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Gray SL, Hanlon JT. Anticholinergic medication use and dementia: latest evidence and clinical implications. Ther Adv Drug Saf 2016; 7:217-224. [PMID: 27695623 DOI: 10.1177/2042098616658399] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Use of medications with anticholinergic activity is widespread in older adults. Several studies have highlighted that anticholinergic use may be associated with an increased risk of dementia. The objective of this narrative review is to describe and evaluate studies of anticholinergic medication use and dementia and provide practical suggestions for avoiding use of these medications in older adults. A comprehensive review of the literature, citations from recent reviews and the author's personal files was conducted. Four studies were found that evaluated anticholinergic use and dementia as the primary outcome. Three studies focused on overall anticholinergic medication use and reported a statistically significantly increased risk of Alzheimer's disease or dementia. In one study, dementia risk was primarily found with higher cumulative doses; people using anticholinergic medications at the minimum effective dose recommended for older adults for at least 3 years were at highest risk. In contrast, a study conducted in nursing-home residents with depression did not find that paroxetine [a highly anticholinergic selective serotonin reuptake inhibitor antidepressant, (SSRI)] increased risk for dementia compared with other SSRIs (without anticholinergic activity). Further study is needed to understand the mechanism by which anticholinergic medications may increase risk. In conclusion, there is evidence from three observational studies suggesting that anticholinergic medications may increase dementia risk. Given this potential risk and the myriad of other well-known adverse effects (i.e. constipation, blurred vision, urinary retention, and delirium) associated with anticholinergic medications, it is prudent for prescribers and older adults to minimize use of these medications and consider alternatives when possible.
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Affiliation(s)
- Shelly L Gray
- School of Pharmacy, Health Sciences Building, H-361D Box 357630, University of Washington, Seattle, WA 98195-7630, USA
| | - Joseph T Hanlon
- Division of Geriatrics, Department of Medicine, School of Medicine, Department of Pharmacy and Therapeutics, School of Pharmacy, and Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, PA; Geriatric Research, Education, and Clinical Center and Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
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Huang Y, Zhao Z, Wei X, Zheng Y, Yu J, Zheng J, Wang L. Long-term trihexyphenidyl exposure alters neuroimmune response and inflammation in aging rat: relevance to age and Alzheimer's disease. J Neuroinflammation 2016; 13:175. [PMID: 27411393 PMCID: PMC4942910 DOI: 10.1186/s12974-016-0640-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 06/22/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinical studies have shown an association between long-term anticholinergic (AC) drug exposure and Alzheimer's disease (AD) pathogenesis, which has been primarily investigated in Parkinson's disease (PD). However, long-term AC exposure as a risk factor for developing neurodegenerative disorders and the exact mechanisms and potential for disease progression remain unclear. Here, we have addressed the issue using trihexyphenidyl (THP), a commonly used AC drug in PD patients, to determine if THP can accelerate AD-like neurodegenerative progression and study potential mechanisms involved. METHODS Male Sprague-Dawley rats (SD) were intraperitoneally injected with THP (0.3 and 1.0 mg/kg) or normal saline (NS) for 7 months. Alterations in cognitive and behavioral performance were assessed using the Morris water maze (MWM) and open field tests. After behavior tests, whole genome oligo microarrays, quantitative real-time reverse transcription-polymerase chain reaction (qRT-PCR), immunohistochemistry, and immunofluorescence-confocal were used to investigate the global mechanisms underlying THP-induced neuropathology with aging. RESULTS Compared with NS controls, the MWM test results showed that THP-treated rats exhibited significantly extended mean latencies during the initial 3 months of testing; however, this behavioral deficit was restored between the fourth and sixth month of MWM testing. The same tendencies were confirmed by MWM probe and open field tests. Gene microarray analysis identified 68 (47 %) upregulated and 176 (53 %) downregulated genes in the "THP-aging" vs. "NS-aging" group. The most significant populations of genes downregulated by THP were the immune response-, antigen processing and presentation-, and major histocompatibility complex (MHC)-related genes, as validated by qRT-PCR. The decreased expression of MHC class I in THP-treated aging brains was confirmed by confocal analysis. Notably, long-term THP treatment primed hippocampal and cortical microglia to undergo an inflammatory phenotypic switch, causing microgliosis and microglia activation, which were positively accompanied by pathological misfolded tau lesions. CONCLUSIONS Our findings suggest that immune response and neuroinflammation represent a pivotal mechanism in THP-induced AD-like neuropathology processes with long-term exposure to AC drugs.
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Affiliation(s)
- Yuqi Huang
- Department of Pharmacology, Ningxia Medical University, 1160 Shengli Street, Yinchuan, 750004, Ningxia, Peoples' Republic of China
| | - Zhe Zhao
- State Key Laboratory of Toxicology and Medical Countermeasures, Beijing Institute of Pharmacology and Toxicology, Beijing, 100850, Peoples' Republic of China
| | - Xiaoli Wei
- State Key Laboratory of Toxicology and Medical Countermeasures, Beijing Institute of Pharmacology and Toxicology, Beijing, 100850, Peoples' Republic of China
| | - Yong Zheng
- State Key Laboratory of Toxicology and Medical Countermeasures, Beijing Institute of Pharmacology and Toxicology, Beijing, 100850, Peoples' Republic of China
| | - Jianqiang Yu
- Department of Pharmacology, Ningxia Medical University, 1160 Shengli Street, Yinchuan, 750004, Ningxia, Peoples' Republic of China
| | - Jianquan Zheng
- State Key Laboratory of Toxicology and Medical Countermeasures, Beijing Institute of Pharmacology and Toxicology, Beijing, 100850, Peoples' Republic of China
| | - Liyun Wang
- State Key Laboratory of Toxicology and Medical Countermeasures, Beijing Institute of Pharmacology and Toxicology, Beijing, 100850, Peoples' Republic of China.
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Welt T, Kulic L, Hoey SE, McAfoose J, Späni C, Chadha AS, Fisher A, Nitsch RM. Acute Effects of Muscarinic M1 Receptor Modulation on AβPP Metabolism and Amyloid-β Levels in vivo: A Microdialysis Study. J Alzheimers Dis 2016; 46:971-82. [PMID: 25881909 DOI: 10.3233/jad-150152] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Indirect modulation of cholinergic activity by cholinesterase inhibition is currently a widely established symptomatic treatment for Alzheimer's disease (AD). Selective activation of certain muscarinic receptor subtypes has emerged as an alternative cholinergic-based amyloid-lowering strategy for AD, as selective muscarinic M1 receptor agonists can reduce amyloid-β (Aβ) production by shifting endoproteolytic amyloid-β protein precursor (AβPP) processing toward non-amyloidogenic pathways. In this study, we addressed the hypothesis that acute stimulation of muscarinic M1 receptors can inhibit Aβ production in awake and freely moving AβPP transgenic mice. By combining intracerebral microdialysis with retrodialysis, we determined hippocampal Aβ concentrations during simultaneous pharmacological modulation of brain M1 receptor function. Infusion with a M1 receptor agonist AF102B resulted in a rapid reduction of interstitial fluid (ISF) Aβ levels while treatment with the M1 antagonist dicyclomine increased ISF Aβ levels reaching significance within 120 minutes of treatment. The reduction in Aβ levels was associated with PKCα and ERK activation resulting in increased levels of the α-secretase ADAM17 and a shift in AβPP processing toward the non-amyloidogenic processing pathway. In contrast, treatment with the M1 receptor antagonist dicyclomine caused a decrease in levels of phosphorylated ERK that was independent of PKCα, and led to an elevation of β-secretase levels associated with increased amyloidogenic AβPP processing. The results of this study demonstrate rapid effects of in vivo M1 receptor modulation on the ISF pool of Aβ and suggest that intracerebral microdialysis with retrodialysis is a useful technical approach for monitoring acute treatment effects of muscarinic receptor modulators on AβPP/Aβ metabolism.
