical University of South Carolina and Ralph H. Johnson Veterans Administration Medical Center, Charleston, SC, USA
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15
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van Dyck CH, Arnsten AFT, Padala PR, Brawman-Mintzer O, Lerner AJ, Porsteinsson AP, Scherer RW, Levey AI, Herrmann N, Jamil N, Mintzer JE, Lanctôt KL, Rosenberg PB. Neurobiologic Rationale for Treatment of Apathy in Alzheimer's Disease With Methylphenidate. Am J Geriatr Psychiatry 2021; 29:51-62. [PMID: 32461027 PMCID: PMC7641967 DOI: 10.1016/j.jagp.2020.04.026] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 04/28/2020] [Accepted: 04/29/2020] [Indexed: 11/23/2022]
Abstract
The public health burden of Alzheimer's disease (AD) is related not only to cognitive symptoms, but also to neuropsychiatric symptoms, including apathy. Apathy is defined as a quantitative reduction of goal-directed activity in comparison to a previous level of functioning and affects 30%-70% of persons with AD. Previous attempts to treat apathy in AD-both nonpharmacologically and pharmacologically-have been wanting. Catecholaminergic treatment with methylphenidate has shown encouraging results in initial trials of apathy in AD. Understanding the neuronal circuits underlying motivated behavior and their reliance on catecholamine actions helps provide a rationale for methylphenidate actions in the treatment of apathy in patients with AD. Anatomical, physiological, and behavioral studies have identified parallel, cortical-basal ganglia circuits that govern action, cognition, and emotion and play key roles in motivated behavior. Understanding the distinct contributions to motivated behavior of subregions of the prefrontal cortex-dorsolateral, orbital-ventromedial, and dorsomedial-helps to explain why degeneration of these areas in AD results in apathetic behaviors. We propose that the degeneration of the prefrontal cortex in AD produces symptoms of apathy. We further propose that methylphenidate treatment may ameliorate those symptoms by boosting norepinephrine and dopamine actions in prefrontal-striatal-thalamocortical circuits.
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Affiliation(s)
| | | | - Prasad R Padala
- University of Arkansas for Medical Sciences, Central Arkansas Veterans Healthcare System (PRP), Little Rock, AR
| | - Olga Brawman-Mintzer
- Medical University of South Carolina and Ralph H. Johnson Veterans Administration Medical Center (OB-M, JEM), Charleston, SC
| | - Alan J Lerner
- University Hospitals - Case Western Reserve University (AJL), Cleveland, OH
| | | | - Roberta W Scherer
- Johns Hopkins University Bloomberg School of Public Health (RWS), Baltimore, MD
| | | | - Nathan Herrmann
- Sunnybrook Research Institute (NH, KLL), Toronto, ON, Canada
| | - Nimra Jamil
- Johns Hopkins University School of Medicine (NJ, PBR), Baltimore, MD
| | - Jacobo E Mintzer
- Medical University of South Carolina and Ralph H. Johnson Veterans Administration Medical Center (OB-M, JEM), Charleston, SC
| | | | - Paul B Rosenberg
- Johns Hopkins University School of Medicine (NJ, PBR), Baltimore, MD
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16
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Abushakra S, Porsteinsson AP, Sabbagh M, Bracoud L, Schaerer J, Power A, Hey JA, Scott D, Suhy J, Tolar M. APOE ε4/ε4 homozygotes with early Alzheimer's disease show accelerated hippocampal atrophy and cortical thinning that correlates with cognitive decline. Alzheimers Dement (N Y) 2020; 6:e12117. [PMID: 33304988 PMCID: PMC7716452 DOI: 10.1002/trc2.12117] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 10/26/2020] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Hippocampal volume (HV) and cortical thickness are commonly used imaging biomarkers in Alzheimer's disease (AD) trials, and may have utility as selection criteria for enrichment strategies. Atrophy rates of these measures, in the high-risk apolipoprotein E (APOE) ε4/ε4 homozygous AD subjects are unknown. METHODS Data from Alzheimer's Disease Neuroimaging Initiative (ADNI-1) and a tramiprosate trial were analyzed in APOE ε4/ε4 and APOE ε3/ε3 subjects with mild cognitive impairment (MCI) or mild AD. Magnetic resonance imaging (MRI) data were centrally processed using FreeSurfer; total HV and composite average cortical thickness were derived and adjusted for age, head size, and education. Volumetric changes from baseline were assessed using Boundary Shift Integral, and correlated with cognitive changes. RESULTS APOE ε4/ε4 MCI subjects showed significantly higher % HV atrophy and cortical thinning at 12 months (4.4%, 3.1%, n = 29) compared to APOE ε3/ε3 subjects (2.8%, 1.8%, n = 93) and similarly in mild AD (7.4%, 4.7% n = 21 vs 5.4%, 3.3% n = 29). Differences were all significant at 24 months. Over 24 months, HV atrophy and cortical thinning correlated significantly with Alzheimer's Disease Assessment Scale-Cognitive subscale worsening in APOE ε4/ε4 MCI subjects, but not in mild AD. DISCUSSION Correlation of volumetric measures to cognitive change in APOE ε4/ε4 subjects with early AD supports their role as efficacy biomarkers. If confirmed in a Phase 3 trial with ALZ-801 (pro-drug of tramiprosate) in APOE ε4/ε4 early AD subjects, it may allow their use as surrogate outcomes in future treatment or prevention trials in AD.
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Affiliation(s)
| | - Anton P. Porsteinsson
- Alzheimer's Disease CareResearch and Education ProgramUniversity of RochesterRochesterNew YorkUSA
| | - Marwan Sabbagh
- Cleveland Clinic Lou Ruvo Center for Brain Health & University of NevadaLas VegasNevadaUSA
| | | | | | | | | | | | - Joyce Suhy
- BioclinicaLyonFrance
- BioclinicaNewarkCaliforniaUSA
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17
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Porsteinsson AP, Clark ED. Editorial: The Trial-Ready Cohort for Preclinical/Prodromal Alzheimer's Disease (TRC-PAD) - A Fundamental Ally in AD Prevention Research. J Prev Alzheimers Dis 2020; 7:206-207. [PMID: 32920620 DOI: 10.14283/jpad.2020.41] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Alzheimer’s disease (AD) remains one of our greatest unmet medical needs, without any approved disease-modifying therapies. The emotional and financial burden of AD is enormous and predicted to grow exponentially with increasing median population age, posing a major public health problem. The potential to prevent or improve cognitive decline due to AD has important implications. There are medications currently approved for symptomatic treatment of AD, but they have limited clinical benefits and do not change the ultimate trajectory of the disease. The need to find effective treatments for AD that can prevent, slow, arrest, or even reverse the disease is ever more urgent and interventions that delay the symptomatic onset of AD would have a major public health impact (1).
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Affiliation(s)
- A P Porsteinsson
- A.P. Porsteinsson, Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA,
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18
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Sabbagh MN, Boada M, Borson S, Chilukuri M, Dubois B, Ingram J, Iwata A, Porsteinsson AP, Possin KL, Rabinovici GD, Vellas B, Chao S, Vergallo A, Hampel H. Early Detection of Mild Cognitive Impairment (MCI) in Primary Care. J Prev Alzheimers Dis 2020; 7:165-170. [PMID: 32463069 DOI: 10.14283/jpad.2020.21] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2024]
Abstract
Mild cognitive impairment (MCI) is significantly misdiagnosed in the primary care setting due to multi-dimensional frictions and barriers associated with evaluating individuals' cognitive performance. To move toward large-scale cognitive screening, a global panel of clinicians and cognitive neuroscientists convened to elaborate on current challenges that hamper widespread cognitive performance assessment. This report summarizes a conceptual framework and provides guidance to clinical researchers and test developers and suppliers to inform ongoing refinement of cognitive evaluation. This perspective builds upon a previous article in this series, which outlined the rationale for and potentially against efforts to promote widespread detection of MCI. This working group acknowledges that cognitive screening by default is not recommended and proposes large-scale evaluation of individuals with a concern or interest in their cognitive performance. Such a strategy can increase the likelihood to timely and effective identification and management of MCI. The rising global incidence of AD demands innovation that will help alleviate the burden to healthcare systems when coupled with the potentially near-term approval of disease-modifying therapies. Additionally, we argue that adequate infrastructure, equipment, and resources urgently should be integrated in the primary care setting to optimize the patient journey and accommodate widespread cognitive evaluation.
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Affiliation(s)
- M N Sabbagh
- Marwan N. Sabbagh, Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, NV, USA, ; Tel.: (702) 483-6029; Fax: (702) 722-6584
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19
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Sabbagh MN, Boada M, Borson S, Doraiswamy PM, Dubois B, Ingram J, Iwata A, Porsteinsson AP, Possin KL, Rabinovici GD, Vellas B, Chao S, Vergallo A, Hampel H. Early Detection of Mild Cognitive Impairment (MCI) in an At-Home Setting. J Prev Alzheimers Dis 2020; 7:171-178. [PMID: 32463070 DOI: 10.14283/jpad.2020.22] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Emerging digital tools have the potential to enable a new generation of qualitative and quantitative assessment of cognitive performance. Moreover, the ubiquity of consumer electronics, such as smartphones and tablets, can be harnessed to support large-scale self-assessed cognitive screening with benefit to healthcare systems and consumers. A wide variety of apps, wearables, and new digital technologies are either available or in development for the detection of mild cognitive impairment (MCI), a risk factor for dementia. Two categories of novel methodologies may be considered: passive technologies (which monitor a user's behavior without active user input) and interactive assessments (which require active user input). Such examinations can be self-administered, supervised by a caregiver, or conducted by an informant at home or outside of a clinical setting. These direct-to-consumer tools have the potential to sidestep barriers associated with cognitive evaluation in primary care, thus improving access to cognitive assessments. Although direct-to-consumer cognitive assessment is associated with its own barriers, including test validation, user experience, and technological concerns, it is conceivable that these issues can be addressed so that a large-scale, self-assessed cognitive evaluation that would represent an initial cognitive screen may be feasible in the future.
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Affiliation(s)
- M N Sabbagh
- Marwan N. Sabbagh, Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, NV, USA, ; Tel.: (702) 483-6029; Fax: (702) 722-6584
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20
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Sabbagh MN, Boada M, Borson S, Chilukuri M, Doraiswamy PM, Dubois B, Ingram J, Iwata A, Porsteinsson AP, Possin KL, Rabinovici GD, Vellas B, Chao S, Vergallo A, Hampel H. Rationale for Early Diagnosis of Mild Cognitive Impairment (MCI) Supported by Emerging Digital Technologies. J Prev Alzheimers Dis 2020; 7:158-164. [PMID: 32463068 DOI: 10.14283/jpad.2020.19] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Disease-modifying pharmacotherapies for Alzheimer's Disease (AD) are currently in late-stage clinical development; once approved, new healthcare infrastructures and services, including primary healthcare, will be necessary to accommodate a huge demand for early and large-scale detection of AD. The increasing global accessibility of digital consumer electronics has opened up new prospects for early diagnosis and management of mild cognitive impairment (MCI) with particular regard to AD. This new wave of innovation has spurred research in both academia and industry, aimed at developing and validating a new "digital generation" of tools for the assessment of the cognitive performance. In light of this paradigm shift, an international working group (the Global Advisory Group on Future MCI Care Pathways) convened to elaborate on how digital tools may be optimally integrated in screening-diagnostic pathways of AD The working group developed consensus perspectives on new algorithms for large-scale screening, detection, and diagnosis of individuals with MCI within primary medical care delivery. In addition, the expert panel addressed operational aspects concerning the implementation of unsupervised at-home testing of cognitive performance. The ultimate intent of the working group's consensus perspectives is to provide guidance to developers of cognitive tests and tools to facilitate the transition toward globally accessible cognitive screening aimed at the early detection, diagnosis, and management of MCI due to AD.
