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Howard R, Cort E, Rawlinson C, Wiegand M, Downey A, Lawrence V, Banerjee S, Bentham P, Fox C, Harwood R, Hunter R, Livingston G, Moniz‐Cook E, Panca M, Raczek M, Ivenso C, Russell G, Thomas A, Wilkinson P, Freemantle N, Gould R. Adapted problem adaptation therapy for depression in mild to moderate Alzheimer's disease dementia: A randomized controlled trial. Alzheimers Dement 2024; 20:2990-2999. [PMID: 38477423 PMCID: PMC11032547 DOI: 10.1002/alz.13766] [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] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/26/2024] [Accepted: 02/02/2024] [Indexed: 03/14/2024]
Abstract
INTRODUCTION Trials of effectiveness of treatment options for depression in dementia are an important priority. METHODS Randomized controlled trial to assess adapted Problem Adaptation Therapy (PATH) for depression in mild/moderate dementia caused by Alzheimer's disease. RESULTS Three hundred thirty-six participants with mild or moderate dementia, >7 on Cornell Scale for Depression in Dementia (CSDD), randomized to adapted PATH or treatment as usual. Mean age 77.0 years, 39.0% males, mean Mini-Mental State Examination 21.6, mean CSDD 12.9. For primary outcome (CSDD at 6 months), no statistically significant benefit with adapted PATH on the CSDD (6 months: -0.58; 95% CI -1.71 to 0.54). The CSDD at 3 months showed a small benefit with adapted PATH (-1.38; 95% CI -2.54 to -0.21) as did the EQ-5D (-4.97; 95% CI -9.46 to -0.48). DISCUSSION An eight-session course of adapted PATH plus two booster sessions administered within NHS dementia services was not effective treatment for depression in people with mild and moderate dementia. Future studies should examine the effect of more intensive and longer-term therapy.
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Affiliation(s)
- Robert Howard
- Division of PsychiatryUniversity College LondonLondonUK
| | | | | | - Martin Wiegand
- Priment Clinical Trials UnitUniversity College LondonLondonUK
| | - Anne Downey
- Priment Clinical Trials UnitUniversity College LondonLondonUK
| | | | | | | | - Chris Fox
- University of East AngliaNorwichNorfolkUK
| | - Rowan Harwood
- University of Nottingham Queen's Medical CentreNottinghamUK
| | - Rachel Hunter
- Priment Clinical Trials UnitUniversity College LondonLondonUK
| | | | | | - Monica Panca
- Priment Clinical Trials UnitUniversity College LondonLondonUK
| | | | - Chineze Ivenso
- Aneurin Bevan NHS TrustSt Cadoc's HospitalNewportSouth WalesUK
| | | | - Alan Thomas
- University of NewcastleCampus for Ageing and VitalityNewcastle upon TyneUK
| | - Philip Wilkinson
- Department of PsychiatryUniversity of OxfordWarneford HospitalOxfordUK
| | | | - Rebecca Gould
- Division of PsychiatryUniversity College LondonLondonUK
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2
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Banerjee S, Farina N, Henderson C, High J, Stirling S, Shepstone L, Fountain J, Ballard C, Bentham P, Burns A, Fox C, Francis P, Howard R, Knapp M, Leroi I, Livingston G, Nilforooshan R, Nurock S, O'Brien J, Price A, Thomas AJ, Swart AM, Telling T, Tabet N. A pragmatic, multicentre, double-blind, placebo-controlled randomised trial to assess the safety, clinical and cost-effectiveness of mirtazapine and carbamazepine in people with Alzheimer's disease and agitated behaviours: the HTA-SYMBAD trial. Health Technol Assess 2023; 27:1-108. [PMID: 37929672 PMCID: PMC10641860 DOI: 10.3310/vpdt7105] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Abstract
Background Agitation is common and impacts negatively on people with dementia and carers. Non-drug patient-centred care is first-line treatment, but we need other treatment when this fails. Current evidence is sparse on safer and effective alternatives to antipsychotics. Objectives To assess clinical and cost-effectiveness and safety of mirtazapine and carbamazepine in treating agitation in dementia. Design Pragmatic, phase III, multicentre, double-blind, superiority, randomised, placebo-controlled trial of the clinical effectiveness of mirtazapine over 12 weeks (carbamazepine arm discontinued). Setting Twenty-six UK secondary care centres. Participants Eligibility: probable or possible Alzheimer's disease, agitation unresponsive to non-drug treatment, Cohen-Mansfield Agitation Inventory score ≥ 45. Interventions Mirtazapine (target 45 mg), carbamazepine (target 300 mg) and placebo. Outcome measures Primary: Cohen-Mansfield Agitation Inventory score 12 weeks post randomisation. Main economic outcome evaluation: incremental cost per six-point difference in Cohen-Mansfield Agitation Inventory score at 12 weeks, from health and social care system perspective. Data from participants and informants at baseline, 6 and 12 weeks. Long-term follow-up Cohen-Mansfield Agitation Inventory data collected by telephone from informants at 6 and 12 months. Randomisation and blinding Participants allocated 1 : 1 : 1 ratio (to discontinuation of the carbamazepine arm, 1 : 1 thereafter) to receive placebo or carbamazepine or mirtazapine, with treatment as usual. Random allocation was block stratified by centre and residence type with random block lengths of three or six (after discontinuation of carbamazepine, two or four). Double-blind, with drug and placebo identically encapsulated. Referring clinicians, participants, trial management team and research workers who did assessments were masked to group allocation. Results Two hundred and forty-four participants recruited and randomised (102 mirtazapine, 102 placebo, 40 carbamazepine). The carbamazepine arm was discontinued due to slow overall recruitment; carbamazepine/placebo analyses are therefore statistically underpowered and not detailed in the abstract. Mean difference placebo-mirtazapine (-1.74, 95% confidence interval -7.17 to 3.69; p = 0.53). Harms: The number of controls with adverse events (65/102, 64%) was similar to the mirtazapine group (67/102, 66%). However, there were more deaths in the mirtazapine group (n = 7) by week 16 than in the control group (n = 1). Post hoc analysis suggests this was of marginal statistical significance (p = 0.065); this difference did not persist at 6- and 12-month assessments. At 12 weeks, the costs of unpaid care by the dyadic carer were significantly higher in the mirtazapine than placebo group [difference: £1120 (95% confidence interval £56 to £2184)]. In the cost-effectiveness analyses, mean raw and adjusted outcome scores and costs of the complete cases samples showed no differences between groups. Limitations Our study has four important potential limitations: (1) we dropped the proposed carbamazepine group; (2) the trial was not powered to investigate a mortality difference between the groups; (3) recruitment beyond February 2020, was constrained by the COVID-19 pandemic; and (4) generalisability is limited by recruitment of participants from old-age psychiatry services and care homes. Conclusions The data suggest mirtazapine is not clinically or cost-effective (compared to placebo) for agitation in dementia. There is little reason to recommend mirtazapine for people with dementia with agitation. Future work Effective and cost-effective management strategies for agitation in dementia are needed where non-pharmacological approaches are unsuccessful. Study registration This trial is registered as ISRCTN17411897/NCT03031184. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 23. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Sube Banerjee
- Faculty of Health, University of Plymouth, Plymouth, UK
| | - Nicolas Farina
- Faculty of Health, University of Plymouth, Plymouth, UK
- Centre for Dementia Studies, Brighton and Sussex Medical School, University of Sussex, Brighton and Hove, UK
| | - Catherine Henderson
- Care Policy and Evaluation Centre, London School of Economics and Political Science, London, UK
| | - Juliet High
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, Norfolk, UK
| | - Susan Stirling
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, Norfolk, UK
| | - Lee Shepstone
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, Norfolk, UK
| | - Julia Fountain
- Coordinator for Service User and Carer Involvement in Research, Sussex Partnership NHS Foundation Trust, Brighton and Hove, UK
| | - Clive Ballard
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Peter Bentham
- Birmingham and Solihull Mental Health Foundation NHS Trust, Birmingham, UK
| | - Alistair Burns
- Department of Psychiatry, University of Manchester, Manchester, UK
| | - Chris Fox
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, Norfolk, UK
| | - Paul Francis
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Robert Howard
- Division of Psychiatry, University College London, London, UK
| | - Martin Knapp
- Care Policy and Evaluation Centre, London School of Economics and Political Science, London, UK
| | - Iracema Leroi
- Department of Psychiatry, Global Brain Health Institute, Trinity College Dublin, Dublin, Ireland
| | - Gill Livingston
- Division of Psychiatry, University College London, London, UK
| | - Ramin Nilforooshan
- Research and Development, Surrey and Borders Partnership NHS Foundation Trust, Leatherhead, UK
| | - Shirley Nurock
- Former Carer, Alzheimer's Society Research Network, London, UK
| | - John O'Brien
- Department of Psychiatry, University of Cambridge School of Medicine, Cambridge, UK
| | - Annabel Price
- Cambridgeshire and Peterborough Foundation Trust, Cambridge, UK
| | - Alan J Thomas
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Ann Marie Swart
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, Norfolk, UK
| | - Tanya Telling
- Joint Clinical Research Office, University of Sussex, Brighton, UK
| | - Naji Tabet
- Centre for Dementia Studies, Brighton and Sussex Medical School, University of Sussex, Brighton and Hove, UK
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3
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Mroczkowska S, Shokr H, Benavente-Pérez A, Negi A, Bentham P, Gherghel D. Retinal Microvascular Dysfunction Occurs Early and Similarly in Mild Alzheimer's Disease and Primary-Open Angle Glaucoma Patients. J Clin Med 2022; 11:jcm11226702. [PMID: 36431179 PMCID: PMC9717733 DOI: 10.3390/jcm11226702] [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] [Received: 09/29/2022] [Revised: 11/06/2022] [Accepted: 11/11/2022] [Indexed: 11/16/2022] Open
Abstract
Purpose: To assess the similarities and differences in retinal microvascular function between mild Alzheimer’s disease (AD) patients, early-stage primary open angle glaucoma (POAG) patients and healthy controls. Methods: Retinal vessel reactivity to flickering light was assessed in 10 AD, 19 POAG and 20 healthy age matched control patients by means of dynamic retinal vessel analysis (DVA, IMEDOS, GmbH, Jena, Germany) according to an established protocol. All patients additionally underwent BP measurements and blood analysis for glucose and lipid metabolism markers. Results: AD and POAG patients demonstrated comparable alterations in retinal artery reactivity, in the form of an increased arterial reaction time (RT) to flicker light on the final flicker cycle (p = 0.009), which was not replicated by healthy controls (p > 0.05). Furthermore, the sequential changes in RT on progressing from flicker one to flicker three were found to differ between healthy controls and the two disease groups (p = 0.001). Conclusion: AD and POAG patients demonstrate comparable signs of vascular dysfunction in their retinal arteries at the early stages of their disease process. This provides support for the concept of a common underlying vascular aetiology in these two neurodegenerative diseases.
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Affiliation(s)
- Stephanie Mroczkowska
- Vascular Research Laboratory, Ophthalmic Research Group, College Health and Life Sciences, Aston University, Birmingham B4 7ET, UK
- Eye and Vision Research Group, School of Health Professions, Plymouth University, Plymouth PL4 8AA, UK
- Correspondence: (S.M.); (D.G.); Tel.: +44-0121-204-3000 (D.G.)
| | - Hala Shokr
- Vascular Research Laboratory, Ophthalmic Research Group, College Health and Life Sciences, Aston University, Birmingham B4 7ET, UK
- Pharmacy Division, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
| | - Alexandra Benavente-Pérez
- Vascular Research Laboratory, Ophthalmic Research Group, College Health and Life Sciences, Aston University, Birmingham B4 7ET, UK
| | - Anil Negi
- Medical Innovation Development and Research Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 1NT, UK
| | - Peter Bentham
- Medical Innovation Development and Research Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 1NT, UK
| | - Doina Gherghel
- Vascular Research Laboratory, Ophthalmic Research Group, College Health and Life Sciences, Aston University, Birmingham B4 7ET, UK
- Division of Cardiovascular Sciences, University of Manchester, Manchester M13 9PL, UK
- Correspondence: (S.M.); (D.G.); Tel.: +44-0121-204-3000 (D.G.)
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4
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Wischik CM, Bentham P, Gauthier S, Miller S, Kook K, Schelter BO. Oral Tau Aggregation Inhibitor for Alzheimer’s Disease: Design, Progress and Basis for Selection of the 16 mg/day Dose in a Phase 3, Randomized, Placebo-Controlled Trial of Hydromethylthionine Mesylate. J Prev Alzheimers Dis 2022; 9:780-790. [PMID: 36281683 PMCID: PMC9226274 DOI: 10.14283/jpad.2022.63] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Hydromethylthionine mesylate is a tau aggregation inhibitor shown to have exposure-dependent pharmacological activity on cognitive decline and brain atrophy in two completed Phase 3 trials in mild/moderate Alzheimer’s disease (AD). Objectives The present report summarises the basis for selection of 16 mg/day as monotherapy as the optimal treatment regime and the design rationale of a confirmatory Phase 3 trial (LUCIDITY). Design The trial comprises a 12-month double-blind, placebo-controlled phase followed by a 12-month modified delayed-start open-label treatment phase. Setting 76 clinical research sites in North America and Europe. Participants 545 patients with probable AD or MCI-AD in the final version of the protocol. Intervention Participants were assigned randomly to receive hydromethylthione mesylate at doses of 16 mg/day, 8 mg/day or placebo at a 4:1:4 ratio during the double-blind phase. All participants in the open-label phase receive the 16 mg/day dose. Measurements Co-primary clinical outcomes are the 11-item Alzheimer’s Disease Assessment Scale (ADAS-cog11) and the 23-item Alzheimer’s Disease Cooperative Study — Activities of Daily Living (ADCS-ADL23). Secondary biomarker measures include whole-brain atrophy and temporal lobe 18F-fluorodeoxyglucose positron emission tomography. Results 446 participants are expected to complete the 12-month placebo-controlled phase in March 2022. Conclusions If the primary end points are met, the data will provide confirmatory evidence of the clinical and biomarker benefits of hydromethylthionine mesylate in minimal to moderate AD. As low-dose oral hydromethylthionine mesylate is simple to use clinically, does not cause amyloid-related imaging abnormalities and has a benign safety profile, it would likely improve AD management.
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Affiliation(s)
- C M Wischik
- Professor Claude Wischik, TauRx Therapeutics Ltd, 395 King Street, Aberdeen AB24 5RP, United Kingdom. ; Tel: +441224 440905; Fax: +441224 440225
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5
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Vuksanović V, Staff RT, Morson S, Ahearn T, Bracoud L, Murray AD, Bentham P, Kipps CM, Harrington CR, Wischik CM. Degeneration of basal and limbic networks is a core feature of behavioural variant frontotemporal dementia. Brain Commun 2021; 3:fcab241. [PMID: 34939031 PMCID: PMC8688778 DOI: 10.1093/braincomms/fcab241] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 05/13/2021] [Accepted: 05/24/2021] [Indexed: 11/13/2022] Open
Abstract
The behavioural variant of frontotemporal dementia is a clinical syndrome characterized by changes in behaviour, cognition and functional ability. Although atrophy in frontal and temporal regions would appear to be a defining feature, neuroimaging studies have identified volumetric differences distributed across large parts of the cortex, giving rise to a classification into distinct neuroanatomical subtypes. Here, we extended these neuroimaging studies to examine how distributed patterns of cortical atrophy map onto brain network hubs. We used baseline structural magnetic resonance imaging data collected from 213 behavioural variant of frontotemporal dementia patients meeting consensus diagnostic criteria and having definite evidence of frontal and/or temporal lobe atrophy from a global clinical trial conducted in 70 sites in Canada, United States of America, Australia, Asia and Europe. These were compared with data from 244 healthy elderly subjects from a well-characterized cohort study. We have used statistical methods of hierarchical agglomerative clustering of 68 regional cortical and subcortical volumes (34 in each hemisphere) to determine the reproducibility of previously described neuroanatomical subtypes in a global study. We have also attempted to link the structural findings to clinical features defined systematically using well-validated clinical scales (Addenbrooke’s Cognitive Examination Revised, the Mini-Mental Status Examination, the Frontotemporal Dementia Rating Scale and the Functional Assessment Questionnaire) and subscales derived from them. Whilst we can confirm that the subtypes are robust, they have limited value in explaining the clinical heterogeneity of the syndrome. We have found that a common pattern of degeneration affecting a small number of subcortical, limbic and frontal nodes within highly connected networks (most previously identified as rich club members or functional binding nodes) is shared by all the anatomical subtypes. Degeneration in these core regions is correlated with cognitive and functional impairment, but less so with behavioural impairment. These findings suggest that degeneration in highly connected basal, limbic and frontal networks is a core feature of the behavioural variant of frontotemporal dementia phenotype irrespective of neuroanatomical and clinical heterogeneity, and may underly the impairment of integration in cognition, function and behaviour responsible for the loss of insight that characterizes the syndrome.
