Assessing frailty at the centers for dementia and cognitive decline in Italy: potential implications for improving care of older people living with dementia

INTRODUCTION

Frailty is strongly associated with the clinical course of cognitive impairment and dementia, thus arguing for the need of its assessment in individuals affected by cognitive deficits. This study aimed to retrospectively evaluate frailty in patients aged 65 years and older referred to two Centers for Cognitive Decline and Dementia (CCDDs).

METHODS

A total of 1256 patients consecutively referred for a first visit to two CCDDs in Lombardy (Italy) between January 2021 to July 2022 were included. All patients were evaluated by an expert physician in diagnosis and care of dementia according to a standardized clinical protocol. Frailty was assessed using a 24-items Frailty Index (FI) based on routinely collected health records, excluding cognitive decline or dementia, and categorized as mild, moderate, and severe.

RESULTS

Overall, 40% of patients were affected by mild frailty and 25% of the sample has moderate to severe frailty. The prevalence and severity of frailty increased with decreasing Mini Mental State Examination (MMSE) score and advancing age. Frailty was also detected in 60% of patients with mild cognitive impairment.

CONCLUSION

Frailty is common in patients referring to CCDDs for cognitive deficits. Its systematic assessment using a FI generated with readily available medical information could help develop appropriate models of assistance and guide personalization of care.

Challenges in the Development of Intravenous Neurokinin-1 Receptor Antagonists: Results of a Safety and Pharmacokinetics Dose-Finding, Phase 1 Study of Intravenous Fosnetupitant

Oral NEPA is the fixed-combination antiemetic comprising netupitant (neurokinin-1 receptor antagonist [NK₁ RA]) and palonosetron (5-hydroxytryptamine-3 receptor antagonist [5-HT₃ RA]). Intravenous (IV) NEPA, containing fosnetupitant, a water-soluble N-phosphoryloxymethyl prodrug of netupitant, has been developed. Fosnetupitant does not require excipients or solubility enhancers often used to increase IV NK₁ RA water solubility, preventing the occurrence of hypersensitivity and infusion-site reactions associated with these products. In this phase 1 study, subjects received a 30-minute placebo or fosnetupitant (17.6-353 mg) infusion and an oral NEPA or placebo capsule, with 2-sequence crossover treatment for fosnetupitant 118- to 353-mg dose cohorts. IV fosnetupitant safety and pharmacokinetics were evaluated, and its equivalence to an oral netupitant 300-mg dose was defined. Overall, 158 healthy volunteers were enrolled. All adverse events (AEs) were mild or moderate in intensity. Doppler-identified infusion-site asymptomatic thrombosis occurred in 5.4% (fosnetupitant) and 1.2% (oral NEPA) of subjects. The frequency or number of treatment-related AEs did not increase with ascending fosnetupitant doses. The most common treatment-related AEs were headache (fosnetupitant, 8.1%; oral NEPA, 12.7%) and constipation (fosnetupitant, 1.4%; oral NEPA, 7.5%). A fosnetupitant 235-mg dose was equivalent, in terms of netupitant exposure, to 300-mg oral netupitant. The safety profile of a single fosnetupitant 235-mg infusion was similar to that of single-dose oral NEPA.

Pharmacokinetic profile and safety of intravenous NEPA, a fixed combination of fosnetupitant and palonosetron, in cancer patients: Prevention of chemotherapy-induced nausea and vomiting associated with highly emetogenic chemotherapy

NEPA is the fixed combination antiemetic composed of the neurokinin-1 receptor antagonist netupitant and the 5-hydroxytryptamine-3 receptor antagonist palonosetron. The intravenous (i.v.) formulation of NEPA (fosnetupitant 235 mg/palonosetron 0.25 mg) was developed to enhance the convenience of NEPA administration. In a phase 3 study, i.v. NEPA showed acceptable safety with low risk for injection-site reactions. This study evaluated the pharmacokinetics and safety of i.v. NEPA in cancer patients. This was a single-center, single-dose phase 1 study in patients receiving highly emetogenic chemotherapy. Patients received a 30-min infusion of i.v. NEPA plus oral dexamethasone (12 mg) prior to chemotherapy, and oral dexamethasone (8 mg/daily) on days 2-4. Twenty-four patients received the complete i.v. NEPA infusion volume. Fosnetupitant maximum plasma concentration (C_max) was reached at the end of infusion and decreased to <1% of C_max 30 min later. Netupitant was rapidly released from its prodrug and C_max of 590 ng/ml was reached at the end of fosnetupitant infusion, with a mean exposure (AUC_∞) of 15,588 h∙ng/ml. Palonosetron C_max was reached at the end of infusion, with a mean AUC_∞ of 36.07 h∙ng/ml. The most common adverse events were constipation (29%), nausea (17%), and vasospasm (8%). No i.v. NEPA-related injection site reactions occurred. Fosnetupitant conversion to netupitant occurred rapidly in cancer patients. Netupitant and palonosetron pharmacokinetic profiles in i.v. NEPA were similar to those reported for oral NEPA. i.v. NEPA was well tolerated with a similar safety profile to oral NEPA. i.v. NEPA provides additional administration convenience. Clinical trial registration number: EudraCT 2015-004750-18.