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Affiliation(s)
- M N Sabbagh
- Marwan N. Sabbagh, Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, NV, USA, ; Tel.: (702) 483-6029; Fax: (702) 722-6584
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21
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Ehrhardt S, Porsteinsson AP, Munro CA, Rosenberg PB, Pollock BG, Devanand DP, Mintzer J, Rajji TK, Ismail Z, Schneider LS, Baksh SN, Drye LT, Avramopoulos D, Shade DM, Lyketsos CG. Escitalopram for agitation in Alzheimer's disease (S-CitAD): Methods and design of an investigator-initiated, randomized, controlled, multicenter clinical trial. Alzheimers Dement 2019; 15:1427-1436. [PMID: 31587995 DOI: 10.1016/j.jalz.2019.06.4946] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 06/16/2019] [Accepted: 06/24/2019] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Alzheimer's disease (AD) is a disabling, common cause of dementia, and agitation is one of the most common and distressing symptoms for patients with AD. Escitalopram for agitation in Alzheimer's disease (S-CitAD) tests a novel, clinically derived therapeutic approach to treat agitation in patients with AD. METHODS S-CitAD is a NIH-funded, investigator-initiated, randomized, multicenter clinical trial. Participants receive a structured psychosocial intervention (PSI) as standard of care. Participants without sufficient response to PSI are randomized to receive 15 mg escitalopram/day or a matching placebo in addition to PSI. Primary outcome is the Modified Alzheimer's Disease Cooperative Study - Clinical Global Impression of Change (mADCS-CGIC). DISCUSSION S-CitAD will provide information about a practical, immediately available approach to treating agitation in patients with AD. S-CitAD may become a model of how to evaluate and predict treatment response in patients with AD and agitation as a neuropsychiatric symptom (ClinicalTrials.gov Identifier: NCT03108846).
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Affiliation(s)
- Stephan Ehrhardt
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Anton P Porsteinsson
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Cynthia A Munro
- Division of Geriatric Psychiatry and Neuropsychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine and Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Paul B Rosenberg
- Division of Geriatric Psychiatry and Neuropsychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine and Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Bruce G Pollock
- Campbell Family Research Institute and Division of Adult Neurodevelopment and Geriatric Psychiatry, CAMH, Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Davangere P Devanand
- Division of Geriatric Psychiatry, New York State Psychiatric Institute and College of Physicians and Surgeons of Columbia University, New York, NY, USA
| | - Jacobo Mintzer
- Roper St. Francis Research and Innovation Center, Charleston, SC, USA; Medical University of South Carolina, College of Health Professionals and Ralph H Johnson VA Medical Center, Charleston, SC, USA
| | - Tarek K Rajji
- Campbell Family Research Institute and Division of Adult Neurodevelopment and Geriatric Psychiatry, CAMH, Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Zahinoor Ismail
- Department of Psychiatry, Hotchkiss Brain Institute and O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada; Department of Clinical Neurosciences, Hotchkiss Brain Institute and O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, Hotchkiss Brain Institute and O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Lon S Schneider
- Departments of Psychiatry and the Behavioral Sciences and Neurology, University of Southern California Keck School of Medicine and the University of Southern California Leonard Davis School of Gerontology, Los Angeles, CA, USA; Department of Neurology, University of Southern California Keck School of Medicine and the University of Southern California Leonard Davis School of Gerontology, Los Angeles, CA, USA
| | - Sheriza N Baksh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Lea T Drye
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Dimitri Avramopoulos
- Department of Psychiatry and Behavioral Sciences, Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David M Shade
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Constantine G Lyketsos
- Division of Geriatric Psychiatry and Neuropsychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine and Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
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22
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Salloway SP, Sperling R, Fox NC, Sabbagh MN, Honig LS, Porsteinsson AP, Rofael H, Ketter N, Wang D, Liu E, Carr S, Black RS, Brashear HR. Long-Term Follow Up of Patients with Mild-to-Moderate Alzheimer's Disease Treated with Bapineuzumab in a Phase III, Open-Label, Extension Study. J Alzheimers Dis 2019; 64:689-707. [PMID: 29914022 DOI: 10.3233/jad-171157] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND A 3-year extension of two Phase III parent studies of intravenous (IV) bapineuzumab in patients with mild-to-moderate Alzheimer's disease dementia (apolipoprotein (APOE) ɛ4 carriers and noncarriers) is summarized. OBJECTIVES The primary and secondary objectives were to evaluate the long-term safety, tolerability, and maintenance of efficacy of bapineuzumab. METHODS A multicenter study in patients who had participated in double-blind placebo-controlled parent studies. Patients enrolled in the extension study were assigned to receive IV infusions of bapineuzumab (0.5 or 1.0 mg/kg) every 13 weeks until termination but were blinded to whether they had received bapineuzumab or placebo in the parent studies. RESULTS A total of 1,462 (688 were APOEɛ4 carriers and 774 were noncarriers) patients were enrolled. Extension-onset adverse events occurred in >81% of the patients in each dose group. Fall, urinary tract infection, agitation, and ARIA-E occurred in ≥10% of participants. The incidence proportion of ARIA-E was higher among carriers and noncarriers who received bapineuzumab for the first time in the extension study (11.8% and 5.4%, respectively) versus those who were previously exposed in the parent studies (5.1% and 1.3%, respectively). After 6 to 12 months exposure to bapineuzumab IV in the extension study, similar deterioration of cognition and function occurred with no significant differences between the dose groups. CONCLUSIONS Infusion of bapineuzumab 0.5 or 1.0 mg/kg every 13 weeks for up to 3 years was generally well tolerated, with a safety and tolerability profile similar to that in previous studies.
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Affiliation(s)
| | - Reisa Sperling
- Center for Alzheimer Research and Treatment, Brigham and Women's Hospital, MA, USA
| | - Nick C Fox
- Dementia Research Centre, University College London, Institute of Neurology, London, UK
| | | | | | | | - Hany Rofael
- Janssen Alzheimer Immunotherapy Research & Development, LLC, South San Francisco, CA, USA
| | - Nzeera Ketter
- Janssen Alzheimer Immunotherapy Research & Development, LLC, South San Francisco, CA, USA
| | - Daniel Wang
- Janssen Alzheimer Immunotherapy Research & Development, LLC, South San Francisco, CA, USA
| | - Enchi Liu
- Janssen Alzheimer Immunotherapy Research & Development, LLC, South San Francisco, CA, USA
| | - Stephen Carr
- Janssen Alzheimer Immunotherapy Research & Development, LLC, South San Francisco, CA, USA
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Wang X, Ren P, Mapstone M, Conwell Y, Porsteinsson AP, Foxe JJ, Raizada RDS, Lin F. Identify a shared neural circuit linking multiple neuropsychiatric symptoms with Alzheimer's pathology. Brain Imaging Behav 2019; 13:53-64. [PMID: 28913718 DOI: 10.1007/s11682-017-9767-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Neuropsychiatric symptoms (NPS) are common in Alzheimer's disease (AD)-associated neurodegeneration. However, NPS lack a consistent relationship with AD pathology. It is unknown whether any common neural circuits can link these clinically disparate while mechanistically similar features with AD pathology. Here, we explored the neural circuits of NPS in AD-associated neurodegeneration using multivariate pattern analysis (MVPA) of resting-state functional MRI data. Data from 98 subjects (70 amnestic mild cognitive impairment and 28 AD subjects) were obtained. The top 10 regions differentiating symptom presence across NPS were identified, which were mostly the fronto-limbic regions (medial prefrontal cortex, caudate, etc.). These 10 regions' functional connectivity classified symptomatic subjects across individual NPS at 69.46-81.27%, and predicted multiple NPS (indexed by Neuropsychiatric Symptom Questionnaire-Inventory) and AD pathology (indexed by baseline and change of beta-amyloid/pTau ratio) all above 70%. Our findings suggest a fronto-limbic dominated neural circuit that links multiple NPS and AD pathology. With further examination of the structural and pathological changes within the circuit, the circuit may shed light on linking behavioral disturbances with AD-associated neurodegeneration.
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Affiliation(s)
- Xixi Wang
- Department of Biomedical Engineering, University of Rochester, Rochester, NY, 14627, USA
| | - Ping Ren
- School of Nursing, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Mark Mapstone
- Department of Neurology, University of California-Irvine, Irvine, CA, 92697, USA
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Anton P Porsteinsson
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - John J Foxe
- Department of Neuroscience, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Rajeev D S Raizada
- Department of Brain and Cognitive Sciences, University of Rochester, Rochester, NY, 14627, USA
| | - Feng Lin
- School of Nursing, University of Rochester Medical Center, Rochester, NY, 14642, USA. .,Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, 14642, USA. .,Department of Neuroscience, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA. .,Department of Brain and Cognitive Sciences, University of Rochester, Rochester, NY, 14627, USA.
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24
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Yu F, Lin FV, Salisbury DL, Shah KN, Chow L, Vock D, Nelson NW, Porsteinsson AP, Jack C. Efficacy and mechanisms of combined aerobic exercise and cognitive training in mild cognitive impairment: study protocol of the ACT trial. Trials 2018; 19:700. [PMID: 30577848 PMCID: PMC6303946 DOI: 10.1186/s13063-018-3054-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 11/14/2018] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Developing non-pharmacological interventions with strong potential to prevent or delay the onset of Alzheimer's disease (AD) in high-risk populations is critical. Aerobic exercise and cognitive training are two promising interventions. Aerobic exercise increases aerobic fitness, which in turn improves brain structure and function, while cognitive training improves selective brain function intensively. Hence, combined aerobic exercise and cognitive training may have a synergistic effect on cognition by complementary strengthening of different neural functions. Few studies have tested the effects of such a combined intervention, and the findings have been discrepant, largely due to varying doses and formats of the interventions. METHODS/DESIGN The purpose of this single-blinded, 2 × 2 factorial phase II randomized controlled trial is to test the efficacy and synergistic effects of a 6-month combined cycling and speed of processing training intervention on cognition and relevant mechanisms (aerobic fitness, cortical thickness, and functional connectivity in the default mode network) in older adults with amnestic mild cognitive impairment. This trial will randomize 128 participants equally to four arms: cycling and speed of processing, cycling only, speed of processing only, or attention control for 6 months, and then follow them for another 12 months. Cognition and aerobic fitness will be assessed at baseline and at 3, 6, 12, and 18 months; cortical thickness and functional connectivity at baseline and at 6, 12, and 18 months; Alzheimer's disease (AD) conversion at 6, 12, and 18 months. The specific aims are to (1) determine the efficacy and synergistic effects of the combined intervention on cognition over 6 months, (2) examine the underlying mechanisms of the combined intervention, and (3) calculate the long-term effect sizes of the combined intervention on cognition and AD conversion. The analysis will use intention-to-treat and linear mixed-effects modeling. DISCUSSION This trial will be among the first to test the synergistic effects on cognition and mechanisms (relevant to Alzheimer's-associated neurodegeneration) of a uniquely conceptualized and rigorously designed aerobic exercise and cognitive training intervention in older adults with mild cognitive impairment. It will advance Alzheimer's prevention research by providing precise effect-size estimates of the combined intervention. TRIAL REGISTRATION ClinicalTrials.gov, NCT03313895 . Registered on 18 October 2017.
