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Clark S, Johnson T, Runkel K, Wallace J. Update on Therapies in Older Adults. Med Clin North Am 2024; 108:895-910. [PMID: 39084840 DOI: 10.1016/j.mcna.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2024]
Abstract
Memory loss and dementia are among older adults' greatest health fears. This article provides insight into new developments to help delay the onset of dementia, to treat dementia in its earliest stages, and to manage behavioral problems that occur in persons with dementia. Urinary incontinence (UI) is another common problem in older adults that has a major impact on quality of life. This article evaluates newer medications for reducing urinary urge/UI and provides perspective in their role for managing UI.
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Affiliation(s)
- Sophie Clark
- Division of Geriatric Medicine, University of Colorado School of Medicine, 12631 East 17th Avenue, Box B179, Aurora, CO 80045, USA
| | - Thomas Johnson
- Division of Geriatric Medicine, University of Colorado School of Medicine, 12631 East 17th Avenue, Box B179, Aurora, CO 80045, USA. https://twitter.com/TMJohnsonMD
| | - Katherine Runkel
- Division of Geriatric Medicine, University of Colorado School of Medicine, 12631 East 17th Avenue, Box B179, Aurora, CO 80045, USA
| | - Jeffrey Wallace
- Division of Geriatric Medicine, University of Colorado School of Medicine, 12631 East 17th Avenue, Box B179, Aurora, CO 80045, USA.
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Habuchi F, Ishida N, Matsushita R, Ishizaki J, Suga Y. Analysis of Atypical Antipsychotics-Induced Adverse Events Related to Diabetes Mellitus in Patients With Dementia Using the Japanese Adverse Drug Event Report Database. Ann Pharmacother 2024; 58:912-920. [PMID: 38124305 DOI: 10.1177/10600280231213507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Patients with dementia are prescribed low-dose atypical antipsychotics (AAPs) to treat psycho-behavioral symptoms. Although AAPs are known to cause diabetes mellitus-related adverse events (DMAEs), information regarding AAPs-induced DMAEs experienced by patients with dementia is lacking. OBJECTIVE To use the Japan Adverse Drug Event Report (JADER) database to assess the onset tendencies and patterns of DMAEs attributable to AAPs prescribed to patients with dementia. METHODS We performed an analysis using dementia cases from the JADER database that were registered from April 2004 to December 2022. Data in the JADER database are completely anonymized; thus, we did not require institutional review board approval for using the JADER database in our study. The reporting odds ratio and proportional reporting ratio (PRR) were used to assess the onset tendencies of DMAEs with AAPs. In addition, Weibull shape parameters were used to assess the patterns of DMAEs that occur with the use of AAPs. RESULTS We identified AAPs associated with DMAEs. In particular, low doses of quetiapine showed the potential to induce DMAEs. An analysis of the onset of DMAEs showed the early failure patterns for AAPs (median onset = 38 days). CONCLUSION AND RELEVANCE The AAPs may cause DMAEs in patients with dementia. Low doses of quetiapine may induce DMAEs. Health care workers should focus on the development of DMAEs during the early administration period of AAPs. These results may assist with the safe management of patients with dementia who use AAPs.