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Affiliation(s)
- Vesna Vuksanović
- Swansea University Medical School, Health Data Research UK, Swansea University, Swansea SA2 8PP, UK.,School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK.,TauRx Therapeutics, Aberdeen AB24 5RP, UK
| | - Roger T Staff
- Medical Physics, NHS Grampian, Aberdeen AB25 2ZD, UK
| | - Suzannah Morson
- TauRx Therapeutics, Aberdeen AB24 5RP, UK.,School of Psychology, University of Aberdeen, Aberdeen AB24 3FX, UK
| | - Trevor Ahearn
- Medical Physics, NHS Grampian, Aberdeen AB25 2ZD, UK
| | | | - Alison D Murray
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK
| | | | - Christopher M Kipps
- University Hospital Southampton and University of Southampton, Southampton SO16 6YD, UK
| | - Charles R Harrington
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK.,TauRx Therapeutics, Aberdeen AB24 5RP, UK
| | - Claude M Wischik
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK.,TauRx Therapeutics, Aberdeen AB24 5RP, UK
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6
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Banerjee S, High J, Stirling S, Shepstone L, Swart AM, Telling T, Henderson C, Ballard C, Bentham P, Burns A, Farina N, Fox C, Francis P, Howard R, Knapp M, Leroi I, Livingston G, Nilforooshan R, Nurock S, O'Brien J, Price A, Thomas AJ, Tabet N. Study of mirtazapine for agitated behaviours in dementia (SYMBAD): a randomised, double-blind, placebo-controlled trial. Lancet 2021; 398:1487-1497. [PMID: 34688369 PMCID: PMC8546216 DOI: 10.1016/s0140-6736(21)01210-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 05/03/2021] [Accepted: 05/14/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Agitation is common in people with dementia and negatively affects the quality of life of both people with dementia and carers. Non-drug patient-centred care is the first-line treatment, but there is a need for other treatment when this care is not effective. Current evidence is sparse on safer and effective alternatives to antipsychotics. We assessed the efficacy and safety of mirtazapine, an antidepressant prescribed for agitation in dementia. METHODS This parallel-group, double-blind, placebo-controlled trial-the Study of Mirtazapine for Agitated Behaviours in Dementia trial (SYMBAD)-was done in 26 UK centres. Participants had probable or possible Alzheimer's disease, agitation unresponsive to non-drug treatment, and a Cohen-Mansfield Agitation Inventory (CMAI) score of 45 or more. They were randomly assigned (1:1) to receive either mirtazapine (titrated to 45 mg) or placebo. The primary outcome was reduction in CMAI score at 12 weeks. This trial is registered with ClinicalTrials.gov, NCT03031184, and ISRCTN17411897. FINDINGS Between Jan 26, 2017, and March 6, 2020, 204 participants were recruited and randomised. Mean CMAI scores at 12 weeks were not significantly different between participants receiving mirtazapine and participants receiving placebo (adjusted mean difference -1·74, 95% CI -7·17 to 3·69; p=0·53). The number of controls with adverse events (65 [64%] of 102 controls) was similar to that in the mirtazapine group (67 [66%] of 102 participants receiving mirtazapine). However, there were more deaths in the mirtazapine group (n=7) by week 16 than in the control group (n=1), with post-hoc analysis suggesting this difference was of marginal statistical significance (p=0·065). INTERPRETATION This trial found no benefit of mirtazapine compared with placebo, and we observed a potentially higher mortality with use of mirtazapine. The data from this study do not support using mirtazapine as a treatment for agitation in dementia. FUNDING UK National Institute for Health Research Health Technology Assessment Programme.
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Affiliation(s)
- Sube Banerjee
- Faculty of Health, University of Plymouth, Plymouth, UK.
| | - Juliet High
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, UK
| | - Susan Stirling
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, UK
| | - Lee Shepstone
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, UK
| | - Ann Marie Swart
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, UK
| | - Tanya Telling
- Joint Clinical Research Office, University of Sussex, Brighton, UK
| | - Catherine Henderson
- Care Policy and Evaluation Centre, London School of Economics and Political Science, London, UK
| | - Clive Ballard
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Peter Bentham
- Birmingham and Solihull Mental Health Foundation NHS Trust, Birmingham, UK
| | | | - Nicolas Farina
- Centre for Dementia Studies, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Chris Fox
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, UK
| | - Paul Francis
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Robert Howard
- Division of Psychiatry, University College London, London, UK
| | - Martin Knapp
- Care Policy and Evaluation Centre, London School of Economics and Political Science, London, UK
| | - Iracema Leroi
- Department of Psychiatry, Global Brain Health Institute, Trinity College, Dublin, Ireland
| | - Gill Livingston
- Division of Psychiatry, University College London, London, UK
| | | | - Shirley Nurock
- Former Carer, Alzheimer's Society Research Network, University of Cambridge School of Medicine, Cambridge, UK
| | - John O'Brien
- Department of Psychiatry, University of Cambridge School of Medicine, Cambridge, UK
| | - Annabel Price
- Cambridgeshire and Peterborough Foundation Trust, Cambridge, UK
| | - Alan J Thomas
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Naji Tabet
- Centre for Dementia Studies, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
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7
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Bentham P, Staff RT, Schelter BO, Shiells H, Harrington CR, Wischik CM. Long-Term Hydromethylthionine Treatment Is Associated with Delayed Clinical Onset and Slowing of Cerebral Atrophy in a Pre-Symptomatic P301S MAPT Mutation Carrier. J Alzheimers Dis 2021; 83:1017-1023. [PMID: 34366349 PMCID: PMC8543267 DOI: 10.3233/jad-210390] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
One of the mutations in the microtubule-associated protein tau, P301S, is causative for dominantly inherited frontotemporal dementia characterized by extensive tau pathology for which no licensed treatment is available. Hydromethylthionine is a potent tau aggregation inhibitor. We report treatment of an asymptomatic carrier of the P301S mutation using hydromethylthionine over a 5-year period beginning at the mean age of onset of clinical decline in the family. During the period of treatment, the rates of progression of cerebral atrophy were reduced by 61%–66% in frontal and temporal lobes, and the patient remained clinically asymptomatic.
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Affiliation(s)
| | - Roger T Staff
- Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | - Bjoern O Schelter
- TauRx Therapeutics Ltd., Aberdeen, UK.,Institute for Complex Systems and Mathematical Biology, University of Aberdeen, Aberdeen, UK
| | | | - Charles R Harrington
- TauRx Therapeutics Ltd., Aberdeen, UK.,School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Foresterhill, Aberdeen, UK
| | - Claude M Wischik
- TauRx Therapeutics Ltd., Aberdeen, UK.,School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Foresterhill, Aberdeen, UK
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8
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Shiells H, Schelter BO, Bentham P, Baddeley TC, Rubino CM, Ganesan H, Hammel J, Vuksanovic V, Staff RT, Murray AD, Bracoud L, Wischik DJ, Riedel G, Gauthier S, Jia J, Moebius HJ, Hardlund J, Kipps CM, Kook K, Storey JMD, Harrington CR, Wischik CM. Concentration-Dependent Activity of Hydromethylthionine on Clinical Decline and Brain Atrophy in a Randomized Controlled Trial in Behavioral Variant Frontotemporal Dementia. J Alzheimers Dis 2021; 75:501-519. [PMID: 32280089 PMCID: PMC7306898 DOI: 10.3233/jad-191173] [Citation(s) in RCA: 12] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Hydromethylthionine is a potent inhibitor of pathological aggregation of tau and TDP-43 proteins. OBJECTIVE To compare hydromethylthionine treatment effects at two doses and to determine how drug exposure is related to treatment response in bvFTD. METHODS We undertook a 52-week Phase III study in 220 bvFTD patients randomized to compare hydromethylthionine at 200 mg/day and 8 mg/day (intended as a control). The principal outcomes were change on the Addenbrookes Cognitive Examination - Revised (ACE-R), the Functional Activities Questionnaire (FAQ), and whole brain volume. Secondary outcomes included Modified Clinical Global Impression of Change (Modified-CGIC). A population pharmacokinetic exposure-response analysis was undertaken in 175 of the patients with available blood samples and outcome data using a discriminatory plasma assay for the parent drug. RESULTS There were no significant differences between the two doses as randomized. There were steep concentration-response relationships for plasma levels in the range 0.3-0.6 ng/ml at the 8 mg/day dose on clinical and MRI outcomes. There were significant exposure-dependent differences at 8 mg/day for FAQ, Modified-CGIC, and whole brain atrophy comparing patients with plasma levels greater than 0.346 ng/ml with having minimal drug exposure. The exposure-response is biphasic with worse outcomes at the high concentrations produced by 200 mg/day. CONCLUSIONS Hydromethylthionine has a similar concentration-response profile for effects on clinical decline and brain atrophy at the 8 mg/day dose in bvFTD as recently reported in AD. Treatment responses in bvFTD are predicted to be maximal at doses in the range 20-60 mg/day. A confirmatory placebo-controlled trial is now planned.
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Affiliation(s)
| | - Bjoern O Schelter
- TauRx Therapeutics Ltd., Aberdeen, UK.,Institute for Complex Systems and Mathematical Biology, University of Aberdeen, Aberdeen, UK
| | | | - Thomas C Baddeley
- TauRx Therapeutics Ltd., Aberdeen, UK.,Department of Chemistry, University of Aberdeen, Aberdeen, UK
| | | | - Harish Ganesan
- Institute of Clinical Pharmacodynamics, Schenectady, NY, USA
| | - Jeffrey Hammel
- Institute of Clinical Pharmacodynamics, Schenectady, NY, USA
| | - Vesna Vuksanovic
- Aberdeen Biomedical Imaging Centre, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Roger T Staff
- Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | - Alison D Murray
- Aberdeen Biomedical Imaging Centre, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | | | - Damon J Wischik
- TauRx Therapeutics Ltd., Aberdeen, UK.,Department of Computer Science and Technology, University of Cambridge, Cambridge, UK
| | - Gernot Riedel
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Foresterhill, Aberdeen, UK
| | - Serge Gauthier
- McGill Centre for Studies in Aging, Alzheimer's Disease Research Unit, and Douglas Mental Health University Institute, Montreal, QC, Canada
| | - Jianping Jia
- Beijing Institute for Brain Disorders Alzheimer's Disease Centre, Beijing, China
| | | | | | | | | | - John M D Storey
- TauRx Therapeutics Ltd., Aberdeen, UK.,Department of Chemistry, University of Aberdeen, Aberdeen, UK
| | - Charles R Harrington
- TauRx Therapeutics Ltd., Aberdeen, UK.,School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Foresterhill, Aberdeen, UK
| | - Claude M Wischik
- TauRx Therapeutics Ltd., Aberdeen, UK.,School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Foresterhill, Aberdeen, UK
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9
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Howard R, Gathercole R, Bradley R, Harper E, Davis L, Pank L, Lam N, Talbot E, Hooper E, Winson R, Scutt B, Ordonez Montano V, Nunn S, Lavelle G, Bateman A, Bentham P, Burns A, Dunk B, Forsyth K, Fox C, Poland F, Leroi I, Newman S, O’Brien J, Henderson C, Knapp M, Woolham J, Gray R. The effectiveness and cost-effectiveness of assistive technology and telecare for independent living in dementia: a randomised controlled trial. Age Ageing 2021; 50:882-890. [PMID: 33492349 PMCID: PMC8099012 DOI: 10.1093/ageing/afaa284] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Indexed: 11/14/2022] Open
Abstract
Objectives The use of assistive technology and telecare (ATT) has been promoted to manage risks associated with independent living in people with dementia but with little evidence for effectiveness. Methods Participants were randomly assigned to receive an ATT assessment followed by installation of all appropriate ATT devices or limited control of appropriate ATT. The primary outcomes were time to institutionalisation and cost-effectiveness. Key secondary outcomes were number of incidents involving risks to safety, burden and stress in family caregivers and quality of life. Results Participants were assigned to receive full ATT (248 participants) or the limited control (247 participants). After adjusting for baseline imbalance of activities of daily living score, HR for median pre-institutionalisation survival was 0.84; 95% CI, 0.63 to 1.12; P = 0.20. There were no significant differences between arms in health and social care (mean -£909; 95% CI, -£5,336 to £3,345, P = 0.678) and societal costs (mean -£3,545; 95% CI, -£13,914 to £6,581, P = 0.499). ATT group members had reduced participant-rated quality-adjusted life years (QALYs) at 104 weeks (mean − 0.105; 95% CI, −0.204 to −0.007, P = 0.037) but did not differ in QALYs derived from proxy-reported EQ-5D. Discussion Fidelity of the intervention was low in terms of matching ATT assessment, recommendations and installation. This, however, reflects current practice within adult social care in England. Conclusions Time living independently outside a care home was not significantly longer in participants who received full ATT and ATT was not cost-effective. Participants with full ATT attained fewer QALYs based on participant-reported EQ-5D than controls at 104 weeks.
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Affiliation(s)
| | | | - Rosie Bradley
- Medical Research Council Population Health Research Unit, UK
| | - Emma Harper
- Medical Research Council Population Health Research Unit, UK
| | - Lucy Davis
- Medical Research Council Population Health Research Unit, UK
| | - Lynn Pank
- Medical Research Council Population Health Research Unit, UK
| | - Natalie Lam
- Medical Research Council Population Health Research Unit, UK
| | - Emma Talbot
- Norfolk and Suffolk NHS Foundation Trust, UK
| | - Emma Hooper
- Lancashire Care NHS Foundation Trust and University of Manchester, UK
| | - Rachel Winson
- Cambridgeshire and Peterborough NHS Foundation Trust, UK
| | | | | | | | | | | | - Peter Bentham
- Birmingham and Solihull Mental Health NHS Foundation Trust, UK
| | | | - Barbara Dunk
- South London and Maudsley NHS Foundation Trust, UK
| | | | | | | | | | | | | | | | - Martin Knapp
- London School of Economics and Political Science, UK
| | | | - Richard Gray
- Medical Research Council Population Health Research Unit, UK
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10
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Jenkins C, Oyebode J, Bicknell S, Webster N, Bentham P, Smythe A. Exploring newly qualified nurses' experiences of support and perceptions of peer support online: A qualitative study. J Clin Nurs 2021; 30:2924-2934. [PMID: 33870599 DOI: 10.1111/jocn.15798] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 12/10/2020] [Revised: 03/18/2021] [Accepted: 03/22/2021] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES To explore newly qualified nurses' support needs and their perceptions of online peer support. BACKGROUND The experience of being a newly qualified nurse is stressful and isolating. Support from colleagues and peers can enhance perceptions of competence and confidence in newly qualified nurses, improve well-being and aid retention. However, despite initiatives such as preceptorship, support needs may remain unmet in busy clinical environments. Online support has potential to offer a partial solution to professional isolation, but there is a lack of research into how technology can support nurses' emotional and social well-being. DESIGN A qualitative exploratory study was designed, employing semi-structured focus groups, analysed using thematic analysis. The study is reported in accordance with the COnsolidated criteria for REporting Qualitative research checklist. METHODS Eight focus groups, supplemented by one individual interview, were conducted with newly qualified nurses between June 2018-January 2019. FINDINGS Two main themes arose. The first was Drowning, a lot of the time with two sub-themes: (i) Feelings and emotions about being a Newly Qualified Nurse: 'Absolutely terrified' and (ii) Support within the role: 'Somebody you can count on'. The second was Potential advantages and disadvantages of online modality: 'Somebody is going to get in that phone!' which included three sub-themes (i) Potential advantages, (ii) Potential disadvantages and (iii) Preferences and recommendations. CONCLUSIONS This study demonstrates that if barriers can be overcome, then online support has potential to contribute to newly qualified nurses' well-being. Further research is needed to explore technical and ethical issues around online support and evaluate its effectiveness for newly qualified nurses. RELEVANCE TO CLINICAL PRACTICE Online support has the potential to add to existing strategies to support nurses during stressful times. This may be particularly relevant when many staff are working under increased pressure due to the COVID-19 pandemic.
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Affiliation(s)
| | | | - Sarah Bicknell
- Birmingham and Solihull Mental Health Foundation Trust, Birmingham, UK
| | | | - Peter Bentham
- Birmingham and Solihull Mental Health Foundation Trust, Birmingham, UK
| | - Analisa Smythe
- Birmingham and Solihull Mental Health Foundation Trust, Birmingham, UK.,Royal Wolverhampton NHS Trust, Wolverhampton, UK
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11
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Liu KY, Borissova A, Mahmood J, Elliott T, Knowles M, Bentham P, Reeves S, Howard R. Pharmacological treatment trials of agitation in Alzheimer's disease: A systematic review of ClinicalTrials.gov registered trials. Alzheimers Dement (N Y) 2021; 7:e12157. [PMID: 33816763 PMCID: PMC8010365 DOI: 10.1002/trc2.12157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 11/09/2020] [Revised: 01/12/2021] [Accepted: 02/05/2021] [Indexed: 11/11/2022]
Abstract
INTRODUCTION There is increasing emphasis on the importance of optimizing and standardizing clinical trials of agitation in Alzheimer's disease (AD), but the risks of bias arising from published trials and the number and design of unpublished studies are poorly understood. METHODS Using the ClinicalTrials.gov database, we systematically reviewed all registered investigational clinical trials for agitation in AD to describe the landscape of agitation drug treatment trials and to assess their quality and generalizability. RESULTS We included 52 clinical studies registered over the past 25 years. Within published randomized controlled trials (RCTs), there was a high rate of participant dropout, poor reporting of randomization procedures, and inconsistent definitions of the sample included for analysis. There was also evidence of publication and funder bias. DISCUSSION We discuss factors that limit the internal and external validity of published RCTs and make additional recommendations for the conduct and reporting of future clinical trials of agitation in AD.