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Affiliation(s)
- Fang Yu
- University of Minnesota School of Nursing, 5-160 WDH 1331, 308 Harvard St SE, Minneapolis, MN 55455 USA
| | - Feng Vankee Lin
- University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY 14642 USA
| | - Dereck L. Salisbury
- University of Minnesota School of Nursing, 5-160 WDH 1331, 308 Harvard St SE, Minneapolis, MN 55455 USA
| | - Krupa N. Shah
- University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY 14642 USA
| | - Lisa Chow
- University of Minnesota School of Medicine, Minneapolis, MN USA
| | - David Vock
- University of Minnesota Division of Biostatistics, Minneapolis, MN USA
| | | | | | - Clifford Jack
- Department of Radiology, Mayo Clinic, Rochester, MN USA
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25
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Tao Y, Peters ME, Drye LT, Devanand DP, Mintzer JE, Pollock BG, Porsteinsson AP, Rosenberg PB, Schneider LS, Shade DM, Weintraub D, Yesavage J, Lyketsos CG, Munro CA. Sex Differences in the Neuropsychiatric Symptoms of Patients With Alzheimer's Disease. Am J Alzheimers Dis Other Demen 2018; 33:450-457. [PMID: 29969907 PMCID: PMC6219457 DOI: 10.1177/1533317518783278] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim of this study was to describe sex differences in neuropsychiatric symptoms (NPSs) in patients with Alzheimer's disease (AD). Baseline scores on the Cohen-Mansfield Agitation Inventory, Neurobehavioral Rating Scale-Agitation subscale, and the Neuropsychiatric Inventory from patients with AD enrolled in a multicenter trial of citalopram for the treatment of agitation were analyzed. We found not only that patients with AD having agitation were likely to exhibit many other NPSs but also that the women in this study were more likely to exhibit a broader range of NPS than were the men. These results suggest greater heterogeneity in the clinical presentation of women compared to men, and thus in the potential targets for treatment in these patients. Further characterization of sex differences in NPS can inform future efforts aimed at establishing subtypes of patients for whom various treatment approaches will be most appropriate.
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Affiliation(s)
- Ye Tao
- Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Matthew E. Peters
- Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lea T. Drye
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Jacobo E. Mintzer
- Medical University of South Carolina, Clinical Biotechnology Research Institute–Roper St Francis Healthcare, Ralph H. Johnson VA Medical Center, Charleston, SC, USA
| | | | | | - Paul B. Rosenberg
- Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lon S. Schneider
- University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - David M. Shade
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Daniel Weintraub
- University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | | | | | - Cynthia A. Munro
- Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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26
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Lei L, Cooley SG, Phibbs CS, Kinosian B, Allman RM, Porsteinsson AP, Intrator O. Attributable Cost of Dementia: Demonstrating Pitfalls of Ignoring Multiple Health Care System Utilization. Health Serv Res 2018; 53 Suppl 3:5331-5351. [PMID: 30246404 DOI: 10.1111/1475-6773.13048] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES To determine dementia prevalence and costs attributable to dementia using Veterans Health Administration (VHA) data with and without Medicare data. DATA SOURCES VHA inpatient, outpatient, purchased care and other data and Medicare enrollment, claims, and assessments in fiscal year (FY) 2013. STUDY DESIGN Analyses were conducted with VHA data alone and with combined VHA and Medicare data. Dementia was identified from a VHA sanctioned list of ICD-9 diagnoses. Attributable cost of dementia was estimated using recycled predictions. DATA COLLECTION Veterans age 65 and older who used VHA and were enrolled in Traditional Medicare in FY 2013 (1.9 million). PRINCIPAL FINDINGS VHA records indicated the prevalence of dementia in FY 2013 was 4.8 percent while combined VHA and Medicare data indicated the prevalence was 7.4 percent. Attributable cost of dementia to VHA was, on average, $10,950 per veteran per year (pvpy) using VHA alone and $6,662 pvpy using combined VHA and Medicare data. Combined VHA and Medicare attributable cost of dementia was $11,285 pvpy. Utilization attributed to dementia using VHA data alone was lower for long-term institutionalization and higher for supportive care services than indicated in combined VHA and Medicare data. CONCLUSIONS Better planning for clinical and cost-efficient care requires VHA and Medicare to share data for veterans with dementia and likely more generally.
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Affiliation(s)
- Lianlian Lei
- VHA Office Geriatrics & Extended Care Data Analysis Center (GECDAC), Washington, DC.,Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Susan G Cooley
- VHA Office Geriatrics & Extended Care, U.S. Dept. Veterans Affairs, Washington, DC
| | - Ciaran S Phibbs
- VHA Office Geriatrics & Extended Care Data Analysis Center (GECDAC), Washington, DC.,Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA.,Department of Pediatrics-Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, CA
| | - Bruce Kinosian
- VHA Office Geriatrics & Extended Care Data Analysis Center (GECDAC), Washington, DC.,Division of Geriatrics, University of Pennsylvania, Philadelphia, PA
| | | | - Anton P Porsteinsson
- Department of Psychiatry, University of Rochester School ofMedicine and Dentistry, Rochester, NY
| | - Orna Intrator
- VHA Office Geriatrics & Extended Care Data Analysis Center (GECDAC), Washington, DC.,Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
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27
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Chapman RM, Gardner MN, Klorman R, Mapstone M, Porsteinsson AP, Antonsdottir IM, Kamalyan L. Temporospatial components of brain ERPs as biomarkers for Alzheimer's disease. Alzheimers Dement (Amst) 2018; 10:604-614. [PMID: 30417070 PMCID: PMC6215980 DOI: 10.1016/j.dadm.2018.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Introduction Developing biomarkers that distinguish individuals with Alzheimer's disease (AD) from those with normal cognition remains a crucial goal for improving the health of older adults. We investigated adding brain spatial information to temporal event-related potentials (ERPs) to increase AD identification accuracy over temporal ERPs alone. Methods With two-step principal components analysis, we applied multivariate analyses that incorporated temporal and spatial ERP information from a cognitive task. Discriminant analysis used temporospatial ERP scores to classify participants as belonging to either the AD or healthy control group. Results Temporospatial ERPs produced a cross-validated area under the curve of 0.84. Adding spatial information through a formal procedure significantly improves classification accuracy. Discussion A weighted combination of temporospatial ERP markers performs well in detecting AD. Because ERPs are noninvasive and inexpensive, they may be promising biomarkers for AD that can add functional information to other biomarker systems while providing the individual's probability of correct classification.
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Affiliation(s)
- Robert M Chapman
- Department of Brain and Cognitive Sciences and Center for Visual Science at the University of Rochester, Rochester, NY, USA
| | - Margaret N Gardner
- Department of Brain and Cognitive Sciences and Center for Visual Science at the University of Rochester, Rochester, NY, USA
| | - Rafael Klorman
- Department of Clinical and Social Sciences in Psychology at the University of Rochester, Rochester, NY, USA
| | - Mark Mapstone
- Department of Neurology, University of California Irvine, Irvine, CA, USA
| | - Anton P Porsteinsson
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Inga M Antonsdottir
- Department of Brain and Cognitive Sciences and Center for Visual Science at the University of Rochester, Rochester, NY, USA
| | - Lily Kamalyan
- Department of Brain and Cognitive Sciences and Center for Visual Science at the University of Rochester, Rochester, NY, USA
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28
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Abushakra S, Porsteinsson AP, Sadowsky CH. P4‐197: CLINICAL BENEFITS OF ORAL TRAMIPROSATE IN APOE4/4 HOMOZYGOTES WITH MILD ALZHEIMER'S DISEASE: RESPONDER ANALYSES FROM THE PHASE 3 NORTH AMERICAN TRIAL. Alzheimers Dement 2018. [DOI: 10.1016/j.jalz.2018.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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29
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Lin F, Ren P, Lo RY, Chapman BP, Jacobs A, Baran TM, Porsteinsson AP, Foxe JJ. Insula and Inferior Frontal Gyrus' Activities Protect Memory Performance Against Alzheimer's Disease Pathology in Old Age. J Alzheimers Dis 2018; 55:669-678. [PMID: 27716674 DOI: 10.3233/jad-160715] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Apolipoprotein E (APOE) ɛ4 carriers and patients with amnestic mild cognitive impairment (MCI) have high risk of developing Alzheimer's disease (AD). The Scaffolding Theory of Aging and Cognition proposes that recruitment of additional frontal brain regions can protect cognition against aging. This thesis has yet to be fully tested in older adults at high risk for AD. In the present study, 75 older participants (mean age: 74 years) were included. Applying a voxel-wise approach, fractional amplitude of low-frequency fluctuations (fALFF) in resting-state functional neuroimaging data were analyzed as a function of APOEɛ4 status (carrier versus noncarrier) and clinical status (healthy control [HC] versus MCI) using a 2×2 analysis of covariance (ANCOVA). Measures of cognition and cerebrospinal fluid levels of amyloid- β were also obtained. Three frontal regions were identified with significant interaction effects using ANCOVA (corrected p < 0.01): left-insula, left-inferior frontal gyrus (IFG), and right-precentral gyrus. The HC/APOEɛ4 carrier group had significantly higher fALFF in all three regions than other groups. In the entire sample, for two regions (left insula and left IFG), a significant positive relationship between amyloid-β and memory was only observed among individuals with low fALFF. Our results suggest higher activity in frontal regions may explain being cognitively normal among a subgroup of APOEɛ4 carriers and protect against the negative impact of AD-associated pathology on memory. This is an observation with potential implications for AD therapeutics.
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Affiliation(s)
- Feng Lin
- School of Nursing, University of Rochester Medical Center, Rochester, NY, USA.,Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA.,Department of Brain and Cognitive Science, University of Rochester, Rochester, NY, USA
| | - Ping Ren
- School of Nursing, University of Rochester Medical Center, Rochester, NY, USA
| | - Raymond Y Lo
- Department of Neurology, Buddhist Tzu Chi General Hospital, Tzu Chi University, Taiwan, Taipai
| | - Benjamin P Chapman
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA.,Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Alanna Jacobs
- School of Nursing, University of Rochester Medical Center, Rochester, NY, USA.,Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA
| | - Timothy M Baran
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Anton P Porsteinsson
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA.,Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - John J Foxe
- Department of Neuroscience & The Ernest J. Del Monte Institute for Neuromedicine, University of Rochester Medical Center, Rochester, NY, USA
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30
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Lin F, Heffner KL, Ren P, Tivarus ME, Brasch J, Chen DG, Mapstone M, Porsteinsson AP, Tadin D. Cognitive and Neural Effects of Vision-Based Speed-of-Processing Training in Older Adults with Amnestic Mild Cognitive Impairment: A Pilot Study. J Am Geriatr Soc 2017; 64:1293-8. [PMID: 27321608 DOI: 10.1111/jgs.14132] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To examine the cognitive and neural effects of vision-based speed-of-processing (VSOP) training in older adults with amnestic mild cognitive impairment (aMCI) and contrast those effects with an active control (mental leisure activities (MLA)). DESIGN Randomized single-blind controlled pilot trial. SETTING Academic medical center. PARTICIPANTS Individuals with aMCI (N = 21). INTERVENTION Six-week computerized VSOP training. MEASUREMENTS Multiple cognitive processing measures, instrumental activities of daily living (IADLs), and two resting state neural networks regulating cognitive processing: central executive network (CEN) and default mode network (DMN). RESULTS VSOP training led to significantly greater improvements in trained (processing speed and attention: F1,19 = 6.61, partial η(2) = 0.26, P = .02) and untrained (working memory: F1,19 = 7.33, partial η(2) = 0.28, P = .01; IADLs: F1,19 = 5.16, partial η(2) = 0.21, P = .03) cognitive domains than MLA and protective maintenance in DMN (F1, 9 = 14.63, partial η(2) = 0.62, P = .004). VSOP training, but not MLA, resulted in a significant improvement in CEN connectivity (Z = -2.37, P = .02). CONCLUSION Target and transfer effects of VSOP training were identified, and links between VSOP training and two neural networks associated with aMCI were found. These findings highlight the potential of VSOP training to slow cognitive decline in individuals with aMCI. Further delineation of mechanisms underlying VSOP-induced plasticity is necessary to understand in which populations and under what conditions such training may be most effective.
