[Pharmacotherapy of central oculomotor disorders]

Nystagmus causes blurred vision due to oscillopsia, as well as impaired balance. Depending on etiology, additional cerebellar and brain stem signs may occur. We present the current pharmacotherapy of the most common forms of central nystagmus: downbeat nystagmus (DBN), upbeat nystagmus (UBN), acquired pendular nystagmus (APN), and congenital nystagmus (CGN). Recommended medical therapies are aminopyridines (4-AP) for DBN and UBN, gabapentin and memantine for CGN and APN, and baclofen for periodic alternating nystagmus (PAN).

Impact of APOE status on cognitive maintenance in healthy elderly persons

OBJECTIVE

The epsilon4 allele, a variant of the apolipoprotein E (ApoE) gene, is the most prominent genetic risk factor for sporadic, non-familial Alzheimer's disease (AD) currently known. We investigated the impact of the ApoE-epsilon4 status on cognitive performance at repeated test administration in elderly non-symptomatic persons, with a specific focus on practice effects.

METHODS

Three hundred and fifty-five physically and mentally healthy participants of the Basel Study on the Elderly (119 F, 236 M; age 68.3 +/- 7.6; years of education 12.7 +/- 3.1; Mini-Mental State scores 29.0 +/- 1.0) were grouped into ApoE epsilon4 carriers and ApoE epsilon4 non-carriers (36.9% and 63.1% of the sample, respectively). Participants were assessed at the beginning of the longitudinal study and on average two years later by means of the California Verbal Learning Test (CVLT) and the Consortium to Establish a Registry for Alzheimer's Disease-Neuropsychological Assessment Battery (CERAD-NAB), a multidimensional cognitive test battery. Baseline and change scores were analyzed with multiple regression procedures and adjusted for age, education and gender; change scores were also adjusted for baseline performance.

RESULTS

The ApoE epsilon4 non-carriers showed slightly better performance with regard to most cognitive parameters at baseline. Mean practice effects of the ApoE epsilon4 non-carriers in 12 out of 13 CVLT variables and in five out of the nine main CERAD-NAB variables were above the 50th percentile, while those of the ApoE epsilon4 carriers were below the 50th percentile in the respective distributions of test-retest change scores.

CONCLUSIONS

The epsilon4 allele of the ApoE gene has a negative impact on cognitive performance, notably on episodic memory functions, in physically and mentally healthy aged persons. Practice effects seen in carriers of the ApoE epsilon4 were inferior in most areas tested to the effects seen in ApoE epsilon4 non-carriers. Further follow-up of these subjects will help to determine the clinical significance of these findings.

Retrospective evaluation of an intensive method of treatment for children with pervasive developmental disorder

The objective of this preliminary study was to evaluate a novel intensive therapy program in young children with pervasive developmental disorder (PDD). Twenty-three children treated at the Mifne Institute in Israel between 1997 and 1999 were assessed. Videos taken before coming to Mifne and after intensive treatment at the institute and before and after another 6 months of continued treatment at children's homes were coded and blind rated by trained personnel using the Childhood Autism Rating Scale (CARS) and the Social Behavior Rating Scale (SBRS). Total scores on both scales improved significantly after 3 weeks and after 6 months. There were some significant improvements at item level although the magnitude of the changes was modest. Despite the small number of participants, the modest increase in test scores, and the retrospective study design, these preliminary results are promising. There is a case for performing a full prospective, comparative investigation of this treatment approach.

The variable clinical phenotype of liver glycogen synthase deficiency

We report two new cases of liver glycogen synthase deficiency (GSD0). The first patient presented at the age of 8 months with recurrent hypoglycemic seizures. The second patient presented at 14 months with asymptomatic incidental hyperglycemia. Glucose monitoring in both patients revealed daily fluctuations from fasting hypoglycemia to postprandial hyperglycemia. Genetic analysis of the GYS2 gene confirmed the diagnosis. GSD0 is more common than previously assumed. Recognition of the variable phenotype spectrum of GSD0 and routine analysis of GYS2 are essential for the correct diagnosis.

