Inhibition of hippocampal function in mild cognitive impairment: targeting the cholinergic hypothesis

A double-blind, placebo-controlled pilot study of galantamine to improve cognitive dysfunction in minimally symptomatic bipolar disorder

OBJECTIVE

There is increasing evidence that cognitive impairment is common in patients with bipolar disorder. The purpose of this study was to determine whether galantamine augmentation improved cognition in patients with euthymic bipolar disorder. In addition, the effect of galantamine on clinical measures of functioning and psychopathology was assessed.

METHOD

This study was a randomized double-blind, placebo-controlled, parallel design examining the impact of galantamine augmentation on cognition and other clinical measures in 30 patients during the course of 3 months. Sixteen subjects who completed baseline and follow-up second neuropsychological testing were evaluable (10 with galantamine and 6 with placebo).

RESULTS

The galantamine group showed improved performance on the California Verbal Learning Test total learning and the placebo group showed improved performance on the 2 Delis-Kaplan Executive Functioning System trail-making conditions and category fluency.

CONCLUSIONS

Episodic memory performance was improved in the galantamine treatment group but did not improve in the placebo group. In contrast, performance on 2 of the processing speed measures showed significant improvement in the placebo condition, whereas that of the patients treated with galantamine did not improve. Galantamine may thus have specific benefits for episodic memory, but not processing speed, in patients with cognitive impairment as part of bipolar disorder.

Galantamine-induced improvements in cognitive function are not related to alterations in alpha(4)beta (2) nicotinic receptors in early Alzheimer's disease as measured in vivo by 2-[18F]fluoro-A-85380 PET

INTRODUCTION

The nicotinic acetylcholine receptor (nAChR) system plays a regulatory role in a number of cognitive processes. Cholinesterase inhibitors (i.e., galantamine) that potentiate cholinergic neurotransmission improve cognitive function in Alzheimer's disease (AD); however, the relationship between these effects and associated changes in nAChRs are yet to be established in vivo.

MATERIALS AND METHODS

2-[18F]Fluoro-A-85380 (2-FA) binds to nAChRs and with positron emission tomography (PET) imaging provides a composite measure of receptor density and ligand affinity. This study aimed to: (1) quantify nAChRs in vivo in 15 drug-naïve patients with mild AD before and after chronic treatment with galantamine, using 2-FA and PET, and (2) examine the relationship between treatment-induced changes in nAChRs and improvements in cognitive function. Participants were nonsmokers and underwent extensive cognitive testing and a PET scan after injection of approximately 200 MBq of 2-FA on two occasions (before and after 12 weeks, galantamine treatment). A 3-day washout period preceded the second scan. Brain regional 2-FA binding was assessed through a simplified estimation of distribution volume (DV(S)).

RESULTS

Performance on global measures of cognition significantly improved following galantamine treatment (p < 0.05). This improvement extended to specific cognitive measures of language and verbal learning. No significant differences in nAChR DV(S) before and after galantamine treatment were found. The treatment-induced improvement in cognition was not correlated with regional or global nAChR DV(S), suggesting that changes in nAChRs may not be responsible for the improvements in cognition following galantamine in patients with mild AD.

Modification of adenosine modulation of acetylcholine release in the hippocampus of aged rats

Adenosine is a neuromodulator acting through inhibitory A(1) receptors (A(1)Rs) and facilitatory A(2A)Rs. Since A(2A)R antagonists attenuate memory deficits in aged animals and memory deficits might involve a decreased cholinergic function, we investigated how aging affects the density and function of adenosine receptors in rat hippocampal cholinergic terminals. In young adult (2 months) rats, 64 and 36% of cholinergic terminals (immunopositive for vesicular ACh transporters) possessed A(1)Rs and A(2A)Rs, respectively. In aged (24 months) rats, the percentage of cholinergic terminals with A(1)Rs was preserved, whereas that with A(2A)Rs was larger (49%). In young adults adenosine only tonically inhibited ACh release through A(1)Rs, whereas in aged rats there was a greater A(1)R-mediated inhibition and a simultaneous A(2A)R-mediated facilitation of ACh release. Thus, the enhanced A(2A)R density and facilitation compensates for the greater tonic A(1)R modulation, preserving the global adenosine modulation of ACh release in aged rats. Furthermore, since A(2A)R antagonists inhibit ACh release, the beneficial effects of A(2A)R antagonists on memory in aged rats might not result from ACh release modulation.