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Affiliation(s)
- Feng Lin
- School of Nursing, University of Rochester, Rochester, New York.,Department of Psychiatry, University of Rochester, Rochester, New York
| | - Kathi L Heffner
- Department of Psychiatry, University of Rochester, Rochester, New York
| | - Ping Ren
- School of Nursing, University of Rochester, Rochester, New York
| | - Madalina E Tivarus
- Department of Imaging Sciences, University of Rochester, Rochester, New York
| | - Judith Brasch
- School of Nursing, University of Rochester, Rochester, New York
| | - Ding-Geng Chen
- School of Nursing, University of Rochester, Rochester, New York.,Department of Biostatics and Computational Biology, University of Rochester, Rochester, New York
| | - Mark Mapstone
- Department of Neurology, School of Medicine and Dentistry, University of Rochester, Rochester, New York
| | | | - Duje Tadin
- Department of Ophthalmology, University of Rochester, Rochester, New York.,Center for Visual Science, University of Rochester, Rochester, New York.,Department of Brain and Cognitive Sciences, University of Rochester, Rochester, New York
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31
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Abushakra S, Sadowsky CH, Porsteinsson AP, Gauthier S, Vellas B, Power A, Shen L, Wang P, Hey J, Tolar M. [P1–052]: CLINICAL EFFECTS OF TRAMIPROSATE IN APOE4 HOMOZYGOTES WITH MILD TO MODERATE ALZHEIMER'S DISEASE (AD) ARE SUSTAINED OVER 130 WEEKS: RESULTS OF A PHASE 3 EXTENSION STUDY. Alzheimers Dement 2017. [DOI: 10.1016/j.jalz.2017.06.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | | | | | - Serge Gauthier
- McGill University Research Centre for Studies in AgingVerdunQCCanada
| | - Bruno Vellas
- Gerontopole, INSERM UToulouseFrance1027
- Alzheimer's Disease Research and Clinical Center, Toulouse University HospitalToulouseFrance
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Abstract
INTRODUCTION Neuropsychiatric symptoms (NPS) in Alzheimer's disease (AD) are associated with significant negative outcomes for patients and their caregivers. Agitation, one of the most distressing NPS, lacks safe and effective long term interventions. Nonpharmacological interventions are suggested as first-line treatment, but aren't effective for every patient, resulting in pharmacological interventions for some patients, consisting of off-label use of antipsychotics, sedative/hypnotics, anxiolytics, acetylcholinesterase inhibitors, memantine, and antidepressants; where efficacy doesn't necessarily outweigh associated risks. Areas covered: Gains in understanding neurobiological mechanisms underlying agitation have fueled several recent clinical trials. This article updates our review published in 2014. Comprehensive literature search for published articles from January 2014 to December 2016 evaluating pharmacologic interventions for agitation in AD was done. A review of several clinical trials was completed: dextromethorphan/quinidine, scyllo-inositol, brexpiprazole, prazosin, cannabinoids, citalopram, escitalopram, pimavanserin, ITI-007, ORM-12741 show promise in treating agitation. Expert opinion: Neurobiological findings, innovative trials designs, statistical approaches, and preliminary paths for regulatory agency acceptance have re-ignited the area of pharmacological treatment of NPS. Though further research is needed to fully determine the safety, tolerability and efficacy of these treatments, the mission to find effective treatments for neuropsychiatric symptoms such as agitation in patients with dementia is well underway.
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Affiliation(s)
- Anton P Porsteinsson
- a Alzheimer's Disease Care, Research and Education Program (AD-CARE), Department of Psychiatry , University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Inga M Antonsdottir
- b Department of Psychiatry and Behavioral Sciences, Division of Geriatric Psychiatry and Neuropsychiatry , Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Antonsdottir IM, Makino KM, Porsteinsson AP. Dazed and Confused: Medical Cannabis in Alzheimer Disease. Am J Geriatr Psychiatry 2016; 24:1004-1006. [PMID: 27665036 DOI: 10.1016/j.jagp.2016.08.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 08/29/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Inga M Antonsdottir
- Department of Psychiatry and Behavioral Sciences, Division of Geriatric Psychiatry and Neuropsychiatry, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kelly M Makino
- Department of Family Medicine, University of Hawaii School of Medicine, Honolulu, HI
| | - Anton P Porsteinsson
- Alzheimer's Disease Care, Research and Education Program, Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, NY.
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34
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Rosenberg PB, Lanctôt KL, Herrmann N, Mintzer JE, Porsteinsson AP, Sun X, Raman R. Changes in Neuropsychiatric Inventory Associated with Semagacestat Treatment of Alzheimer’s Disease. J Alzheimers Dis 2016; 54:373-81. [DOI: 10.3233/jad-151113] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Paul B. Rosenberg
- Department of Psychiatry and Behavioral Sciences, Division of Geriatric Psychiatry and Neuropsychiatry, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Krista L. Lanctôt
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
- Departments of Psychiatry and Pharmacology/Toxicology, University of Toronto, Toronto, ON, Canada
| | - Nathan Herrmann
- Division of Geriatric Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Psychiatry, Division of Geriatric Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Jacobo E. Mintzer
- Roper St. Francis Clinical Biotechnology Research Institute, Charleston, SC, USA
- Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA
- Medical University of South Carolina, Charleston, SC, USA
- School of Internal Medicine, University of South Carolina, Columbia, SC, USA
| | - Anton P. Porsteinsson
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Xiaoying Sun
- Biostatistics Research Center, University of California, San Diego, La Jolla, CA, USA
| | - Rema Raman
- Alzheimer’s Therapeutic Research Institute (ATRI), Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, USA
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Yesavage JA, Taylor JL, Friedman L, Rosenberg PB, Lazzeroni LC, Leoutsakos JMS, Kinoshita LM, Perlow MJ, Munro CA, Devanand DP, Drye LT, Mintzer JE, Pollock BG, Porsteinsson AP, Schneider LS, Shade DM, Weintraub D, Lyketsos CG, Noda A. Principal components analysis of agitation outcomes in Alzheimer's disease. J Psychiatr Res 2016; 79:4-7. [PMID: 27115509 PMCID: PMC4891245 DOI: 10.1016/j.jpsychires.2016.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 04/05/2016] [Accepted: 04/14/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND We developed a composite measure of agitation as a secondary outcome of change over time in the Citalopram for Agitation in Alzheimer's disease study (CitAD). CitAD demonstrated a positive effect of citalopram on agitation on the Neurobehavioral Rating Scale agitation subscale (NBRS-A). CitAD included additional agitation measures such as the Cohen-Mansfield Agitation Inventory and the Neuropsychiatric Inventory. METHODS We performed principal components analyses on change in individual item of these scales for the same, original CitAD subjects. RESULTS The first principal component accounted for 12.6% of the observed variance and was composed of items that appear to reflect agitation. The effect size for citalopram calculated using this component was 0.53 (95% CI 0.22-0.83) versus 0.32 for the NBRS-A (95% CI 0.01-0.62). CONCLUSIONS Results suggest that a composite measure of change in agitation might be more sensitive than change in a single primary agitation measure.
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Affiliation(s)
- Jerome A Yesavage
- Department of Veterans Affairs Health Care System, Palo Alto, CA, 94304, United States; Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, 94305, United States; Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, 94305, United States.
| | - Joy L Taylor
- Department of Veterans Affairs Health Care System, Palo Alto, CA, 94304, United States; Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, 94305, United States
| | - Leah Friedman
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, 94305, United States
| | - Paul B Rosenberg
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Bayview Medical Center, Johns Hopkins School of Medicine, Baltimore, MD, 21205, United States
| | - Laura C Lazzeroni
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, 94305, United States
| | - Jeannie-Marie S Leoutsakos
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Bayview Medical Center, Johns Hopkins School of Medicine, Baltimore, MD, 21205, United States
| | - Lisa M Kinoshita
- Department of Veterans Affairs Health Care System, Palo Alto, CA, 94304, United States
| | - Mark J Perlow
- Department of Veterans Affairs Health Care System, Palo Alto, CA, 94304, United States
| | - Cynthia A Munro
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Bayview Medical Center, Johns Hopkins School of Medicine, Baltimore, MD, 21205, United States
| | - D P Devanand
- Division of Geriatric Psychiatry, New York State Psychiatric Institute, New York, NY, 10032, United States; College of Physicians and Surgeons of Columbia University, New York, NY, 10032, United States
| | - Lea T Drye
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, United States
| | - Jacobo E Mintzer
- Clinical Biotechnology Research Institute, Roper St. Francis Healthcare, Charleston, SC, 29401, United States; Ralph H. Johnson VA Medical Center, Charleston, SC, 29401, United States
| | - Bruce G Pollock
- Campbell Institute, CAMH, University of Toronto, Toronto, Ontario, M5S 2S1, Canada
| | - Anton P Porsteinsson
- University of Rochester School of Medicine and Dentistry, Rochester, NY, 14642, United States
| | - Lon S Schneider
- University of Southern California Keck School of Medicine, Los Angeles, CA, 90089, United States
| | - David M Shade
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, United States
| | - Daniel Weintraub
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, 19104, United States; Department of Veterans Affairs, Philadelphia, PA, 19104, United States
| | - Constantine G Lyketsos
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Bayview Medical Center, Johns Hopkins School of Medicine, Baltimore, MD, 21205, United States
| | - Art Noda
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, 94305, United States
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Ho T, Pollock BG, Mulsant BH, Schantz O, Devanand DP, Mintzer JE, Porsteinsson AP, Schneider LS, Weintraub D, Yesavage J, Drye LT, Munro CA, Shade DM, Lyketsos C, Bies R. R- and S-citalopram concentrations have differential effects on neuropsychiatric scores in elders with dementia and agitation. Br J Clin Pharmacol 2016; 82:784-92. [PMID: 27145364 DOI: 10.1111/bcp.12997] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 04/22/2016] [Accepted: 04/29/2016] [Indexed: 12/26/2022] Open
Abstract
AIMS The aim was to determine the relationship between (R) and (S)-citalopram enantiomer exposure (AUC(0,24 h)) and therapeutic response in agitated individuals greater than 60 years old with Alzheimer's dementia (AD). METHODS Citalopram enantiomer exposures (AUC(0,24 h)) derived from an established population pharmacokinetic analysis were utilized to explore the relationship between (R)- and (S)-citalopram area under the curve (AUC(0,24 )) and Mini-Mental State Examination (MMSE), Neurobehavioural Rating Scale-Agitation Subscale (NBRS-A), modified Alzheimer's Disease Cooperative Study-Clinical Global Impression of Change (mADCS-CGIC) and Neuropsychiatric Inventory Agitation subscale (NPIA) scores. Time dependent changes in these scores (disease progression) were accounted for prior to exploring the exposure effect relationship for each enantiomer. These relationships were evaluated using a non-linear-mixed effects modelling approach as implemented in nonmem v7.3. RESULTS (S)-AUC(0,24 h) and (R)-AUC(0,24 h) each contributed to improvement in NBRS-A scores (k3(R) -0.502; k4(S) -0.712) as did time in treatment. However, increasing (R)-AUC(0,24 h) decreased the probability of patient response (maximum Δ -0.182%/AUC(0,24 h)) based on the CGIC while (S)-AUC(0,24 h) improved the probability of response (maximum Δ 0.112%/AUC(0,24 h)). (R)-AUC(0,24 h) was also associated with worsening in MMSE scores (-0.5 points). CONCLUSIONS Our results suggest that citalopram enantiomers contributed differentially to treatment outcomes. (R)-citalopram accounted for a greater proportion of the adverse consequences associated with racemic citalopram treatment in patients with AD including a decreased probability of treatment response as measured by the CGIC and a reduction in MMSE scores. The S-enantiomer was associated with increased probability of response based on the CGIC.