Stability of rifabutin in two extemporaneously compounded oral liquids

The stability of rifabutin 20 mg/mL in two oral liquids was studied. Powder from 100 150-mg rifabutin capsules was placed in a glass mortar. Cherry syrup (pH 2.9) or a 1:1 mixture of Ora-Sweet and Ora-Plus (Paddock Laboratories) was added to produce 750 mL of each formulation, which was then stored in 2-oz plastic prescription bottles. Three bottles of each formulation were stored at 4, 25, 30, and 40 degrees C. At 0, 1, 2, 4, 8, and 12 weeks, the bottles were collected and allowed to remain at room temperature for one hour; samples of about 1 mL were collected from each bottle, weighed, and assayed for rifabutin content by high-performance liquid chromatography. The rifabutin liquids prepared with cherry syrup and stored at 4, 25, and 30 degrees C lost a mean of < 8% of the initial drug concentration during the 12-week study; at 40 degrees C, the liquids lost > 10% of the initial drug concentration by 12 weeks. There was a mean loss of < 5% of the initial rifabutin concentration in all the liquids prepared with Ora-Sweet and Ora-Plus. The liquid prepared with cherry syrup, upon standing, showed a tendency for some of the ingredients to float. The suspension prepared with Ora-Sweet and Ora-Plus had a tendency to retain bubbles after it was shaken, but the ingredients did not settle upon standing. Rifabutin 20 mg/mL in two extemporaneously compounded oral liquids prepared from capsules and sweetened vehicles was stable for at least 12 weeks at 4, 25, 30, and 40 degrees C with the exception of rifabutin in cherry syrup, which was stable for only 8 weeks at 40 degrees C.

Enhancement of bioavailability of a hydrophobic amine antimalarial by formulation with oleic acid in a soft gelatin capsule

The relative availability of the orally administered hydrophobic antimalarial alpha-(dibutylaminomethyl)-6,8-dichloro-2-(3',4'-dichlorophenyl)-4-quinolinemethanol (I) from two dosage forms was determined in beagle dogs. Compound I was soluble in oleic acid to the extent of 23.5% (w/w), and oleic acid was suitable for encapsulation in soft gelatin capsules. The availability of I formulated as its hydrochloride salt in a standard hard gelatin capsule formulation was significantly lower than that of I formulated in a soft gelatin capsule with oleic acid as the solvent. A 20% solution of I in oleic acid (soft gelatin capsules) maintained at 23 degrees provided 4% of the oleic acid ester of I iwithin 1 month. Further reaction, however, was not seen over 2 years.

Acylation of phenol by cyclic and acyclic anhydrides in anhydrous acetic acid

Acylation of phenol with succinic, glutaric, trans-1,2-cyclohexanedicarboxylic, maleic, phthalic, and cis-1,2-cyclohexanedicarboxylic anhydrides in anhydrous acetic acid generally resulted in phenyl acetate as the major product. The formation of phenyl acetate as the major reaction product could be rationalized as being due to the reactivity of the cyclic anhydrides with acetic acid to form acetic anhydride as well as the greater reactivity of phenol with formed acetic anhydride than with the cyclic anhydride.

Solvolytic reactions of cyclic anhydrides in anhydrous acetic acid

The reversible reactions of several cyclic anhydrides with acetic acid to form acetic anhydride and the corresponding dicarboxylic acid, catalyzed by perchloric acid at 25degree, were studied. The equilibrium constants, calculated from spectral data, were 4.85 X 10-4, 1.08 X 10-1, and 4.6 X 10-1 M for succinic, trans-1,2-cyclohexanedicarboxylic, and glutaric anhydrides, respectively. Maleic, phthalic, and cis-1,2-cyclohexanedicarboxylic anhydrides did not undergo any detectable reaction with acetic acid under these conditions, suggesting still higher stability. The reverse rate constants were found to be relatively independent of the structure of the attacking diacid, while the forward rate constants were found to parrallel the equilibrium constants. The rate-determining step for the forward reaction appears to be the breakdown of the tetrahedral intermediate formed by the attack of an acetic acid molecule on the protonated cyclic anhydride.

Photolytic degradation of alpha-[(dibutylamino)methyl]-6,8-dichloro-2-(3',4'-dichlorophenyl)-4-quinoline methanol: an experimental antimalarial

A study of the effects of various storage conditions on the rate and products of degradation of the quinoline methanol antimalarial agent, alpha-[(dibutylamino)methyl]-6,8-dichloro-2-(3',4'-dichlorophenyl)-4-quinoline methanol, was undertaken. The degradation was followed by high-pressure liquid chromatography and TLC in oxygenated and deoxygenated methanol, ethanol, chloroform, and chloroform-heptane mixtures under UV and laboratory fluorescent lighting irradiation, as well as in the absence of light. The kinetics of degradation confirmed the major catalyzing factor to be UV irradiation. The compound was stable in the absence of light and reasonably stable under fluorescent lighting both in the presence and absence of oxygen. The degradation resulted in a major product, 6,8-dichloro-2-(3',4'-dichlorophenyl)-4-quinoline-carboxaldehyde, whose structure was confirmed by elemental analysis and IR, NMR, and mass spectral data.