Severe infantile type of carnitine palmitoyltransferase II (CPT II) deficiency due to homozygous R503C mutation

We report a patient with severe infantile carnitine palmitoyltransferase II (CPT II) deficiency who died at the age of 3 months. Genetic analysis of the CPT2 gene revealed that the patient was homozygous, and her parents were heterozygous, for a R503C missense mutation. Heterozygosity for R503C, without a second mutation, has previously been reported in symptomatic patients from two families, one with the mild adult myopathic form and one with malignant hyperthermia. In contrast, the R503C heterozygous parents of the patient were entirely asymptomatic, suggesting that additional genetic and/or environmental factors must have contributed to the occurrence of symptoms in previously reported carriers. Our findings indicate that the mutation R503C should be added to the handful of mutations associated with the severe phenotype when present in the homozygous state or combined with another severe mutation.

Assessment of everyday behavior in Alzheimer's disease patients: its significance for diagnostics and prediction of disease progression

In addition to cognitive decline, current diagnostic criteria for Alzheimer's disease (AD) require evidence of impaired social and/or occupational functioning. The Nurses' Observation Scale for Geriatric Patients (NOSGER) is used to rate the frequency of disturbances in everyday behaviors and, although not specifically developed for this purpose, is often applied for diagnostic purposes. The NOSGER assesses six dimensions: Memory, Instrumental Activities of Daily Living (IADLs), Self-Care (ADL), Mood, Social Behavior, and Disturbing Behavior. The goals of this study were 1) to establish normative data for the NOSGER as a function of demographic variables (i.e., age, years of education, and gender) in healthy elderly subjects; 2) to obtain cutoff values distinguishing healthy elderly subjects from probable AD patients with mild dementia; and 3) to describe the natural course of behavioral changes occurring in mild AD according to the NOSGER dimensions. NOSGER data of 445 normal controls [NCs, 376 men, 69 women; Mini-Mental Status Examination (MMSE) = 28.8 +/- 1.17] and 217 probable AD patients with mild dementia (97 men, 120 women; MMSE = 26.1 +/- 1.59) from the Memory Clinic of Basel, Switzerland, were analyzed. Cutoff scores for distinguishing between average NCs and mildly demented AD patients ranged between 7 and 9 for different NOSGER dimensions. Formulae to obtain demographically adjusted and z-transformed NOSGER dimension and MMSE scores for assessment of individual cases were determined. NCs were best distinguished from patients in the NOSGER dimension Mood, followed by Memory, ADLs, Social Behavior, and Disturbing Behavior. Linear courses of behavioral deterioration were found-in four NOSGER dimensions (Memory, IADLs, Mood, and Social Behavior) in these mildly demented patients. No quadratic course was found for any of the NOSGER dimensions. The NOSGER revealed good discriminatory power in those behavioral dimensions affected in early stages of AD and is suitable for monitoring behavioral changes as a function of disease progression. Its use in combination with the MMSE for dementia screening purposes is recommended.

Cognitive performance in Alzheimer's disease patients receiving rivastigmine for up to 5 years

This analysis aimed to assess mini-mental state examination (MMSE) scores in patients with Alzheimer's disease who received rivastigmine, an inhibitor of acetylcholinesterase and butyrylcholinesterase, for up to 5 years. Rivastigmine data came from two pooled open-label extensions of four 6-month, randomised, placebo-controlled trials. Projections of decline, had the same patients not been treated, were made using a baseline-dependent mathematical model. MMSE data were available for 1998 rivastigmine-treated patients and 657, 298 and 83 were still on treatment at 3, 4 and 5 years, respectively. The mean (+/-SD) baseline MMSE score was 19.3 (+/-4.9). Projected mean scores in model-based untreated patients declined below 10 points on the MMSE at about 3 years, while the mean MMSE score of patients who remained on rivastigmine stayed above 10 points for 5 years.