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Affiliation(s)
- Thang Ho
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Bruce G Pollock
- Campbell Family Mental Health Research Institute, CAMH, University of Toronto, Toronto, Ontario, Canada
| | - Benoit H Mulsant
- Campbell Family Mental Health Research Institute, CAMH, University of Toronto, Toronto, Ontario, Canada
| | - Oliver Schantz
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Devangere P Devanand
- Division of Geriatric Psychiatry, Colleges of Physicians and Surgeons, Columbia University, New York, New York
| | - Jacobo E Mintzer
- Clinical Biotechnology Research Institute, Roper St. Francis Healthcare, Charleston, South Carolina
| | - Anton P Porsteinsson
- Alzheimer's Disease Care, Research and Education Program (AD-CARE), University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Lon S Schneider
- Department of Psychiatry and Behavioral Science, Keck School of Medicine, University of Southern California, California
| | - Daniel Weintraub
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jerome Yesavage
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California
| | - Lea T Drye
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Cynthia A Munro
- Department of Psychiatry and Behavioral Sciences, Department of Neurology, Johns Hopkins Bayview and Johns Hopkins School of Medicine, Baltimore, Maryland
| | - David M Shade
- Department of Medicine (Pulmonary) and Epidemiology (Center for Clinical Trials), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Constantine Lyketsos
- Memory and Alzheimer's Treatment Center, Johns Hopkins Bayview and Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Robert Bies
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Campbell Family Mental Health Research Institute, CAMH, University of Toronto, Toronto, Ontario, Canada
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Leonpacher AK, Peters ME, Drye LT, Makino KM, Newell JA, Devanand DP, Frangakis C, Munro CA, Mintzer JE, Pollock BG, Rosenberg PB, Schneider LS, Shade DM, Weintraub D, Yesavage J, Lyketsos CG, Porsteinsson AP. Effects of Citalopram on Neuropsychiatric Symptoms in Alzheimer's Dementia: Evidence From the CitAD Study. Am J Psychiatry 2016; 173:473-80. [PMID: 27032628 DOI: 10.1176/appi.ajp.2016.15020248] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Citalopram has been shown to improve agitation in patients with Alzheimer's disease. The authors evaluated whether other neuropsychiatric symptoms improve with citalopram treatment compared with placebo. METHOD In this planned secondary analysis of the Citalopram for Agitation in Alzheimer's Disease study, the authors evaluated the effect of citalopram on the 12 neuropsychiatric symptom domains assessed by the Neuropsychiatric Inventory (NPI). They compared caregiver-reported NPI scores at week 9 in patients receiving citalopram (30 mg/day) or placebo with regard to both the presence or absence of individual neuropsychiatric symptoms and individual domain scores (reflecting severity) in participants who had symptoms at week 9. RESULTS At week 9, participants treated with citalopram were significantly less likely to be reported as showing delusions (odds ratio=0.40), anxiety (odds ratio=0.43), and irritability/lability (odds ratio=0.38). A comparison of median scores of participants with symptoms present at week 9 showed significant differences favoring citalopram for hallucinations and favoring placebo for sleep/nighttime behavior disorders. CONCLUSIONS While dosage constraints must be considered because of citalopram's adverse effect profile, this agent's overall therapeutic effects in patients with Alzheimer's disease and agitation, in addition to efficacy for agitation/aggression, included reductions in the frequency of irritability, anxiety, and delusions; among patients who had these symptoms at week 9, they included a reduction in the severity of hallucinations but an increase in the severity of sleep/nighttime behavior disorders.
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Affiliation(s)
- Anne K Leonpacher
- From the Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore; the Johns Hopkins Bloomberg School of Public Health, Baltimore; the Alzheimer's Disease Care, Research, and Education Program, University of Rochester School of Medicine and Dentistry, Rochester, N.Y.; the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford; the Division of Geriatric Psychiatry, Department of Psychiatry, New York State Psychiatric Institute and College of Physicians and Surgeons of Columbia University, New York; the Clinical Biotechnology Research Institute, Roper St. Francis Healthcare, and the Department of Psychiatry, Ralph H. Johnson VA Medical Center, Charleston, S.C.; the Campbell Institute, Centre for Addiction and Mental Health, and the Department of Psychiatry, University of Toronto, Toronto; the Department of Psychiatry and Behavioral Sciences and the Department of Neurology, Keck School of Medicine of University of Southern California, Los Angeles; and the Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Matthew E Peters
- From the Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore; the Johns Hopkins Bloomberg School of Public Health, Baltimore; the Alzheimer's Disease Care, Research, and Education Program, University of Rochester School of Medicine and Dentistry, Rochester, N.Y.; the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford; the Division of Geriatric Psychiatry, Department of Psychiatry, New York State Psychiatric Institute and College of Physicians and Surgeons of Columbia University, New York; the Clinical Biotechnology Research Institute, Roper St. Francis Healthcare, and the Department of Psychiatry, Ralph H. Johnson VA Medical Center, Charleston, S.C.; the Campbell Institute, Centre for Addiction and Mental Health, and the Department of Psychiatry, University of Toronto, Toronto; the Department of Psychiatry and Behavioral Sciences and the Department of Neurology, Keck School of Medicine of University of Southern California, Los Angeles; and the Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Lea T Drye
- From the Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore; the Johns Hopkins Bloomberg School of Public Health, Baltimore; the Alzheimer's Disease Care, Research, and Education Program, University of Rochester School of Medicine and Dentistry, Rochester, N.Y.; the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford; the Division of Geriatric Psychiatry, Department of Psychiatry, New York State Psychiatric Institute and College of Physicians and Surgeons of Columbia University, New York; the Clinical Biotechnology Research Institute, Roper St. Francis Healthcare, and the Department of Psychiatry, Ralph H. Johnson VA Medical Center, Charleston, S.C.; the Campbell Institute, Centre for Addiction and Mental Health, and the Department of Psychiatry, University of Toronto, Toronto; the Department of Psychiatry and Behavioral Sciences and the Department of Neurology, Keck School of Medicine of University of Southern California, Los Angeles; and the Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Kelly M Makino
- From the Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore; the Johns Hopkins Bloomberg School of Public Health, Baltimore; the Alzheimer's Disease Care, Research, and Education Program, University of Rochester School of Medicine and Dentistry, Rochester, N.Y.; the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford; the Division of Geriatric Psychiatry, Department of Psychiatry, New York State Psychiatric Institute and College of Physicians and Surgeons of Columbia University, New York; the Clinical Biotechnology Research Institute, Roper St. Francis Healthcare, and the Department of Psychiatry, Ralph H. Johnson VA Medical Center, Charleston, S.C.; the Campbell Institute, Centre for Addiction and Mental Health, and the Department of Psychiatry, University of Toronto, Toronto; the Department of Psychiatry and Behavioral Sciences and the Department of Neurology, Keck School of Medicine of University of Southern California, Los Angeles; and the Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jeffery A Newell
- From the Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore; the Johns Hopkins Bloomberg School of Public Health, Baltimore; the Alzheimer's Disease Care, Research, and Education Program, University of Rochester School of Medicine and Dentistry, Rochester, N.Y.; the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford; the Division of Geriatric Psychiatry, Department of Psychiatry, New York State Psychiatric Institute and College of Physicians and Surgeons of Columbia University, New York; the Clinical Biotechnology Research Institute, Roper St. Francis Healthcare, and the Department of Psychiatry, Ralph H. Johnson VA Medical Center, Charleston, S.C.; the Campbell Institute, Centre for Addiction and Mental Health, and the Department of Psychiatry, University of Toronto, Toronto; the Department of Psychiatry and Behavioral Sciences and the Department of Neurology, Keck School of Medicine of University of Southern California, Los Angeles; and the Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - D P Devanand
- From the Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore; the Johns Hopkins Bloomberg School of Public Health, Baltimore; the Alzheimer's Disease Care, Research, and Education Program, University of Rochester School of Medicine and Dentistry, Rochester, N.Y.; the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford; the Division of Geriatric Psychiatry, Department of Psychiatry, New York State Psychiatric Institute and College of Physicians and Surgeons of Columbia University, New York; the Clinical Biotechnology Research Institute, Roper St. Francis Healthcare, and the Department of Psychiatry, Ralph H. Johnson VA Medical Center, Charleston, S.C.; the Campbell Institute, Centre for Addiction and Mental Health, and the Department of Psychiatry, University of Toronto, Toronto; the Department of Psychiatry and Behavioral Sciences and the Department of Neurology, Keck School of Medicine of University of Southern California, Los Angeles; and the Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Constantine Frangakis
- From the Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore; the Johns Hopkins Bloomberg School of Public Health, Baltimore; the Alzheimer's Disease Care, Research, and Education Program, University of Rochester School of Medicine and Dentistry, Rochester, N.Y.; the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford; the Division of Geriatric Psychiatry, Department of Psychiatry, New York State Psychiatric Institute and College of Physicians and Surgeons of Columbia University, New York; the Clinical Biotechnology Research Institute, Roper St. Francis Healthcare, and the Department of Psychiatry, Ralph H. Johnson VA Medical Center, Charleston, S.C.; the Campbell Institute, Centre for Addiction and Mental Health, and the Department of Psychiatry, University of Toronto, Toronto; the Department of Psychiatry and Behavioral Sciences and the Department of Neurology, Keck School of Medicine of University of Southern California, Los Angeles; and the Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Cynthia A Munro
- From the Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore; the Johns Hopkins Bloomberg School of Public Health, Baltimore; the Alzheimer's Disease Care, Research, and Education Program, University of Rochester School of Medicine and Dentistry, Rochester, N.Y.; the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford; the Division of Geriatric Psychiatry, Department of Psychiatry, New York State Psychiatric Institute and College of Physicians and Surgeons of Columbia University, New York; the Clinical Biotechnology Research Institute, Roper St. Francis Healthcare, and the Department of Psychiatry, Ralph H. Johnson VA Medical Center, Charleston, S.C.; the Campbell Institute, Centre for Addiction and Mental Health, and the Department of Psychiatry, University of Toronto, Toronto; the Department of Psychiatry and Behavioral Sciences and the Department of Neurology, Keck School of Medicine of University of Southern California, Los Angeles; and the Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jacobo E Mintzer
- From the Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore; the Johns Hopkins Bloomberg School of Public Health, Baltimore; the Alzheimer's Disease Care, Research, and Education Program, University of Rochester School of Medicine and Dentistry, Rochester, N.Y.; the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford; the Division of Geriatric Psychiatry, Department of Psychiatry, New York State Psychiatric Institute and College of Physicians and Surgeons of Columbia University, New York; the Clinical Biotechnology Research Institute, Roper St. Francis Healthcare, and the Department of Psychiatry, Ralph H. Johnson VA Medical Center, Charleston, S.C.; the Campbell Institute, Centre for Addiction and Mental Health, and the Department of Psychiatry, University of Toronto, Toronto; the Department of Psychiatry and Behavioral Sciences and the Department of Neurology, Keck School of Medicine of University of Southern California, Los Angeles; and the Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Bruce G Pollock
- From the Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore; the Johns Hopkins Bloomberg School of Public Health, Baltimore; the Alzheimer's Disease Care, Research, and Education Program, University of Rochester School of Medicine and Dentistry, Rochester, N.Y.; the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford; the Division of Geriatric Psychiatry, Department of Psychiatry, New York State Psychiatric Institute and College of Physicians and Surgeons of Columbia University, New York; the Clinical Biotechnology Research Institute, Roper St. Francis Healthcare, and the Department of Psychiatry, Ralph H. Johnson VA Medical Center, Charleston, S.C.; the Campbell Institute, Centre for Addiction and Mental Health, and the Department of Psychiatry, University of Toronto, Toronto; the Department of Psychiatry and Behavioral Sciences and the Department of Neurology, Keck School of Medicine of University of Southern California, Los Angeles; and the Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Paul B Rosenberg