Episodic-like and procedural memory impairments in histamine H1 Receptor knockout mice coincide with changes in acetylcholine esterase activity in the hippocampus and dopamine turnover in the cerebellum

We investigated episodic-like (ELM) and procedural memory (PM) in histamine H1 receptor knockout (H1R-KO) mice. In order to relate possible behavioral deficits to neurobiological changes, we examined H1R-KO and wild-type (WT) mice in terms of acetylcholine esterase (AChE) activity in subregions of the hippocampus and AChE and tyrosine hydroxylase (TH) expression in the striatum. Furthermore, we analyzed acetylcholine (ACh), 5-HT and dopamine (DA) levels, including metabolites, in the cerebellum of H1R-KO and WT mice. The homozygous H1R-KO mice showed impaired ELM as compared with the heterozygous H1R-KO and WT mice. The performance of homozygous H1R-KO mice in the ELM task was primarily driven by familiarity-based memory processes. While the homozygous H1R-KO mice performed similar to the heterozygous H1R-KO and WT mice during the acquisition of a PM, as measured with an accelerating rotarod, after a retention interval of 7 days their performance was impaired relative to the heterozygous H1R-KO and WT mice. These findings suggest that, both, ELM and long-term PM are impaired in the homozygous H1R-KO mice. Neurochemical assays revealed that the H1R-KO mice had significantly lower levels of AChE activity in the dentate gyrus (DG) and CA1 subregions of the hippocampus as compared with the WT mice. The homozygous H1R-KO mice also displayed significantly reduced dihydroxyphenylacetic acid (DOPAC) levels and a reduced DOPAC/DA ratio in the cerebellum, suggesting that the DA turnover in the cerebellum is decelerated in homozygous H1R-KO mice. In conclusion, homozygous H1R-KO mice display severe long-term memory deficits in, both, ELM and PM, which coincide with changes in AChE activity in the hippocampus as well as DA turnover in the cerebellum. The importance of these findings for Alzheimer's (AD) and Parkinson's disease (PD) is discussed.

Magnetic resonance imaging in clinical trials

PURPOSE OF REVIEW

The aim of this article is to review the latest clinical trials in neurological diseases where magnetic resonance imaging was used to assess treatment outcome.

RECENT FINDINGS

The unique sensitivity of magnetic resonance imaging for detecting disorders in the brain has made it an attractive noninvasive tool for assessing treatment efficacy in several diseases. Volumetric and functional magnetic resonance imaging have proved to represent robust biomarkers for the evaluation of anti-Alzheimer treatments, and have demonstrated a significant impact of cholinesterase inhibitors. The optimization of thrombolytic therapy in acute ischemic stroke has concentrated on the quantification of the ischemic penumbra, using perfusion-weighted and diffusion-weighted imaging. Standard assessment of T2 or fluid-attenuated inversion recovery lesion load remains the method of choice to evaluate new therapeutic strategy in multiple sclerosis. Other nonconventional quantitative magnetic resonance imaging techniques such as magnetic resonance volumetry, magnetization transfer imaging, diffusion-weighted imaging, or magnetic resonance spectroscopy are increasingly used in the field.

SUMMARY

Magnetic resonance imaging has become a major surrogate marker of treatment response in clinical trials of neurological disorders, offering the possibility to reduce the required sample size or to shorten the duration of the trial.

fMRI: use in early Alzheimer’s disease and in clinical trials

The pathophysiological process of Alzheimer’s disease (AD) begins years, even decades, prior to the time a clinical diagnosis can be established. This long asymptomatic or minimally symptomatic phase of AD provides a potential period for early therapeutic interventions to slow and perhaps ultimately prevent the progression to clinical dementia. Functional MRI (fMRI) provides an in vivo means to investigate alterations in brain function related to the earliest symptoms of AD, possibly before development of significant irreversible structural damage. fMRI during tasks probing episodic memory, which is the cognitive function most characteristically impaired in early AD, are of particular interest. In this paper, we review the current knowledge of the pathophysiological fMRI correlates of AD and of at-risk states for AD, such as presence of mild cognitive impairment or the apolipoprotein E ε4 allele. We will summarize previous studies demonstrating changes in task-related fMRI activity, primarily focusing on memory tasks, as well as studies investigating resting-state fMRI findings in clinical AD patients and at-risk subjects compared with healthy elderly individuals. We will also discuss the potential use of fMRI in clinical trials of AD therapeutic agents, as well as the limitations of this promising imaging technique.

Randomized double-blind placebo-controlled donepezil augmentation in antidepressant-treated elderly patients with depression and cognitive impairment: a pilot study

OBJECTIVE

To assess combined antidepressant and cognitive enhancer treatment in elderly patients presenting with depression plus cognitive impairment.

METHODS

Twenty-three elderly (>50 years old) depressed, cognitively impaired (DEP-CI) patients participated in a pilot study. We evaluated whether, after 8 weeks of open antidepressant treatment, donepezil HCl (Aricept) would afford added cognitive benefit compared to placebo in a randomized 12-week trial. A subsample continued in an 8-month extension phase of open treatment with donepezil. Neuropsychological testing (NPT) was performed and antidepressant response monitored at baseline and the 8, 20, and 52-week time points.