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Affiliation(s)
- Kathy Y. Liu
- Division of PsychiatryUniversity College LondonLondonUK
| | - Anya Borissova
- Institute of PsychiatryPsychology and NeuroscienceKing's College LondonLondonUK
| | | | | | | | - Peter Bentham
- Birmingham and Solihull Mental Health NHS Foundation TrustBirminghamUK
| | | | - Robert Howard
- Division of PsychiatryUniversity College LondonLondonUK
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12
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Gathercole R, Bradley R, Harper E, Davies L, Pank L, Lam N, Davies A, Talbot E, Hooper E, Winson R, Scutt B, Montano VO, Nunn S, Lavelle G, Lariviere M, Hirani S, Brini S, Bateman A, Bentham P, Burns A, Dunk B, Forsyth K, Fox C, Henderson C, Knapp M, Leroi I, Newman S, O'Brien J, Poland F, Woolham J, Gray R, Howard R. Assistive technology and telecare to maintain independent living at home for people with dementia: the ATTILA RCT. Health Technol Assess 2021; 25:1-156. [PMID: 33755548 DOI: 10.3310/hta25190] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Assistive technology and telecare have been promoted to manage the risks associated with independent living for people with dementia, but there is limited evidence of their effectiveness. OBJECTIVES This trial aimed to establish whether or not assistive technology and telecare assessments and interventions extend the time that people with dementia can continue to live independently at home and whether or not they are cost-effective. Caregiver burden, the quality of life of caregivers and of people with dementia and whether or not assistive technology and telecare reduce safety risks were also investigated. DESIGN This was a pragmatic, randomised controlled trial. Blinding was not undertaken as it was not feasible to do so. All consenting participants were included in an intention-to-treat analysis. SETTING This trial was set in 12 councils in England with adult social services responsibilities. PARTICIPANTS Participants were people with dementia living in the community who had an identified need that might benefit from assistive technology and telecare. INTERVENTIONS Participants were randomly assigned to receive either assistive technology and telecare recommended by a health or social care professional to meet their assessed needs (a full assistive technology and telecare package) or a pendant alarm, non-monitored smoke and carbon monoxide detectors and a key safe (a basic assistive technology and telecare package). MAIN OUTCOME MEASURES The primary outcomes were time to admission to care and cost-effectiveness. Secondary outcomes assessed caregivers using the 10-item Center for Epidemiological Studies Depression Scale, the State-Trait Anxiety Inventory 6-item scale and the Zarit Burden Interview. RESULTS Of 495 participants, 248 were randomised to receive full assistive technology and telecare and 247 received the limited control. Comparing the assistive technology and telecare group with the control group, the hazard ratio for institutionalisation was 0.76 (95% confidence interval 0.58 to 1.01; p = 0.054). After adjusting for an imbalance in the baseline activities of daily living score between trial arms, the hazard ratio was 0.84 (95% confidence interval 0.63 to 1.12; p = 0.20). At 104 weeks, there were no significant differences between groups in health and social care resource use costs (intervention group - control group difference: mean -£909, 95% confidence interval -£5336 to £3345) or in societal costs (intervention group - control group difference: mean -£3545; 95% confidence interval -£13,914 to £6581). At 104 weeks, based on quality-adjusted life-years derived from the participant-rated EuroQol-5 Dimensions questionnaire, the intervention group had 0.105 (95% confidence interval -0.204 to -0.007) fewer quality-adjusted life-years than the control group. The number of quality-adjusted life-years derived from the proxy-rated EuroQol-5 Dimensions questionnaire did not differ between groups. Caregiver outcomes did not differ between groups over 24 weeks. LIMITATIONS Compliance with the assigned trial arm was variable, as was the quality of assistive technology and telecare needs assessments. Attrition from assessments led to data loss additional to that attributable to care home admission and censoring events. CONCLUSIONS A full package of assistive technology and telecare did not increase the length of time that participants with dementia remained in the community, and nor did it decrease caregiver burden, depression or anxiety, relative to a basic package of assistive technology and telecare. Use of the full assistive technology and telecare package did not increase participants' health and social care or societal costs. Quality-adjusted life-years based on participants' EuroQol-5 Dimensions questionnaire responses were reduced in the intervention group compared with the control group; groups did not differ in the number of quality-adjusted life-years based on the proxy-rated EuroQol-5 Dimensions questionnaire. FUTURE WORK Future work could examine whether or not improved assessment that is more personalised to an individual is beneficial. TRIAL REGISTRATION Current Controlled Trials ISRCTN86537017. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 19. See the NIHR Journals Library website for further project information.
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Affiliation(s)
| | - Rosie Bradley
- Medical Research Council Population Health Research Unit, University of Oxford, Oxford, UK
| | - Emma Harper
- Medical Research Council Population Health Research Unit, University of Oxford, Oxford, UK
| | - Lucy Davies
- Medical Research Council Population Health Research Unit, University of Oxford, Oxford, UK
| | - Lynn Pank
- Medical Research Council Population Health Research Unit, University of Oxford, Oxford, UK
| | - Natalie Lam
- Medical Research Council Population Health Research Unit, University of Oxford, Oxford, UK
| | - Anna Davies
- School of Health Sciences, City, University of London, London, UK.,Population Health Sciences, University of Bristol, Bristol, UK
| | - Emma Talbot
- Norfolk and Suffolk NHS Foundation Trust, Stowmarket, UK
| | - Emma Hooper
- Lancashire Care NHS Foundation Trust, Preston, UK.,Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Rachel Winson
- Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
| | - Bethany Scutt
- Department of Old Age Psychiatry, King's College London, London, UK
| | | | - Samantha Nunn
- Cambridgeshire Community Services NHS Trust, Cambridge, UK
| | - Grace Lavelle
- Department of Old Age Psychiatry, King's College London, London, UK
| | - Matthew Lariviere
- Centre for International Research on Care, Labour and Equalities, University of Sheffield, Sheffield, UK
| | | | - Stefano Brini
- School of Health Sciences, City, University of London, London, UK
| | - Andrew Bateman
- School of Health and Social Care, University of Essex, Colchester, UK
| | - Peter Bentham
- Birmingham and Solihull Mental Health NHS Foundation Trust, Birmingham, UK
| | - Alistair Burns
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Barbara Dunk
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Kirsty Forsyth
- School of Health Sciences, Queen Margaret University, Edinburgh, UK
| | - Chris Fox
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Catherine Henderson
- Care Policy and Evaluation Centre, London School of Economics and Political Science, London, UK
| | - Martin Knapp
- Care Policy and Evaluation Centre, London School of Economics and Political Science, London, UK
| | - Iracema Leroi
- Global Brain Health Institute, Trinity College Dublin, Dublin, Ireland
| | - Stanton Newman
- School of Health Sciences, City, University of London, London, UK
| | - John O'Brien
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Fiona Poland
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - John Woolham
- National Institute for Health Research (NIHR) Health & Social Care Workforce Research Unit, King's College London, London, UK
| | - Richard Gray
- Medical Research Council Population Health Research Unit, University of Oxford, Oxford, UK
| | - Robert Howard
- Division of Psychiatry, University College London, London, UK
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13
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Howard R, Zubko O, Bradley R, Harper E, Pank L, O'Brien J, Fox C, Tabet N, Livingston G, Bentham P, McShane R, Burns A, Ritchie C, Reeves S, Lovestone S, Ballard C, Noble W, Nilforooshan R, Wilcock G, Gray R. Minocycline at 2 Different Dosages vs Placebo for Patients With Mild Alzheimer Disease: A Randomized Clinical Trial. JAMA Neurol 2020; 77:164-174. [PMID: 31738372 PMCID: PMC6865324 DOI: 10.1001/jamaneurol.2019.3762] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Question Can 2 years of minocycline treatment modify the course of mild Alzheimer disease? Findings In this randomized clinical trial that included 544 participants, 24 months of minocycline treatment did not significantly delay progression of functional and cognitive impairment compared with placebo. Meaning Minocycline is not a candidate for disease modification for patients with symptomatic Alzheimer disease. Importance There are no disease-modifying treatments for Alzheimer disease (AD), the most common cause of dementia. Minocycline is anti-inflammatory, protects against the toxic effects of β-amyloid in vitro and in animal models of AD, and is a credible repurposed treatment candidate. Objective To determine whether 24 months of minocycline treatment can modify cognitive and functional decline in patients with mild AD. Design, Setting, and Participants Participants were recruited into a double-blind randomized clinical trial from May 23, 2014, to April 14, 2016, with 24 months of treatment and follow-up. This multicenter study in England and Scotland involved 32 National Health Service memory clinics within secondary specialist services for people with dementia. From 886 screened patients, 554 patients with a diagnosis of mild AD (Standardised Mini-Mental State Examination [sMMSE] score ≥24) were randomized. Interventions Participants were randomly allocated 1:1:1 in a semifactorial design to receive minocycline (400 mg/d or 200 mg/d) or placebo for 24 months. Main Outcomes and Measures Primary outcome measures were decrease in sMMSE score and Bristol Activities of Daily Living Scale (BADLS), analyzed by intention-to-treat repeated-measures regression. Results Of 544 eligible participants (241 women and 303 men), the mean (SD) age was 74.3 (8.2) years, and the mean (SD) sMMSE score was 26.4 (1.9). Fewer participants completed 400-mg minocycline hydrochloride treatment (28.8% [53 of 184]) than 200-mg minocycline treatment (61.9% [112 of 181]) or placebo (63.7% [114 of 179]; P < .001), mainly because of gastrointestinal symptoms (42 in the 400-mg group, 15 in the 200-mg group, and 10 in the placebo group; P < .001), dermatologic adverse effects (10 in the 400-mg group, 5 in the 200-mg group, and 1 in the placebo group; P = .02), and dizziness (14 in the 400-mg group, 3 in the 200-mg group, and 1 in the placebo group; P = .01). Assessment rates were lower in the 400-mg group: 68.4% (119 of 174 expected) for sMMSE at 24 months compared with 81.8% (144 of 176) for the 200-mg group and 83.8% (140 of 167) for the placebo group. Decrease in sMMSE scores over 24 months in the combined minocycline group was similar to that in the placebo group (4.1 vs 4.3 points). The combined minocycline group had mean sMMSE scores 0.1 points higher than the placebo group (95% CI, −1.1 to 1.2; P = .90). The decrease in mean sMMSE scores was less in the 400-mg group than in the 200-mg group (3.3 vs 4.7 points; treatment effect = 1.2; 95% CI, −0.1 to 2.5; P = .08). Worsening of BADLS scores over 24 months was similar in all groups: 5.7 in the 400-mg group, 6.6 in the 200-mg group, and 6.2 in the placebo groups (treatment effect for minocycline vs placebo = –0.53; 95% CI, −2.4 to 1.3; P = .57; treatment effect for 400 mg vs 200 mg of minocycline = –0.31; 95% CI, −0.2 to 1.8; P = .77). Results were similar in different patient subgroups and in sensitivity analyses adjusting for missing data. Conclusions and Relevance Minocycline did not delay the progress of cognitive or functional impairment in people with mild AD during a 2-year period. This study also found that 400 mg of minocycline is poorly tolerated in this population. Trial Registration isrctn.org Identifier: ISRCTN16105064
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Affiliation(s)
- Robert Howard
- Division of Psychiatry, University College London, London, United Kingdom
| | - Olga Zubko
- Old Age Psychiatry, King's College London, London, United Kingdom
| | - Rosie Bradley
- Medical Research Council Population Health Research Unit, University of Oxford, Oxford, United Kingdom
| | - Emma Harper
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Lynn Pank
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - John O'Brien
- Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
| | - Chris Fox
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Naji Tabet
- Department of Old Age Psychiatry, University of Sussex, Brighton, United Kingdom
| | - Gill Livingston
- Division of Psychiatry, University College London, London, United Kingdom
| | - Peter Bentham
- Birmingham and Solihull Mental Health National Health Service Foundation Trust, Birmingham, United Kingdom
| | - Rupert McShane
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom
| | - Alistair Burns
- Department of Old Age Psychiatry, University of Manchester, Manchester, United Kingdom
| | - Craig Ritchie
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Suzanne Reeves
- Division of Psychiatry, University College London, London, United Kingdom
| | - Simon Lovestone
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom
| | - Clive Ballard
- Medical School, University of Exeter, Exeter, United Kingdom
| | - Wendy Noble
- Department of Basic and Clinical Neuroscience, King's College London, London, United Kingdom
| | - Ramin Nilforooshan
- Surrey and Borders Partnership National Health Service Foundation Trust, United Kingdom
| | - Gordon Wilcock
- Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Richard Gray
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
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14
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Smythe A, Jenkins C, Galant-Miecznikowska M, Dyer J, Downs M, Bentham P, Oyebode J. A qualitative study exploring nursing home nurses' experiences of training in person centred dementia care on burnout. Nurse Educ Pract 2020; 44:102745. [PMID: 32200294 DOI: 10.1016/j.nepr.2020.102745] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 12/17/2019] [Accepted: 02/21/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Analisa Smythe
- Birmingham and Solihull Mental Health Foundation Trust, UK.
| | | | | | - Jane Dyer
- Birmingham and Solihull Mental Health Foundation Trust, UK
| | | | | | - Jan Oyebode
- Birmingham and Solihull Mental Health Foundation Trust, UK; University of Bradford, UK
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15
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Forsyth K, Henderson C, Davis L, Singh Roy A, Dunk B, Curnow E, Gathercole R, Lam N, Harper E, Leroi I, Woolham J, Fox C, O'Brien J, Bateman A, Poland F, Bentham P, Burns A, Davies A, Gray R, Bradley R, Knapp M, Newman S, McShane R, Ritchie C, Talbot E, Hooper E, Winson R, Scutt B, Ordonez V, Nunn S, Lavelle G, Howard R. Assessment of need and practice for assistive technology and telecare for people with dementia-The ATTILA (Assistive Technology and Telecare to maintain Independent Living At home for people with dementia) trial. Alzheimers Dement (N Y) 2019; 5:420-430. [PMID: 31517029 PMCID: PMC6728826 DOI: 10.1016/j.trci.2019.07.010] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Introduction The objective of this study was to define current assistive technology and telecare (ATT) practice for people with dementia living at home. Methods This is a randomized controlled trial (N = 495) of ATT assessment and ATT installation intervention, compared with control (restricted ATT package). ATT assessment and installation data were collected. Qualitative work identified value networks delivering ATT, established an ATT assessment standard. Results ATT was delivered by public and not-for-profit telecare networks. ATT assessments showed 52% fidelity to the ATT assessment standard. Areas of assessment most frequently leading to identifying ATT need were daily activities (93%), memory (89%), and problem-solving (83%). ATT needs and recommendations were weakly correlated (τ = 0.242; P < .000), with ATT recommendations and installations moderately correlated (τ = −0.470; P < .000). Half (53%) of recommended technology was not installed. Safety concerns motivated 38% of installations. Discussion Assessment recommendations were routinely disregarded at the point of installation. ATT was commonly recommended for safety and seldom for supporting leisure.