- From the Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore; the Johns Hopkins Bloomberg School of Public Health, Baltimore; the Alzheimer's Disease Care, Research, and Education Program, University of Rochester School of Medicine and Dentistry, Rochester, N.Y.; the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford; the Division of Geriatric Psychiatry, Department of Psychiatry, New York State Psychiatric Institute and College of Physicians and Surgeons of Columbia University, New York; the Clinical Biotechnology Research Institute, Roper St. Francis Healthcare, and the Department of Psychiatry, Ralph H. Johnson VA Medical Center, Charleston, S.C.; the Campbell Institute, Centre for Addiction and Mental Health, and the Department of Psychiatry, University of Toronto, Toronto; the Department of Psychiatry and Behavioral Sciences and the Department of Neurology, Keck School of Medicine of University of Southern California, Los Angeles; and the Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Lon S Schneider
- From the Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore; the Johns Hopkins Bloomberg School of Public Health, Baltimore; the Alzheimer's Disease Care, Research, and Education Program, University of Rochester School of Medicine and Dentistry, Rochester, N.Y.; the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford; the Division of Geriatric Psychiatry, Department of Psychiatry, New York State Psychiatric Institute and College of Physicians and Surgeons of Columbia University, New York; the Clinical Biotechnology Research Institute, Roper St. Francis Healthcare, and the Department of Psychiatry, Ralph H. Johnson VA Medical Center, Charleston, S.C.; the Campbell Institute, Centre for Addiction and Mental Health, and the Department of Psychiatry, University of Toronto, Toronto; the Department of Psychiatry and Behavioral Sciences and the Department of Neurology, Keck School of Medicine of University of Southern California, Los Angeles; and the Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - David M Shade
- From the Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore; the Johns Hopkins Bloomberg School of Public Health, Baltimore; the Alzheimer's Disease Care, Research, and Education Program, University of Rochester School of Medicine and Dentistry, Rochester, N.Y.; the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford; the Division of Geriatric Psychiatry, Department of Psychiatry, New York State Psychiatric Institute and College of Physicians and Surgeons of Columbia University, New York; the Clinical Biotechnology Research Institute, Roper St. Francis Healthcare, and the Department of Psychiatry, Ralph H. Johnson VA Medical Center, Charleston, S.C.; the Campbell Institute, Centre for Addiction and Mental Health, and the Department of Psychiatry, University of Toronto, Toronto; the Department of Psychiatry and Behavioral Sciences and the Department of Neurology, Keck School of Medicine of University of Southern California, Los Angeles; and the Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Daniel Weintraub
- From the Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore; the Johns Hopkins Bloomberg School of Public Health, Baltimore; the Alzheimer's Disease Care, Research, and Education Program, University of Rochester School of Medicine and Dentistry, Rochester, N.Y.; the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford; the Division of Geriatric Psychiatry, Department of Psychiatry, New York State Psychiatric Institute and College of Physicians and Surgeons of Columbia University, New York; the Clinical Biotechnology Research Institute, Roper St. Francis Healthcare, and the Department of Psychiatry, Ralph H. Johnson VA Medical Center, Charleston, S.C.; the Campbell Institute, Centre for Addiction and Mental Health, and the Department of Psychiatry, University of Toronto, Toronto; the Department of Psychiatry and Behavioral Sciences and the Department of Neurology, Keck School of Medicine of University of Southern California, Los Angeles; and the Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jerome Yesavage
- From the Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore; the Johns Hopkins Bloomberg School of Public Health, Baltimore; the Alzheimer's Disease Care, Research, and Education Program, University of Rochester School of Medicine and Dentistry, Rochester, N.Y.; the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford; the Division of Geriatric Psychiatry, Department of Psychiatry, New York State Psychiatric Institute and College of Physicians and Surgeons of Columbia University, New York; the Clinical Biotechnology Research Institute, Roper St. Francis Healthcare, and the Department of Psychiatry, Ralph H. Johnson VA Medical Center, Charleston, S.C.; the Campbell Institute, Centre for Addiction and Mental Health, and the Department of Psychiatry, University of Toronto, Toronto; the Department of Psychiatry and Behavioral Sciences and the Department of Neurology, Keck School of Medicine of University of Southern California, Los Angeles; and the Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Constantine G Lyketsos
- From the Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore; the Johns Hopkins Bloomberg School of Public Health, Baltimore; the Alzheimer's Disease Care, Research, and Education Program, University of Rochester School of Medicine and Dentistry, Rochester, N.Y.; the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford; the Division of Geriatric Psychiatry, Department of Psychiatry, New York State Psychiatric Institute and College of Physicians and Surgeons of Columbia University, New York; the Clinical Biotechnology Research Institute, Roper St. Francis Healthcare, and the Department of Psychiatry, Ralph H. Johnson VA Medical Center, Charleston, S.C.; the Campbell Institute, Centre for Addiction and Mental Health, and the Department of Psychiatry, University of Toronto, Toronto; the Department of Psychiatry and Behavioral Sciences and the Department of Neurology, Keck School of Medicine of University of Southern California, Los Angeles; and the Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Anton P Porsteinsson
- From the Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore; the Johns Hopkins Bloomberg School of Public Health, Baltimore; the Alzheimer's Disease Care, Research, and Education Program, University of Rochester School of Medicine and Dentistry, Rochester, N.Y.; the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford; the Division of Geriatric Psychiatry, Department of Psychiatry, New York State Psychiatric Institute and College of Physicians and Surgeons of Columbia University, New York; the Clinical Biotechnology Research Institute, Roper St. Francis Healthcare, and the Department of Psychiatry, Ralph H. Johnson VA Medical Center, Charleston, S.C.; the Campbell Institute, Centre for Addiction and Mental Health, and the Department of Psychiatry, University of Toronto, Toronto; the Department of Psychiatry and Behavioral Sciences and the Department of Neurology, Keck School of Medicine of University of Southern California, Los Angeles; and the Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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38
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Schneider LS, Frangakis C, Drye LT, Devanand D, Marano CM, Mintzer J, Mulsant BH, Munro CA, Newell JA, Pawluczyk S, Pelton G, Pollock BG, Porsteinsson AP, Rabins PV, Rein L, Rosenberg PB, Shade D, Weintraub D, Yesavage J, Lyketsos CG. Heterogeneity of Treatment Response to Citalopram for Patients With Alzheimer's Disease With Aggression or Agitation: The CitAD Randomized Clinical Trial. Am J Psychiatry 2016; 173:465-72. [PMID: 26771737 PMCID: PMC6419726 DOI: 10.1176/appi.ajp.2015.15050648] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Pharmacological treatments for agitation and aggression in patients with Alzheimer's disease have shown limited efficacy. The authors assessed the heterogeneity of response to citalopram in the Citalopram for Agitation in Alzheimer Disease (CitAD) study to identify individuals who may be helped or harmed. METHOD In this double-blind parallel-group multicenter trial of 186 patients with Alzheimer's disease and clinically significant agitation, participants were randomly assigned to receive citalopram or placebo for 9 weeks, with the dosage titrated to 30 mg/day over the first 3 weeks. Five planned potential predictors of treatment outcome were assessed, along with six additional predictors. The authors then used a two-stage multivariate method to select the most likely predictors; grouped participants into 10 subgroups by their index scores; and estimated the citalopram treatment effect for each. RESULTS Five covariates were likely predictors, and treatment effect was heterogeneous across the subgroups. Patients for whom citalopram was more effective were more likely to be outpatients, have the least cognitive impairment, have moderate agitation, and be within the middle age range (76-82 years). Patients for whom placebo was more effective were more likely to be in long-term care, have more severe cognitive impairment, have more severe agitation, and be treated with lorazepam. CONCLUSIONS Considering several covariates together allowed the identification of responders. Those with moderate agitation and with lower levels of cognitive impairment were more likely to benefit from citalopram, and those with more severe agitation and greater cognitive impairment were at greater risk for adverse responses. Considering the dosages used and the association of citalopram with cardiac QT prolongation, use of this agent to treat agitation may be limited to a subgroup of people with dementia.
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Affiliation(s)
- Lon S. Schneider
- Department of psychiatry and the behavioral sciences, and department of neurology, Keck School of Medicine of the University of Southern California
| | | | - Lea T Drye
- Department of Epidemiology, Center for Clinical Trials and Evidence Synthesis, Johns Hopkins Bloomberg School of Public Health
| | - D.P. Devanand
- Division of Geriatric Psychiatry, Department of Psychiatry, New York State Psychiatric Institute and Columbia University Medical Center
| | - Christopher M. Marano
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Bayview, Johns Hopkins Medicine
| | - Jacob Mintzer
- Clinical Biotechnology Research Institute, Roper St. Francis Healthcare, Charleston, South Carolina
| | - Benoit H. Mulsant
- Campbell Institute, Centre for Addiction and Mental Health; Department of Psychiatry, University of Toronto
| | - Cynthia A. Munro
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine
| | - Jeffery A. Newell
- Culture and Mental Health Laboratory, University of Southern California
| | - Sonia Pawluczyk
- Department of psychiatry and the behavioral sciences, and department of neurology, Keck School of Medicine of the University of Southern California
| | - Gregory Pelton
- Division of Geriatric Psychiatry, Department of Psychiatry, New York State Psychiatric Institute and Columbia University Medical Center
| | - Bruce G Pollock
- Campbell Institute, Centre for Addiction and Mental Health; Department of Psychiatry, University of Toronto
| | | | - Peter V. Rabins
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine
| | - Lisa Rein
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine
| | - Paul B. Rosenberg
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry
| | - David Shade
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health
| | - Daniel Weintraub
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania
| | - Jerome Yesavage
- Department of Veterans Affairs Health Care System, Palo Alto, California, and Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine
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Chapman RM, Gardner MN, Mapstone M, Klorman R, Porsteinsson AP, Dupree HM, Antonsdottir IM, Kamalyan L. ERP C250 shows the elderly (cognitively normal, Alzheimer's disease) store more stimuli in short-term memory than Young Adults do. Clin Neurophysiol 2016; 127:2423-35. [PMID: 27178862 DOI: 10.1016/j.clinph.2016.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2014] [Revised: 02/15/2016] [Accepted: 03/04/2016] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To determine how aging and dementia affect the brain's initial storing of task-relevant and irrelevant information in short-term memory. METHODS We used brain Event-Related Potentials (ERPs) to measure short-term memory storage (ERP component C250) in 36 Young Adults, 36 Normal Elderly, and 36 early-stage AD subjects. Participants performed the Number-Letter task, a cognitive paradigm requiring memory storage of a first relevant stimulus to compare it with a second stimulus. RESULTS In Young Adults, C250 was more positive for the first task-relevant stimulus compared to all other stimuli. C250 in Normal Elderly and AD subjects was roughly the same to relevant and irrelevant stimuli in Intratrial Parts 1-3 but not 4. The AD group had lower C250 to relevant stimuli in part 1. CONCLUSIONS Both normal aging and dementia cause less differentiation of relevant from irrelevant information in initial storage. There was a large aging effect involving differences in the pattern of C250 responses of the Young Adult versus the Normal Elderly/AD groups. Also, a potential dementia effect was obtained. SIGNIFICANCE C250 is a candidate tool for measuring short-term memory performance on a biological level, as well as a potential marker for memory changes due to normal aging and dementia.
