Mild cognitive impairment clinical trials

Do MCI criteria in drug trials accurately identify subjects with predementia Alzheimer's disease?

BACKGROUND

Drugs effective in Alzheimer-type dementia have been tested in subjects with mild cognitive impairment (MCI) because these are supposed to have Alzheimer's disease in the predementia stage.

OBJECTIVES

To investigate whether MCI criteria used in these drug trials can accurately diagnose subjects with predementia Alzheimer's disease.

METHODS

MCI criteria of the Gal-Int 11 study, InDDEx study, ADCS memory impairment study, ampakine CX 516 study, piracetam study, and Merck rofecoxib study were applied retrospectively in a cohort of 150 non-demented subjects from a memory clinic. Forty two had progressed to Alzheimer type dementia during a five year follow up period and were considered to have predementia Alzheimer's disease at baseline. Outcome measures were the odds ratio, sensitivity, specificity, and positive and negative predictive value.

RESULTS

The odds ratio of the MCI criteria for predementia Alzheimer's disease varied between 0.84 and 11. Sensitivity varied between 0.46 and 0.83 and positive predictive value between 0.43 and 0.76. None of the criteria combined a high sensitivity with a high positive predictive value. Exclusion criteria for depression led to an increase in positive predictive value and specificity at the cost of sensitivity. In subjects older than 65 years the positive predictive value was higher than in younger subjects.

CONCLUSIONS

The diagnostic accuracy of MCI criteria used in trials for predementia Alzheimer's disease is low to moderate. Their use may lead to inclusion of many patients who do not have predementia Alzheimer's disease or to exclusion of many who do. Subjects with moderately severe depression should not be excluded from trials in order not to reduce the sensitivity.

APH-1a is the principal mammalian APH-1 isoform present in gamma-secretase complexes during embryonic development

APH-1 (anterior pharynx defective) along with nicastrin and PEN-2 (presenilin enhancer) are essential components of the presenilin (PS)-dependent gamma-secretase complex. There exist three murine Aph-1 alleles termed Aph-1a, Aph-1b, and Aph-1c that encode four distinct APH-1 isoforms: APH-1aL and APH-1aS derived from differential splicing of Aph-1a, APH-1b, and APH-1c. To determine the contributions of mammalian APH-1 homologs in formation of functional gamma-secretase complexes, we generated Aph-1a-/- mice and derived immortalized fibroblasts from these embryos. Compared with littermate controls, the development of Aph-1a-/- embryos was dramatically retarded by embryonic day 9.5 and exhibited patterning defects that resemble, but are not identical to, those of Notch1, nicastrin, or PS null embryos. Moreover, in immortalized Aph-1a-/- fibroblasts, the levels of nicastrin, PS fragments, and PEN-2 were dramatically decreased. Consequently, deletion of Aph-1a resulted in significant reduction in levels of high-molecular-weight gamma-secretase complex and secretion of beta-amyloid (Abeta). Importantly, complementation analysis revealed that all mammalian APH-1 isoforms were capable of restoring the levels of nicastrin, PS, and PEN-2, as well as Abeta secretion in Aph-1a-/- cells. Together, our findings establish that APH-1a is the major mammalian APH-1 homolog present in PS-dependent gamma-secretase complexes during embryogenesis and support the view that mammalian APH-1 isoforms define a set of distinct functional gamma-secretase complexes.

Neuropsychological evaluation of mild cognitive impairment: three case reports

Recent research on mild cognitive impairment (MCI) has focused on the description of the disorder, its biological markers, and conversion rates to dementia. Studies of cognitive deficits in individuals who present with memory decline but do not fulfill criteria for dementia have analyzed baseline group data according to outcome diagnosis. The application of these findings to the individual person remains problematic. The current article presents three cases with a relatively isolated deficit in memory for word lists but better performance on other memory tests. Questions arising with regards to the MCI criteria are discussed in light of these case reports.