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Affiliation(s)
- Kirsty Forsyth
- School of Health Sciences, Queen Margaret University, Edinburgh, UK
| | - Catherine Henderson
- Personal Social Services Research Unit, London School of Economics and Political Science, London, UK
| | | | - Anusua Singh Roy
- School of Health Sciences, Queen Margaret University, Edinburgh, UK
| | - Barbara Dunk
- South London and Maudsley NHS Foundation Trust, The Maudsley, UK
| | - Eleanor Curnow
- School of Health Sciences, Queen Margaret University, Edinburgh, UK
| | | | | | | | - Iracema Leroi
- School of Community Based Medicine, University of Manchester, Manchester, UK
| | - John Woolham
- Social Care Workforce Research Unit, King's College London, London, UK
| | - Chris Fox
- School of Medicine, Health Policy and Practice, University of East Anglia, Norwich, Norfolk, UK
| | - John O'Brien
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Andrew Bateman
- Oliver Zangwill Centre for Neuropsychological Rehabilitation, Princess of Wales Hospital, Ely, UK
| | - Fiona Poland
- School of Allied Health Professionals, University of East Anglia, Norwich, Norfolk, UK
| | | | - Alistair Burns
- School of Community Based Medicine, University of Manchester, Manchester, UK
| | - Anna Davies
- School of Community and Health Science, City University, London, UK
| | | | | | - Martin Knapp
- Department of Old Age Psychiatry, Institute of Psychiatry, London, UK
| | - Stanton Newman
- School of Community and Health Science, City University, London, UK
| | - Rupert McShane
- Oxford Health NHS Foundation Trust, Warneford Hospital, Headington, Oxford, UK
| | - Craig Ritchie
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Emma Talbot
- Norfolk and Suffolk NHS Foundation Trust, Suffolk, UK
| | | | - Rachel Winson
- Cambridgeshire Community Services NHS Trust, Oliver Zangwill Centre, Ely, UK
| | - Bethany Scutt
- Department of Old Age Psychiatry, Institute of Psychiatry, London, UK
| | - Victoria Ordonez
- Cambridgeshire Community Services NHS Trust, Oliver Zangwill Centre, Ely, UK
| | - Samantha Nunn
- Cambridgeshire Community Services NHS Trust, Oliver Zangwill Centre, Ely, UK
| | - Grace Lavelle
- Department of Old Age Psychiatry, Institute of Psychiatry, London, UK
| | - Robert Howard
- Division of Psychiatry, University College London, London, UK
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16
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Howard R, Cort E, Bradley R, Harper E, Kelly L, Bentham P, Ritchie C, Reeves S, Fawzi W, Livingston G, Sommerlad A, Oomman S, Nazir E, Nilforooshan R, Barber R, Fox C, Macharouthu A, Ramachandra P, Pattan V, Sykes J, Curran V, Katona C, Dening T, Knapp M, Romeo R, Gray R. Amisulpride for very late-onset schizophrenia-like psychosis: the ATLAS three-arm RCT. Health Technol Assess 2019; 22:1-62. [PMID: 30507375 DOI: 10.3310/hta22670] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Very late-onset (aged ≥ 60 years) schizophrenia-like psychosis (VLOSLP) occurs frequently but no placebo-controlled, randomised trials have assessed the efficacy or risks of antipsychotic treatment. Most patients are not prescribed treatment. OBJECTIVES The study investigated whether or not low-dose amisulpride is superior to placebo in reducing psychosis symptoms over 12 weeks and if any benefit is maintained by continuing treatment thereafter. Treatment safety and cost-effectiveness were also investigated. DESIGN Three-arm, parallel-group, placebo-controlled, double-blind, randomised controlled trial. Participants who received at least one dose of study treatment were included in the intention-to-treat analyses. SETTING Secondary care specialist old age psychiatry services in 25 NHS mental health trusts in England and Scotland. PARTICIPANTS Patients meeting diagnostic criteria for VLOSLP and scoring > 30 points on the Brief Psychiatric Rating Scale (BPRS). INTERVENTION Participants were randomly assigned to three arms in a two-stage trial: (1) 100 mg of amisulpride in both stages, (2) amisulpride then placebo and (3) placebo then amisulpride. Treatment duration was 12 weeks in stage 1 and 24 weeks (later reduced to 12) in stage 2. Participants, investigators and outcome assessors were blind to treatment allocation. MAIN OUTCOME MEASURES Primary outcomes were psychosis symptoms assessed by the BPRS and trial treatment discontinuation for non-efficacy. Secondary outcomes were extrapyramidal symptoms measured with the Simpson-Angus Scale, quality of life measured with the World Health Organization's quality-of-life scale, and cost-effectiveness measured with NHS, social care and carer work loss costs and EuroQol-5 Dimensions. RESULTS A total of 101 participants were randomised. Ninety-two (91%) participants took the trial medication, 59 (64%) completed stage 1 and 33 (56%) completed stage 2 treatment. Despite suboptimal compliance, improvements in BPRS scores at 12 weeks were 7.7 points (95% CI 3.8 to 11.5 points) greater with amisulpride than with placebo (11.9 vs. 4.2 points; p = 0.0002). In stage 2, BPRS scores improved by 1.1 point in those who continued with amisulpride but deteriorated by 5.2 points in those who switched from amisulpride to placebo, a difference of 6.3 points (95% CI 0.9 to 11.7 points; p = 0.024). Fewer participants allocated to the amisulpride group stopped treatment because of non-efficacy in stages 1 (p = 0.01) and 2 (p = 0.031). The number of patients stopping because of extrapyramidal symptoms and other side effects did not differ significantly between groups. Amisulpride treatment in the base-case analyses was associated with non-significant reductions in combined NHS, social care and unpaid carer costs and non-significant reductions in quality-adjusted life-years (QALYs) in both stages. Including patients who were intensive users of inpatient services in sensitivity analyses did not change the QALY result but resulted in placebo dominance in stage 1 and significant reductions in NHS/social care (95% CI -£8923 to -£122) and societal costs (95% CI -£8985 to -£153) for those continuing with amisulpride. LIMITATIONS The original recruitment target of 300 participants was not achieved and compliance with trial medication was highly variable. CONCLUSIONS Low-dose amisulpride is effective and well tolerated as a treatment for VLOSLP, with benefits maintained by prolonging treatment. Potential adverse events include clinically significant extrapyramidal symptoms and falls. FUTURE WORK Trials should examine the longer-term effectiveness and safety of antipsychotic treatment in this patient group, and assess interventions to improve their appreciation of potential benefits of antipsychotic treatment and compliance with prescribed medication. TRIAL REGISTRATION Current Controlled Trials ISRCTN45593573 and EudraCT2010-022184-35. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 67. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Robert Howard
- Department of Old Age Psychiatry, King's College London, London, UK
| | - Elizabeth Cort
- Department of Old Age Psychiatry, King's College London, London, UK
| | - Rosie Bradley
- Medical Research Council Population Health Research Unit, University of Oxford, Oxford, UK
| | - Emma Harper
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Linda Kelly
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Peter Bentham
- Birmingham and Solihull Mental Health NHS Foundation Trust, Birmingham, UK
| | | | - Suzanne Reeves
- Department of Old Age Psychiatry, King's College London, London, UK
| | | | - Gill Livingston
- Division of Psychiatry, University College London, London, UK
| | | | - Sabu Oomman
- Cheshire and Wirral Partnership NHS Foundation Trust, Chester, UK
| | - Ejaz Nazir
- South Staffordshire and Shropshire Healthcare NHS Foundation Trust, Stafford, UK
| | | | - Robert Barber
- Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Chris Fox
- Norwich Medical School, University of East Anglia, Norwich, UK
| | | | | | | | - John Sykes
- Derbyshire Healthcare NHS Foundation Trust, Derby, UK
| | - Valerie Curran
- Black Country Partnership NHS Foundation Trust, West Bromwich, UK
| | | | - Tom Dening
- Division of Psychiatry and Applied Psychology, University of Nottingham, Nottingham, UK
| | - Martin Knapp
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Renee Romeo
- Health Service and Population Research Department, King's College London, London, UK
| | - Richard Gray
- Medical Research Council Population Health Research Unit, University of Oxford, Oxford, UK
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Webster N, Jenkins C, Oyebode J, Bentham P, Smythe A. Experiences of peer support for newly qualified nurses in a dedicated online group: Study protocol. J Adv Nurs 2019; 75:1585-1591. [DOI: 10.1111/jan.14001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 01/12/2019] [Accepted: 03/13/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Natalie Webster
- Birmingham and Solihull Mental Health NHS Foundation Trust Birmingham UK
| | | | | | - Peter Bentham
- Birmingham and Solihull Mental Health NHS Foundation Trust Birmingham UK
| | - Analisa Smythe
- Birmingham and Solihull Mental Health NHS Foundation Trust Birmingham UK
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Schelter BO, Shiells H, Baddeley TC, Rubino CM, Ganesan H, Hammel J, Vuksanovic V, Staff RT, Murray AD, Bracoud L, Riedel G, Gauthier S, Jia J, Bentham P, Kook K, Storey JM, Harrington CR, Wischik CM. Concentration-Dependent Activity of Hydromethylthionine on Cognitive Decline and Brain Atrophy in Mild to Moderate Alzheimer's Disease. J Alzheimers Dis 2019; 72:931-946. [PMID: 31658058 PMCID: PMC6918900 DOI: 10.3233/jad-190772] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Although hydromethylthionine is a potent tau aggregation inhibitor, no difference was found in either of two Phase III trials in mild to moderate Alzheimer's disease (AD) comparing doses in the range 150-250 mg/day with 8 mg/day intended as a control. OBJECTIVE To determine how drug exposure is related to treatment response. METHODS A sensitive plasma assay for the drug was used in a population pharmacokinetic analysis of samples from 1,162 of the 1,686 patients who participated in either of the Phase III trials with available samples and efficacy outcome data. RESULTS There are steep concentration-response relationships for steady state plasma levels in the range 0.3-0.8 ng/ml at the 8 mg/day dose. Using a threshold based on the lower limit of quantitation of the assay on Day 1, there are highly significant differences in cognitive decline and brain atrophy in patients with above threshold plasma levels, both for monotherapy and add-on therapy, but with effect sizes reduced by half as add-on. Plasma concentrations in the range 4-21 ng/ml produced by the high doses are not associated with any additional benefit. CONCLUSIONS Hydromethylthionine has pharmacological activity on brain structure and function at the 8 mg/day dose as monotherapy or as add-on to symptomatic treatments. This combined with a plateau at higher doses is consistent with the lack of dose-response seen in the Phase III trials. Treatment benefit is predicted to be maximal at 16 mg/day as monotherapy. A placebo-controlled trial in mild/moderate AD is now ongoing to confirm efficacy at this dose.
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Affiliation(s)
- Bjoern O. Schelter
- TauRx Therapeutics Ltd., Singapore, Singapore
- Institute for Complex Systems and Mathematical Biology, University of Aberdeen, Aberdeen, UK
| | | | | | | | - Harish Ganesan
- Institute of Clinical Pharmacodynamics, Schenectady, NY, USA
| | - Jeffrey Hammel
- Institute of Clinical Pharmacodynamics, Schenectady, NY, USA
| | - Vesna Vuksanovic
- Aberdeen Biomedical Imaging Center, University of Aberdeen, Foresterhill, Aberdeen, UK
| | | | - Alison D. Murray
- Aberdeen Biomedical Imaging Center, University of Aberdeen, Foresterhill, Aberdeen, UK
| | | | - Gernot Riedel
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Foresterhill, Aberdeen, UK
| | - Serge Gauthier
- McGill Centre for Studies in Aging, Alzheimer’s Disease Research Unit, and Douglas Mental Health University Institute, Montreal, QC, Canada
| | - Jianping Jia
- Innovation Center for Neurological Disorders, Neurology Department, Xuanwu Hospital, Capital Medical University, Beijing, China
| | | | | | - John M.D. Storey
- TauRx Therapeutics Ltd., Singapore, Singapore
- Department of Chemistry, University of Aberdeen, Aberdeen, UK
| | - Charles R. Harrington
- TauRx Therapeutics Ltd., Singapore, Singapore
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Foresterhill, Aberdeen, UK
| | - Claude M. Wischik
- TauRx Therapeutics Ltd., Singapore, Singapore
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Foresterhill, Aberdeen, UK
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Wilcock GK, Gauthier S, Frisoni GB, Jia J, Hardlund JH, Moebius HJ, Bentham P, Kook KA, Schelter BO, Wischik DJ, Davis CS, Staff RT, Vuksanovic V, Ahearn T, Bracoud L, Shamsi K, Marek K, Seibyl J, Riedel G, Storey JMD, Harrington CR, Wischik CM. Potential of Low Dose Leuco-Methylthioninium Bis(Hydromethanesulphonate) (LMTM) Monotherapy for Treatment of Mild Alzheimer's Disease: Cohort Analysis as Modified Primary Outcome in a Phase III Clinical Trial. J Alzheimers Dis 2018; 61:435-457. [PMID: 29154277 PMCID: PMC5734125 DOI: 10.3233/jad-170560] [Citation(s) in RCA: 101] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background: LMTM is being developed as a treatment for AD based on inhibition of tau aggregation. Objectives: To examine the efficacy of LMTM as monotherapy in non-randomized cohort analyses as modified primary outcomes in an 18-month Phase III trial in mild AD. Methods: Mild AD patients (n = 800) were randomly assigned to 100 mg twice a day or 4 mg twice a day. Prior to unblinding, the Statistical Analysis Plan was revised to compare the 100 mg twice a day as monotherapy subgroup (n = 79) versus 4 mg twice a day as randomized (n = 396), and 4 mg twice a day as monotherapy (n = 76) versus 4 mg twice a day as add-on therapy (n = 297), with strong control of family-wise type I error. Results: The revised analyses were statistically significant at the required threshold of p < 0.025 in both comparisons for change in ADAS-cog, ADCS-ADL, MRI atrophy, and glucose uptake. The brain atrophy rate was initially typical of mild AD in both add-on and monotherapy groups, but after 9 months of treatment, the rate in monotherapy patients declined significantly to that reported for normal elderly controls. Differences in severity or diagnosis at baseline between monotherapy and add-on patients did not account for significant differences in favor of monotherapy. Conclusions: The results are consistent with earlier studies in supporting the hypothesis that LMTM might be effective as monotherapy and that 4 mg twice a day may serve as well as higher doses. A further suitably randomized trial is required to test this hypothesis.
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Affiliation(s)
- Gordon K Wilcock
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Serge Gauthier
- McGill Centre for Studies in Aging, Alzheimer's Disease Research Unit, and Douglas Mental Health University Institute, Montreal, QC, Canada
| | | | - Jianping Jia
- Beijing Institute for Brain Disorders Alzheimer's Disease Centre, Beijing, China
| | | | | | - Peter Bentham
- Birmingham and Solihull Mental Health Foundation Trust, Birmingham, UK
| | | | - Bjoern O Schelter
- Institute for Complex Systems and Mathematical Biology, University of Aberdeen, Aberdeen, UK
| | | | | | - Roger T Staff
- Aberdeen Biomedical Imaging Centre, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Vesna Vuksanovic
- Aberdeen Biomedical Imaging Centre, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Trevor Ahearn
- Aberdeen Biomedical Imaging Centre, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | | | | | | | | | - Gernot Riedel
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - John M D Storey
- TauRx Therapeutics, Aberdeen, UK.,Department of Chemistry, University of Aberdeen, Aberdeen, UK
| | - Charles R Harrington
- TauRx Therapeutics, Aberdeen, UK.,School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Claude M Wischik
- TauRx Therapeutics, Aberdeen, UK.,School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
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Howard R, Cort E, Bradley R, Harper E, Kelly L, Bentham P, Ritchie C, Reeves S, Fawzi W, Livingston G, Sommerlad A, Oomman S, Nazir E, Nilforooshan R, Barber R, Fox C, Macharouthu AV, Ramachandra P, Pattan V, Sykes J, Curran V, Katona C, Dening T, Knapp M, Gray R. Antipsychotic treatment of very late-onset schizophrenia-like psychosis (ATLAS): a randomised, controlled, double-blind trial. Lancet Psychiatry 2018; 5:553-563. [PMID: 29880238 PMCID: PMC6015223 DOI: 10.1016/s2215-0366(18)30141-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 03/27/2018] [Accepted: 04/05/2018] [Indexed: 10/25/2022]
Abstract
BACKGROUND Very late (aged ≥60 years) onset schizophrenia-like psychosis occurs frequently but no placebo-controlled, randomised trials have assessed the efficacy and risks of antipsychotic treatment. We investigated whether low-dose amisulpride (100 mg daily) is superior to placebo in reducing psychosis symptoms over 12 weeks and whether any benefit is maintained by continuing treatment after 12 weeks. METHODS The ATLAS double-blind controlled trial enrolled participants from 25 old age psychiatry services in the UK. Eligible participants (ie, those with a diagnosis of very late-onset schizophrenia-like psychosis and a Brief Psychiatric Rating Scale [BPRS] score of ≥30, without cognitive impairment) were randomly assigned (1:1:1) to one of three groups in a two-stage trial: amisulpride in stage 1 and 2 (group A), amisulpride then placebo (group B), or placebo then amisulpride (group C). Treatment (100 mg oral amisulpride daily vs placebo) was given for 12 weeks in stage 1 and, initially, 24 weeks then reduced to 12 weeks in stage 2. Participants, investigators, and outcome assessors were masked to treatment allocation. Primary outcomes were psychosis symptoms assessed by the BPRS at 4, 12, and 24, or 36 weeks, and trial treatment discontinuation for non-efficacy. The primary, secondary, and safety endpoints were all analysed in participants given at least one dose of study treatment in modified intention-to-treat analyses. This study is registered with EudraCT, number 2010-022184-35, and ISRCTN, number ISRCTN45593573. FINDINGS Between Sept 27, 2012, and June 28, 2016, we recruited 101 participants. 92 (91%) of 101 participants took trial medication, of whom 59 (64%) completed stage 1 and 34 (58%) of these 59 participants completed stage 2 treatment. Despite suboptimal compliance, improvements in BPRS scores at 12 weeks were 7·7 points (95% CI 3·8-11·5, p=0·0002) greater with amisulpride (mean 11·9 points [SE 1·3]) than with placebo (4·2 points [1·0]). In stage 2, BPRS scores improved by a mean of 1·1 points (1·6) from 12 weeks to the final assessment in those who continued amisulpride but deteriorated by 5·2 points (2·0) in those who switched from amisulpride to placebo (difference 6·3 points [95% CI 0·9-11·7], p=0·024). Fewer participants who were allocated amisulpride than placebo stopped treatment because of non-efficacy in stage 1 (p=0·010) and stage 2 (p=0·031). Serious adverse events were reported more frequently in the amisulpride group than in the placebo group in stage 1 (p=0·057) and stage 2 (p=0·19). The most common serious adverse events were infection (five patients in the amisulpride group, three in the placebo group) and extrapyramidal side-effects (three patients in the amisulpride group, none in the placebo group). Five patients died during the study, one from a gastric ulcer bleed before treatment started (group B), two while taking stage 2 treatment (one in group A and one in group C), and two who stopped trial treatment in stage 1 and died many weeks later (one in group B and one in group C). No deaths were related to treatment. INTERPRETATION Low-dose amisulpride is effective and well tolerated as a treatment for very late-onset schizophrenia-like psychosis, with benefits maintained by prolonging treatment. FUNDING UK National Institute for Health Research.