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Affiliation(s)
- Tobias Welt
- Division of Psychiatry Research, University of Zürich Campus Schlieren, Switzerland
| | - Luka Kulic
- Division of Psychiatry Research, University of Zürich Campus Schlieren, Switzerland.,Center for Integrative Human Physiology (ZIHP), University of Zurich, Switzerland
| | - Sarah E Hoey
- Division of Psychiatry Research, University of Zürich Campus Schlieren, Switzerland
| | - Jordan McAfoose
- Division of Psychiatry Research, University of Zürich Campus Schlieren, Switzerland
| | - Claudia Späni
- Division of Psychiatry Research, University of Zürich Campus Schlieren, Switzerland
| | | | - Abraham Fisher
- Israel Institute for Biological Research, Ness-Ziona, Israel
| | - Roger M Nitsch
- Division of Psychiatry Research, University of Zürich Campus Schlieren, Switzerland
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Nishtala PS, Salahudeen MS, Hilmer SN. Anticholinergics: theoretical and clinical overview. Expert Opin Drug Saf 2016; 15:753-68. [DOI: 10.1517/14740338.2016.1165664] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
| | | | - Sarah N. Hilmer
- Sydney Medical School, Royal North Shore Hospital and Kolling Institute of Medical Research, University of Sydney, St Leonards, NSW, Australia
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Abstract
BACKGROUND Visual hallucinations are a common phenomenon, among the older adult population. They can be functional or organic in aetiology. However, new onset visual hallucinations in this population are strongly suggestive of organic brain disease. Visual impairment, cerebrovascular disease and Parkinson's disease are three causes of visual hallucinations, considered in this case series. The evidence in the literature, for the treatment of these conditions is scant at best. There is a paucity of randomised controlled trials available concerning possible therapeutic options. Aims/Methods We describe three case reports of visual hallucinations due to diverse underlying aetiologies. We then discuss the aetiologies of visual hallucinations in general and then in these particular cases and finally include results of a literature search examining the available evidence for any therapeutic options proposed. RESULTS Our three cases have different, underlying aetiologies. One case is of Charles Bonnet syndrome. The next is of visual hallucinations associated with vascular dementia. The final case is of visual hallucinations associated with Parkinson's disease. The first two cases are of particular interest due to the efficacy of Amisulpride in both clinical scenarios. CONCLUSIONS Visual hallucinations are a common phenomenon in the elderly population They can be due to a myriad of underlying causes. There are a number of neurochemical factors and neuroanatomical structures implicated. The evidence for psychopharmacological interventions is scanty. Randomised controlled trials are lacking in the area. An interesting finding in this case series, was of the clinical utility of Amisulpiride. Given this agent's unique psychopharmacological profile it is possible that it may be efficacious in other cases of visual hallucinations associated with particular neurochemical factors.
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Yarnall AJ, Lashley T, Ling H, Lees AJ, Coleman SY, O'Sullivan SS, Compta Y, Revesz T, Burn DJ. Apomorphine: A potential modifier of amyloid deposition in Parkinson's disease? Mov Disord 2015; 31:668-75. [PMID: 27156393 DOI: 10.1002/mds.26422] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Revised: 07/23/2015] [Accepted: 08/06/2015] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Evidence from clinical and pathological studies suggests a role for both alpha-synuclein and amyloid-beta in the pathophysiology of dementia associated with PD. Recent work demonstrated improvement in memory and reduced amyloid-beta burden in transgenic murine Alzheimer's models given subcutaneous apomorphine. The aim of this work was to determine whether antemortem exposure to apomorphine was associated with lower levels of amyloid-beta in brain tissue in a clinicopathological study of PD. METHODS The case notes of donors with pathologically proven PD who had (n = 36) and had not received apomorphine (n = 35) during life for motor complications were reviewed to determine presence or absence of cognitive impairment. The four groups were well matched for disease duration, age at death, sex, and apolipoprotein E4 genotype. The severity of amyloid-beta mature/diffuse plaque load, tau pathology, and alpha-synuclein pathology were all established. Cerebral amyloid angiopathy was determined based on a four-tier grading system. RESULTS Within the cognitively normal cases, significantly reduced amyloid-beta deposition was present in those with antemortem apomorphine exposure; this finding was not replicated in those with cognitive impairment plus previous apomorphine use. In the apomorphine cognitively normal group only, a significant negative association was observed between maximum apomorphine dose received and amyloid-beta burden. Early and maximum doses of apomorphine plus apolipoprotein genotype and sex were significant predictors of total plaque load in an explanatory model. CONCLUSION This exploratory study suggests that apomorphine may have a modifying effect on amyloid deposition in nondemented PD cases and thus may represent a potential therapy to reduce cognitive impairment in PD. © 2015 Movement Disorder Society.
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Affiliation(s)
- Alison J Yarnall
- Institute of Neuroscience, Newcastle University, Newcastle, United Kingdom
| | - Tammaryn Lashley
- The Queen Square Brain Bank for Neurological Disorders, Department of Molecular Neuroscience, UCL Institute of Neurology, London, United Kingdom
| | - Helen Ling
- Reta Lila Weston Institute of Neurological Studies, University College London, United Kingdom
| | - Andrew J Lees
- The Queen Square Brain Bank for Neurological Disorders, Department of Molecular Neuroscience, UCL Institute of Neurology, London, United Kingdom.,Reta Lila Weston Institute of Neurological Studies, University College London, United Kingdom
| | - Shirley Y Coleman
- Industrial Statistics Research Unit, Newcastle University, Newcastle, United Kingdom
| | | | - Yaroslau Compta
- Parkinson Disease and Movement Disorders Unit, Neurology Service, IDIBAPS, CIBERNED, Hospital Clinic, Barcelona, Catalonia, Spain
| | - Tamas Revesz
- The Queen Square Brain Bank for Neurological Disorders, Department of Molecular Neuroscience, UCL Institute of Neurology, London, United Kingdom
| | - David J Burn
- Institute of Neuroscience, Newcastle University, Newcastle, United Kingdom
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Fasano A, Lang AE. Unfreezing of gait in patients with Parkinson's disease. Lancet Neurol 2015; 14:675-7. [DOI: 10.1016/s1474-4422(15)00053-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 04/16/2015] [Indexed: 10/23/2022]
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Yoshiyama Y, Kojima A, Itoh K, Isose S, Koide M, Hori K, Arai K. Does Anticholinergic Activity Affect Neuropathology? Implication of Neuroinflammation in Alzheimer's Disease. NEURODEGENER DIS 2015; 15:140-8. [PMID: 26138491 DOI: 10.1159/000381484] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
One characteristic neuropathological feature of Alzheimer's disease (AD) is profound neuronal loss in the nucleus basalis of Meynert, the major source of cholinergic innervation of the cerebral cortex. Clinically, anticholinergic activity causes a decline in cognitive function and increases the risk of dementia, thus possibly enhancing AD pathologies and neurodegeneration. Until now there has been insufficient human neuropathological data to support this conclusion. Experimental studies using a tauopathy mouse model demonstrated anticholinergics enhanced tau pathology and neurodegeneration corresponding to central anticholinergic activity. Additionally, donepezil, a cholinesterase inhibitor, ameliorated tau pathology and neurodegeneration in the same mouse model. These results indicate the balance between cholinergic and anticholinergic activities might affect neurodegeneration. Importantly, neurodegeneration observed in the mouse model seemed to correspond to the distribution of microglial activation, and it was reported that neuroinflammation plays an important role in the pathomechanism of AD, while anticholinergic activity augments inflammatory responses. Moreover, some studies indicated β-amyloid itself depletes cholinergic function similarly to anticholinergic activity. Thus, anticholinergic activity might initiate and/or accelerate AD pathology. Limited human data support the conclusion that anticholinergic activity enhances AD-related neuropathology and neurodegeneration. However, experimental data from a tauopathy mouse model indicated anticholinergic activity might enhance neurodegeneration with enhanced neuroinflammation including microglial activation.
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Hosoi M, Hori K, Konishi K, Tani M, Tomioka H, Kitajima Y, Akashi N, Inamoto A, Kurosawa K, Yuda H, Hanashi T, Ouchi H, Hachisu M. Pharmacotherapy for Neurocognitive Disorders Based on the Hypothesis of Endogenous Appearance of Anticholinergic Activity. NEURODEGENER DIS 2015; 15:157-61. [DOI: 10.1159/000381513] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Konishi K, Hori K, Tani M, Tomioka H, Kitajima Y, Akashi N, Inamoto A, Kurosawa K, Yuda H, Hanashi T, Ouchi H, Hosoi M, Hachisu M. Hypothesis of Endogenous Anticholinergic Activity in Alzheimer's Disease. NEURODEGENER DIS 2015; 15:149-56. [PMID: 26138492 DOI: 10.1159/000381511] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
In this article, we review and repropose our hypothesis of the endogenous appearance of anticholinergic activity (AA) in Alzheimer's disease (AD). First, we introduce our previous articles and speculate that, because acetylcholine (ACh) regulates both cognitive function and inflammation, downregulation of this neurotransmitter causes upregulation of the inflammatory system. AA then appears endogenously with the production of cytokines and the downregulation of ACh in AD. To support our hypothesis, we present a female AD patient whose AA was considered to occur endogenously through her AD pathology. Her serum anticholinergic activity (SAA) was positive at her first visit to our memory clinic, was negative at the 1-year and 2-year follow-up visits, and had become positive again by 3 years. We speculate that the initial positive SAA was related to her AD pathology plus mental stress, and that her SAA at 3 years was related to her AD pathology only. Consequently, we believe that 2 patterns of SAA positivity (and therefore AA) exist. One occurs when the downregulation of ACh reaches a critical level, and the other occurs with the addition of some other factor such as medication, induced illness or mental stress that causes AA to affect AD pathology. Finally, we consider the pharmacotherapy of AD based on the proposed hypothesis and conclude that cholinesterase inhibitors can be used to prevent rapid disease progression, whereas N-methyl-D-aspartate receptor antagonists should be reserved for the treatment of AD that is already in a stage of rapid progression. We also propose a staging schema for patients with AD.