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Affiliation(s)
- Fuga Habuchi
- Division of Pharmacy, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Natsuko Ishida
- Clinical Pharmacy and Healthcare Sciences, Faculty of Pharmacy, Institute of Medical, Pharmaceutical & Health Science, Kanazawa University, Kanazawa, Japan
| | - Ryo Matsushita
- Clinical Pharmacy and Healthcare Sciences, Faculty of Pharmacy, Institute of Medical, Pharmaceutical & Health Science, Kanazawa University, Kanazawa, Japan
| | - Junko Ishizaki
- Clinical Pharmacy and Healthcare Sciences, Faculty of Pharmacy, Institute of Medical, Pharmaceutical & Health Science, Kanazawa University, Kanazawa, Japan
| | - Yukio Suga
- Clinical Pharmacy and Healthcare Sciences, Faculty of Pharmacy, Institute of Medical, Pharmaceutical & Health Science, Kanazawa University, Kanazawa, Japan
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Khalid J, Aparasu RR. Adverse effects associated with antipsychotic use in older adults. Expert Opin Drug Saf 2024:1-15. [PMID: 39076106 DOI: 10.1080/14740338.2024.2386377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 06/17/2024] [Accepted: 07/16/2024] [Indexed: 07/31/2024]
Abstract
INTRODUCTION Antipsychotic (AP) medications are extensively utilized for diverse psychiatric and non-psychiatric conditions, but they are associated with significant adverse effects in older adults. This expert opinion review provides an updated profile of adverse effects associated with AP medications in older adults. AREAS COVERED This review specifically examines real-world evidence for adverse events associated with AP use, including all-cause mortality, falls and fractures, diabetes, cardiovascular and cerebrovascular events, acute kidney injury, venous thromboembolism/pulmonary embolism, extrapyramidal symptoms, and infections based on real-world evidence. EXPERT OPINION This comprehensive safety review of AP revealed multiple adverse events in older adults. All-cause mortality, more associated with typical APs than atypicals, underscores a dose-dependent risk, urging cautious prescribing practices and avoidance of typical APs. Falls/fractures associated with atypical APs highlight the importance of judicious dosing and -close monitoring, especially after initiation. Cardiovascular risks, particularly stroke, with AP use emphasize the need for vigilant monitoring. Extrapyramidal symptoms, more linked to typical APs, also pose a significant risk in older adults. Pneumonia and pulmonary embolism/venous thromboembolism demand cautious consideration of APs, prompting the need for additional real-world studies to inform clinical practice. Conflicting evidence on diabetes and acute kidney injury necessitates ongoing studies and further research in older adults.
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Affiliation(s)
- Javeria Khalid
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, Texas, USA
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Hu Q, Zhao M, Teng F, Lin G, Jin Z, Xu T. A model for identifying potentially inappropriate medication used in older people with dementia: a machine learning study. Int J Clin Pharm 2024; 46:937-946. [PMID: 38980590 PMCID: PMC11286713 DOI: 10.1007/s11096-024-01730-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 03/21/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND Older adults with dementia often face the risk of potentially inappropriate medication (PIM) use. The quality of PIM evaluation is hindered by researchers' unfamiliarity with evaluation criteria for inappropriate drug use. While traditional machine learning algorithms can enhance evaluation quality, they struggle with the multilabel nature of prescription data. AIM This study aimed to combine six machine learning algorithms and three multilabel classification models to identify correlations in prescription information and develop an optimal model to identify PIMs in older adults with dementia. METHOD This study was conducted from January 1, 2020, to December 31, 2020. We used cluster sampling to obtain prescription data from patients 65 years and older with dementia. We assessed PIMs using the 2019 Beers criteria, the most authoritative and widely recognized standard for PIM detection. Our modeling process used three problem transformation methods (binary relevance, label powerset, and classifier chain) and six classification algorithms. RESULTS We identified 18,338 older dementia patients and 36 PIMs types. The classifier chain + categorical boosting (CatBoost) model demonstrated superior performance, with the highest accuracy (97.93%), precision (95.39%), recall (94.07%), F1 score (95.69%), and subset accuracy values (97.41%), along with the lowest Hamming loss value (0.0011) and an acceptable duration of the operation (371s). CONCLUSION This research introduces a pioneering CC + CatBoost warning model for PIMs in older dementia patients, utilizing machine-learning techniques. This model enables a quick and precise identification of PIMs, simplifying the manual evaluation process.
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Affiliation(s)
- Qiaozhi Hu
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, China
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Mengnan Zhao
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Fei Teng
- School of Information Science and Technology, Southwest Jiaotong University, Chengdu, China
| | - Gongchao Lin
- School of Information Science and Technology, Southwest Jiaotong University, Chengdu, China
| | - Zhaohui Jin
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, China.
| | - Ting Xu
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, China
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Malena K, Rao S, Mosler C. Review of Current Clinical Options for the Management of Behavioral and Psychological Symptoms of Dementia. Sr Care Pharm 2024; 39:300-310. [PMID: 39080869 DOI: 10.4140/tcp.n.2024.300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2024]
Abstract
Dementia is a disease most prevalent in the older adult population. The cognitive symptoms of dementia include impairments in problem-solving, memory, and language. Some patients experience noncognitive symptoms in addition to the cognitive symptoms of dementia. These noncognitive symptoms are called behavioral and psychological symptoms of dementia or BPSD. The primary objective of our study was to examine the therapeutic options, guidelines, and clinical considerations for the management of BPSD. The existing literature about BPSD was reviewed with searches in PubMed, MEDLINE, and online search platforms. Dysregulation of neurotransmission involving acetylcholine, dopamine, and serotonin has been shown to cause behavioral and psychological symptoms of Alzheimer's disease. BPSD can include hallucinations, agitation, delusions, anxiety, apathy, abnormal body movements, irritability, depression, disinhibition, and sleep or appetite changes. Pharmacologic therapies used in the treatment of BPSD include antidepressants, antipsychotics, anxiolytics, and anticonvulsants. Treatment can be tailored to the specific noncognitive symptoms that are experienced. The use of these agents may be limited based on recommendations from the Beers Criteria®, STOPP criteria, treatment guidelines, and FDA warnings.