RESULTS

At 8-weeks, the antidepressant response rate was 61% (14/23). Improvement in SRT immediate recall (SRT-IR; e.g. episodic verbal memory) was observed in responders compared to non-responders. During the 12-week, placebo-controlled, donepezil add-on trial, patients on donepezil showed further improvement in SRT-IR versus patients on placebo. In the open extension phase, patients who continued open donepezil treatment (n = 6) maintained improvement in memory and tended to show an advantage over patients who never received donepezil and were evaluated at the 52-week time point (n = 6). There were no observed significant donepezil effects on non-memory cognitive domains.

CONCLUSION

These preliminary findings suggest that addition of a cholinesterase inhibitor (AChEI) following antidepressant medication treatment in elderly Dep-CI patients may improve cognition, and support the need for a confirmatory, larger randomized placebo-controlled trial.

Prolonged cholinergic enrichment influences regional cortical activation in early Alzheimer's disease

Neuroimaging studies of cholinesterase inhibitor (ChEI) treatment in Alzheimer's disease (AD) indicate that the short and long term actions of ChEIs are dissimilar. fMRI studies of the ChEI rivastigmine have focused on its short term action. In this exploratory study the effect of prolonged (20 weeks) rivastigmine treatment on regional brain activity was measured with fMRI in patients with mild AD. Eleven patients with probable AD and nine age-matched controls were assessed with a Pyramids and Palm Trees semantic association and an n-back working memory fMRI paradigm. In the patient group only, the assessment was repeated after 20 weeks of treatment. There was an increase in task-related brain activity after treatment with activations more like those of normal healthy elderly. Behaviorally, however, there were no significant differences between baseline and retest scores, with a range of performance probably reflecting variation in drug efficacy across patients. Variable patient response and drug dynamic/kinetic factors in small patient groups will inevitably bias (either way) the effect size of any relevant drug related changes in activation. Future studies should take drug response into account to provide more insight into the benefits of ChEI drugs at the individual level.

VRX-03011, a novel 5-HT4 agonist, enhances memory and hippocampal acetylcholine efflux

Recent evidence suggests that 5-hydroxytryptamine (5-HT)(4) receptor activity enhances cognition and provides neuroprotection. Here we report the effects of VRX-03011, a novel partial 5-HT(4) agonist, that is both potent (K(i) approximately 30 nM) and highly selective (K(i) > 5 microM for all other 5-HT receptors tested). In separate experiments, rats received VRX-03011 (0.1-10 mg/kg i.p.) 30 min prior to spontaneous alternation testing in a no-delay or a 30-s delay condition. VRX-03011 (1, 5 and 10 mg/kg, but not 0.1 mg/kg) significantly enhanced delayed spontaneous alternation performance while none of the doses enhanced performance in the no-delay test. VRX-03011 (1 and 5 mg/kg) concomitantly enhanced hippocampal acetylcholine output and delayed spontaneous alternation scores compared to that of vehicle controls, but had no effect on hippocampal acetylcholine release under a resting condition. Moreover, suboptimal doses of VRX-03011 and the acetylcholinesterase inhibitor galanthamine combined to enhance memory. VRX-03011 also regulated amyloid precursor protein (APP) metabolism by inducing a concentration-dependent increase in the non-amyloidogenic soluble form of APP (sAPPalpha) with an EC(50) approximately 1--10 nM. VRX-03011 had no effect on contractile properties in guinea pig ileum or colon preparations with an EC(50) > 10 microM and did not alter rat intestinal transit at doses up to 10 mg/kg. These findings suggest that VRX-03011 may represent a novel treatment for Alzheimer's disease that reduces cognitive impairments and provides neuroprotection without gastrointestinal side effects.

Imaging treatment effects in Alzheimer's disease

Alzheimer's disease (AD) is the commonest form of degenerative dementia and is characterised by progressive cognitive decline. Despite extensive research, the cause of AD is unknown and there is no cure at present. Of the deficits found in AD, that affecting the cholinergic neurotransmitter system is the best established and the only one translated into symptomatic treatment. Cholinergic enhancement with cholinesterase inhibitor (ChEI) drugs has been achieved and their efficacy and safety ascertained by conventional clinical trials. The mechanism of action of these drugs, however, is not well understood. Imaging with SPECT, PET, MRI and fMRI after treatment has clarified what happens in the brains of those AD patients treated with ChEI drugs. Studies with these techniques have identified increases in brain blood flow and glucose metabolism, restoration of nicotinic receptor function and re-establishment of task-related regional brain activation in response to cognitive stimulation after treatment. Structural MRI studies have explained, to some degree, why only a proportion of patients benefits from ChEI treatment and there is some evidence that some ChEI drugs might be neuroprotective. There are, however, many unsolved problems. Timing of treatment intervention to obtain maximum response and the determinants of treatment response are mostly unknown. It is also unclear whether administration of treatment in those patients who have no potential for response accelerates disease progression. These issues cannot be solved by conventional clinical trials. Pharmacoimaging studies could assist the development and refinement of drugs to treat those diseases, such as AD, which affect the central nervous system.