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Affiliation(s)
- Kimiko Konishi
- Department of Psychiatry, Showa University Northern Yokohama Hospital, Yokohama, Japan
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Meredith ME, Salameh TS, Banks WA. Intranasal Delivery of Proteins and Peptides in the Treatment of Neurodegenerative Diseases. AAPS JOURNAL 2015; 17:780-7. [PMID: 25801717 DOI: 10.1208/s12248-015-9719-7] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 01/12/2015] [Indexed: 12/28/2022]
Abstract
The blood-brain barrier (BBB) is a major impediment to the therapeutic delivery of peptides and proteins to the brain. Intranasal delivery often provides a non-invasive means to bypass the BBB. Advantages of using intranasal delivery include minimizing exposure to peripheral organs and tissues, thus reducing systemic side effects. It also allows substances that typically have rapid degradation in the blood time to exert their effect. Intranasal delivery provides the ability to target proteins and peptides to specific regions of the brain when administered with substrates like cyclodextrins. In this review, we examined the use of intranasal delivery of various proteins and peptides that have implications in the treatment of neurodegenerative diseases, focusing especially on albumin, exendin/GLP-1, GALP, insulin, leptin, and PACAP. We have described their rationale for use, distribution in the brain after intranasal injection, how intranasal administration differed from other modes of delivery, and their use in clinical trials, if applicable. Intranasal delivery of drugs, peptides, and other proteins could be very useful in the future for the prevention or treatment of brain related diseases.
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Gray SL, Anderson ML, Dublin S, Hanlon JT, Hubbard R, Walker R, Yu O, Crane PK, Larson EB. Cumulative use of strong anticholinergics and incident dementia: a prospective cohort study. JAMA Intern Med 2015; 175:401-7. [PMID: 25621434 PMCID: PMC4358759 DOI: 10.1001/jamainternmed.2014.7663] [Citation(s) in RCA: 634] [Impact Index Per Article: 70.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Many medications have anticholinergic effects. In general, anticholinergic-induced cognitive impairment is considered reversible on discontinuation of anticholinergic therapy. However, a few studies suggest that anticholinergics may be associated with an increased risk for dementia. OBJECTIVE To examine whether cumulative anticholinergic use is associated with a higher risk for incident dementia. DESIGN, SETTING, AND PARTICIPANTS Prospective population-based cohort study using data from the Adult Changes in Thought study in Group Health, an integrated health care delivery system in Seattle, Washington. We included 3434 participants 65 years or older with no dementia at study entry. Initial recruitment occurred from 1994 through 1996 and from 2000 through 2003. Beginning in 2004, continuous replacement for deaths occurred. All participants were followed up every 2 years. Data through September 30, 2012, were included in these analyses. EXPOSURES Computerized pharmacy dispensing data were used to ascertain cumulative anticholinergic exposure, which was defined as the total standardized daily doses (TSDDs) dispensed in the past 10 years. The most recent 12 months of use was excluded to avoid use related to prodromal symptoms. Cumulative exposure was updated as participants were followed up over time. MAIN OUTCOMES AND MEASURES Incident dementia and Alzheimer disease using standard diagnostic criteria. Statistical analysis used Cox proportional hazards regression models adjusted for demographic characteristics, health behaviors, and health status, including comorbidities. RESULTS The most common anticholinergic classes used were tricyclic antidepressants, first-generation antihistamines, and bladder antimuscarinics. During a mean follow-up of 7.3 years, 797 participants (23.2%) developed dementia (637 of these [79.9%] developed Alzheimer disease). A 10-year cumulative dose-response relationship was observed for dementia and Alzheimer disease (test for trend, P < .001). For dementia, adjusted hazard ratios for cumulative anticholinergic use compared with nonuse were 0.92 (95% CI, 0.74-1.16) for TSDDs of 1 to 90; 1.19 (95% CI, 0.94-1.51) for TSDDs of 91 to 365; 1.23 (95% CI, 0.94-1.62) for TSDDs of 366 to 1095; and 1.54 (95% CI, 1.21-1.96) for TSDDs greater than 1095. A similar pattern of results was noted for Alzheimer disease. Results were robust in secondary, sensitivity, and post hoc analyses. CONCLUSIONS AND RELEVANCE Higher cumulative anticholinergic use is associated with an increased risk for dementia. Efforts to increase awareness among health care professionals and older adults about this potential medication-related risk are important to minimize anticholinergic use over time.
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Affiliation(s)
- Shelly L Gray
- School of Pharmacy, University of Washington, Seattle
| | | | - Sascha Dublin
- Group Health Research Institute, Seattle, Washington3Department of Epidemiology, University of Washington, Seattle
| | - Joseph T Hanlon
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Rebecca Hubbard
- Group Health Research Institute, Seattle, Washington5Department of Biostatistics, University of Washington, Seattle6currently with the Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Rod Walker
- Group Health Research Institute, Seattle, Washington
| | - Onchee Yu
- Group Health Research Institute, Seattle, Washington
| | - Paul K Crane
- Division of General Internal Medicine, University of Washington, Seattle
| | - Eric B Larson
- Group Health Research Institute, Seattle, Washington7Division of General Internal Medicine, University of Washington, Seattle
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Block CK, Logue E, Thaler NS, Scarisbrick DM, Mahoney JJ, Scott J, Duff K. The interaction between medical burden and anticholinergic cognitive burden on neuropsychological function in a geriatric primary care sample. Arch Clin Neuropsychol 2014; 30:105-13. [PMID: 25549761 DOI: 10.1093/arclin/acu073] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Poorer neuropsychological function is associated with increased medical burden (MB) and the use of more anticholinergic medications. However, the interaction between MB and anticholinergic cognitive burden (AB) on neuropsychological performance is unknown. In a sample of 290 elderly primary care patients, those with a greater level of AB demonstrated poorer Total Index performance on the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). Further, an interaction effect was noted such that there was a greater anticholinergic effect on RBANS Total, Attention, and Delayed Memory Index scores for participants with fewer MB. Participants with more MB demonstrated poorer performance irrespective of their level of AB. These results indicate that MB effects may be overshadowed by anticholinergic effects in older patients.
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Affiliation(s)
- Cady K Block
- Department of Psychiatry and Behavioral Sciences, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73126-0901, USA
| | - Erin Logue
- Department of Psychiatry and Behavioral Sciences, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73126-0901, USA
| | - Nicholas S Thaler
- UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA 90095-1759, USA
| | - David M Scarisbrick
- Department of Psychiatry and Behavioral Sciences, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73126-0901, USA
| | - James J Mahoney
- Department of Psychiatry and Behavioral Sciences, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73126-0901, USA
| | - James Scott
- Department of Psychiatry and Behavioral Sciences, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73126-0901, USA
| | - Kevin Duff
- The University of Utah, Salt Lake City, UT 84108, USA
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Faulkner MA. Safety overview of FDA-approved medications for the treatment of the motor symptoms of Parkinson's disease. Expert Opin Drug Saf 2014; 13:1055-69. [PMID: 24962891 DOI: 10.1517/14740338.2014.931369] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Parkinson's disease (PD) is among the most common of the neurodegenerative disorders. Treatment is primarily focused on correcting neurotransmitter imbalances. Several classes of medication are available for this purpose. AREAS COVERED A Medline search was performed to gather information about the safety of the medications approved for the treatment of the motor symptoms of PD. This was supplemented with additional articles obtained from online sources and information provided by the FDA and the manufacturers. The focus of this review is the side-effect and safety profiles of carbidopa/levodopa, dopamine agonists, selective monoamine oxidase inhibitors, catechol-o-methyltransferase inhibitors, anticholinergics and amantadine. EXPERT OPINION Though serious side-effects may occur, as a group, the medications used for the treatment of PD motor symptoms tend to produce side-effects that are mild to moderate in nature, and that primarily reflect the focus on dopaminergic therapies. Care plans for Parkinson's patients should be approached based on the needs of the individual as disease presentation, lifestyle, level of disability, concurrent disease states and the presence of non-motor symptoms make each case unique. Patients and caregivers must have realistic expectations about the use of PD medications.