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Lü W, Liu F, Zhang Y, He X, Hu Y, Xu H, Yang X, Li J, Kuang W. Efficacy, acceptability and tolerability of second-generation antipsychotics for behavioural and psychological symptoms of dementia: a systematic review and network meta-analysis. BMJ MENTAL HEALTH 2024; 27:e301019. [PMID: 39079887 PMCID: PMC11293415 DOI: 10.1136/bmjment-2024-301019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 07/15/2024] [Indexed: 08/03/2024]
Abstract
BACKGROUND Behavioural and psychological symptoms of dementia (BPSD) are highly prevalent in people living with dementia. Second-generation antipsychotics (SGAs) are commonly used to treat BPSD, but their comparative efficacy and acceptability are unknown. METHODS The standard mean difference (SMD) was used to pool the fixed effects of continuous outcomes. We calculated ORs with corresponding 95% credible intervals (CI) for the categorical variable. Efficacy was defined as the scores improved on the standardised scales. Acceptability was defined as the all-cause dropout rate. Tolerability was defined as the discontinuation rate due to adverse effects (AEs). The relative treatment rankings were reported with the surface under the cumulative curve. The AE outcomes included mortality, cerebrovascular adverse events (CVAEs), falls, sedation, extrapyramidal symptoms and urinary symptoms. RESULTS Twenty randomised controlled trials with a total of 6374 individuals containing 5 types of SGAs (quetiapine, olanzapine, risperidone, brexpiprazole and aripiprazole) with intervention lengths ranging from 6 weeks to 36 weeks were included in this network meta-analysis. For the efficacy outcome, compared with the placebo, brexpiprazole (SMD=-1.77, 95% CI -2.80 to -0.74) was more efficacious, and brexpiprazole was better than quetiapine, olanzapine and aripiprazole. Regarding acceptability, only aripiprazole (OR=0.72, 95% CI 0.54 to 0.96) was better than the placebo, and aripiprazole was also better than brexpiprazole (OR=0.61, 95% CI 0.37 to 0.99). In terms of tolerability, olanzapine was worse than placebo (OR=6.02, 95% CI 2.87 to 12.66), risperidone (OR=3.67, 95% CI 1.66 to 8.11) and quetiapine (OR=3.71, 95% CI 1.46 to 9.42), while aripiprazole was better than olanzapine (OR=0.25, 95% CI 0.08 to 0.78). Quetiapine presented good safety in CVAE. Brexpiprazole has better safety in terms of falls and showed related safety in sedation among included SGAs. CONCLUSION Brexpiprazole showing great efficacy in the treatment of BPSD, with aripiprazole showing the highest acceptability and olanzapine showing the worst tolerability. The results of this study may be used to guide decision-making.