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Affiliation(s)
- Robert Howard
- Division of Psychiatry, University College London, London, UK.
| | - Elizabeth Cort
- Department of Old Age Psychiatry, King's College London, London, UK; South London and Maudsley NHS Foundation Trust, London, UK
| | - Rosie Bradley
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Emma Harper
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Linda Kelly
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Peter Bentham
- Birmingham and Solihull Mental Health NHS Foundation Trust, Birmingham, UK
| | - Craig Ritchie
- Centre for Dementia Prevention, University of Edinburgh, Edinburgh, UK
| | - Suzanne Reeves
- Division of Psychiatry, University College London, London, UK
| | - Waleed Fawzi
- Mile End Hospital, East London NHS Foundation Trust, London, UK
| | - Gill Livingston
- Division of Psychiatry, University College London, London, UK; Camden and Islington NHS Foundation Trust, London, UK
| | | | - Sabu Oomman
- Cheshire and Wirral NHS Foundation Trust, Cheshire, UK
| | - Ejaz Nazir
- South Staffordshire and Shropshire Healthcare NHS Foundation Trust, Shrewsbury, UK
| | | | - Robert Barber
- Northumberland Tyne and Wear NHS Foundation Trust, Newcastle, UK
| | - Chris Fox
- Norwich Medical School, University of East Anglia, Norwich, UK; Norfolk & Suffolk NHS Foundation Trust, Norwich, UK
| | | | | | | | - John Sykes
- Derbyshire Healthcare NHS Foundation Trust, Derby, UK
| | - Val Curran
- Edward Street Hospital, West Bromwich, UK
| | | | - Tom Dening
- Division of Psychiatry and Applied Psychology, University of Nottingham, Nottingham, UK
| | - Martin Knapp
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Richard Gray
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Greening J, Bentham P, Stemman J, Staples V, Ambegaokar S, Upthegrove R, Day E. The effect of structured consent on recall of information pre- and post-electroconvulsive therapy: a pilot study. Psychiatr bull 2018. [DOI: 10.1192/pb.23.8.471] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Aims and methodA randomised, blind comparison of a structured consent procedure against routine consent was conducted to determine whether it had any utility in improving treatment knowledge In patients receiving electroconvulsive therapy (ECT). Additionally we aimed to determine whether degree of cognitive impairment intelligence and severity of depression influenced recall of information.ResultsThirty-two subjects were investigated. Structured consent significantly improved the number of knowledge items recalled pre-ECT (P<0.05). Knowledge scores declined significantly after completion of the treatment course in both structured consent (P<0.05) and control groups (P<0.06). There was a significant correlation between Mini-Mental State Examination (MMSE) scores and the number of knowledge items recalled both pre- (r=0.43, P<0.05) and post-ECT (r=0.53, P<0.01).Clinical implicationsStructured consent procedures may be a useful way of improving patient knowledge of ECT and merit further study. Low scores on MMSE should caution clinicians to take particular care when consenting patients to ECT.
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Abstract
Aims and methodClinical audit methodology was used to compare the treatment of alcohol misusers at risk of Wernicke's encephalopathy in an acute medical setting, and to assess the impact of providing information about best practice to prescribing doctors. All patients prescribed thiamine during an admission to an acute hospital trust over a 6-month period were identified, and data about their treatment episode were collected retrospectively. Hospital pharmacists then provided all prescribers with a flowchart summarising current prescribing guidelines, and prescribing patterns were re-audited 6 months later.ResultsOver two audit periods, half of the patients prescribed thiamine whose case notes we examined had symptoms suggestive of Wernicke's encephalopathy, and another 30% were at high risk. Prescribing adhered to hospital guidelines only in 14% of cases, with the pharmacy-led intervention associated with a small but significant increase in the number of patients receiving adequate treatment for Wernicke's encephalopathy.Clinical implicationsWernicke's encephalopathy is relatively common in alcohol-dependent individuals admitted to hospital, and it is easily and cheaply managed. However, even when potential cases are identified, prescribing guidelines are followed in a minority of cases, even with prompting by a hospital pharmacist. This may be related to the limited research base concerning the optimum dosing schedule of thiamine, or fears about possible anaphylaxis when using parenteral preparations.
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Abstract
This study aimed to describe the prevalence of dental pathology in patients receiving electroconvulsive therapy and to prospectively determine the incidence of dental complications arising during treatment. Of 30 subjects, 93% complained of a dry mouth and 83% were taking drugs with anticholinergic properties. A third wore dentures and the dentate population had a mean of 15 decayed, missing or filled teeth. Oral hygiene and periodontal condition was poor with one-third requiring scaling and 30% complex periodontal treatment. Temporomandibular pain followed 44% of treatments, and minor buccal lesions occurred in 22%. Greater emphasis must be placed on dental care, and guidelines are suggested to improve practice.
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Laidlaw J, Bentham P, Khan G, Staples V, Dhariwal A, Coope B, Day E, Fear C, Marley C, Stemman J. A comparison of stimulus dosing methods for electroconvulsive therapy. Psychiatr bull 2018. [DOI: 10.1192/pb.24.5.184] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Aims and MethodsA prospective study comparing initial electroconvulsive therapy treatment doses determined by empirical dose titration with estimates derived from two simple dose prediction methods and a fixed-dose regimen (275 mC).ResultsThirty-three patients had seizure thresholds between 25 mC and 403 mC. The dose titration method led to a mean initial treatment dose of 195 mC that was intermediate between those predicted by the age method (275 mC) and the half-age method (137 mC). Estimates were within acceptable limits in 33% of cases for the age method, 64% for the half-age method and 40% for the fixed-dose method.Clinical ImplicationsEither dose prediction or dose titration methods may be more appropriate in different clinical situations. The half-age method appears to be a more accurate predictor of optimum initial treatment dose.
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Knapp M, King D, Romeo R, Adams J, Baldwin A, Ballard C, Banerjee S, Barber R, Bentham P, Brown RG, Burns A, Dening T, Findlay D, Holmes C, Johnson T, Jones R, Katona C, Lindesay J, Macharouthu A, McKeith I, McShane R, O'Brien JT, Phillips PPJ, Sheehan B, Howard R. Cost-effectiveness of donepezil and memantine in moderate to severe Alzheimer's disease (the DOMINO-AD trial). Int J Geriatr Psychiatry 2017; 32:1205-1216. [PMID: 27739182 PMCID: PMC5724694 DOI: 10.1002/gps.4583] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 08/25/2016] [Accepted: 08/25/2016] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Most investigations of pharmacotherapy for treating Alzheimer's disease focus on patients with mild-to-moderate symptoms, with little evidence to guide clinical decisions when symptoms become severe. We examined whether continuing donepezil, or commencing memantine, is cost-effective for community-dwelling, moderate-to-severe Alzheimer's disease patients. METHODS Cost-effectiveness analysis was based on a 52-week, multicentre, double-blind, placebo-controlled, factorial clinical trial. A total of 295 community-dwelling patients with moderate/severe Alzheimer's disease, already treated with donepezil, were randomised to: (i) continue donepezil; (ii) discontinue donepezil; (iii) discontinue donepezil and start memantine; or (iv) continue donepezil and start memantine. RESULTS Continuing donepezil for 52 weeks was more cost-effective than discontinuation, considering cognition, activities of daily living and health-related quality of life. Starting memantine was more cost-effective than donepezil discontinuation. Donepezil-memantine combined is not more cost-effective than donepezil alone. CONCLUSIONS Robust evidence is now available to inform clinical decisions and commissioning strategies so as to improve patients' lives whilst making efficient use of available resources. Clinical guidelines for treating moderate/severe Alzheimer's disease, such as those issued by NICE in England and Wales, should be revisited. © 2016 The Authors. International Journal of Geriatric Psychiatry published by John Wiley & Sons Ltd.
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Affiliation(s)
- Martin Knapp
- Personal Social Services Research UnitLondon School of Economics and Political ScienceLondonUK
| | - Derek King
- Personal Social Services Research UnitLondon School of Economics and Political ScienceLondonUK
| | - Renée Romeo
- King's Health EconomicsInstitute of Psychiatry, Psychology and Neuroscience, King's College LondonLondonUK
| | - Jessica Adams
- Department of BiostaticsInstitute of Psychiatry, Psychology and Neuroscience, King's College LondonLondonUK
| | - Ashley Baldwin
- Five Boroughs Partnership NHS Foundation TrustWarringtonUK
| | - Clive Ballard
- Wolfson Centre for Age Related DisordersKing's College, LondonLondonUK
| | - Sube Banerjee
- Brighton and Sussex Medical SchoolUniversity of SussexBrightonUK
| | | | - Peter Bentham
- Birmingham and Solihull Mental Health NHS Foundation TrustBirminghamUK
| | - Richard G Brown
- Department of PsychologyInstitute of Psychiatry, Psychology and Neuroscience, King's College LondonLondonUK
| | - Alistair Burns
- Faculty of Medical and Human SciencesInstitute of Brain, Behaviour and Mental Health, University of ManchesterManchesterUK
| | - Tom Dening
- Division of Psychiatry and Applied PsychologyUniversity of NottinghamNottinghamUK
| | | | - Clive Holmes
- Faculty of MedicineUniversity of SouthamptonSouthamptonUK
| | - Tony Johnson
- Medical Research Council Clinical Trials UnitUniversity College LondonLondonUK
| | - Robert Jones
- Division of Psychiatry and Applied PsychologyUniversity of NottinghamNottinghamUK
| | | | | | - Ajay Macharouthu
- Ayrshire and Arran NHSUniversity Hospital CrosshouseKilmarnockUK
| | - Ian McKeith
- Institute for AgeingUniversity of NewcastleNewcastle upon TyneUK
| | - Rupert McShane
- Oxford Health NHS Foundation TrustWarneford HospitalOxfordUK
| | - John T O'Brien
- Department of PsychiatryUniversity of CambridgeCambridgeUK
| | | | - Bart Sheehan
- Oxford University Hospitals NHS Foundation TrustOxfordUK
| | - Robert Howard
- Division of PsychiatryUniversity College LondonLondonUK
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Abstract
In the UK, one third of the 850,000 people with dementia live in care homes. This article explores the process of carrying out research in nursing homes, identifying barriers and enabling factors, and making recommendations for researchers. The authors' experiences derive from an ongoing study investigating the effect of educational interventions to promote and embed person-centred care, designed for nurses caring for the people with dementia in nursing homes. Design issues arose from the need to use cluster randomisation which requires a large sample size, implementation fidelity, poor compliance and high numbers of participants lost to follow up. Further difficulties included gaining ethical approval, recruitment, raising concerns and the practicalities of participant retention. There are many benefits of conducting research in care homes, for the homes themselves, their staff and residents. These include training and education, networking and empowerment of staff and subsequent improved standards of care. For the research team, benefits include opportunities to contribute to an underserved setting, to advance care standards and improve nurses' working lives.
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Affiliation(s)
| | - Analisa Smythe
- Birmingham and Solihull Mental Health NHS Foundation Trust
| | | | - Peter Bentham
- Birmingham and Solihull Mental Health NHS Foundation Trust
| | - Jan Oyebode
- Faculty of Health Studies, University of Bradford
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Smythe A, Jenkins C, Galant-Miecznikowska M, Bentham P, Oyebode J. A qualitative study investigating training requirements of nurses working with people with dementia in nursing homes. Nurse Educ Today 2017; 50:119-123. [PMID: 28043078 DOI: 10.1016/j.nedt.2016.12.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 11/15/2016] [Accepted: 12/13/2016] [Indexed: 06/06/2023]
Abstract
BACKGROUND The care home workforce (over half a million people in the UK) has a pivotal role in the quality of care provided to the residents. Much care in this setting is inadequate, lacks a person-centred focus and neglects the dignity of residents. A combination of factors leads to burnout in nurses working in nursing homes, contributing to poor quality care. Recent reports have indicated that cultures of care need to be addressed through training, improved workforce support and supervision and that improving the quality of care for people with dementia can be achieved by the development of leadership in nursing and clarifying professional values. Addressing burnout through an educational intervention should improve quality of care and nurses' experiences. OBJECTIVES The study aimed to explore the training needs of nurses working with people with dementia in nursing homes with a view to developing an educational intervention to reduce nurses' burnout and improve person-centred care. DESIGN Four focus groups were conducted with 11 qualified nurses working in nursing homes; data was analysed using thematic analysis. RESULTS Four themes emerged through the analysis of the transcripts. Participants reported that their work responsibilities revolved mainly around directing others, day to day care, paper work and supporting family carers. Nurses identified the importance of person-centred ways of being, communication and clinical skills when working in nursing home setting. They expressed their frustrations associated with managing staff levels, responding to behaviour that challenges and lack of time. CONCLUSIONS The barriers to learning, experience of previous training and gaps in knowledge identified could inform the design of future training and support programmes.
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Affiliation(s)
- Analisa Smythe
- BSMHFT, 25 Vincent Drive, Edgbaston B15 2FG, United Kingdom.
| | | | | | | | - Jan Oyebode
- Dementia Care, Bradford Dementia Group, School of Health Studies, United Kingdom
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Gauthier S, Feldman HH, Schneider LS, Wilcock GK, Frisoni GB, Hardlund JH, Moebius HJ, Bentham P, Kook KA, Wischik DJ, Schelter BO, Davis CS, Staff RT, Bracoud L, Shamsi K, Storey JMD, Harrington CR, Wischik CM. Efficacy and safety of tau-aggregation inhibitor therapy in patients with mild or moderate Alzheimer's disease: a randomised, controlled, double-blind, parallel-arm, phase 3 trial. Lancet 2016; 388:2873-2884. [PMID: 27863809 PMCID: PMC5164296 DOI: 10.1016/s0140-6736(16)31275-2] [Citation(s) in RCA: 197] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 07/20/2016] [Accepted: 07/21/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Leuco-methylthioninium bis(hydromethanesulfonate; LMTM), a stable reduced form of the methylthioninium moiety, acts as a selective inhibitor of tau protein aggregation both in vitro and in transgenic mouse models. Methylthioninium chloride has previously shown potential efficacy as monotherapy in patients with Alzheimer's disease. We aimed to determine whether LMTM was safe and effective in modifying disease progression in patients with mild to moderate Alzheimer's disease. METHODS We did a 15-month, randomised, controlled double-blind, parallel-group trial at 115 academic centres and private research clinics in 16 countries in Europe, North America, Asia, and Russia with patients younger than 90 years with mild to moderate Alzheimer's disease. Patients concomitantly using other medicines for Alzheimer's disease were permitted to be included because we considered it infeasible not to allow their inclusion; however, patients using medicines carrying warnings of methaemoglobinaemia were excluded because the oxidised form of methylthioninium in high doses has been shown to induce this condition. We randomly assigned participants (3:3:4) to 75 mg LMTM twice a day, 125 mg LMTM twice a day, or control (4 mg LMTM twice a day to maintain blinding with respect to urine or faecal discolouration) administered as oral tablets. We did the randomisation with an interactive web response system using 600 blocks of length ten, and stratified patients by severity of disease, global region, whether they were concomitantly using Alzheimer's disease-labelled medications, and site PET capability. Participants, their study partners (generally carers), and all assessors were masked to treatment assignment throughout the study. The coprimary outcomes were progression on the Alzheimer's Disease Assessment Scale-Cognitive Subscale (ADAS-Cog) and the Alzheimer's Disease Co-operative Study-Activities of Daily Living Inventory (ADCS-ADL) scales from baseline assessed at week 65 in the modified intention-to-treat population. This trial is registered with Clinicaltrials.gov (NCT01689246) and the European Union Clinical Trials Registry (2012-002866-11). FINDINGS Between Jan 29, 2013, and June 26, 2014, we recruited and randomly assigned 891 participants to treatment (357 to control, 268 to 75 mg LMTM twice a day, and 266 to 125 mg LMTM twice a day). The prespecified primary analyses did not show any treatment benefit at either of the doses tested for the coprimary outcomes (change in ADAS-Cog score compared with control [n=354, 6·32, 95% CI 5·31-7·34]: 75 mg LMTM twice a day [n=257] -0·02, -1·60 to 1·56, p=0·9834, 125 mg LMTM twice a day [n=250] -0·43, -2·06 to 1·20, p=0·9323; change in ADCS-ADL score compared with control [-8·22, 95% CI -9·63 to -6·82]: 75 mg LMTM twice a day -0·93, -3·12 to 1·26, p=0·8659; 125 mg LMTM twice a day -0·34, -2·61 to 1·93, p=0·9479). Gastrointestinal and urinary effects were the most common adverse events with both high doses of LMTM, and the most common causes for discontinuation. Non-clinically significant dose-dependent reductions in haemoglobin concentrations were the most common laboratory abnormality. Amyloid-related imaging abnormalities were noted in less than 1% (8/885) of participants. INTERPRETATION The primary analysis for this study was negative, and the results do not suggest benefit of LMTM as an add-on treatment for patients with mild to moderate Alzheimer's disease. Findings from a recently completed 18-month trial of patients with mild Alzheimer's disease will be reported soon. FUNDING TauRx Therapeutics.
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Affiliation(s)
- Serge Gauthier
- McGill Centre for Studies in Aging, Alzheimer's Disease Research Unit, and Douglas Mental Health University Institute, Montreal, QC, Canada
| | - Howard H Feldman
- Department of Neurosciences, School of Medicine, University of California, San Diego, CA, USA
| | - Lon S Schneider
- Department of Psychiatry and Behavioral Sciences, and Department of Neurology, Keck School of Medicine, Leonard Davis School of Gerontology of the University of Southern California, Los Angeles, CA, USA
| | - Gordon K Wilcock
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | | | | | | | | | | | | | - Bjoern O Schelter
- Institute for Complex Systems and Mathematical Biology, University of Aberdeen, Aberdeen, UK
| | | | - Roger T Staff
- Aberdeen Biomedical Imaging Centre, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | | | | | - John M D Storey
- Department of Chemistry, University of Aberdeen, Aberdeen, UK
| | - Charles R Harrington
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Claude M Wischik
- TauRx Therapeutics, Aberdeen, UK; School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK.