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Affiliation(s)
- Robert M Chapman
- Department of Brain and Cognitive Sciences and Center for Visual Science at the University of Rochester, Rochester, NY 14627, United States.
| | - Margaret N Gardner
- Department of Brain and Cognitive Sciences and Center for Visual Science at the University of Rochester, Rochester, NY 14627, United States
| | - Mark Mapstone
- Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, NY 14642, United States
| | - Rafael Klorman
- Department of Clinical and Social Sciences in Psychology at the University of Rochester, Rochester, NY 14627, United States
| | - Anton P Porsteinsson
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, NY 14642, United States
| | - Haley M Dupree
- Department of Brain and Cognitive Sciences and Center for Visual Science at the University of Rochester, Rochester, NY 14627, United States
| | - Inga M Antonsdottir
- Department of Brain and Cognitive Sciences and Center for Visual Science at the University of Rochester, Rochester, NY 14627, United States
| | - Lily Kamalyan
- Department of Brain and Cognitive Sciences and Center for Visual Science at the University of Rochester, Rochester, NY 14627, United States
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Peters ME, Vaidya V, Drye LT, Devanand DP, Mintzer JE, Pollock BG, Porsteinsson AP, Rosenberg PB, Schneider LS, Shade DM, Weintraub D, Yesavage J, Lyketsos CG, Avramopoulos D. Citalopram for the Treatment of Agitation in Alzheimer Dementia: Genetic Influences. J Geriatr Psychiatry Neurol 2016; 29:59-64. [PMID: 26303700 PMCID: PMC5166612 DOI: 10.1177/0891988715601735] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To assess potential genetic influences on citalopram treatment efficacy for agitation in individuals with Alzheimer dementia (AD). Six functional genetic variants were studied in the following genes: serotonin receptor 2A (HTR2A-T102C), serotonin receptor 2C (HTR2C-Cys23Ser), serotonin transporter (5HTT-LPR), brain-derived neurotropic factor (BDNF-Val66Met), apolipoprotein E (ε2, ε3, ε4 variants), and cytochrome P450 (CYP2C19). Treatment response by genotype was measured by (1) the agitation domain of the Neurobehavioral Rating Scale, (2) the modified Alzheimer Disease Cooperative Study-Clinical Global Impression of Change scale (mADCS-CGIC), (3) the agitation domain of the Neuropsychiatric Inventory (NPI), and (4) the Cohen-Mansfield Agitation Inventory. METHOD We utilized data from the Citalopram for Agitation in Alzheimer's Disease (CitAD) database. CitAD was a 9-week randomized, double-blind, placebo-controlled multicenter clinical trial showing significant improvement in agitation and caregiver distress in patients treated with citalopram. Proportional odds logistic regression and mixed effects models were used to examine the above-mentioned outcome measures. RESULTS Significant interactions were noted on the NPI agitation domain for HTR2A (likelihood ratio [LR] = 6.19, df = 2, P = .04) and the mADCS-CGIC for HTR2C (LR = 4.33, df = 2, P = .02) over 9 weeks. DISCUSSION Treatment outcomes in CitAD showed modest, although statistically significant, influence of genetic variation at HTR2A and HTR2C loci. Future studies should continue to examine the interaction of known genetic variants with antidepressant treatment in patients with AD having agitation.
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Affiliation(s)
| | - Vijay Vaidya
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Lea T. Drye
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | | | - Bruce G. Pollock
- Centre for Addiction and Mental Health, Campbell Family Institute, Toronto, Canada,University of Toronto, Toronto, Canada
| | | | | | - Lon S. Schneider
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - David M. Shade
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Daniel Weintraub
- University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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David ND, Lin F, Porsteinsson AP. Trajectories of Neuropsychiatric Symptoms and Cognitive Decline in Mild Cognitive Impairment. Am J Geriatr Psychiatry 2016; 24:70-80. [PMID: 26525995 PMCID: PMC4691566 DOI: 10.1016/j.jagp.2015.06.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Revised: 06/04/2015] [Accepted: 06/08/2015] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To characterize the course of neuropsychiatric symptoms (NPS) in adults with mild cognitive impairment (MCI), and to examine baseline individual-level predictors and associated cognitive and functional outcomes. DESIGN A 2-year prospective cohort study. SETTING Multicenter clinical settings. PARTICIPANTS Five hundred sixty individuals with MCI at baseline. MEASUREMENTS NPS severity (measured using Neuropsychiatric Inventory Questionnaire) and cognitive and functional outcomes were assessed at baseline and every 6 months thereafter. Potential individual-level predictors were collected at baseline. RESULTS Three latent classes of NPS courses were identified using growth mixture modeling: a stable class in which a low NPS burden remained relatively unchanged over time (N = 503, 89.8%); a worsened class in which an initially moderate NPS burden increased (N = 39, 7.0%); and an improved class in which an initially high NPS burden decreased (N = 18, 3.2%). There were no associations between class membership and baseline individual characteristics. Members of the worsened class were 1.74 times more likely to be diagnosed with incident Alzheimer disease (AD) than members of the stable class (95% confidence interval: 1.07-2.84). The worsened class also showed significantly more rapid declines in cognitive and functional outcomes than the stable class. Class membership did not predict rate of brain atrophy. CONCLUSIONS Patients with MCI may experience different trajectories of NPS over time. Patients with worsening NPS may be at greater risk of developing AD and severe cognitive and functional impairment.
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Affiliation(s)
| | - Feng Lin
- University of Rochester School of Medicine and Dentistry,University of Rochester School of Nursing
| | - Anton P. Porsteinsson
- University of Rochester School of Medicine and Dentistry,Corresponding author: Anton P. Porsteinsson, M.D., Department of Psychiatry, University of Rochester School of Medicine and Dentistry, 435 East Henrietta Road, Rochester, NY 14620, Telephone: 585-760-6550, Fax: 585-760-6572,
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42
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Akil A, Bies RR, Pollock BG, Avramopoulos D, Devanand DP, Mintzer JE, Porsteinsson AP, Schneider LS, Weintraub D, Yesavage J, Shade DM, Lyketsos CG. A population pharmacokinetic model for R- and S-citalopram and desmethylcitalopram in Alzheimer's disease patients with agitation. J Pharmacokinet Pharmacodyn 2015; 43:99-109. [PMID: 26611790 PMCID: PMC4720707 DOI: 10.1007/s10928-015-9457-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 11/14/2015] [Indexed: 11/26/2022]
Abstract
The citalopram for Alzheimer’s disease trial evaluated citalopram for the management for agitation in Alzheimer’s disease patients. Sparse data was available from this elderly patient population. A nonlinear mixed effects population pharmacokinetic modeling approach was used to describe the pharmacokinetics of R- and S-citalopram and their primary metabolite (desmethylcitalopram). A structural model with 4 compartments (one compartment/compound) with linear oral absorption and elimination described the data adequately. Overall, the model showed that clearance of the R-enantiomer was slower than the clearance of the S-enantiomer. Without accounting for any patient-specific covariates, the population estimate of the metabolic clearance of citalopram was 8.6 (R-citalopram) and 14 L/h (S-citalopram). The population estimate of the clearance of desmethylcitalopram was 23.8 (R-Dcit) and 38.5 L/h (S-Dcit). Several patient-specific covariates were found to have a significant effect on the pharmacokinetics of R,S-citalopram and desmethylcitalopram. A significant difference in the metabolic clearance of R-citalopram between males and females (13 vs 9.05 L/h) was identified in this analysis. Both R- and S-citalopram metabolic clearance decreased with age. Additionally, consistent with literature reports S-citalopram metabolic clearance increased with increasing body weight and was significantly influenced by CYPC19 genotype, with a difference of 5.8 L/h between extensive/rapid and intermediate/poor metabolizers. R,S-desmethylcitalopram clearance increased with increasing body weight. This model may allow for the opportunity to delineate the effect of R- and S-citalopram on pharmacodynamics outcomes related to the management of agitation in Alzheimer’s disease.
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Affiliation(s)
- Ayman Akil
- Division of Clinical Pharmacology, Department of Medicine, School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Robert R Bies
- Division of Clinical Pharmacology, Department of Medicine, School of Medicine, Indiana University, Indianapolis, IN, USA.
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, State University of New York at Buffalo, Buffalo, NY, 14214, USA.
| | - Bruce G Pollock
- Campbell Institute, CAMH, University of Toronto, Toronto, ON, Canada
| | - Dimitrios Avramopoulos
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - D P Devanand
- Division of Geriatric Psychiatry, New York State Psychiatric Institute and College of Physicians and Surgeons of Columbia University, New York, NY, USA
| | - Jacobo E Mintzer
- Clinical Biotechnology Research Institute, Roper St. Francis Healthcare, Charleston, SC, USA
| | | | - Lon S Schneider
- University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Daniel Weintraub
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jerome Yesavage
- Stanford University School of Medicine and VA Palo Alto Health Care System, Stanford, CA, USA
| | - David M Shade
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Weintraub D, Drye LT, Porsteinsson AP, Rosenberg PB, Pollock BG, Devanand D, Frangakis C, Ismail Z, Marano C, Meinert CL, Mintzer JE, Munro CA, Pelton G, Rabins PV, Schneider LS, Shade DM, Yesavage J, Lyketsos CG. Time to Response to Citalopram Treatment for Agitation in Alzheimer Disease. Am J Geriatr Psychiatry 2015; 23:1127-33. [PMID: 26238225 PMCID: PMC4653092 DOI: 10.1016/j.jagp.2015.05.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 05/07/2015] [Accepted: 05/12/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Agitation is a common and significant problem in Alzheimer disease (AD). In the recent Citalopram for Agitation in Alzheimer's Disease (CitAD) study, citalopram was efficacious for the treatment of AD agitation. Here we examined the time course and predictors of response to treatment. METHODS Response in CitAD was defined as a modified Alzheimer Disease Cooperative Study Clinical Global Impression of Change (CGIC) score of 1 or 2 or a Neurobehavioral Rating Scale agitation subscale (NBRS-A) score reduction ≥ 50% from baseline. "Stable early response" was defined as meeting the aforementioned criteria at both weeks 3 and 9, "late response" was response at week 9 but not at week 3, and "unstable response" was response at week 3 but not at week 9. RESULTS In the primary analyses, citalopram was superior to placebo on both the CGIC and the NBRS-A response measures. Little between-group differences were found in response rates in the first 3 weeks of the study (21% versus 19% on the CGIC). Citalopram patients were more likely than placebo patients to be a late responder (18% versus 8% on CGIC, Fisher's exact p = 0.09; 31% versus 15% on NBRS-A, Fisher's exact p = 0.02). Approximately half of citalopram responders (45%-56%) at end of study achieved response later in the study compared with 30%-44% of placebo responders. CONCLUSION Treatment with citalopram for agitation in AD needs to be at least 9 weeks in duration to allow sufficient time for full response. Study duration is an important factor to consider in the design of clinical trials for agitation in AD.