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Affiliation(s)
- Wenqi Lü
- Department of Psychiatry, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Fangzhou Liu
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Yuwei Zhang
- Department of Psychiatry, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
- Department of Geriatrics, Chengdu Second People’s Hospital, Chengdu, Sichuan Province, China
| | - Xiance He
- Department of Geriatric Psychiatry, The Fourth People’s Hospital of Chengdu, Chengdu, Sichuan Province, China
| | - Yongbo Hu
- Department of Radiology, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Huifang Xu
- Department of Geriatric Psychiatry, The Fourth People’s Hospital of Chengdu, Chengdu, Sichuan Province, China
| | - Xin Yang
- Department of Psychiatry, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Jin Li
- Department of Psychiatry, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Weihong Kuang
- Department of Psychiatry, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
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Xiao S, Yin H, Lv X, Wang Z, Jiang L, Xia Y, Liu Y. Efficacy and safety of androgen receptor inhibitors for treatment of advanced prostate cancer: A systematic review and network meta-analysis. Br J Clin Pharmacol 2024. [PMID: 38992964 DOI: 10.1111/bcp.16176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 06/19/2024] [Accepted: 06/21/2024] [Indexed: 07/13/2024] Open
Abstract
AIMS Androgen receptor inhibitors (ARIs) have become an effective treatment for advanced prostate cancer (PC). However, it is unknown which ARI is the most helpful and safe for men with advanced PC. Our aim is to help physicians make clinical decisions and provide medication guidelines for patients with advanced PC to avoid potential risks when using ARIs for treatment. METHODS We systematically searched the following databases: PubMed, Embase and Cochrane Library, with a literature publication deadline of February 2023. The primary efficacy outcomes were 18-month overall survival (OS), treatment-emergent adverse events (TEAEs), hypertension and fatigue. The network meta-analysis (NMA) was performed by Stata 15.1, and Revman 5.3 was used to assess the included studies' risk of bias. RESULTS The analysis included 26 trials with 26 263 people. The surface under the cumulative ranking curve (SUCRA) concluded that enzalutamide (86.8%) showed the best effect in prolonging the OS of patients. Flutamide led to the highest risk of TEAEs (29.9%) and AEs leading to discontinuation (12.8%). Apalutamide (13.4%) led to the highest risk of grade ≥3 TEAEs. Enzalutamide had the highest risk of hypertension (0.2%), grade ≥3 hypertension (4.5%) and fatigue (5.2%). CONCLUSIONS This NMA indicates there is no one ARI to reach both the most effective and safe therapy aims for treating advanced PC and that there is a compromise between the efficacy and safety of ARIs in the treatment of advanced PC. Physicians should weigh the risks to safety against the anticipated benefits when prescribing these drugs to patients with PC.
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Affiliation(s)
- Shichao Xiao
- School of Chemical Engineering, Ocean and Life Sciences, Dalian University of Technology, Panjin, China
| | - Hang Yin
- School of Chemical Engineering, Ocean and Life Sciences, Dalian University of Technology, Panjin, China
| | - Xin Lv
- School of Chemical Engineering, Ocean and Life Sciences, Dalian University of Technology, Panjin, China
| | - Zhen Wang
- School of Chemical Engineering, Ocean and Life Sciences, Dalian University of Technology, Panjin, China
| | - Lili Jiang
- School of Chemical Engineering, Ocean and Life Sciences, Dalian University of Technology, Panjin, China
| | - Yangliu Xia
- School of Chemical Engineering, Ocean and Life Sciences, Dalian University of Technology, Panjin, China
| | - Yong Liu
- School of Chemical Engineering, Ocean and Life Sciences, Dalian University of Technology, Panjin, China
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Tada T, Suzuki T, Iwata Y, Kubota M, Watanabe K, Sakurai H. A Trajectory of Long-Term Antipsychotic Medication Dosage in Inpatients with Severe Behavioral and Psychological Symptoms of Dementia: A Retrospective Study. PHARMACOPSYCHIATRY 2024. [PMID: 38917847 DOI: 10.1055/a-2336-3317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
INTRODUCTION While antipsychotics are often prescribed for behavioral and psychological symptoms of dementia (BPSD), typically on an off-label basis, these medications have serious adverse effects. This study investigated the long-term use of antipsychotics among inpatients with dementia displaying severe BPSD, focusing on how prescriptions change over time. METHODS Medical charts at Kusakabe Memorial Hospital were retrospectively reviewed from October 2012 to September 2021. The study included patients diagnosed with dementia, admitted for BPSD, and were continuing antipsychotics at 3 months of their admission. Antipsychotic dosages were categorized as high (≥300 mg/d), medium (100-300 mg/d), and low (<100 mg/d) based on chlorpromazine equivalents and tracked until 15 months during hospitalization. Binary logistic regression was used to identify factors associated with dosage reductions between months 3 and 6. RESULTS This study involved 188 patients, with an average age of 81.2 years, 67% of whom were diagnosed with Alzheimer's dementia. At 3 months, 15.4% were taking high, 44.1% on medium, and 40.4% on low dosages of antipsychotics. The highest average dosage was observed at 3 months, with a subsequent decrease over time. By the 12th month, 20-30% of patients in all dosage categories had stopped their antipsychotic medication. Significant factors for dosage reduction included higher initial doses (OR 1.003, 95%Cl: 1.001-1.006, P=0.01) and male gender (OR 2.481, 95%Cl: 1.251-4.918, P=0.009). DISCUSSION A trajectory of antipsychotic dosage in inpatients with severe BPSD has rarely been reported. This research emphasizes the need for personalized strategies in managing long-term pharmacotherapy for this vulnerable group of patients.