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Affiliation(s)
- Michele A Faulkner
- Creighton University School of Pharmacy and Health Professions and School of Medicine , 2500 California Plaza, Omaha, NE 68178 , USA +1 402 280 3145 ;
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Müller T. Current status of safinamide for the drug portfolio of Parkinson's disease therapy. Expert Rev Neurother 2014; 13:969-77. [PMID: 24053341 DOI: 10.1586/14737175.2013.827488] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Parkinson's disease (PD) is characterized by a slowly ongoing neuronal death. This alters dopaminergic and glutamatergic neurotransmission and causes a wide variety of motor and non-motor features. Safinamide has a unique pharmacological profile, which combines modulation of dopamine metabolism by reversible, highly specific monoamine oxidase-B inhibition, blockage of voltage-dependent sodium channels, modulation of calcium channels and of glutamate release induced by abnormal neuronal activity. Therefore, safinamide represents an ideal candidate for the treatment of PD. This compound asks for one time daily intake only within an optimum dose range between 50 and 100 mg. In clinical trials, safinamide was well tolerated and safe, improved motor behavior even in combination with dopamine agonist only, ameliorated levodopa-associated motor complications. Safinamide has the potential to become an important compound for the therapy of PD, since its symptomatic efficacy appears to be superior to available monoamine oxidase-B inhibitors or N-methyl-d-aspartate receptor antagonists like amantadine, according to available trial outcomes.
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Affiliation(s)
- Thomas Müller
- Department of Neurology, St. Joseph Hospital Berlin-Weißensee, Gartenstr. 1, 13088 Berlin, Germany +49 309 279 0223 +49 309 279 0703
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Rojas-Fernandez CH, Patel T, Lee L. An interdisciplinary memory clinic: a novel practice setting for pharmacists in primary care. Ann Pharmacother 2014; 48:785-95. [PMID: 24651163 DOI: 10.1177/1060028014526857] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Pharmacists have developed innovative practices in various settings as singular providers or as members of multidisciplinary or interdisciplinary teams. Examples include pharmacists practicing in heart failure, hypertension, or hyperlipidemia clinics. There is a paucity of literature describing pharmacists in interdisciplinary memory clinics and specifically pharmacists practicing in interdisciplinary, primary care-based memory clinics. New practice models should be disseminated to guide others in the development of similar models given the complexity of this population. Patients with dementia are more difficult to manage because of cognitive impairment, behavioral and psychological symptoms, the common presence of multiple comorbidities, and related polypharmacy and caregiver issues. These challenges require expertise in neurodegenerative disorders and geriatrics. The purpose of this article is to describe the role of clinical pharmacists providing care to patients with cognitive complaints in a primary care-based, interdisciplinary memory clinic, with a focus on how the pharmacist practices and is integrated in this collaborative care setting. Patients are assessed using an interdisciplinary approach, with team consensus for assessment and planning of care. Pharmacists' activities include assessment of (1) appropriateness of medications based on frailty, (2) medications that can impair cognition and/or function, (3) medication adherence and management skills, and (4) vascular risk factor control. Pharmacists provide education regarding medications and diseases, ensure appropriate transitions in care, and conduct home visits. Pharmacist participation in this clinic represents a novel opportunity to advance pharmacy practice in primary care, interdisciplinary models. Work is ongoing to describe outcomes attributable to pharmacist participation in this clinic.
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JAKUBÍK J, ŠANTRŮČKOVÁ E, RANDÁKOVÁ A, JANÍČKOVÁ H, ZIMČÍK P, RUDAJEV V, MICHAL P, EL-FAKAHANY EE, DOLEŽAL V. Outline of Therapeutic Interventions With Muscarinic Receptor-Mediated Transmission. Physiol Res 2014; 63:S177-89. [DOI: 10.33549/physiolres.932675] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Muscarinc receptor-mediated signaling takes part in many physiological functions ranging from complex higher nervous activity to vegetative responses. Specificity of action of the natural muscarinic agonist acetylcholine is effected by action on five muscarinic receptor subtypes with particular tissue and cellular localization, and coupling preference with different G-proteins and their signaling pathways. In addition to physiological roles it is also implicated in pathologic events like promotion of carcinoma cells growth, early pathogenesis of neurodegenerative diseases in the central nervous system like Alzheimer´s disease and Parkinson´s disease, schizophrenia, intoxications resulting in drug addiction, or overactive bladder in the periphery. All of these disturbances demonstrate involvement of specific muscarinic receptor subtypes and point to the importance to develop selective pharmacotherapeutic interventions. Because of the high homology of the orthosteric binding site of muscarinic receptor subtypes there is virtually no subtype selective agonist that binds to this site. Activation of specific receptor subtypes may be achieved by developing allosteric modulators of acetylcholine binding, since ectopic binding domains on the receptor are less conserved compared to the orthosteric site. Potentiation of the effects of acetylcholine by allosteric modulators would be beneficial in cases where acetylcholine release is reduced due to pathological conditions. When presynaptic function is severly compromised, the utilization of ectopic agonists can be a thinkable solution.
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Affiliation(s)
| | | | | | | | | | | | | | | | - V. DOLEŽAL
- Department of Neurochemistry, Institute of Physiology Academy of Sciences of the Czech Republic, Prague, Czech Republic
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68
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Abuhamdah S, Habash M, Taha MO. Elaborate ligand-based modeling coupled with QSAR analysis and in silico screening reveal new potent acetylcholinesterase inhibitors. J Comput Aided Mol Des 2013; 27:1075-92. [PMID: 24338032 DOI: 10.1007/s10822-013-9699-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Accepted: 12/03/2013] [Indexed: 10/25/2022]
Abstract
Inhibition of the enzyme acetylcholinesterase (AChE) has been shown to alleviate neurodegenerative diseases prompting several attempts to discover and optimize new AChE inhibitors. In this direction, we explored the pharmacophoric space of 85 AChE inhibitors to identify high quality pharmacophores. Subsequently, we implemented genetic algorithm-based quantitative structure-activity relationship (QSAR) modeling to select optimal combination of pharmacophoric models and 2D physicochemical descriptors capable of explaining bioactivity variation among training compounds (r2(68)=0.94, F-statistic=125.8, r2 LOO=0.92, r2 PRESS against 17 external test inhibitors = 0.84). Two orthogonal pharmacophores emerged in the QSAR equation suggesting the existence of at least two binding modes accessible to ligands within AChE binding pocket. The successful pharmacophores were comparable with crystallographically resolved AChE binding pocket. We employed the pharmacophoric models and associated QSAR equation to screen the national cancer institute list of compounds. Twenty-four low micromolar AChE inhibitors were identified. The most potent gave IC50 value of 1.0 μM.
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Affiliation(s)
- Sawsan Abuhamdah
- Department of Biopharmaceutics and Clinical Pharmacy, Faculty of Pharmacy, The University of Jordan, Amman, Jordan
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69
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Yamazaki T, Fukata A. Imidafenacin has no influence on learning in nucleus basalis of Meynert-lesioned rats. Naunyn Schmiedebergs Arch Pharmacol 2013; 386:1095-102. [DOI: 10.1007/s00210-013-0910-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Accepted: 08/16/2013] [Indexed: 11/29/2022]
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70
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Zúñiga-Ramírez C, Micheli F. Preladenant: an adenosine A2A receptor antagonist for Parkinson’s disease. FUTURE NEUROLOGY 2013. [DOI: 10.2217/fnl.13.52] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Preladenant (SCH 420814) is a potent selective antagonist at the adenosine A2A receptor that is being studied for treatment in early Parkinson’s disease (PD) as a monotherapy, and in moderate-to-severe PD as an add on to levodopa therapy. Unlike other drugs used for this disease, preladenant modulates adenosine action at the striatal level in order to block the inhibitory action of the basal ganglia output nuclei. Animal models of PD suggested that preladenant could be an effective treatment, which was further supported in a Phase II study of subjects with idiopathic PD who demonstrated a benefit in reducing off-time with an increase in on-time. In this article, we review current perspectives concerning pharmacological approaches to PD, the pharmacological properties of preladenant, its efficiency and safety, as well as the results reported for parkinsonian subjects treated with this drug.