Disease stage in Alzheimer disease and treatment effects of rivastigmine

The efficacy and tolerability of the cholinesterase inhibitor rivastigmine in the treatment of Alzheimer disease (AD) have been demonstrated in several clinical trials, which included patients with a wide range of dementia severities. To investigate the association between severity of disease and treatment response, the combined data from three large randomized, placebo-controlled trials were analyzed. The pooled patient population was stratified into three cohorts showing moderately severe (Mini-Mental State Examination score [MMSE] < or = 15), moderate (MMSE 16-22), and mild (MMSE > or = 22) dementia. In each cohort, the effects of rivastigmine 6 to 12 mg/day versus placebo were evaluated using the cognitive subscale of the Alzheimer Disease Assessment Scale (ADAS-cog) and the Progressive Deterioration Scale. Rivastigmine 6 to 12 mg/day maintained ADAS-cog scores at or above placebo levels in all cohorts, while cognitive deterioration with placebo was progressive and severity dependent. Activities of daily living showed statistically significant benefits with rivastigmine across all severity cohorts.

Eosinophilic pericarditis: a rare complication of idiopathic hypereosinophilic syndrome in a child

We describe an 18-month-old child with idiopathic hypereosinophilic syndrome (IHES) who presented with fever, and cervical lymphadenopathy. Chest X-ray showed marked cardiomegaly, and echocardiogram revealed large pericardial effusion. Other causes of pericarditis were excluded. Despite the initiation of steroid therapy, signs of impending cardiac tamponade developed. Pericardiocentesis yielded bloody fluid with a white blood count of 14,800/mm3, of which 23% were eosinophils. The child recovered after pericardial drainage and prolonged systemic steroid therapy. Eosinophilic pericarditis is a rare but potentially dangerous complication of IHES.

Rivastigmine in Alzheimer disease: efficacy over two years

OBJECTIVE

Beyond 6 to 9 months of treatment with cholinesterase inhibitors (ChE-Is), there is a notable increase in the rate of cognitive decline in Alzheimer disease (AD) patients, and there are few longer-term studies to evaluate this finding. The authors examined whether the ChE-I rivastigmine continued to be therapeutically effective after up to 2 years of treatment in 2,010 patients with probable AD.

METHODS

The clinical course of AD patients treated with rivastigmine was compared with a prediction of their course derived by a baseline-dependent historical model of disease progression developed from data in untreated AD patients. Rivastigmine efficacy data came from four 6-month, placebo-controlled, randomized, controlled trials (RCTs) and two open-label extension studies. Cognitive performance was assessed by various clinician- and caregiver-rated measures.

RESULTS

After 2 years on rivastigmine, there was less cognitive deterioration than in historical-control subjects. These effects of rivastigmine on cognitive performance were considered clinically meaningful relative to expected global decline. Treatment-emergent adverse events were the commonly-seen side effects of ChEIs and were similar in frequency to those seen in patients assigned to shorter-term rivastigmine therapy.

CONCLUSION

Rivastigmine had a beneficial effect on cognitive performance for up to 2 years in patients with AD, versus no treatment or placebo treatment in historical-control subjects. Caregiver and clinician assessments indicated that the cognitive performance findings were of a magnitude relevant to global patient functioning. Rivastigmine remained safe over this 2-year treatment period.

Preserved cognitive function after 12 months of treatment with rivastigmine in mild Alzheimer's disease in comparison with untreated AD and MCI patients