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Affiliation(s)
- Daniel Weintraub
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Lea T. Drye
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Paul B. Rosenberg
- Johns Hopkins Bayview and Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Bruce G. Pollock
- Campbell Institute, CAMH, University of Toronto, Toronto, ON, Canada
| | - D.P. Devanand
- Division of Geriatric Psychiatry, New York State Psychiatric Institute and College of Physicians and Surgeons of Columbia University, New York, NY, USA
| | | | - Zahinoor Ismail
- Departments of Psychiatry and Neurology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Christopher Marano
- Johns Hopkins Bayview and Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | - Jacobo E. Mintzer
- Clinical Biotechnology Research Institute, Roper St. Francis Healthcare, Charleston, SC, USA
| | - Cynthia A. Munro
- Johns Hopkins Bayview and Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Gregory Pelton
- Division of Geriatric Psychiatry, New York State Psychiatric Institute and College of Physicians and Surgeons of Columbia University, New York, NY, USA
| | - Peter V. Rabins
- Johns Hopkins Bayview and Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Lon S. Schneider
- University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - David M. Shade
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jerome Yesavage
- Stanford University School of Medicine and VA Palo Alto Health Care System, Stanford, CA, USA
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Cummings JL, Lyketsos CG, Peskind ER, Porsteinsson AP, Mintzer JE, Scharre DW, De La Gandara JE, Agronin M, Davis CS, Nguyen U, Shin P, Tariot PN, Siffert J. Effect of Dextromethorphan-Quinidine on Agitation in Patients With Alzheimer Disease Dementia: A Randomized Clinical Trial. JAMA 2015; 314:1242-54. [PMID: 26393847 DOI: 10.1001/jama.2015.10214] [Citation(s) in RCA: 118] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
IMPORTANCE Agitation is common among patients with Alzheimer disease; safe, effective treatments are lacking. OBJECTIVE To assess the efficacy, safety, and tolerability of dextromethorphan hydrobromide-quinidine sulfate for Alzheimer disease-related agitation. DESIGN, SETTING, AND PARTICIPANTS Phase 2 randomized, multicenter, double-blind, placebo-controlled trial using a sequential parallel comparison design with 2 consecutive 5-week treatment stages conducted August 2012-August 2014. Patients with probable Alzheimer disease, clinically significant agitation (Clinical Global Impressions-Severity agitation score ≥4), and a Mini-Mental State Examination score of 8 to 28 participated at 42 US study sites. Stable dosages of antidepressants, antipsychotics, hypnotics, and antidementia medications were allowed. INTERVENTIONS In stage 1, 220 patients were randomized in a 3:4 ratio to receive dextromethorphan-quinidine (n = 93) or placebo (n = 127). In stage 2, patients receiving dextromethorphan-quinidine continued; those receiving placebo were stratified by response and rerandomized in a 1:1 ratio to dextromethorphan-quinidine (n = 59) or placebo (n = 60). MAIN OUTCOMES AND MEASURES The primary end point was change from baseline on the Neuropsychiatric Inventory (NPI) Agitation/Aggression domain (scale range, 0 [absence of symptoms] to 12 [symptoms occur daily and with marked severity]). RESULTS A total of 194 patients (88.2%) completed the study. With the sequential parallel comparison design, 152 patients received dextromethorphan-quinidine and 127 received placebo during the study. Analysis combining stages 1 (all patients) and 2 (rerandomized placebo nonresponders) showed significantly reduced NPI Agitation/Aggression scores for dextromethorphan-quinidine vs placebo (ordinary least squares z statistic, -3.95; P < .001). In stage 1, mean NPI Agitation/Aggression scores were reduced from 7.1 to 3.8 with dextromethorphan-quinidine and from 7.0 to 5.3 with placebo. Between-group treatment differences were significant in stage 1 (least squares mean, -1.5; 95% CI, -2.3 to -0.7; P<.001). In stage 2, NPI Agitation/Aggression scores were reduced from 5.8 to 3.8 with dextromethorphan-quinidine and from 6.7 to 5.8 with placebo. Between-group treatment differences were also significant in stage 2 (least squares mean, -1.6; 95% CI, -2.9 to -0.3; P=.02). Adverse events included falls (8.6% for dextromethorphan-quinidine vs 3.9% for placebo), diarrhea (5.9% vs 3.1% respectively), and urinary tract infection (5.3% vs 3.9% respectively). Serious adverse events occurred in 7.9% with dextromethorphan-quinidine vs 4.7% with placebo. Dextromethorphan-quinidine was not associated with cognitive impairment, sedation, or clinically significant QTc prolongation. CONCLUSIONS AND RELEVANCE In this preliminary 10-week phase 2 randomized clinical trial of patients with probable Alzheimer disease, combination dextromethorphan-quinidine demonstrated clinically relevant efficacy for agitation and was generally well tolerated. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01584440.
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Affiliation(s)
| | - Constantine G Lyketsos
- Johns Hopkins Memory and Alzheimer's Treatment Center, Johns Hopkins Bayview, Baltimore, Maryland
| | - Elaine R Peskind
- VA Puget Sound Health Care System, University of Washington School of Medicine, Seattle
| | | | - Jacobo E Mintzer
- Clinical Biotechnology Research Institute, Roper St Francis Hospital, Charleston, South Carolina6Ralph H. Johnson VA Medical Center, Charleston, South Carolina
| | | | | | | | | | - Uyen Nguyen
- Avanir Pharmaceuticals Inc, Aliso Viejo, California
| | - Paul Shin
- Avanir Pharmaceuticals Inc, Aliso Viejo, California
| | | | - João Siffert
- Avanir Pharmaceuticals Inc, Aliso Viejo, California
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Antonsdottir IM, Smith J, Keltz M, Porsteinsson AP. Advancements in the treatment of agitation in Alzheimer’s disease. Expert Opin Pharmacother 2015; 16:1649-56. [DOI: 10.1517/14656566.2015.1059422] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Neuropsychiatric symptoms (NPS) are common among individuals with Alzheimer's disease (AD), associated with excess morbidity and mortality, greater healthcare use, earlier institutionalization, and caregiver burden. Agitation presents as emotional distress, excessive psychomotor activity, aggressive behaviors, disruptive irritability and dishibition. There is an unmet need to find pharmacologic treatment for agitation in patients with AD that can be safely and effectively used as a concurrent treatment alongside psychosocial interventions. A recent, multicenter, randomized, placebo-controlled trial explored the efficacy of a 30-mg daily dose of citalopram for agitation in patients with AD and showed a significant decrease in agitation for citalopram compared with placebo. Both QTc prolongation and cognitive worsening, as measured by the Mini Mental State Examination, were observed in the citalopram group and present a concern to clinicians. Citalopram at a 20-mg daily dose should be considered as a possible first-line treatment in addition to psychosocial intervention.
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Affiliation(s)
- Anton P Porsteinsson
- University of Rochester School of Medicine & Dentistry Alzheimer's Disease Care, Research & Education Program (AD-CARE), 435 East Henrietta Road, Rochester, NY 14620, USA
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47
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Cummings JL, Lyketsos C, Peskind ER, Porsteinsson AP, Mintzer JE, Scharre DW, Gándara JE, Agronin M, Davis CS, Nguyen U, Shin P, Tariot PN, Siffert J. P3‐301: Dextromethorphan/quinidine (AVP‐923) phase 2 study for treatment of agitation in Alzheimer's disease: Comparing the enrolled agitation sample with the international psychogeriatric association definition of agitation in cognitive disorders (NCT01584440). Alzheimers Dement 2015. [DOI: 10.1016/j.jalz.2015.06.1675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
| | | | - Elaine R. Peskind
- VA Puget Sound Health Care SystemSeattleWAUSA
- University of WashingtonSeattleWAUSA
| | | | - Jacobo E. Mintzer
- Roper St. Francis HospitalThe Clinical Biotechnology Research InstituteCharlestonSCUSA
- Ralph H. Johnson VA Medical CenterCharlestonSCUSA
| | | | | | | | | | - Uyen Nguyen
- Avanir Pharmaceuticals, Inc.Aliso ViejoCAUSA
| | - Paul Shin
- Avanir Pharmaceuticals, Inc.Aliso ViejoCAUSA
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Abstract
Neuropsychiatric symptoms (NPS) are a major concern in the treatment of Alzheimer's disease. Historically, NPS are difficult to treat effectively due to a high side-effect burden associated with commonly used medications, such as atypical antipsychotics. Non-pharmacological treatment approaches have become the first line option. However, when such treatment fails, pharmacological options are often used. Thus, a push toward finding safer alternative pharmacological treatments has occurred. Antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs) have shown promise in clinical trials for alleviating the burden of NPS. Lower overall agitation and caregiver stress has been reported to correlate to treatment with the SSRI citalopram. However, certain side effects of citalopram, such as QTc interval prolongation and increased cognitive decline, carry clinical concern and should be weighed when prescribing their use.
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Affiliation(s)
- Anton P Porsteinsson
- University of Rochester School of Medicine and Dentistry, 435 East Henrietta Road, Rochester, NY14620, USA
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49
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Affiliation(s)
- Anton P Porsteinsson
- From the Alzheimer's Disease Care, Research and Education Program (AD-CARE), Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, N.Y.; and the Department of Brain and Cognitive Sciences and Center for Visual Science at the University of Rochester, Rochester, N.Y
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50
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Chapman RM, Porsteinsson AP, Gardner MN, Mapstone M, McCrary JW, Sandoval TC, Guillily MD, Reilly LA, DeGrush E. The impact of AD drug treatments on event-related potentials as markers of disease conversion. Curr Alzheimer Res 2014; 10:732-41. [PMID: 23905997 DOI: 10.2174/15672050113109990148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Accepted: 07/17/2013] [Indexed: 11/22/2022]
Abstract
This paper investigates how commonly prescribed pharmacologic treatments for Alzheimer's disease (AD) affect Event-Related Potential (ERP) biomarkers as tools for predicting AD conversion in individuals with Mild Cognitive Impairment (MCI). We gathered baseline ERP data from two MCI groups (those taking AD medications and those not) and later determined which subjects developed AD (Convert->AD) and which subjects remained cognitively stable (Stable). We utilized a previously developed and validated multivariate system of ERP components to measure medication effects among these four subgroups. Discriminant analysis produced classification scores for each individual as a measure of similarity to each clinical group (Convert->AD, Stable), and we found a large significant main Group effect but no main AD Medications effect and no Group by Medications interaction. This suggested AD medications have negligible influence on this set of ERP components as weighted markers of disease progression. These results provide practical information to those using ERP measures as a biomarker to identify and track AD in individuals in a clinical or research setting.
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Affiliation(s)
- Robert M Chapman
- Department of Brain and Cognitive Sciences, 775 Library Road, University of Rochester, Rochester, NY 14627, USA.
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