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Alahmadi HH, Shen Y, Fouad S, Luft CDB, Bentham P, Kourtzi Z, Tino P. Classifying Cognitive Profiles Using Machine Learning with Privileged Information in Mild Cognitive Impairment. Front Comput Neurosci 2016; 10:117. [PMID: 27909405 PMCID: PMC5112260 DOI: 10.3389/fncom.2016.00117] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 10/31/2016] [Indexed: 11/28/2022] Open
Abstract
Early diagnosis of dementia is critical for assessing disease progression and potential treatment. State-or-the-art machine learning techniques have been increasingly employed to take on this diagnostic task. In this study, we employed Generalized Matrix Learning Vector Quantization (GMLVQ) classifiers to discriminate patients with Mild Cognitive Impairment (MCI) from healthy controls based on their cognitive skills. Further, we adopted a “Learning with privileged information” approach to combine cognitive and fMRI data for the classification task. The resulting classifier operates solely on the cognitive data while it incorporates the fMRI data as privileged information (PI) during training. This novel classifier is of practical use as the collection of brain imaging data is not always possible with patients and older participants. MCI patients and healthy age-matched controls were trained to extract structure from temporal sequences. We ask whether machine learning classifiers can be used to discriminate patients from controls and whether differences between these groups relate to individual cognitive profiles. To this end, we tested participants in four cognitive tasks: working memory, cognitive inhibition, divided attention, and selective attention. We also collected fMRI data before and after training on a probabilistic sequence learning task and extracted fMRI responses and connectivity as features for machine learning classifiers. Our results show that the PI guided GMLVQ classifiers outperform the baseline classifier that only used the cognitive data. In addition, we found that for the baseline classifier, divided attention is the only relevant cognitive feature. When PI was incorporated, divided attention remained the most relevant feature while cognitive inhibition became also relevant for the task. Interestingly, this analysis for the fMRI GMLVQ classifier suggests that (1) when overall fMRI signal is used as inputs to the classifier, the post-training session is most relevant; and (2) when the graph feature reflecting underlying spatiotemporal fMRI pattern is used, the pre-training session is most relevant. Taken together these results suggest that brain connectivity before training and overall fMRI signal after training are both diagnostic of cognitive skills in MCI.
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Affiliation(s)
- Hanin H Alahmadi
- School of Computer Science, The University of Birmingham Birmingham, UK
| | - Yuan Shen
- School of Computer Science, The University of Birmingham Birmingham, UK
| | - Shereen Fouad
- School of Dentistry, The University of Birmingham Birmingham, UK
| | - Caroline Di B Luft
- School of Biological and Chemical Sciences, Queen Mary University of London London, UK
| | - Peter Bentham
- School of Clinical and Experimental Medicine, The University of Birmingham Birmingham, UK
| | - Zoe Kourtzi
- Department of Psychology, The University of Cambridge Cambridge, UK
| | - Peter Tino
- School of Computer Science, The University of Birmingham Birmingham, UK
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30
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Howard R, McShane R, Lindesay J, Ritchie C, Baldwin A, Barber R, Burns A, Dening T, Findlay D, Holmes C, Jones R, Jones R, McKeith I, Macharouthu A, O'Brien J, Sheehan B, Juszczak E, Katona C, Hills R, Knapp M, Ballard C, Brown RG, Banerjee S, Adams J, Johnson T, Bentham P, Phillips PPJ. Nursing home placement in the Donepezil and Memantine in Moderate to Severe Alzheimer's Disease (DOMINO-AD) trial: secondary and post-hoc analyses. Lancet Neurol 2015; 14:1171-81. [PMID: 26515660 DOI: 10.1016/s1474-4422(15)00258-6] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 09/21/2015] [Accepted: 09/25/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Findings from observational studies have suggested a delay in nursing home placement with dementia drug treatment, but findings from a previous randomised trial of patients with mild-to-moderate Alzheimer's disease showed no effect. We investigated the effects of continuation or discontinuation of donepezil and starting of memantine on subsequent nursing home placement in patients with moderate-to-severe Alzheimer's disease. METHODS In the randomised, double-blind, placebo-controlled Donepezil and Memantine in Moderate to Severe Alzheimer's Disease (DOMINO-AD) trial, community-living patients with moderate-to-severe Alzheimer's disease (who had been prescribed donepezil continuously for at least 3 months at a dose of 10 mg for at least the previous 6 weeks and had a score of between 5 and 13 on the Standardised Mini-Mental State Examination) were recruited from 15 secondary care memory centres in England and Scotland and randomly allocated to continue donepezil 10 mg per day without memantine, discontinue donepezil without memantine, discontinue donepezil and start memantine 20 mg per day, or continue donepezil 10 mg per day and start memantine 20 mg per day, for 52 weeks. After 52 weeks, choice of treatment was left to participants and their physicians. Place of residence was recorded during the first 52 weeks of the trial and then every 26 weeks for a further 3 years. A secondary outcome of the trial, reported in this study, was nursing home placement: an irreversible move from independent accommodation to a residential caring facility. Analyses restricted to risk of placement in the first year of follow-up after the patients had completed the double-blind phase of the trial were post-hoc. The DOMINO-AD trial is registered with the ISRCTN Registry, number ISRCTN49545035. FINDINGS Between Feb 11, 2008, and March 5, 2010, 73 (25%) patients were randomly assigned to continue donepezil without memantine, 73 (25%) to discontinue donepezil without memantine, 76 (26%) to discontinue donepezil and start memantine, and 73 (25%) to continue donepezil and start memantine. 162 (55%) patients underwent nursing home placement within 4 years of randomisation, with similar numbers for all groups (36 [49%] in patients who continued donepezil without memantine, 42 [58%] who discontinued donepezil without memantine, 41 [54%] who discontinued donepezil and started memantine, and 43 [59%] who continued donepezil and started memantine). We noted significant (p=0·010) heterogeneity of treatment effect over time, with significantly more nursing home placements in the combined donepezil discontinuation groups during the first year (hazard ratio 2·09 [95% CI 1·29-3·39]) than in the combined donepezil continuation groups, and no difference during the next 3 years (0·89 [0·58-1·35]). We noted no effect of patients starting memantine compared with not starting memantine during the first year (0·92 [0·58-1·45]) or the next 3 years (1·23 [0·81-1·87]). INTERPRETATION Withdrawal of donepezil in patients with moderate-to-severe Alzheimer's disease increased the risk of nursing home placement during 12 months of treatment, but made no difference during the following 3 years of follow-up. Decisions to stop or continue donepezil treatment should be informed by potential risks of withdrawal, even if the perceived benefits of continued treatment are not clear. FUNDING Medical Research Council and UK Alzheimer's Society.
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Affiliation(s)
- Robert Howard
- Division of Psychiatry, University College London, London, UK; Department of Old Age Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
| | - Rupert McShane
- Oxford Health NHS Foundation Trust, Warneford Hospital, Headington, Oxford, UK
| | | | - Craig Ritchie
- Centre for Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Ashley Baldwin
- Five Boroughs Partnership NHS Foundation Trust, Winwick, Warrington, UK
| | - Robert Barber
- Centre for Ageing and Vitality, Newcastle upon Tyne, UK
| | - Alistair Burns
- Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester, UK
| | - Tom Dening
- Institute of Mental Health, University of Nottingham, Nottingham, UK
| | | | - Clive Holmes
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Robert Jones
- Department of Pyschiatry, University of Nottingham, Nottingham, UK
| | - Roy Jones
- Research Institute for the Care of Older People, Bath, UK
| | - Ian McKeith
- Newcastle; University Institute for Ageing, Newcastle University, Newcastle Upon Tyne, UK
| | - Ajay Macharouthu
- Ayrshire and Arran NHS, University Hospital Crosshouse, Crosshouse, Kilmarnock, UK
| | - John O'Brien
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Bart Sheehan
- Oxford University Hospitals NHS Trust, Headington, Oxford, UK
| | - Edmund Juszczak
- National Perinatal Epidemiology Unit Clinical Trials Unit, University of Oxford, Oxford, UK
| | | | - Robert Hills
- Cardiff University School of Medicine, Cardiff, UK
| | | | - Clive Ballard
- Wolfson Centre for Age Related Disorders, King's College London, London, UK
| | | | - Sube Banerjee
- Brighton and Sussex Medical School, University of Sussex, Brighton, East Sussex, UK
| | - Jessica Adams
- Department of Old Age Psychiatry, King's College London, London, UK
| | - Tony Johnson
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Peter Bentham
- Birmingham and Solihull Mental Health NHS Foundation Trust, Birmingham, UK
| | - Patrick P J Phillips
- Medical Research Council Clinical Trials Unit, University College London, London, UK
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Wischik CM, Staff RT, Wischik DJ, Bentham P, Murray AD, Storey JMD, Kook KA, Harrington CR. Tau aggregation inhibitor therapy: an exploratory phase 2 study in mild or moderate Alzheimer's disease. J Alzheimers Dis 2015; 44:705-20. [PMID: 25550228 DOI: 10.3233/jad-142874] [Citation(s) in RCA: 170] [Impact Index Per Article: 18.9] [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 As tau aggregation pathology correlates with clinical dementia in Alzheimer's disease (AD), a tau aggregation inhibitor (TAI) could have therapeutic utility. Methylthioninium (MT) acts as a selective TAI in vitro and reduces tau pathology in transgenic mouse models. OBJECTIVE To determine the minimum safe and effective dose of MT required to prevent disease progression on clinical and functional molecular imaging outcomes. METHODS An exploratory double-blind, randomized, placebo-controlled, dose-finding trial of MT (69, 138, and 228 mg/day) was conducted in 321 mild/moderate AD subjects. The primary outcome was change on the Alzheimer's Disease Assessment Scale-cognitive subscale (ADAS-cog) at 24 weeks relative to baseline severity. Effect of treatment on regional cerebral blood flow decline was determined in a sub-study in 135 subjects. After 24 weeks, subjects were re-consented to enter sequential 6- and 12-month blinded extension phases. Registered with ClinicalTrials.gov (NCT00515333). RESULTS At 24 weeks, there were significant treatment benefits in two independent populations at the 138 mg/day dose: in moderate subjects on the ADAS-cog scale (treatment effect: -5.42 units, corrected p = 0.047) and two other clinical scales; in mild subjects on the more sensitive regional cerebral blood flow measure (treatment effect: 1.97%, corrected p < 0.001). With continued treatment for 50 weeks, benefit was seen on the ADAS-cog scale in both mild and moderate subjects. The delivery of the highest dose was impaired due to dose-dependent dissolution and absorption limitations. CONCLUSION The minimum safe and effective daily MT dose is 138 mg and suggests that further study of MT is warranted in AD.
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Affiliation(s)
- Claude M Wischik
- School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK
| | - Roger T Staff
- Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | | | - Peter Bentham
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Alison D Murray
- Aberdeen Biomedical Imaging Centre, School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK
| | - John M D Storey
- Department of Chemistry, University of Aberdeen, Aberdeen, UK
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Wheeler NL, Allen JL, Bentham P, Cook E, Davies Y, McDonald P. A specialist welfare advice and advocacy service for people with early onset dementia. ACTA ACUST UNITED AC 2015. [DOI: 10.7748/mhp.18.10.20.e948] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Baker R, Bentham P, Kourtzi Z. Learning to predict is spared in mild cognitive impairment due to Alzheimer's disease. Exp Brain Res 2015; 233:2859-67. [PMID: 26105754 DOI: 10.1007/s00221-015-4356-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [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: 02/17/2015] [Accepted: 06/09/2015] [Indexed: 12/01/2022]
Abstract
Learning the statistics of the environment is critical for predicting upcoming events. However, little is known about how we translate previous knowledge about scene regularities to sensory predictions. Here, we ask whether patients with mild cognitive impairment due to Alzheimer's disease (MCI-AD) that are known to have spared implicit but impaired explicit recognition memory are able to learn temporal regularities and predict upcoming events. We tested the ability of MCI-AD patients and age-matched controls to predict the orientation of a test stimulus following exposure to sequences of leftwards or rightwards oriented gratings. Our results demonstrate that exposure to temporal sequences without feedback facilitates the ability to predict an upcoming stimulus in both MCI-AD patients and controls. Further, we show that executive cognitive control may account for individual variability in predictive learning. That is, we observed significant positive correlations of performance in attentional and working memory tasks with post-training performance in the prediction task. Taken together, these results suggest a mediating role of circuits involved in cognitive control (i.e. frontal circuits) that may support the ability for predictive learning in MCI-AD.
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Affiliation(s)
- Rosalind Baker
- School of Psychology, University of Birmingham, Birmingham, B15 2TT, UK
| | - Peter Bentham
- Birmingham and Solihull Mental Health Foundation Trust (BSMHFT), Edgbaston, Birmingham, UK
| | - Zoe Kourtzi
- Department of Psychology, University of Cambridge, Cambridge, UK.
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Di Bernardi Luft C, Baker R, Bentham P, Kourtzi Z. Learning temporal statistics for sensory predictions in mild cognitive impairment. Neuropsychologia 2015; 75:368-80. [PMID: 26093288 DOI: 10.1016/j.neuropsychologia.2015.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [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: 02/17/2015] [Revised: 05/28/2015] [Accepted: 06/02/2015] [Indexed: 10/23/2022]
Abstract
Training is known to improve performance in a variety of perceptual and cognitive skills. However, there is accumulating evidence that mere exposure (i.e. without supervised training) to regularities (i.e. patterns that co-occur in the environment) facilitates our ability to learn contingencies that allow us to interpret the current scene and make predictions about future events. Recent neuroimaging studies have implicated fronto-striatal and medial temporal lobe brain regions in the learning of spatial and temporal statistics. Here, we ask whether patients with mild cognitive impairment due to Alzheimer's disease (MCI-AD) that are characterized by hippocampal dysfunction are able to learn temporal regularities and predict upcoming events. We tested the ability of MCI-AD patients and age-matched controls to predict the orientation of a test stimulus following exposure to sequences of leftwards or rightwards orientated gratings. Our results demonstrate that exposure to temporal sequences without feedback facilitates the ability to predict an upcoming stimulus in both MCI-AD patients and controls. However, our fMRI results demonstrate that MCI-AD patients recruit an alternate circuit to hippocampus to succeed in learning of predictive structures. In particular, we observed stronger learning-dependent activations for structured sequences in frontal, subcortical and cerebellar regions for patients compared to age-matched controls. Thus, our findings suggest a cortico-striatal-cerebellar network that may mediate the ability for predictive learning despite hippocampal dysfunction in MCI-AD.
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Affiliation(s)
| | - Rosalind Baker
- School of Psychology, University of Birmingham, Birmingham B15 2TT, UK
| | - Peter Bentham
- Birmingham and Solihull Mental Health Foundation Trust (BSMHFT), Edgbaston, Birmingham, UK
| | - Zoe Kourtzi
- Department of Psychology, University of Cambridge, Cambridge, UK.
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Smythe A, Jenkins C, Harries M, Atkins S, Miller J, Wright J, Wheeler N, Dee P, Bentham P, Oyebode J. Evaluation of dementia training for staff in acute hospital settings. Nurs Older People 2014; 26:18-24. [PMID: 24576247 DOI: 10.7748/nop2014.02.26.2.18.e527] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The development, pilot and evaluation of a brief psychosocial training intervention (BPTI) for staff working with people with dementia in an acute hospital setting are described. The project had two phases. Phase one involved adapting an existing competency framework and developing the BPTI using focus groups. For the pilot and evaluation, in phase two, a mixed methods approach was adopted using self-administered standardised questionnaires and qualitative interviews. Qualitative analysis suggested that delivering skills-based training can develop communication, problem-solving and self-directed learning skills; benefit staff in terms of increased knowledge, skills and confidence; and be problematic in the clinical area in terms of time, organisation and the physical environment. These factors must be taken into consideration when delivering training. These changes were not reflected in the quantitative results and measures were not always sensitive to changes in this setting. Definitive conclusions cannot be drawn about the efficacy of the intervention, due to the contradictory outcomes between the quantitative and qualitative data. Further developments and research are required to explore how staff and organisations can be supported to deliver the best possible care.
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Affiliation(s)
- Analisa Smythe
- Birmingham and Solihull Mental Health Foundation Trust (BSMHFT)
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36
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Leroi I, Woolham J, Gathercole R, Howard R, Dunk B, Fox C, O’Brien J, Bateman A, Poland F, Bentham P, Burns A, Davies A, Forsyth K, Gray R, Knapp M, Newman S, McShane R, Ritchie C. Does telecare prolong community living in dementia? A study protocol for a pragmatic, randomised controlled trial. Trials 2013; 14:349. [PMID: 24152600 PMCID: PMC4015839 DOI: 10.1186/1745-6215-14-349] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Accepted: 10/08/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Assistive technology and telecare (ATT) are relatively new ways of delivering care and support to people with social care needs. It is claimed that ATT reduces the need for community care, prevents unnecessary hospital admission, and delays or prevents admission into residential or nursing care. The current economic situation in England has renewed interest in ATT instead of community care packages. However, at present, the evidence base to support claims about the impact and effectiveness of ATT is limited, despite its potential to mitigate the high financial cost of caring for people with dementia and the social and psychological cost to unpaid carers. METHOD/DESIGN ATTILA (Assistive Technology and Telecare to maintain Independent Living At Home for People with Dementia) is a pragmatic, multi-centre, randomised controlled trial over 104 weeks that compares outcomes for people with dementia who receive ATT and those who receive equivalent community services but not ATT. The study hypothesis is that fewer people in the ATT group will go into institutional care over the 4-year period for which the study is funded. The study aims to recruit 500 participants, living in community settings, with dementia or significant cognitive impairment, who have recently been referred to social services.Primary outcome measures are time in days from randomisation to institutionalisation and cost effectiveness. Secondary outcomes are caregiver burden, health-related quality of life in carers, number and severity of serious adverse events, and data on acceptability, applicability and reliability of ATT intervention packages. Assessments will be undertaken in weeks 0 (baseline), 12, 24, 52 and 104 or until institutionalisation or withdrawal of the participant from the trial. DISCUSSION In a time of financial austerity, CASSRs in England are increasingly turning to ATT in the belief that it will deliver good outcomes for less money. There is an absence of robust evidence for the cost-effectiveness and benefit of using assistive technology and telecare. The ATTILA trial meets a pressing need for robust, generalisable evidence to either justify continuing investment or reappraise the appropriate scale of ATT use. TRIAL REGISTRATION Current Controlled Trials ISRCTN86537017.