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Affiliation(s)
- Teruo Tada
- Department of Neuropsychiatry, Kyorin University Faculty of Medicine, Mitaka-shi, Tokyo, Japan
| | - Takefumi Suzuki
- Department of Neuropsychiatry, University of Yamanashi Faculty of Medicine, Chuo-shi, Yamanashi, Japan
| | - Yusuke Iwata
- Department of Neuropsychiatry, University of Yamanashi Faculty of Medicine, Chuo-shi, Yamanashi, Japan
| | - Masaharu Kubota
- Department of Neuropsychiatry, Kusakabe Memorial Hospital, Yamanashi-shi, Yamanashi, Japan
| | - Koichiro Watanabe
- Department of Neuropsychiatry, Kyorin University Faculty of Medicine, Mitaka-shi, Tokyo, Japan
| | - Hitoshi Sakurai
- Department of Neuropsychiatry, Kyorin University Faculty of Medicine, Mitaka-shi, Tokyo, Japan
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Wang HJ, Chinna-Meyyappan A, Feldman OJ, Lanctôt KL. Emerging therapies for treatment of agitation, psychosis, or apathy in Alzheimer's disease. Expert Opin Emerg Drugs 2024:1-15. [PMID: 38822731 DOI: 10.1080/14728214.2024.2363215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 05/30/2024] [Indexed: 06/03/2024]
Abstract
INTRODUCTION Agitation, psychosis, and apathy are prevalent and highly distressing neuropsychiatric symptoms (NPS) of Alzheimer's disease (AD) that have been linked to numerous negative outcomes, including increased mortality, worsened cognitive decline, and caregiver burden. Current treatments for AD-associated agitation, namely atypical antipsychotics, provide some benefits but may increase the risk of serious adverse events and death. Meanwhile, no pharmacotherapies have been approved by regulatory agencies for the treatment of psychosis or apathy in AD. Over the past decade, many new and repurposed drugs have emerged as potential therapeutic options for managing these challenging NPS. AREAS COVERED This review aims to provide a comprehensive summary of pharmacotherapies that have recently been investigated in phase 2 and 3 clinical trials for the treatment of agitation, psychosis, or apathy in AD. EXPERT OPINION Novel atypical antipsychotics, serotonergic antidepressants, cannabinoids, and dextromethorphan combination drugs have shown promising results for alleviating agitation. Pimavanserin appears to be the most effective emerging therapy for psychosis, while methylphenidate has demonstrated good efficacy for apathy. Further research on biomarkers of NPS severity and treatment response, as well as continued improvements in methodological approaches are needed to advance the field.
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Affiliation(s)
- Hui Jue Wang
- Neuropsychopharmacology Group, Sunnybrook Research Institute, Toronto, ON, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Arun Chinna-Meyyappan
- Neuropsychopharmacology Group, Sunnybrook Research Institute, Toronto, ON, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Oriel J Feldman
- Neuropsychopharmacology Group, Sunnybrook Research Institute, Toronto, ON, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Krista L Lanctôt
- Neuropsychopharmacology Group, Sunnybrook Research Institute, Toronto, ON, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Xu W, Zheng B, Su L, Xiang Y. Association of plasma high-density lipoprotein cholesterol level with risk of stress urinary incontinence in women: a retrospective study. Lipids Health Dis 2024; 23:171. [PMID: 38849942 PMCID: PMC11157702 DOI: 10.1186/s12944-024-02137-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 05/08/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND Studies have found that high density lipoprotein cholesterol (HDL-C) levels are linked to a variety of diseases. However, evidence for the relationship between stress urinary incontinence (SUI) and HDL-C remain limited. METHODS 590 eligible women were enrolled. Basic characteristic, gynecological examinations and blood sampling were collected. The examination of the possible link between HDL-C and SUI was done using univariate and multivariate logistic regression. Feature importance ranking and Receiver operating characteristic (ROC) curves were performed to further evaluate the association between HDL-C and SUI in women. RESULTS A significant association was found between HDL-C and SUI in women, revealing higher HDL-C levels were related to a lower risk of SUI (OR 0.238; 95%CI: 0.091-0.623; P < 0.01) after adjustment for potential key confounders. The AUC for the SUI predicted by the combined HDL-C was 0.845 (95%CI: 0.798-0.891, P < 0.001). The feature importance ranking revealed that vaginal delivery, HDL-C were the top two important factors. CONCLUSIONS HDL-C levels were correlated with the development of SUI. In addition to physical and surgical treatments, HDL-C may offer the possibility of potential targeted treatment and prevention of SUI afterwards.