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Affiliation(s)
- Carlos Zúñiga-Ramírez
- Movement Disorders & Neurodegenerative Diseases Unit, Hospital Civil de Guadalajara ‘Fray Antonio Alcalde’, Guadalajara, Mexico
| | - Federico Micheli
- Parkinson’s Disease & Movement Disorders Program, Hospital de Clínicas ‘José de San Martín’, Buenos Aires, Argentina
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71
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West T, Pruchnicki MC, Porter K, Emptage R. Evaluation of anticholinergic burden of medications in older adults. J Am Pharm Assoc (2003) 2013; 53:496-504. [DOI: 10.1331/japha.2013.12138] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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72
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Cai X, Campbell N, Khan B, Callahan C, Boustani M. Long-term anticholinergic use and the aging brain. Alzheimers Dement 2013; 9:377-85. [PMID: 23183138 PMCID: PMC3674201 DOI: 10.1016/j.jalz.2012.02.005] [Citation(s) in RCA: 123] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2011] [Revised: 02/01/2012] [Accepted: 02/01/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Older Americans are facing an epidemic of chronic diseases and are thus exposed to anticholinergics (ACs) that might negatively affect their risk of developing mild cognitive impairment (MCI) or dementia. OBJECTIVE To investigate the association between impairment in cognitive function and previous AC exposure. DESIGN A retrospective cohort study. SETTING Primary care clinics in Indianapolis, Indiana. PARTICIPANTS A total of 3690 older adults who have undergone cognitive assessment and had a 1-year medication-dispensing record. OUTCOME Cognitive function was measured in two sequential steps: a two-step screening process followed by a formal diagnostic process for participants with positive screening results. EXPOSURE Three patterns of AC exposure were defined by the duration of AC exposure, the number of AC medications dispensed at the same time, and the severity of AC effects as determined by the Anticholinergic Cognitive Burden list. RESULTS Compared with older adults with no AC exposure and after adjusting for age, race, gender, and underlying comorbidity, the odds ratio for having a diagnosis of MCI was 2.73 (95% confidence interval, 1.27-5.87) among older adults who were exposed to at least three possible ACs for at least 90 days; the odds ratio for having dementia was 0.43 (95% confidence interval, 0.10-1.81). CONCLUSION Exposure to medications with severe AC cognitive burden may be a risk factor for developing MCI.
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Affiliation(s)
- Xueya Cai
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Noll Campbell
- Regenstrief Institute, Inc., Indianapolis, Indiana
- Indiana University Center for Aging Research, Indianapolis, Indiana
- Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette, IN
- Wishard Health Services, Indianapolis, Indiana
| | - Babar Khan
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Chris Callahan
- Regenstrief Institute, Inc., Indianapolis, Indiana
- Indiana University Center for Aging Research, Indianapolis, Indiana
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Malaz Boustani
- Regenstrief Institute, Inc., Indianapolis, Indiana
- Indiana University Center for Aging Research, Indianapolis, Indiana
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
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73
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Wagg AS. Antimuscarinic treatment in overactive bladder: special considerations in elderly patients. Drugs Aging 2013; 29:539-48. [PMID: 22715861 DOI: 10.1007/bf03262272] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Overactive bladder is a common condition that increases in prevalence in association with age. Antimuscarinic therapy remains the mainstay of pharmacological treatment for the condition, and there is an increasing body of evidence that supports the use of these drugs. Despite this, and because of concerns about associated adverse effects, older people are less likely to receive active treatment for their condition. This review considers some of the factors that need to be taken into account when using these medications.
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Affiliation(s)
- Adrian S Wagg
- Division of Geriatric Medicine, Department of Medicine, University of Alberta, Edmonton, AB, Canada.
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74
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Konishi K, Hori K, Tomioka H, Minegishi G, Tani M, Tanaka H, Akita R, Yokoyama S, Oshio T, Hachisu M. Donepezil abolishes anticholinergic activity in a patient with amnesia. Pharmacology 2012; 91:86-91. [PMID: 23258422 DOI: 10.1159/000345344] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Accepted: 10/22/2012] [Indexed: 11/19/2022]
Abstract
We report the case of a 74-year-old woman who presented with amnesia and positive serum anticholinergic activity (SAA), which disappeared after treatment with the cholinesterase inhibitor donepezil for 1 year. Her only other regular medications were topical glaucoma preparations. We suggest that mental stress, mild cognitive impairment and Alzheimer's disease pathology combined to generate SAA in this patient. We also consider that SAA may have subsequently become negative because of upregulation of acetylcholine production by donepezil, and because the patient's other medications and physical condition (including glaucoma) remained unchanged during the 1-year period.
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Affiliation(s)
- Kimiko Konishi
- Department of Psychiatry, Showa University Northern Yokohama Hospital, Yokohama, Japan
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75
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Wojtalik JA, Eack SM, Pollock BG, Keshavan MS. Prefrontal gray matter morphology mediates the association between serum anticholinergicity and cognitive functioning in early course schizophrenia. Psychiatry Res 2012; 204:61-7. [PMID: 23158779 PMCID: PMC3518587 DOI: 10.1016/j.pscychresns.2012.04.014] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Revised: 03/20/2012] [Accepted: 04/23/2012] [Indexed: 12/13/2022]
Abstract
Antipsychotic and other medications used in the treatment of schizophrenia place a burden on the cholinergic subsystems of the brain, which have been associated with increased cognitive impairment in the disorder. This study sought to examine the neurobiologic correlates of the association between serum anticholinergic activity (SAA) and cognitive impairments in early schizophrenia. Neurocognitive performance on measures of memory and executive function, structural magnetic resonance imaging (MRI) scans, and SAA assays were collected from 47 early course, stabilized outpatients with schizophrenia or schizoaffective disorder. Voxel-based morphometry analyses employing general linear models, adjusting for demographic and illness-related confounds, were used to investigate the associations between SAA, gray matter morphology, and neurocognitive impairment. SAA was related to working memory and executive function impairments. Higher SAA was significantly associated with lower gray matter density in broad regions of the frontal and medial-temporal lobes, including the dorsolateral prefrontal cortex (DLPFC), hippocampus, and striatum. Lower gray matter volume in the left DLPFC was found to significantly mediate the association between SAA and working memory impairment. Disease- and/or medication-related cholinergic dysfunction may be associated with brain volume abnormalities in early course schizophrenia, which may account for the association between SAA and cognitive dysfunction in the disorder.
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Affiliation(s)
- Jessica A. Wojtalik
- School of Social Work, University of Pittsburgh, Pittsburgh, PA, USA,Address correspondence to Jessica A. Wojtalik, School of Social Work, University of Pittsburgh, 2117 Cathedral of Learning, Pittsburgh, PA 15260, USA, Tel: 412.648.9029, Fax: 412.624.6323,
| | - Shaun M. Eack
- School of Social Work, University of Pittsburgh, Pittsburgh, PA, USA,Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Bruce G. Pollock
- Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada
| | - Matcheri S. Keshavan
- Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA,Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
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Abstract
The overproduction of β-amyloid (Aβ) fragments in transgenic APPswe/PS1dE9 mice results in formation of amyloid deposits in the cerebral cortex and hippocampus starting around four months of age and leading to cognitive impairment much later. We have previously found an age and transgene-dependent weakening of muscarinic receptor-mediated transmission that was not present in young (6-10-week-old) animals but preceded both amyloid deposits and cognitive deficits. Now we investigated immediate and prolonged in vitro effects of non-aggregated Aβ(1-42) on coupling of individual muscarinic receptor subtypes expressed in CHO (Chinese hamster ovary) cells and their underlying mechanisms. Immediate application of 1 μM Aβ(1-42) had no effect on the binding of the muscarinic antagonist N-methylscopolamine or the agonist carbachol. In contrast, 4-day treatment of CHO cells expressing the M1 muscarinic receptor with 100 nM Aβ(1-42) significantly changed the binding characteristics of the muscarinic agonist carbachol and reduced the extent of the M1 receptor-stimulated breakdown of phosphatidylinositol while it did not demonstrate overt toxic effects. The treatment had no influence on the expression of either G-proteins or muscarinic receptors. In concert, we found no change in the gene expression of muscarinic receptor subtypes and gene or protein expression of the G(s), G(q/11), and G(i/o) G-proteins in the cerebral cortex of young adult APPswe/PS1dE9 mice that demonstrate high concentrations of soluble Aβ(1-42) and impaired muscarinic receptor-mediated G-protein activation. Our results provide strong evidence that the initial injurious effects of Aβ(1-42) on M1 muscarinic receptor-mediated transmissionis is due to compromised coupling of the receptor with G(q/11) G-protein.