Regional brain activity after prolonged cholinergic enhancement in early Alzheimer's disease

This functional magnetic resonance imaging (fMRI) study examined changes in brain activation after prolonged (20 weeks) and stabilized treatment with the cholinesterase inhibitor galantamine in a small group of patients with very mild Alzheimer's disease (AD). Two cognitive activation paradigms were chosen: one requiring semantic association and the other relying on attention and requiring target detection. A group of age- and education-matched healthy controls was also scanned for comparison. A modest (but not statistically significant) improvement in behavioral scores after treatment was observed in both fMRI tasks. There were brain activation increases in the semantic association task after treatment, and the differences in brain activation present in the comparison of AD patients' baseline images with those of controls were not detectable after treatment. In the target detection task, regions that were activated in the elderly controls but not in the baseline images of the AD group also showed significant activation after treatment. Overall, however, the increases were modest and might reflect the heterogeneity of clinical response to treatment in this small group. Future pharmacological fMRI studies should include clinical response as a factor in the analysis of cholinergic enhancement effects in AD patients.

The significance of the cholinergic system in the brain during aging and in Alzheimer's disease

Acetylcholine is widely distributed in the nervous system and has been implicated to play a critical role in cerebral cortical development, cortical activity, controlling cerebral blood flow and sleep-wake cycle as well as in modulating cognitive performances and learning and memory processes. Cholinergic neurons of the basal forebrain complex have been described to undergo moderate degenerative changes during aging, resulting in cholinergic hypofunction that has been related to the progressing memory deficits with aging. Basal forebrain cholinergic cell loss is also a consistent feature of Alzheimer's disease, which has been suggested to cause, at least partly, the cognitive deficits observed, and has led to the formulation of the cholinergic hypotheses of geriatric memory dysfunction. Impaired cortical cholinergic neurotransmission may also contribute to beta-amyloid plaque pathology and increase phosphorylation of tau protein the main component of neurofibrillar tangles in Alzheimer's disease. Understanding the molecular mechanisms underlying the interrelationship between cortical cholinergic dysfunction, beta-amyloid formation and deposition, and tau pathology in Alzheimer's disease, would allow to derive potential treatment strategies to pharmacologically intervene in the disease-causing signaling cascade.

Neuroprotective effects of behavioural training and nicotine on age-related deficits in spatial learning

Studies in humans and animals show a clear decline in spatial memory with age and several approaches have been adopted to alleviate this impairment. The purpose of our review is to assess the studies that have suggested the possible neuroprotective actions of behavioural training and nicotine-applied both independently and in conjunction-on age-related deficits in spatial learning. Both spatial pretraining and nonspatial experiences influence an animal's performance in spatial tasks. In aged rats, the experience of training in the water maze task increases the number of newly generated neurons in the hippocampus. The neuroprotective effects of nicotine have been demonstrated in both in-vitro and in-vivo models, although the molecular mechanisms underlying these actions are not yet fully understood. It had been concluded in different studies that nicotine can improve, impair or have no effect on performance in the water maze. Neurobiological data also suggest an interaction between nicotine and prior experience in complex tasks, although few studies have raised the question of whether nicotine treatment and training in spatial tasks may contribute in an interactive manner to alleviate spatial cognition impairment associated with the ageing process. Different findings suggest that past experience could be a confounding variable in longitudinal studies that aim to evaluate the neuroprotective effects of nicotine on age-related deficits in spatial learning.

Neuropsychological testing in the diagnosis of dementia

Neuropsychological testing can play a major role in the diagnosis of dementia by documenting cognitive deficits, the key criteria for the diagnosis. Because the most common dementia diagnosis, Alzheimer's disease, focuses on memory impairment, tests to assess this domain and to detect and characterize memory deficit are well established with recognized predictive value. Other neuropsychological domains are less well characterized and there are fewer tools to assess them. One domain that has been characterized as important in a number of other dementias is executive function. Improved neuropsychological assessment and characterization of other domains, such as executive function and attention, may assist in better identifying the pathophysiology of deficits in these areas, perhaps in combination with new technologies such as functional imaging. Finally, improved assessment tools for specific cognitive domains should assist in identifying a broad range of cognitive deficits at earlier stages and ultimately lead to more effective interventions for a wider range of cognitive deficits.