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Affiliation(s)
- Iracema Leroi
- Institute of Brain, Behaviour and Mental Health, University of Manchester, Jean McFarlane Building, 3rd floor, Oxford Rd, Manchester M13 9PL, UK
| | - John Woolham
- Faculty of Health & Life Sciences, Charles Ward Building, Coventry University, Coventry CV1 5FB, UK
| | - Rebecca Gathercole
- Department of Old Age Psychiatry, King’s College London, Institute of Psychiatry, De Crespigny Park, Box 070, London SE5 8AF, UK
| | - Robert Howard
- Department of Old Age Psychiatry, Institute of Psychiatry, De Crespigny Park, Box 070, London SE5 8AF, UK
| | - Barbara Dunk
- South London & Maudsley NHS Foundation Trust, 115 Denmark Hill, The Maudsley, London SE5 8AZ, UK
| | - Chris Fox
- School of Medicine, Health Policy and Practice, University of East Anglia, Norwich, Norfolk NR4 7TJ, UK
| | - John O’Brien
- Department of Psychiatry, University of Cambridge, Level E4, Box 189, Addenbrookes Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Andrew Bateman
- Oliver Zangwill Centre for Neuropsychological Rehabilitation, Princess of Wales Hospital, Ely CB6 1DN, UK
| | - Fiona Poland
- School of Allied Health Professionals, University of East Anglia, Norwich, Norfolk NR7 4TJ, UK
| | - Peter Bentham
- The Barberry Centre, 25 Vincent Drive, Birmingham B15 2FG, UK
| | - Alistair Burns
- School of Community Based Medicine, University of Manchester, Jean McFarlane Building, 3rd floor, Oxford Rd, Manchester M139PL, UK
| | - Anna Davies
- School of Community and Health Science, City University, University Building A224, St John St, London EC1V 0HB, UK
| | | | - Richard Gray
- Clinical Trial Service Unit, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford OX3 7TF, UK
| | - Martin Knapp
- Personal Social Services Research Unit, London School of Economics and Political Science, Houghton St, London WC2A 2AE, UK
| | - Stanton Newman
- School of Community and Health Sciences, City University, Northampton Square, London EC1V 0HB, UK
| | - Rupert McShane
- Oxfordshire & Buckinghamshire Mental Health NHS Foundation Trust, Warneford Hospital, Old Road, Headington, Oxford OX3 7JX, UK
| | - Craig Ritchie
- Centre for Mental Health, Imperial College London, Claybrook Centre, Charing Cross Campus 37 Claybrook Rd, London W6 8LN, UK
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Banerjee S, Hellier J, Romeo R, Dewey M, Knapp M, Ballard C, Baldwin R, Bentham P, Fox C, Holmes C, Katona C, Lawton C, Lindesay J, Livingston G, McCrae N, Moniz-Cook E, Murray J, Nurock S, Orrell M, O'Brien J, Poppe M, Thomas A, Walwyn R, Wilson K, Burns A. Study of the use of antidepressants for depression in dementia: the HTA-SADD trial--a multicentre, randomised, double-blind, placebo-controlled trial of the clinical effectiveness and cost-effectiveness of sertraline and mirtazapine. Health Technol Assess 2013; 17:1-166. [PMID: 23438937 DOI: 10.3310/hta17070] [Citation(s) in RCA: 117] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Depression is common in dementia, causing considerable distress and other negative impacts. Treating it is a clinical priority, but the evidence base is sparse and equivocal. This trial aimed to determine clinical effectiveness of sertraline and mirtazapine in reducing depression 13 weeks post randomisation compared with placebo. DESIGN Multicentre, parallel-group, double-blind placebo-controlled randomised controlled trial of the clinical effectiveness of sertraline and mirtazapine with 13- and 39-week follow-up. SETTING Nine English old-age psychiatry services. PARTICIPANTS A pragmatic trial. Eligibility: probable or possible Alzheimer's disease (AD), depression (4+ weeks) and Cornell Scale for Depression in Dementia (CSDD) score of 8+. EXCLUSIONS clinically too critical (e.g. suicide risk); contraindication to medication; taking antidepressants; in another trial; and having no carer. INTERVENTIONS (1) Sertraline; (2) mirtazapine; and (3) placebo, all with normal care. Target doses: 150 mg of sertraline or 45 mg of mirtazapine daily. MAIN OUTCOME MEASURES OUTCOME CSDD score. Randomisation: Allocated 1 : 1 : 1 through Trials Unit, independently of trial team. Stratified block randomisation by centre, with randomly varying block sizes; computer-generated randomisation. Blinding: Double blind: medication and placebo identical for each antidepressant. Referring clinicians, research workers, participants and pharmacies were blind. Statisticians blind until analyses completed. RESULTS Numbers randomised: 326 participants randomised (111 placebo, 107 sertraline and 108 mirtazapine). OUTCOME Differences in CSDD at 13 weeks from an adjusted linear-mixed model: mean difference (95% CI) placebo-sertraline 1.17 (-0.23 to 2.78; p = 0.102); placebo-mirtazapine 0.01 (-1.37 to 1.38; p = 0.991); and mirtazapine-sertraline 1.16 (-0.27 to 2.60; p = 0.112). HARMS Placebo group had fewer adverse reactions (29/111, 26%) than sertraline (46/107, 43%) or mirtazapine (44/108, 41%; p = 0.017); 39-week mortality equal, five deaths in each group. CONCLUSIONS This is a trial with negative findings but important clinical implications. The data suggest that the antidepressants tested, given with normal care, are not clinically effective (compared with placebo) for clinically significant depression in AD. This implies a need to change current practice of antidepressants being the first-line treatment of depression in AD. From the data generated we formulated the following recommendations for future work. (1) The secondary analyses presented here suggest that there would be value in carrying out a placebo-controlled trial of the clinical effectiveness and cost-effectiveness of mirtazapine in the management of Behavioural and Psychological Symptoms of Dementia. (2) A conclusion from this study is that it remains both ethical and essential for trials of new medication for depression in dementia to have a placebo arm. (3) Further research is required to evaluate the impact that treatments for depression in people with dementia can have on their carers not only in terms of any impacts on their quality of life, but also the time they spend care-giving. (4) There is a need for research into alternative biological and psychological therapies for depression in dementia. These could include evaluations of new classes of antidepressants (such as venlafaxine) or antidementia medication (e.g. cholinesterase inhibitors). (5) Research is needed to investigate the natural history of depression in dementia in the community when patients are not referred to secondary care services. (6) Further work is needed to investigate the cost modelling results in this rich data set, investigating carer burden and possible moderators to the treatment effects. (7) There is scope for reanalysis of the primary outcome in terms of carer and participant CSDD results.
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Affiliation(s)
- S Banerjee
- Brighton and Sussex Medical School, BSMS Teaching Building, University of Sussex, Brighton, UK
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Davenward S, Bentham P, Wright J, Crome P, Job D, Polwart A, Exley C. Silicon-rich mineral water as a non-invasive test of the 'aluminum hypothesis' in Alzheimer's disease. J Alzheimers Dis 2013; 33:423-30. [PMID: 22976072 DOI: 10.3233/jad-2012-121231] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
There has been a plausible link between human exposure to aluminum and Alzheimer's disease for several decades. We contend that the only direct and ethically acceptable experimental test of the 'aluminum hypothesis', which would provide unequivocal data specific to the link, is to test the null hypothesis that a reduction in the body burden of aluminum to its lowest practical limit would have no influence upon the incidence, progression, or severity of Alzheimer's disease. Herein we are testing the hypothesis that silicon-rich mineral waters can be used as non-invasive methods to reduce the body burden of aluminum in individuals with Alzheimer's disease and a control group consisting of their carers and partners. We have shown that drinking up to 1 L of a silicon-rich mineral water each day for 12 weeks facilitated the removal of aluminum via the urine in both patient and control groups without any concomitant affect upon the urinary excretion of the essential metals, iron and copper. We have provided preliminary evidence that over 12 weeks of silicon-rich mineral water therapy the body burden of aluminum fell in individuals with Alzheimer's disease and, concomitantly, cognitive performance showed clinically relevant improvements in at least 3 out of 15 individuals. This is a first step in a much needed rigorous test of the 'aluminum hypothesis of Alzheimer's disease' and a longer term study involving many more individuals is now warranted.
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Affiliation(s)
- Samantha Davenward
- The Birchall Centre, Lennard-Jones Laboratories, Keele University, Stoke-on-Trent, Staffordshire, UK
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Romeo R, Knapp M, Hellier J, Dewey M, Ballard C, Baldwin R, Bentham P, Burns A, Fox C, Holmes C, Katona C, Lawton C, Lindesay J, Livingston G, McCrae N, Moniz-Cook E, Murray J, Nurock S, O'Brien J, Poppe M, Thomas A, Walwyn R, Wilson K, Banerjee S. Cost-effectiveness analyses for mirtazapine and sertraline in dementia: randomised controlled trial. Br J Psychiatry 2013; 202:121-8. [PMID: 23258767 DOI: 10.1192/bjp.bp.112.115212] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [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: 11/23/2022]
Abstract
BACKGROUND Depression is a common and costly comorbidity in dementia. There are very few data on the cost-effectiveness of antidepressants for depression in dementia and their effects on carer outcomes. AIMS To evaluate the cost-effectiveness of sertraline and mirtazapine compared with placebo for depression in dementia. METHOD A pragmatic, multicentre, randomised placebo-controlled trial with a parallel cost-effectiveness analysis (trial registration: ISRCTN88882979 and EudraCT 2006-000105-38). The primary cost-effectiveness analysis compared differences in treatment costs for patients receiving sertraline, mirtazapine or placebo with differences in effectiveness measured by the primary outcome, total Cornell Scale for Depression in Dementia (CSDD) score, over two time periods: 0-13 weeks and 0-39 weeks. The secondary evaluation was a cost-utility analysis using quality-adjusted life years (QALYs) computed from the Euro-Qual (EQ-5D) and societal weights over those same periods. RESULTS There were 339 participants randomised and 326 with costs data (111 placebo, 107 sertraline, 108 mirtazapine). For the primary outcome, decrease in depression, mirtazapine and sertraline were not cost-effective compared with placebo. However, examining secondary outcomes, the time spent by unpaid carers caring for participants in the mirtazapine group was almost half that for patients receiving placebo (6.74 v. 12.27 hours per week) or sertraline (6.74 v. 12.32 hours per week). Informal care costs over 39 weeks were £1510 and £1522 less for the mirtazapine group compared with placebo and sertraline respectively. CONCLUSIONS In terms of reducing depression, mirtazapine and sertraline were not cost-effective for treating depression in dementia. However, mirtazapine does appear likely to have been cost-effective if costing includes the impact on unpaid carers and with quality of life included in the outcome. Unpaid (family) carer costs were lower with mirtazapine than sertraline or placebo. This may have been mediated via the putative ability of mirtazapine to ameliorate sleep disturbances and anxiety. Given the priority and the potential value of supporting family carers of people with dementia, further research is warranted to investigate the potential of mirtazapine to help with behavioural and psychological symptoms in dementia and in supporting carers.
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Affiliation(s)
- Renee Romeo
- Brighton & Sussex Medical School, University of Sussex, Brighton, East Sussex, UK.
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Howard R, McShane R, Lindesay J, Ritchie C, Baldwin A, Barber R, Burns A, Dening T, Findlay D, Holmes C, Hughes A, Jacoby R, Jones R, Jones R, McKeith I, Macharouthu A, O'Brien J, Passmore P, Sheehan B, Juszczak E, Katona C, Hills R, Knapp M, Ballard C, Brown R, Banerjee S, Onions C, Griffin M, Adams J, Gray R, Johnson T, Bentham P, Phillips P. Donepezil and memantine for moderate-to-severe Alzheimer's disease. N Engl J Med 2012; 366:893-903. [PMID: 22397651 DOI: 10.1056/nejmoa1106668] [Citation(s) in RCA: 391] [Impact Index Per Article: 32.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Clinical trials have shown the benefits of cholinesterase inhibitors for the treatment of mild-to-moderate Alzheimer's disease. It is not known whether treatment benefits continue after the progression to moderate-to-severe disease. METHODS We assigned 295 community-dwelling patients who had been treated with donepezil for at least 3 months and who had moderate or severe Alzheimer's disease (a score of 5 to 13 on the Standardized Mini-Mental State Examination [SMMSE, on which scores range from 0 to 30, with higher scores indicating better cognitive function]) to continue donepezil, discontinue donepezil, discontinue donepezil and start memantine, or continue donepezil and start memantine. Patients received the study treatment for 52 weeks. The coprimary outcomes were scores on the SMMSE and on the Bristol Activities of Daily Living Scale (BADLS, on which scores range from 0 to 60, with higher scores indicating greater impairment). The minimum clinically important differences were 1.4 points on the SMMSE and 3.5 points on the BADLS. RESULTS Patients assigned to continue donepezil, as compared with those assigned to discontinue donepezil, had a score on the SMMSE that was higher by an average of 1.9 points (95% confidence interval [CI], 1.3 to 2.5) and a score on the BADLS that was lower (indicating less impairment) by 3.0 points (95% CI, 1.8 to 4.3) (P<0.001 for both comparisons). Patients assigned to receive memantine, as compared with those assigned to receive memantine placebo, had a score on the SMMSE that was an average of 1.2 points higher (95% CI, 0.6 to 1.8; P<0.001) and a score on the BADLS that was 1.5 points lower (95% CI, 0.3 to 2.8; P=0.02). The efficacy of donepezil and of memantine did not differ significantly in the presence or absence of the other. There were no significant benefits of the combination of donepezil and memantine over donepezil alone. CONCLUSIONS In patients with moderate or severe Alzheimer's disease, continued treatment with donepezil was associated with cognitive benefits that exceeded the minimum clinically important difference and with significant functional benefits over the course of 12 months. (Funded by the U.K. Medical Research Council and the U.K. Alzheimer's Society; Current Controlled Trials number, ISRCTN49545035.).
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Affiliation(s)
- Robert Howard
- Institute of Psychiatry, King's College London, London SE5 8AF, United Kingdom.
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Howard R, Phillips P, Johnson T, O'Brien J, Sheehan B, Lindesay J, Bentham P, Burns A, Ballard C, Holmes C, McKeith I, Barber R, Dening T, Ritchie C, Jones R, Baldwin A, Passmore P, Findlay D, Hughes A, Macharouthu A, Banerjee S, Jones R, Knapp M, Brown RG, Jacoby R, Adams J, Griffin M, Gray R. Determining the minimum clinically important differences for outcomes in the DOMINO trial. Int J Geriatr Psychiatry 2011; 26:812-7. [PMID: 20848576 DOI: 10.1002/gps.2607] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.1] [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] [Received: 07/06/2010] [Accepted: 07/06/2010] [Indexed: 11/12/2022]
Abstract
BACKGROUND Although less likely to be reported in clinical trials than expressions of the statistical significance of differences in outcomes, whether or not a treatment has delivered a specified minimum clinically important difference (MCID) is also relevant to patients and their caregivers and doctors. Many dementia treatment randomised controlled trials (RCTs) have not reported MCIDs and, where they have been done, observed differences have not reached these. METHODS As part of the development of the Statistical Analysis Plan for the DOMINO trial, investigators met to consider expert opinion- and distribution-based values for the MCID and triangulated these to provide appropriate values for three outcome measures, the Standardised Mini-mental State Examination (sMMSE), Bristol Activities of Daily Living Scale (BADLS) and Neuropsychiatric Inventory (NPI). Only standard deviations (SD) were presented to investigators who remained blind to treatment allocation. RESULTS Adoption of values for MCIDs based upon 0.4 of the SD of the change in score from baseline on the sMMSE, BADLS and NPI in the first 127 participants to complete DOMINO yielded MCIDs of 1.4 points for sMMSE, 3.5 for BADLS and 8.0 for NPI. CONCLUSIONS Reference to MCIDs is important for the full interpretation of the results of dementia trials and those conducting such trials should be open about the way in which they have determined and chosen their values for the MCIDs.
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Affiliation(s)
- Robert Howard
- King's College London, Institute of Psychiatry, Department of Old Age Psychiatry, London, UK.