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Affiliation(s)
- Wenning Xu
- Health Management Center, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China
| | - Baojia Zheng
- Health Management Center, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China
| | - Lili Su
- Health Management Center, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China
| | - Yali Xiang
- Health Management Center, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China.
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Jørgensen SM, Lech LVJ, Vermehren C, Schiøtz ML, Andersen JT, Karstoft K, Andersen T, Hansen SV, Birke H. Healthcare professionals' experiences with the use of antipsychotics in dementia. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2024; 14:100446. [PMID: 38845613 PMCID: PMC11152969 DOI: 10.1016/j.rcsop.2024.100446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 04/19/2024] [Accepted: 04/19/2024] [Indexed: 06/09/2024] Open
Abstract
Background Antipsychotics are commonly administered to nursing home residents with dementia, despite the associated risk of severe adverse events. Objective This study aimed to explore healthcare professionals' experiences in caring for nursing home residents with dementia, with a focus on rationales behind the use of antipsychotics. Method Twelve semi-structured interviews with healthcare professionals' from Danish nursing homes were conducted and analyzed using the method Systematic Text Condensation. Results Nonpharmacological interventions were reported as the primary approach to care and the first-choice treatment for behavioral and psychological symptoms of dementia (BPSD). Use of antipsychotics was considered to serve as a last resort, reserved for residents with severe symptoms. However, most informants preferred a more limited use. The study identified four main barriers to reduce the use of antipsychotics: "Scarcity of resources", "Perceiving antipsychotic use to provide relieve", "Reluctance towards deprescribing" and "Limited access to medical counseling", and three potential enablers: "Updating knowledge and nonpharmacological competencies", "Management support and clear procedures" and "Regularity in interdisciplinary collaboration". Conclusion The treatment and care were reported as primarily following guidelines in BPSD. Several barriers were perceived to challenge the healthcare professionals' preference of limited use of antipsychotics. To further reduce the use, this study highlights the importance of understanding the adverse effects caused by limited resources, enhancing employee knowledge and competencies and ensuring regular interprofessional collaboration for assessing and reassessing the need to use antipsychotics.
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Affiliation(s)
- Sidsel Maria Jørgensen
- Center for Clinical Research and Prevention, Copenhagen University Hospital - Bispebjerg and Frederiksberg Hospital, Nordre Fasanvej 57, 2000 Frederiksberg, Denmark
| | - Laura Victoria Jedig Lech
- Department of Clinical Pharmacology, Copenhagen University Hospital - Bispebjerg and Frederiksberg Hospital, Bispebjerg Bakke 23, 2400 Copenhagen NV, Denmark
| | - Charlotte Vermehren
- Department of Clinical Pharmacology, Copenhagen University Hospital - Bispebjerg and Frederiksberg Hospital, Bispebjerg Bakke 23, 2400 Copenhagen NV, Denmark
- Department of Drug Design and Pharmacology, Faculty of Health Sciences, University of Copenhagen, Universitetsparken 2, 2100 Copenhagen, Denmark
- Capital Region Pharmacy, Copenhagen University Hospital - Bispebjerg and Frederiksberg hospital, Bispebjerg Bakke 23, 2400 Copenhagen NV, Denmark
| | - Michaela L. Schiøtz
- Center for Clinical Research and Prevention, Copenhagen University Hospital - Bispebjerg and Frederiksberg Hospital, Nordre Fasanvej 57, 2000 Frederiksberg, Denmark
| | - Jon Trærup Andersen
- Department of Clinical Pharmacology, Copenhagen University Hospital - Bispebjerg and Frederiksberg Hospital, Bispebjerg Bakke 23, 2400 Copenhagen NV, Denmark
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark
| | - Kristian Karstoft
- Department of Clinical Pharmacology, Copenhagen University Hospital - Bispebjerg and Frederiksberg Hospital, Bispebjerg Bakke 23, 2400 Copenhagen NV, Denmark
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark
| | - Tina Andersen
- Hillerød Municipality, Hillerød Rådhus, Trollesminde allé 27, 3400 Hillerød, Denmark
| | - Stine Vest Hansen
- Hillerød Municipality, Hillerød Rådhus, Trollesminde allé 27, 3400 Hillerød, Denmark
| | - Hanne Birke
- Center for Clinical Research and Prevention, Copenhagen University Hospital - Bispebjerg and Frederiksberg Hospital, Nordre Fasanvej 57, 2000 Frederiksberg, Denmark