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77
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Mizuno Y. An update on the management of juvenile and young-onset Parkinson’s disease. FUTURE NEUROLOGY 2012. [DOI: 10.2217/fnl.12.59] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Early-onset Parkinson’s disease (PD) denotes onset of the disease below the age of 40 years. Patients tend to have a slower disease progression, an increased rate of dystonia, an increased rate of dyskinesias in response to L-3,4-dihydroxyphenylalanine and a lower rate of dementia compared with those in late-onset PD. Early-onset PD patients may experience more social and psychosocial conflict compared with late-onset patients and these factors would contribute to greater impairment of quality of life. Unemployment due to disability or early retirement may be causes for these conflicts. We have to take these factors into account whenever we institute drug therapy in early-onset PD. There is no randomized controlled study on early-onset PD; however, we may make a reasonable decision by considering the data on PD in general and clinical characteristics of early-onset patients. The management of motor and non-motor symptoms of early-onset PD patients is reviewed here.
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Affiliation(s)
- Yoshikuni Mizuno
- Department of Neuroregenerative Medicine, Kitasato University School of Medicine, Kanagawa & Department of Neurology, Juntendo University School of Medicine, Kanagawa 2-1-1 Asamizodai, Minamiku, Sagamihara, 252-0360 Kanagawa, Japan
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Konishi K, Hori K, Tomioka H, Tani M, Tanaka H, Akita R, Yokoyama S, Oshio T, Hachisu M. Is anticholinergic activity related with Parkinson's disease? Psychogeriatrics 2012; 12:214. [PMID: 22994621 DOI: 10.1111/j.1479-8301.2011.00392.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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79
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Wagg AS. Antimuscarinic treatment in overactive bladder: special considerations in elderly patients. Drugs Aging 2012. [PMID: 22715861 DOI: 10.2165/11631610-000000000-00000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Overactive bladder is a common condition that increases in prevalence in association with age. Antimuscarinic therapy remains the mainstay of pharmacological treatment for the condition, and there is an increasing body of evidence that supports the use of these drugs. Despite this, and because of concerns about associated adverse effects, older people are less likely to receive active treatment for their condition. This review considers some of the factors that need to be taken into account when using these medications.
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Affiliation(s)
- Adrian S Wagg
- Division of Geriatric Medicine, Department of Medicine, University of Alberta, Edmonton, AB, Canada.
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80
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Chancellor MB, Staskin DR, Kay GG, Sandage BW, Oefelein MG, Tsao JW. Blood–Brain Barrier Permeation and Efflux Exclusion of Anticholinergics Used in the Treatment of Overactive Bladder. Drugs Aging 2012; 29:259-73. [DOI: 10.2165/11597530-000000000-00000] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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81
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Smithard DG, Fox C, Maidment ID, Katona C, Boustani M. Do anticholinergic drugs contribute to functional and cognitive decline? ACTA ACUST UNITED AC 2012. [DOI: 10.2217/ahe.11.87] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
| | - Chris Fox
- Dementia Research & Innovation Group, Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, UK
| | | | | | - Malaz Boustani
- Healthy Aging Brain Center at Wishard, 410 West 10th Street, Suite 2000, Indianapolis, IN 46202, USA
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82
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Yoshiyama Y, Kojima A, Itoh K, Uchiyama T, Arai K. Anticholinergics boost the pathological process of neurodegeneration with increased inflammation in a tauopathy mouse model. Neurobiol Dis 2012; 45:329-36. [DOI: 10.1016/j.nbd.2011.08.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2011] [Accepted: 08/18/2011] [Indexed: 10/17/2022] Open
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83
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Fisher A. Cholinergic modulation of amyloid precursor protein processing with emphasis on M1 muscarinic receptor: perspectives and challenges in treatment of Alzheimer’s disease. J Neurochem 2011; 120 Suppl 1:22-33. [DOI: 10.1111/j.1471-4159.2011.07507.x] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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84
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Abstract
The prevalence of the overactive bladder (OAB) symptom complex increases with age. Older people also appear to experience more severe incontinence syndromes, including OAB, than their younger counterparts. Older patients are more likely than younger individuals to ask for medication for bladder problems and to require higher doses of medication. Conventional treatment for OAB with conservative and lifestyle measures in combination with antimuscarinic pharmacotherapy is effective in older people. Although there is a theoretical potential for cognitive impairment with antimuscarinic agents, the newer antimuscarinics are cognitively safe in cognitively intact older people.
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Affiliation(s)
- Adrian Wagg
- Division of Geriatric Medicine, Department of Medicine, University of Alberta, Edmonton, AB
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85
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Yarnall A, Rochester L, Burn DJ. The interplay of cholinergic function, attention, and falls in Parkinson's disease. Mov Disord 2011; 26:2496-503. [DOI: 10.1002/mds.23932] [Citation(s) in RCA: 157] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Revised: 07/22/2011] [Accepted: 08/02/2011] [Indexed: 11/09/2022] Open
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86
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Gerretsen P, Pollock BG. Drugs with anticholinergic properties: a current perspective on use and safety. Expert Opin Drug Saf 2011; 10:751-65. [DOI: 10.1517/14740338.2011.579899] [Citation(s) in RCA: 110] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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87
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Adverse event assessment of antimuscarinics for treating overactive bladder: a network meta-analytic approach. PLoS One 2011; 6:e16718. [PMID: 21373193 PMCID: PMC3044140 DOI: 10.1371/journal.pone.0016718] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2010] [Accepted: 12/23/2010] [Indexed: 11/25/2022] Open
Abstract
Background Overactive bladder (OAB) affects the lives of millions of people worldwide and antimuscarinics are the pharmacological treatment of choice. Meta-analyses of all currently used antimuscarinics for treating OAB found similar efficacy, making the choice dependent on their adverse event profiles. However, conventional meta-analyses often fail to quantify and compare adverse events across different drugs, dosages, formulations, and routes of administration. In addition, the assessment of the broad variety of adverse events is dissatisfying. Our aim was to compare adverse events of antimuscarinics using a network meta-analytic approach that overcomes shortcomings of conventional analyses. Methods Cochrane Incontinence Group Specialized Trials Register, previous systematic reviews, conference abstracts, book chapters, and reference lists of relevant articles were searched. Eligible studies included randomized controlled trials comparing at least one antimuscarinic for treating OAB with placebo or with another antimuscarinic, and adverse events as outcome measures. Two authors independently extracted data. A network meta-analytic approach was applied allowing for joint assessment of all adverse events of all currently used antimuscarinics while fully maintaining randomization. Results 69 trials enrolling 26′229 patients were included. Similar overall adverse event profiles were found for darifenacin, fesoterodine, transdermal oxybutynin, propiverine, solifenacin, tolterodine, and trospium chloride but not for oxybutynin orally administered when currently used starting dosages were compared. Conclusions The proposed generally applicable transparent network meta-analytic approach summarizes adverse events in an easy to grasp way allowing straightforward benchmarking of antimuscarinics for treating OAB in clinical practice. Most currently used antimuscarinics seem to be equivalent first choice drugs to start the treatment of OAB except for oral oxybutynin dosages of ≥10 mg/d which may have more unfavorable adverse event profiles.
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88
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Abstract
IMPORTANCE OF THE FIELD Parkinson's disease (PD) is characterized by a slowly ongoing neuronal death, which affects neurotransmitter metabolism and causes a wide variety of motor and non-motor features. Until now, therapy approaches have predominantly focused on motor behavior associated with dopamine substitution. AREAS COVERED IN THIS REVIEW This review aims to discuss putative reasons for recent failures of investigated treatment approaches, and to introduce currently tested and future compounds. WHAT THE READER WILL GAIN We will describe how development programs of novel molecules now additionally consider non-motor features of PD as promising targets in order to obtain regulatory approval. Regulatory authorities increasingly exert influence on trial designs, demanding therapeutic effects that are not always clinically feasible given the variety of manifestations of the disease entity known as PD. TAKE HOME MESSAGE In the past, research pitfalls have resulted in the failure of promising new compounds. Among the many reasons for this are massive placebo responses; the participation of too many investigators, with consequent wide variations of efficacy assessments; and a misconception of preclinical drug development, with models of PD that do not mimic its clinical nature. A few compounds are now being tested that have modes of action indirectly modulating the dopamine system; however, critical analysis of the preclinical and clinical research concept and drug approval is warranted to prevent further frustration in this field.
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Affiliation(s)
- Thomas Müller
- St. Joseph Hospital Berlin-Weissensee, Department of Neurology, Gartenstrasse 1, 13088 Berlin, Germany.
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89
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Abstract
Parkinson's disease (PD) is the second most common neurodegenerative illness after Alzheimer's disease (AD). Cognitive impairment and dementia are common features in PD and characterized by a wide range of cognitive deficits distinct from those seen in AD. Mild cognitive impairment occurs even early in PD and is associated with shorter time to dementia. The purpose of this review is to present recent findings on clinical aspects of dementia in PD and to elucidate underlying clinical and neurobiological risk factors.
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Affiliation(s)
- Dag Aarsland
- Department of Psychiatry, Stavanger University Hospital, Postboks 8100, 4068 Stavanger, Norway.