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Banerjee S, Hellier J, Dewey M, Romeo R, Ballard C, Baldwin R, Bentham P, Fox C, Holmes C, Katona C, Knapp M, Lawton C, Lindesay J, Livingston G, McCrae N, Moniz-Cook E, Murray J, Nurock S, Orrell M, O'Brien J, Poppe M, Thomas A, Walwyn R, Wilson K, Burns A. Sertraline or mirtazapine for depression in dementia (HTA-SADD): a randomised, multicentre, double-blind, placebo-controlled trial. Lancet 2011; 378:403-11. [PMID: 21764118 DOI: 10.1016/s0140-6736(11)60830-1] [Citation(s) in RCA: 301] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Depression is common in dementia but the evidence base for appropriate drug treatment is sparse and equivocal. We aimed to assess efficacy and safety of two of the most commonly prescribed drugs, sertraline and mirtazapine, compared with placebo. METHODS We undertook the parallel-group, double-blind, placebo-controlled, Health Technology Assessment Study of the Use of Antidepressants for Depression in Dementia (HTA-SADD) trial in participants from old-age psychiatry services in nine centres in England. Participants were eligible if they had probable or possible Alzheimer's disease, depression (lasting ≥4 weeks), and a Cornell scale for depression in dementia (CSDD) score of 8 or more. Participants were ineligible if they were clinically critical (eg, suicide risk), contraindicated to study drugs, on antidepressants, in another trial, or had no carer. The clinical trials unit at King's College London (UK) randomly allocated participants with a computer-generated block randomisation sequence, stratified by centre, with varying block sizes, in a 1:1:1 ratio to receive sertraline (target dose 150 mg per day), mirtazapine (45 mg), or placebo (control group), all with standard care. The primary outcome was reduction in depression (CSDD score) at 13 weeks (outcomes to 39 weeks were also assessed), assessed with a mixed linear-regression model adjusted for baseline CSDD, time, and treatment centre. This study is registered, number ISRCTN88882979 and EudraCT 2006-000105-38. FINDINGS Decreases in depression scores at 13 weeks did not differ between 111 controls and 107 participants allocated to receive sertraline (mean difference 1·17, 95% CI -0·23 to 2·58; p=0·10) or mirtazapine (0·01, -1·37 to 1·38; p=0·99), or between participants in the mirtazapine and sertraline groups (1·16, -0·25 to 2·57; p=0·11); these findings persisted to 39 weeks. Fewer controls had adverse reactions (29 of 111 [26%]) than did participants in the sertraline group (46 of 107, 43%; p=0·010) or mirtazapine group (44 of 108, 41%; p=0·031), and fewer serious adverse events rated as severe (p=0·003). Five patients in every group died by week 39. INTERPRETATION Because of the absence of benefit compared with placebo and increased risk of adverse events, the present practice of use of these antidepressants, with usual care, for first-line treatment of depression in Alzheimer's disease should be reconsidered. FUNDING UK National Institute of Health Research HTA Programme.
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Affiliation(s)
- Sube Banerjee
- Institute of Psychiatry, Health Services and Population Research Department, King's College London, London, UK.
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Reilly TJ, Staff RT, Ahearn TS, Bentham P, Wischik CM, Murray AD. Regional cerebral blood flow and aberrant motor behaviour in Alzheimer's disease. Behav Brain Res 2011; 222:375-9. [PMID: 21507335 DOI: 10.1016/j.bbr.2011.04.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2011] [Revised: 03/29/2011] [Accepted: 04/03/2011] [Indexed: 11/25/2022]
Abstract
Aberrant motor behaviour (AMB) in Alzheimer's disease shares behavioural correlates with obsessive compulsive disorder (OCD). We investigated whether AMB was also comparable in terms of metabolic activity in the orbitofrontal cortex (OFC), an area shown to be hyperactive in OCD. In this study 135 patients meeting research criteria for Alzheimer's disease were identified from a database of patients recruited as part of a phase II drug trial. These patients were assessed using the Neuropsychiatric Inventory, the Alzheimer's disease assessment scale, cognitive subscale and perfusion SPECT performed with 99Tc(m) hexamethylpropyleneamine oxime. Regions of interest were created for orbitofrontal cortices and basal ganglia. In 35 patients with AMB, adjusted tracer uptake was greater in the OFC. This reached statistical significance in right superior, left superior, right medial and left medial orbital gyri (p < 0.05). The association between AMB and hyperactivity in the OFC remained significant after adjusting for the presence of anxiety. These results parallel the OFC hypermetabolism consistently seen in OCD. One model of OCD, proposes that dysfunctional interactions between frontal regions, including the OFC, produce the characteristic symptoms of OCD. The behaviour is though to be brought about by a perceived incompleteness of performing a task and is caused by an error in normal reward signals initiated upon task completion. These finding indicate that AMB in Alzheimer's disease are brought about by the same mechanistic failure.
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Affiliation(s)
- Thomas J Reilly
- Aberdeen Biomedical Imaging Centre, School of Medicine and Dentistry, University of Aberdeen, UK.
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Abstract
OBJECTIVES Performance on neuropsychological tests can be influenced by non-cognitive factors, including deliberate underperformance, stress, the need to fulfil a sick role, depression, un-cooperativeness, fatigue and unhappiness with the evaluative situation. Tests to detect suboptimal effort are becoming widely used in clinical practice and are based on their reported insensitivity to cognitive dysfunction. A diagnosis of dementia has life-changing implications for an individual of working age. It is therefore crucial that clinicians can be confident they have obtained a valid estimate of current cognitive functioning. This study aimed to establish whether mood or cognitive functioning adversely influenced performance on symptom validity tests (SVTs) in individuals with working age dementia, who were judged to be using full effort. METHOD Forty-two participants with dementia diagnosed before the age of 65 completed measures of emotional and cognitive functioning and six SVTs. RESULTS There were no significant correlations between emotional functioning and measures of effort. However, cognitive functioning, in particular new learning, was significantly related to SVT performance. Participants with mild dementia performed significantly better on all six SVTs than those with moderate/severe dementia. The results also suggest that the SVTs are not equally sensitive to cognitive dysfunction. Rey's Dot Counting Test (DCT) (times criterion) achieved 100% specificity, and was the only test passed by every participant. CONCLUSION Rey's DCT is the only SVT that can be recommended for use in those under 65 years with possible dementia at this time until further validation studies are undertaken.
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Affiliation(s)
- Natalie Rudman
- South Birmingham Primary Care Trust, Moseley Hall Hospital, Birmingham, UK
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Affiliation(s)
- Hanneke Thoonsen
- From the Department of Neurology (H.T., E.R., P.W.A.V.G., P.J.N.) and Clinical Research Unit (N.v.G., R.J.D.H.), Academic Medical Center, University of Amsterdam, The Netherlands; and Department of Psychiatry (P.B.); and Clinical Trials Unit, Robert Aitken Institute for Clinical Research (R.G.), University of Birmingham, United Kingdom
| | - Edo Richard
- From the Department of Neurology (H.T., E.R., P.W.A.V.G., P.J.N.) and Clinical Research Unit (N.v.G., R.J.D.H.), Academic Medical Center, University of Amsterdam, The Netherlands; and Department of Psychiatry (P.B.); and Clinical Trials Unit, Robert Aitken Institute for Clinical Research (R.G.), University of Birmingham, United Kingdom
| | - Peter Bentham
- From the Department of Neurology (H.T., E.R., P.W.A.V.G., P.J.N.) and Clinical Research Unit (N.v.G., R.J.D.H.), Academic Medical Center, University of Amsterdam, The Netherlands; and Department of Psychiatry (P.B.); and Clinical Trials Unit, Robert Aitken Institute for Clinical Research (R.G.), University of Birmingham, United Kingdom
| | - Richard Gray
- From the Department of Neurology (H.T., E.R., P.W.A.V.G., P.J.N.) and Clinical Research Unit (N.v.G., R.J.D.H.), Academic Medical Center, University of Amsterdam, The Netherlands; and Department of Psychiatry (P.B.); and Clinical Trials Unit, Robert Aitken Institute for Clinical Research (R.G.), University of Birmingham, United Kingdom
| | - Nan van Geloven
- From the Department of Neurology (H.T., E.R., P.W.A.V.G., P.J.N.) and Clinical Research Unit (N.v.G., R.J.D.H.), Academic Medical Center, University of Amsterdam, The Netherlands; and Department of Psychiatry (P.B.); and Clinical Trials Unit, Robert Aitken Institute for Clinical Research (R.G.), University of Birmingham, United Kingdom
| | - Rob J. De Haan
- From the Department of Neurology (H.T., E.R., P.W.A.V.G., P.J.N.) and Clinical Research Unit (N.v.G., R.J.D.H.), Academic Medical Center, University of Amsterdam, The Netherlands; and Department of Psychiatry (P.B.); and Clinical Trials Unit, Robert Aitken Institute for Clinical Research (R.G.), University of Birmingham, United Kingdom
| | - Willem A. Van Gool
- From the Department of Neurology (H.T., E.R., P.W.A.V.G., P.J.N.) and Clinical Research Unit (N.v.G., R.J.D.H.), Academic Medical Center, University of Amsterdam, The Netherlands; and Department of Psychiatry (P.B.); and Clinical Trials Unit, Robert Aitken Institute for Clinical Research (R.G.), University of Birmingham, United Kingdom
| | - Paul J. Nederkoorn
- From the Department of Neurology (H.T., E.R., P.W.A.V.G., P.J.N.) and Clinical Research Unit (N.v.G., R.J.D.H.), Academic Medical Center, University of Amsterdam, The Netherlands; and Department of Psychiatry (P.B.); and Clinical Trials Unit, Robert Aitken Institute for Clinical Research (R.G.), University of Birmingham, United Kingdom
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Middle F, Pritchard AL, Handoko H, Haque S, Holder R, Bentham P, Lendon CL. No association between neuregulin 1 and psychotic symptoms in Alzheimer's disease patients. J Alzheimers Dis 2010; 20:561-7. [PMID: 20182055 DOI: 10.3233/jad-2010-1405] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Alzheimer's disease (AD) patients commonly suffer from behavioral and psychological symptoms of dementia (BPSD). Variants within the neuregulin-1 (NRG1) gene have been investigated both in early onset psychiatric disorders, such as schizophrenia and recently in AD patients with psychosis. In this study, we analyzed NRG1 variants in AD patients with and without psychosis. Our large cohort of 399 probable AD patients had longitudinal information on the BPSD, which was used to dichotomize patients into whether they had ever suffered from psychotic symptoms within the study period. The NRG1 single nucleotide polymorphisms rs3924999, rs35753505 (SNP8NRG221533) and the microsatellites 478B14-848 and 420M9-1395 were investigated for association with psychosis using genotype, allele, and haplotype analyses. No associations were found between any of these variants or haplotypic combinations with delusions, hallucinations, psychosis, or elation/mania in our cohort. Positive associations with polymorphisms and haplotype combinations of NRG1 have been reported in psychiatric disorders. One previous study found an association with psychosis in AD, with a SNP outside the haplotype block first reported for association with schizophrenia. We found no association with any of these variants in our cohort. Further investigations of this region on chromosome 8 are clearly required, with replication in different large longitudinal cohorts.
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Affiliation(s)
- Fiona Middle
- Molecular Psychiatry Group, Institute of Biomedical Research, University of Birmingham, Birmingham, UK
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Richard E, Thoonsen H, Bentham P, Gray R, De Haan RJ, Van Gool WA, Nederkoorn PJ. P4‐145: Aspirin in Alzheimer's Disease: Increased Risk of Intracerebral Haemorrhage and no Clinical Benefit. Alzheimers Dement 2010. [DOI: 10.1016/j.jalz.2010.08.204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [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)
- Edo Richard
- Academic Medical Center University of AmsterdamAmsterdam Netherlands
| | - Hanneke Thoonsen
- Academic Medical Center University of AmsterdamAmsterdam Netherlands
| | | | - Richard Gray
- University of BirminghamBirmingham United Kingdom
| | - Rob J. De Haan
- Academic Medical Center University of AmsterdamAmsterdam Netherlands
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Pritchard AL, Ratcliffe L, Sorour E, Haque S, Holder R, Bentham P, Lendon CL. Investigation of dopamine receptors in susceptibility to behavioural and psychological symptoms in Alzheimer's disease. Int J Geriatr Psychiatry 2009; 24:1020-5. [PMID: 19235789 DOI: 10.1002/gps.2214] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [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: 11/07/2022]
Abstract
OBJECTIVE Alzheimer's disease (AD) patients commonly suffer from behavioural and psychological symptoms of dementia (BPSD). A genetic component to the development of BPSD in AD has been supported. Polymorphisms within dopamine receptors DRD1, DRD2, DRD3 and DRD4 have previously been investigated in a few interesting studies that are reviewed here and extended using our patient cohort. METHODS Our large cohort of 395 probable AD patients had longitudinal information on the BPSD (Neuropsychiatric Inventory), which was used to dichotomise patients into whether they had ever suffered from a given symptom within the study period, or not. These measures were related to the DRD1 (A-48G), DRD2 (ser311cys; C-ins/del), DRD3 (ser9gly) and DRD4 (VNTR) genotype and allele frequencies. RESULTS Associations were revealed between DRD3 and elation, and between DRD4 with agitation/aggression and with depression; however, these findings do not remain significant after correction for multiple testing. No associations were found with the other genetic variants and these symptoms and no associations were observed between any of the polymorphic variants examined and delusions, hallucinations, psychosis and aberrant motor behaviour. CONCLUSION Our data, in combination with a review of the literature, reveal a potential role for the VNTR variant of DRD4 in the development of depression in AD patients. The findings presented here need to be replicated in large, well characterised longitudinal cohorts.
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Affiliation(s)
- Antonia L Pritchard
- Molecular Psychiatry Group, Population Studies and Human Genetics, G Floor CBCRC Building, Queensland Institute of Medical Research, Herston, Brisbane, 4006, Australia.
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Jones R, Sheehan B, Phillips P, Juszczak E, Adams J, Baldwin A, Ballard C, Banerjee S, Barber B, Bentham P, Brown R, Burns A, Dening T, Findlay D, Gray R, Griffin M, Holmes C, Hughes A, Jacoby R, Johnson T, Jones R, Knapp M, Lindesay J, McKeith I, McShane R, Macharouthu A, O'Brien J, Onions C, Passmore P, Raftery J, Ritchie C, Howard R. DOMINO-AD protocol: donepezil and memantine in moderate to severe Alzheimer's disease - a multicentre RCT. Trials 2009; 10:57. [PMID: 19630974 PMCID: PMC2723100 DOI: 10.1186/1745-6215-10-57] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2009] [Accepted: 07/24/2009] [Indexed: 12/04/2022] Open
Abstract
Background Alzheimer's disease (AD) is the commonest cause of dementia. Cholinesterase inhibitors, such as donepezil, are the drug class with the best evidence of efficacy, licensed for mild to moderate AD, while the glutamate antagonist memantine has been widely prescribed, often in the later stages of AD. Memantine is licensed for moderate to severe dementia in AD but is not recommended by the England and Wales National Institute for Health and Clinical Excellence. However, there is little evidence to guide clinicians as to what to prescribe as AD advances; in particular, what to do as the condition progresses from moderate to severe. Options include continuing cholinesterase inhibitors irrespective of decline, adding memantine to cholinesterase inhibitors, or prescribing memantine instead of cholinesterase inhibitors. The aim of this trial is to establish the most effective drug option for people with AD who are progressing from moderate to severe dementia despite treatment with donepezil. Method DOMINO-AD is a pragmatic, 15 centre, double-blind, randomized, placebo controlled trial. Patients with AD, currently living at home, receiving donepezil 10 mg daily, and with Standardized Mini-Mental State Examination (SMMSE) scores between 5 and 13 are being recruited. Each is randomized to one of four treatment options: continuation of donepezil with memantine placebo added; switch to memantine with donepezil placebo added; donepezil and memantine together; or donepezil placebo with memantine placebo. 800 participants are being recruited and treatment continues for one year. Primary outcome measures are cognition (SMMSE) and activities of daily living (Bristol Activities of Daily Living Scale). Secondary outcomes are non-cognitive dementia symptoms (Neuropsychiatric Inventory), health related quality of life (EQ-5D and DEMQOL-proxy), carer burden (General Health Questionnaire-12), cost effectiveness (using Client Service Receipt Inventory) and institutionalization. These outcomes are assessed at baseline, 6, 18, 30 and 52 weeks. All participants will be subsequently followed for 3 years by telephone interview to record institutionalization. Discussion There is considerable debate about the clinical and cost effectiveness of anti-dementia drugs. DOMINO-AD seeks to provide clear evidence on the best treatment strategies for those managing patients at a particularly important clinical transition point. Trial registration Current controlled trials ISRCTN49545035
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Affiliation(s)
- Rob Jones
- Section of Old Age Psychiatry, The University of Nottingham, A Floor, South Block, Queen's Medical Centre, Nottingham NG7 2UH, UK.
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Pritchard AL, Pritchard CW, Bentham P, Lendon CL. Investigation of the role of the dopamine transporter in susceptibility to behavioural and psychological symptoms of patients with probable Alzheimer's disease. Dement Geriatr Cogn Disord 2009; 26:257-60. [PMID: 18841010 DOI: 10.1159/000160958] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [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] [Accepted: 05/16/2008] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Alzheimer's disease patients commonly suffer from behavioural and psychological symptoms of dementia (BPSD); a genetic component to the development of BPSD has been demonstrated. Genetic risk factors for other psychiatric disorders have been implicated in BPSD; however, this is the first known investigation of the dopamine transporter (DAT1) gene in BPSD. METHODS Our large cohort of 395 patients with probable Alzheimer's disease was dichotomised into whether they had ever suffered from a given symptom over the study period or not, based on longitudinal data using the BPSD (Neuropsychiatric Inventory). These measures were related to the DAT1 3'-untranslated region (UTR) variable number tandem repeat (VNTR) polymorphism. RESULTS Potential associations were revealed between the 9-repeat allele and presence of irritability and between the 10-repeat allele and aberrant motor behaviour (AMB); however, these do not remain significant after correction for multiple testing. No associations were observed with delusions, hallucinations, depression, agitation/aggression or elation. CONCLUSION Our data suggest that the DAT1 3'-UTR VNTR could play a role in susceptibility to irritability and AMB. The findings presented here require replication in large well-characterised cohorts.
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Affiliation(s)
- Antonia L Pritchard
- Molecular Psychiatry Group, Population Studies and Human Genetics, Queensland Institute of Medical Research, Brisbane, Qld., Australia.
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