Cholinesterase inhibitors (ChEIs) have shown positive symptomatic effects on cognition, activities of daily living, and behavior in patients with Alzheimer's disease (AD). Rivastigmine is a slowly reversible ChEI that inhibits acetylcholinesterase and butyrylcholinesterase. We evaluated the effects of long-term rivastigmine treatment on cognitive function and plasma levels of ChE activity, and the relationship between ChE activity and cognition. Patients with mild AD (n = 11) treated with rivastigmine for 12 months were compared with matched groups of untreated patients with AD (n = 21) or mild cognitive impairment (MCI; n = 22) representing the natural course of the pre-clinical and very early stage of disease. For untreated AD patients, neuropsychological assessment was made at baseline and 12 months. Determination of ChE activity in plasma and assessment of global cognition, episodic memory, visuospatial ability, and attention were performed at 0 (baseline), 3, 6, and 12 months for treated AD patients and untreated MCI patients. At 12 months, cognitive function was slightly improved or maintained in mild AD patients treated with rivastigmine. In contrast, cognition was markedly worsened in untreated AD patients and unchanged or slightly worsened in untreated MCI patients. In the group of treated AD patients, there was a significant correlation between plasma ChE inhibition and cognition, particularly in relation to attention. This effect was most apparent at 3 months of treatment. In conclusion, a clear beneficial effect of rivastigmine was shown on cognitive function for patients with mild AD and plasma values of ChE inhibition were associated with attention.

Efficacy of rivastigmine in subjects with moderately severe Alzheimer's disease

BACKGROUND

Cholinesterase (ChE) inhibitors are primarily used in the treatment of mild to moderate Alzheimer's disease (AD), but may also be effective in more severe disease.

OBJECTIVE

To evaluate the dual ChE inhibitor, rivastigmine, in more severe dementia.

METHODS

We retrospectively analysed pooled data from three randomised, placebo-controlled, double-blind, 6-month trials, involving 2126 AD subjects. Subjects were selected according to baseline Mini-Mental State Examination (MMSE) score to identify subjects with more severe cognitive impairment (10-12 MMSE points). One-hundred-and-seventeen subjects were included who had been treated with rivastigmine 6-12 mg/day or placebo. The AD Assessment Scale-Cognitive Subscale (ADAS-Cog), the MMSE, a six-item subscore of the Progressive Deterioration Scale (PDS) and the BEHAVE-AD assessed efficacy. Tolerability was assessed by recording adverse events (AEs) and the relative risk (RR) of discontinuation.

RESULTS

This group of subjects responded well to rivastigmine. After 6 months, the mean ADAS-Cog score declined by 6.3 points in the placebo group and increased by 0.2 points in the rivastigmine group (observed cases; p<0.001). Clinical benefits were also observed with the MMSE, the six-item PDS score and items of the BEHAVE-AD. Rivastigmine showed the same pattern of AEs as in other studies, but the RR of dropping out due to AEs was lower than in subjects with milder AD.

CONCLUSION

Current treatment guidelines do not recommend treating individuals with severe AD with ChE inhibitors. However, this retrospective analysis suggests that rivastigmine 6-12 mg/day may benefit subjects with more severe disease, as well as subjects with mild to moderate impairment.

[Rivastigmine: a review of its clinical effectiveness]

The progression of Alzheimer s disease (AD) is linked with the appearance of symptoms in three key domains, namely activities of daily living (ADL), behaviour and cognition. The development and decline of these symptoms gives rise to a loss in the patient s functional capacity and contributes to the social, health care and economic costs associated with the disease. Tests suggest that the onset of these symptoms, in AD and in other types of dementia (e.g. frontotemporal dementia, dementia in Parkinson s disease and vascular dementia [VaD]), can be attributed to the loss of acetylcholine and cholinergic neurons in areas of the brain that are central to learning and memory, to execution functions and to behavioural and emotional responses, such as the cerebral cortex, the hippocampus and the limbic regions. There is evidence to show that the use of cholinesterase (ChE) inhibitors, including rivastigmine, donepezil and galanthamine, to enhance the survival of cholinergic neurotransmission is beneficial in the treatment of these symptoms. For example, administering rivastigmine stabilises and improves the performance of ADL in mild to moderate stages and slows down the decline in the capacity to carry out ADL in patients with serious AD. There is an improvement in the behavioural symptoms, the appearance of new symptoms diminishes and the use of other psychotropic drugs is reduced. Cognitive deficits become stable or improve during short term treatment and the treatment also delays the cognitive decline associated with the progression of the disease. A review of the available data reveals that ChE inhibition is beneficial in the long term in the three key symptomatic domains in different stages of the disease, as well as its perhaps being useful in different dementias. Therefore, it is likely that treatment with a ChE inhibitor improves quality of life and reduces the social and economic burden of these disorders