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90
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Neuropsychological and clinical heterogeneity of cognitive impairment and dementia in patients with Parkinson's disease. Lancet Neurol 2010; 9:1200-1213. [PMID: 20880750 DOI: 10.1016/s1474-4422(10)70212-x] [Citation(s) in RCA: 613] [Impact Index Per Article: 43.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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91
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Jakubík J, El-Fakahany EE. Allosteric Modulation of Muscarinic Acetylcholine Receptors. Pharmaceuticals (Basel) 2010; 3:2838-2860. [PMID: 27713379 PMCID: PMC4034100 DOI: 10.3390/ph3092838] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2010] [Revised: 08/17/2010] [Accepted: 08/18/2010] [Indexed: 11/16/2022] Open
Abstract
An allosteric modulator is a ligand that binds to an allosteric site on the receptor and changes receptor conformation to produce increase (positive cooperativity) or decrease (negative cooperativity) in the binding or action of an orthosteric agonist (e.g., acetylcholine). Since the identification of gallamine as the first allosteric modulator of muscarinic receptors in 1976, this unique mode of receptor modulation has been intensively studied by many groups. This review summarizes over 30 years of research on the molecular mechanisms of allosteric interactions of drugs with the receptor and for new allosteric modulators of muscarinic receptors with potential therapeutic use. Identification of positive modulators of acetylcholine binding and function that enhance neurotransmission and the discovery of highly selective allosteric modulators are mile-stones on the way to novel therapeutic agents for the treatment of schizophrenia, Alzheimer’s disease and other disorders involving impaired cognitive function.
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Affiliation(s)
- Jan Jakubík
- Institute of Physiology, Academy of Sciences of the Czech Republic, Vídeňská 1083, 142 00 Praha, Czech Republic.
| | - Esam E El-Fakahany
- Division of Neuroscience Research in Psychiatry, University of Minnesota Medical School, Minneapolis, MN 55455, USA.
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92
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Deletion of M1 muscarinic acetylcholine receptors increases amyloid pathology in vitro and in vivo. J Neurosci 2010; 30:4190-6. [PMID: 20335454 DOI: 10.1523/jneurosci.6393-09.2010] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Alzheimer's disease (AD) is a progressive neurological disorder that causes dementia and poses a major public health crisis as the population ages. Aberrant processing of the amyloid precursor protein (APP) is strongly implicated as a proximal event in AD pathophysiology, but the neurochemical signals that regulate APP processing in the brain are not completely understood. Activation of muscarinic acetylcholine receptors (mAChRs) has been shown to affect APP processing and AD pathology, but less is known about the roles of specific mAChR subtypes. In this study, we used M(1) mAChR knock-out mice (M(1)KO) to isolate the effects of the M(1) mAChR on APP processing in primary neurons and on the development of amyloid pathology in a transgenic mouse model of AD. We demonstrate that the loss of M(1) mAChRs increases amyloidogenic APP processing in neurons, as evidenced by decreased agonist-regulated shedding of the neuroprotective APP ectodomain APPsalpha and increased production of toxic Abeta peptides. Expression of M(1) mAChRs on the M(1)KO background rescued this phenotype, indicating that M(1) mAChRs are sufficient to modulate nonamyloidogenic APP processing. In APP(Swe/Ind) transgenic mice, the loss of M(1) mAChRs resulted in increased levels of brain Abeta and greater accumulation of amyloid plaque pathology. Analysis of APP metabolites in APP(Swe/Ind) brain tissue indicates that the loss of M(1) mAChRs increases amyloidogenic APP processing. These results indicate that the M(1) mAChR is an important regulator of amyloidogenesis in the brain and provide strong support for targeting the M(1) mAChR as a therapeutic candidate in AD.
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93
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Lester DB, Rogers TD, Blaha CD. Acetylcholine-dopamine interactions in the pathophysiology and treatment of CNS disorders. CNS Neurosci Ther 2010; 16:137-62. [PMID: 20370804 DOI: 10.1111/j.1755-5949.2010.00142.x] [Citation(s) in RCA: 136] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Dopaminergic neurons in the substantia nigra pars compacta and ventral tegmental area of the midbrain form the nigrostriatal and mesocorticolimbic dopaminergic pathways that, respectively, project to dorsal and ventral striatum (including prefrontal cortex). These midbrain dopaminergic nuclei and their respective forebrain and cortical target areas are well established as serving a critical role in mediating voluntary motor control, as evidenced in Parkinson's disease, and incentive-motivated behaviors and cognitive functions, as exhibited in drug addiction and schizophrenia, respectively. Although it cannot be disputed that excitatory and inhibitory amino acid-based neurotransmitters, such as glutamate and GABA, play a vital role in modulating activity of midbrain dopaminergic neurons, recent evidence suggests that acetylcholine may be as important in regulating dopaminergic transmission. Midbrain dopaminergic cell tonic and phasic activity is closely dependent upon projections from hindbrain pedunculopontine and the laterodorsal tegmental nuclei, which comprises the only known cholinergic inputs to these neurons. In close coordination with glutamatergic and GABAergic activity, these excitatory cholinergic projections activate nicotinic and muscarinic acetylcholine receptors within the substantia nigra and ventral tegmental area to modulate dopamine transmission in the dorsal/ventral striatum and prefrontal cortex. Additionally, acetylcholine-containing interneurons in the striatum also constitute an important neural substrate to provide further cholinergic modulation of forebrain striatal dopaminergic transmission. In this review, we examine neurological and psychopathological conditions associated with dysfunctions in the interaction of acetylcholine and dopamine and conventional and new pharmacological approaches to treat these disorders.
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94
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Konishi K, Hori K, Uchida H, Watanabe K, Tominaga I, Kimura M, Hosoyamada M, Shibasaki T, Kataoka A, Hachisu M. Adverse effects of anticholinergic activity on cognitive functions in Alzheimer's disease. Psychogeriatrics 2010; 10:34-8. [PMID: 20594285 DOI: 10.1111/j.1479-8301.2010.00310.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Elderly patients with Alzheimer's disease (AD) take more medicines, other than those for anti-dementia agents, than healthy people and are sensitive to anticholinergic medications. There are only a few reports, however, on the relationship between cognitive function and anticholinergic activity in AD patients, which is caused by taking prescribed medication. METHODS We measured serum anticholinergic activity (SAA) in 76 AD patients referred to a Psychogeriatric Unit and separated them into SAA positive group (n= 26, SAA (+) group) and SAA negative group (n= 50, SAA (-) group). The difference in demographic data and cognitive functions were compared between the two groups. RESULTS AND CONCLUSIONS The total scores of the Mini-Mental State Examination (MMSE), the score of MMSE domain of registration and recall were significantly lower (P < 0.05) and the Functional Assessment Staging (FAST) score, the number of different kinds of prescribed psychotropic medications (the number of prescribed psychotropic medications) were significantly higher (P < 0.05) in the SAA (+) group than in the SAA (-). These results suggest that a higher number of psychotropic medications prescribed leads to a tendency for SAA to be positive and that anticholinergic activity accelerates Alzheimer's pathology and decreases cognitive function, especially memory in AD patients. We should more prudently prescribe psychotropic medications to AD patients, because the prescribed psychotropic medications are one of the important causes of decline in cognitive function of AD patients by way of anticholinergic activity.
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Affiliation(s)
- Kimiko Konishi
- Tokyo Metropolitan Tobu Medical Center for Persons with Developmental/Multiple Disabilities, Tokyo, Japan
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95
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Localisation of pre- and postsynaptic cholinergic markers in the human brain. Behav Brain Res 2010; 221:341-55. [PMID: 20170687 DOI: 10.1016/j.bbr.2010.02.025] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2010] [Accepted: 02/10/2010] [Indexed: 12/20/2022]
Abstract
The cholinergic neurotransmission in the central nervous system plays an important role in modulating cognitive processes such as learning, memory, arousal and sleep as well as in modulating locomotor activity. Dysfunction of the central cholinergic system is involved in numerous neuropsychiatric diseases. This review will provide a synopsis on the regional localisation of cholinergic and cholinoceptive structures within the adult human brain. On the cholinergic site data based on the distribution of choline acetyltransferase-immunoreactive structures are in the focus, complemented by data from acetylcholinesterase and vesicular acetylcholine transporter studies. On the cholinoceptive site, the distribution and localisation of receptors that transduce the acetylcholine message, i.e. the muscarinic and the nicotinic acetylcholine receptors is summarized. In addition to these data obtained on post mortem brain an overview of markers which allow for the in vivo monitoring of the cholinergic system in the brain is given. The detailed knowledge on the distribution and localisation of cholinergic markers in human brain will provide further information on the cholinergic circuits of neurotransmission - a prerequisite for the interpretation of in vivo imaging data and the development of selective diagnostic and therapeutic compounds.