Stability and predictability of the classification of mild cognitive impairment as assessed by episodic memory test performance over time

This study aimed to address the criteria and the stability of the classification of MCI. The Foresight Challenge cohort of 157 community-dwelling volunteers was assessed on 3 visits at 2-year intervals with episodic, semantic and working memory tests. Subjective memory complaints were assessed with the CAMDEX. Of the cohort, 2% had dementia and 31% were classified with MCI at visit 3, 43% with stable impairment from Time 1. Thirteen percent of those with objective memory impairment at Time 1 or 2 improved to control status by Time 3. Episodic memory tests were predictive for MCI at all timepoints, as were tests for praxis and Graded Naming, while at Time 3 spatial span lost predictive value, but processing speed became predictive. Decline in processing speed was seen in control and MCI groups, while memory performance and MMSE decline occurred only in the MCI group. The use of combined memory test scores gave better sensitivity to MCI than single tests. Subjective memory complaints were positive for 79% of the MCI group and 62.5% of controls. These findings would suggest consideration of modification of current MCI criteria.

Mild cognitive impairment as a diagnostic entity

The concept of cognitive impairment intervening between normal ageing and very early dementia has been in the literature for many years. Recently, the construct of mild cognitive impairment (MCI) has been proposed to designate an early, but abnormal, state of cognitive impairment. MCI has generated a great deal of research from both clinical and research perspectives. Numerous epidemiological studies have documented the accelerated rate of progression to dementia and Alzheimer's disease (AD) in MCI subjects and certain predictor variables appear valid. However, there has been controversy regarding the precise definition of the concept and its implementation in various clinical settings. Clinical subtypes of MCI have been proposed to broaden the concept and include prodromal forms of a variety of dementias. It is suggested that the diagnosis of MCI can be made in a fashion similar to the clinical diagnoses of dementia and AD. An algorithm is presented to assist the clinician in identifying subjects and subclassifying them into the various types of MCI. By refining the criteria for MCI, clinical trials can be designed with appropriate inclusion and exclusion restrictions to allow for the investigation of therapeutics tailored for specific targets and populations.

Long-Term Treatment of Alzheimer Disease

During the past 20 years, research on Alzheimer disease (AD) and other dementias has increased our understanding of these disorders and has opened doors to new methods of treatment. Acetylcholinesterase inhibitors (AChEIs) have been successful in reducing symptoms in patients with mild-to-moderate AD and led to the US Food and Drug Administration's approval of four AChEIs for the treatment of AD. Although these agents are approved for only mild-to-moderate AD, and the available data for most of them are from trials of only 6 months' duration, long-term studies suggest that the benefits of AChEI treatment can endure for up to 4 years. A common pattern of response to treatment is initial improvement in cognition, followed by maintenance of cognitive gains above baseline for up to 1 year. Generally there is a decline in cognition to below baseline levels after approximately 1 year of treatment, but the level of cognition remains above that predicted for those not receiving pharmacologic treatment. Furthermore, long-term studies suggest that early diagnosis and treatment with AChEIs yield better long-term outcomes. Patients who received continuous pharmacologic treatment from the outset generally had better long-term outcomes than those who received placebo in the double-blind phase of these trials.

Treatment Strategies in Alzheimer???s Disease with a Focus on Early Pharmacological Interventions

Complex interactive effects of genetic predisposition, neurochemical changes and disease comorbidity have been elucidated in the genesis of dementia syndromes. Alzheimer's disease is the most prevalent type of dementia in developed Western countries. In Alzheimer's disease, pharmacological treatment aims at symptomatic relief, disease modification or disease prevention. Cholinesterase inhibitors are established for the treatment of mild-to-moderate Alzheimer's disease. In Europe and the US, memantine is approved for the treatment of moderate-to-severe Alzheimer's disease. To date, there are no drugs with a disease modifying action that have proven efficacy in randomised, double-blind, placebo-controlled clinical trials. In patients not fulfilling the diagnostic criteria for early Alzheimer's disease, e.g. mild cognitive impairment, the efficacy of several drugs, mainly cholinesterase inhibitors, is currently tested in prospective studies by determining the conversion rate to Alzheimer's disease. However, prevention and disease-modifying strategies raise ethical questions because interventions are focused on non-diseased elderly at risk, which means that emphasis should be not only on efficacy but also on long-term safety. No disease-modifying strategy can presently be offered to patients; however, given the pace of recent research there is optimism that slowing progression of Alzheimer's disease will soon be possible.