Inhibition of acetyl- and butyryl-cholinesterase in the cerebrospinal fluid of patients with Alzheimer's disease by rivastigmine: correlation with cognitive benefit

Cholinesterase (ChE) inhibition represents the most efficacious treatment approach for Alzheimer's disease (AD) to date. This multiple-dose study has examined the relationship between inhibition of acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE) activities in the cerebrospinal fluid (CSF) and cognitive change (measured by the Computerised Neuropsychological Test Battery [CNTB]) following administration of the ChE inhibitor, rivastigmine (Exelon). In 18 patients with mild to moderate AD, CNTB scores, activities of AChE and BuChE in the CSF, and plasma BuChE activity were determined prior to treatment with rivastigmine. Doses of rivastigmine were then titrated (1 mg b.i.d./week) to final doses of 1, 2, 3, 4, 5 or 6 mg b.i.d. (n = 3 per dose). Following treatment with the target dose of rivastigmine for at least 3 days, CNTB scores were re-determined. CSF samples were continuously collected together with plasma samples prior to and for 12 hours after the final dose of rivastigmine, and AChE and BuChE activities determined.AChE in CSF and BuChE in plasma were dose-dependently inhibited by rivastigmine treatment. The inhibition of BuChE in CSF was not clearly dose-dependent. A statistically significant correlation was observed between the change in CNTB summary score and inhibition of AChE activity (r = -0.56, p < 0.05) and BuChE activity (r = -0.65, p < 0.01) in CSF. Improvement in speed-, attention- and memory-related subtests of the CNTB correlated significantly with inhibition of BuChE but not AChE activity in CSF. Weak or absent correlation with change in cognitive performance was noted for inhibition of plasma BuChE. These results indicate that cognitive improvement with rivastigmine in AD is associated with central inhibition of ChEs and support a role for central BuChE in addition to AChE inhibition in modulating cholinergic function in AD.

West Nile virus meningoencephalitis complicated by motor aphasia in Hodgkin's lymphoma

A 4 year old boy with Hodgkin's lymphoma was admitted to the paediatric ward with meningoencephalitis dominated by generalised seizures and motor aphasia. Serum IgM specific antibodies to West Nile virus were positive. In view of ongoing neurological deterioration and immunocompromised state he was treated with oral ribavirin for 14 days. A gradual improvement was noted within two weeks of therapy initiation, and with intensive supportive care he recovered completely after four months.

Effects of rivastigmine on cognitive function in dementia with lewy bodies: a randomised placebo-controlled international study using the cognitive drug research computerised assessment system

This study was designed to assess the effects of rivastigmine (Exelon) on the cognitive functioning of patients suffering from dementia with Lewy bodies. This was a prospective, multi-centre, randomised, double-blind, placebo-controlled exploratory study conducted at sites in the UK, Spain and Italy. The treatment period was 20 weeks with a 3-week posttreatment follow-up. The primary outcome measures were the Cognitive Drug Research (CDR) computerised assessment system and the Neuropsychiatric Inventory. Testing was conducted prior to dosing and then again at weeks 12, 20 and 23. Analysis of the data from the 92 patients who completed the study identified a significant pattern of benefits of rivastigmine over placebo on the CDR system. These benefits were seen on tests of attention, working memory and episodic secondary memory. Taking attention for example, patients given placebo showed a significant deterioration from predosing scores at 12 and 20 weeks, whereas patients on rivastigmine performed significantly above their predosing levels. These effects were also large in magnitude, the decline under placebo at week 12 being 19%, while the improvement under rivastigmine was 23%. The clinical relevance of this 23% improvement was that it took the patients 33% towards being normal for their age on this assessment of attention. These benefits to cognitive function were accompanied by a significant improvement of the other primary outcome measure, the Neuropsychiatric Inventory. Three weeks after discontinuation of rivastigmine, most parameters of cognitive performance returned to predrug levels.