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96
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Machová E, Rudajev V, Smycková H, Koivisto H, Tanila H, Dolezal V. Functional cholinergic damage develops with amyloid accumulation in young adult APPswe/PS1dE9 transgenic mice. Neurobiol Dis 2010; 38:27-35. [PMID: 20053373 DOI: 10.1016/j.nbd.2009.12.023] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2009] [Revised: 12/03/2009] [Accepted: 12/26/2009] [Indexed: 10/20/2022] Open
Abstract
We investigated the functional characteristics of pre- and postsynaptic cholinergic transmission in APPswe/PS1dE9 double transgenic mice at a young age (7-10 weeks) before the onset of amyloid plaque formation and at adult age (5-6 months) at its onset. We compared brain slices from cerebral cortex and hippocampus with amyloid deposits to slices from striatum with no amyloid plaques by 6 months of age. In young transgenic mice we found no impairments of preformed and newly synthesized [(3)H]-ACh release, indicating intact releasing machinery and release turnover, respectively. Adult transgenic mice displayed a significant increase in preformed [(3)H]-ACh release in cortex but a decrease in hippocampus and striatum. The extent of presynaptic muscarinic autoregulation was unchanged. Evoked release of newly synthesized [(3)H]-ACh was significantly reduced in the cortex and hippocampus but unchanged in the striatum. Carbachol-induced G-protein activation in cortical membranes displayed decreased potency but normal efficacy in adult animals and no changes in young animals. These results indicate that functional pre- and postsynaptic cholinergic deficits are not present in APPswe/PS1dE9 transgenic mice before 10 weeks of age, but develop along with beta-amyloid accumulation in the brain.
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Affiliation(s)
- Eva Machová
- Institute of Physiology CAS, Vídenská 1083, 14220 Prague 4, Czech Republic
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97
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Abstract
Parkinson's disease (PD) is most frequently associated with characteristic motor symptoms that are known to arise with degeneration of dopaminergic neurons. However, patients with this disease also experience a multitude of non-motor symptoms, such as sleep disturbances, fatigue, apathy, anxiety, depression, cognitive impairment, dementia, olfactory dysfunction, pain, sweating and constipation, some of which can be at least as debilitating as the movement disorders and have a major impact on patients' quality of life. Many of these non-motor symptoms may be evident prior to the onset of motor dysfunction. The neuropathology of PD has shown that complex, interconnected neuronal systems, regulated by a number of different neurotransmitters in addition to dopamine, are involved in the aetiology of motor and non-motor symptoms. This review focuses on the non-dopaminergic neurotransmission systems associated with PD with particular reference to the effect that their modulation and interaction with dopamine has on the non-motor symptoms of the disease. PD treatments that focus on the dopaminergic system alone are unable to alleviate both motor and non-motor symptoms, particularly those that develop at early stages of the disease. The development of agents that interact with several of the affected neurotransmission systems could prove invaluable for the treatment of this disease.
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Affiliation(s)
- P Barone
- Dipartimento di Scienze Neurologiche and IDC-Hermitage-Capodimonte, Naples, Italy.
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98
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Carrière I, Fourrier-Reglat A, Dartigues JF, Rouaud O, Pasquier F, Ritchie K, Ancelin ML. Drugs with anticholinergic properties, cognitive decline, and dementia in an elderly general population: the 3-city study. ACTA ACUST UNITED AC 2009; 169:1317-24. [PMID: 19636034 DOI: 10.1001/archinternmed.2009.229] [Citation(s) in RCA: 257] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Despite the high intake of medications with anticholinergic properties by community-dwelling elderly persons, the effects on cognitive decline and dementia have rarely been evaluated. METHODS Participants were 4128 women and 2784 men 65 years or older from a population-based cohort recruited from 3 French cities. Cognitive performance, clinical diagnosis of dementia, and anticholinergic use were evaluated at baseline and 2 and 4 years later. RESULTS A total of 7.5% of the participants reported anticholinergic drug use at baseline. Multivariate-adjusted logistic regression indicated that women reporting use of anticholinergic drugs at baseline showed greater decline over 4 years in verbal fluency scores (odds ratio [OR], 1.41; 95% confidence interval [CI], 1.11-1.79) and in global cognitive functioning (OR, 1.22; 95% CI, 0.96-1.55) than women not using anticholinergic drugs. In men, an association was found with decline in visual memory (OR, 1.63; 95% CI, 1.08-2.47) and to a lesser extent in executive function (OR, 1.47; 95% CI, 0.89-2.44). Notable interactions were observed in women between anticholinergic use and age, apolipoprotein E, or hormone therapy. A 1.4- to 2-fold higher risk of cognitive decline was observed for those who continuously used anticholinergic drugs but not for those who had discontinued use. The risk of incident dementia over the 4-year follow-up period was also increased in continuous users (hazard ratio [HR], 1.65; 95% CI, 1.00-2.73) but not in those who discontinued the use of anticholinergic drugs (HR, 1.28; 95% CI, 0.59-2.76). CONCLUSIONS Elderly people taking anticholinergic drugs were at increased risk for cognitive decline and dementia. Discontinuing anticholinergic treatment was associated with a decreased risk. Physicians should carefully consider prescription of anticholinergic drugs in elderly people, especially in the very elderly and in persons at high genetic risk for cognitive disorder.
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99
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Weller RO, Boche D, Nicoll JAR. Microvasculature changes and cerebral amyloid angiopathy in Alzheimer's disease and their potential impact on therapy. Acta Neuropathol 2009; 118:87-102. [PMID: 19234858 DOI: 10.1007/s00401-009-0498-z] [Citation(s) in RCA: 199] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2008] [Revised: 02/08/2009] [Accepted: 02/09/2009] [Indexed: 12/25/2022]
Abstract
The introduction of immunotherapy and its ultimate success will require re-evaluation of the pathogenesis of Alzheimer's disease particularly with regard to the role of the ageing microvasculature and the effects of APOE genotype. Arteries in the brain have two major functions (a) delivery of blood and (b) elimination of interstitial fluid and solutes, including amyloid-beta (Abeta), along perivascular pathways (lymphatic drainage). Both these functions fail with age and particularly severely in Alzheimer's disease and vascular dementia. Accumulation of Abeta as plaques in brain parenchyma and artery walls as cerebral amyloid angiopathy (CAA) is associated with failure of perivascular elimination of Abeta from the brain in the elderly and in Alzheimer's disease. High levels of soluble Abeta in the brain correlate with cognitive decline in Alzheimer's disease and reflect the failure of perivascular drainage of solutes from the brain and loss of homeostasis of the neuronal environment. Clinically and pathologically, there is a spectrum of disease related to functional failure of the ageing microvasculature with "pure" Alzheimer's disease at one end of the spectrum and vascular dementia at the other end. Changes in the cerebral microvasculature with age have a potential impact on therapy with cholinesterase inhibitors and especially on immunotherapy that removes Abeta from plaques in the brain, but results in an increase in severity of CAA and no clear improvement in cognition. Drainage of Abeta along perivascular pathways in ageing artery walls may need to be improved to maximise the potential for improvement of cognitive function with immunotherapy.
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Affiliation(s)
- Roy O Weller
- Clinical Neurosciences, University of Southampton School of Medicine, LD74, South Laboratory & Pathology Block, Southampton General Hospital, Southampton SO166YD, UK.
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100
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Cholinesterase inhibitors may increase phosphorylated tau in Alzheimer's disease. J Neurol 2009; 256:717-20. [PMID: 19240967 DOI: 10.1007/s00415-009-5000-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2008] [Revised: 10/06/2008] [Accepted: 11/14/2008] [Indexed: 10/21/2022]
Abstract
Cholinesterase inhibitors (ChEIs) are widely used for the symptomatic treatment of Alzheimer's disease (AD). In vitro and in animal studies, ChEIs have been shown to influence the processing of Abeta and the phosphorylation of tau, proteins that are the principal constituents of the plaques and neurofibrillary tangles, respectively, in AD brain. However, little is known about the effects of these drugs on Abeta and tau pathology in AD. Using avidin-biotin immunohistochemistry and computer-assisted image analysis, we compared Abeta and tau loads in the frontal and temporal cortices of 72 brains from matched cohorts of AD patients who had or had not received ChEIs. Patients treated with ChEIs had accumulated significantly more phospho-tau in their cerebral cortex than had untreated patients (P = 0.004). Abeta accumulation was reduced but not significantly. These data raise the possibility that increased tau phosphorylation may influence long-term clinical responsiveness to ChEIs.
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