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Kotov R, Carpenter WT, Cicero DC, Correll CU, Martin EA, Young JW, Zald DH, Jonas KG. Psychosis superspectrum II: neurobiology, treatment, and implications. Mol Psychiatry 2024; 29:1293-1309. [PMID: 38351173 DOI: 10.1038/s41380-024-02410-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 12/24/2023] [Accepted: 01/04/2024] [Indexed: 02/16/2024]
Abstract
Alternatives to traditional categorical diagnoses have been proposed to improve the validity and utility of psychiatric nosology. This paper continues the companion review of an alternative model, the psychosis superspectrum of the Hierarchical Taxonomy of Psychopathology (HiTOP). The superspectrum model aims to describe psychosis-related psychopathology according to data on distributions and associations among signs and symptoms. The superspectrum includes psychoticism and detachment spectra as well as narrow subdimensions within them. Auxiliary domains of cognitive deficit and functional impairment complete the psychopathology profile. The current paper reviews evidence on this model from neurobiology, treatment response, clinical utility, and measure development. Neurobiology research suggests that psychopathology included in the superspectrum shows similar patterns of neural alterations. Treatment response often mirrors the hierarchy of the superspectrum with some treatments being efficacious for psychoticism, others for detachment, and others for a specific subdimension. Compared to traditional diagnostic systems, the quantitative nosology shows an approximately 2-fold increase in reliability, explanatory power, and prognostic accuracy. Clinicians consistently report that the quantitative nosology has more utility than traditional diagnoses, but studies of patients with frank psychosis are currently lacking. Validated measures are available to implement the superspectrum model in practice. The dimensional conceptualization of psychosis-related psychopathology has implications for research, clinical practice, and public health programs. For example, it encourages use of the cohort study design (rather than case-control), transdiagnostic treatment strategies, and selective prevention based on subclinical symptoms. These approaches are already used in the field, and the superspectrum provides further impetus and guidance for their implementation. Existing knowledge on this model is substantial, but significant gaps remain. We identify outstanding questions and propose testable hypotheses to guide further research. Overall, we predict that the more informative, reliable, and valid characterization of psychopathology offered by the superspectrum model will facilitate progress in research and clinical care.
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Affiliation(s)
- Roman Kotov
- Department of Psychiatry and Behavioral Health, Stony Brook University, Stony Brook, NY, USA.
| | | | - David C Cicero
- Department of Psychology, University of North Texas, Denton, TX, USA
| | - Christoph U Correll
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA
- Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Department of Child and Adolescent Psychiatry, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Elizabeth A Martin
- Department of Psychological Science, University of California, Irvine, Irvine, CA, USA
| | - Jared W Young
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
- Research Service, VA San Diego Healthcare System, San Diego, CA, USA
| | - David H Zald
- Rutgers University, The State University of New Jersey, New Brunswick, NJ, USA
| | - Katherine G Jonas
- Department of Psychiatry and Behavioral Health, Stony Brook University, Stony Brook, NY, USA
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Cummings J, Sano M, Auer S, Bergh S, Fischer CE, Gerritsen D, Grossberg G, Ismail Z, Lanctôt K, Lapid MI, Mintzer J, Palm R, Rosenberg PB, Splaine M, Zhong K, Zhu CW. Reduction and prevention of agitation in persons with neurocognitive disorders: an international psychogeriatric association consensus algorithm. Int Psychogeriatr 2024; 36:251-262. [PMID: 36876335 PMCID: PMC10480345 DOI: 10.1017/s104161022200103x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
OBJECTIVES To develop an agitation reduction and prevention algorithm is intended to guide implementation of the definition of agitation developed by the International Psychogeriatric Association (IPA). DESIGN Review of literature on treatment guidelines and recommended algorithms; algorithm development through reiterative integration of research information and expert opinion. SETTING IPA Agitation Workgroup. PARTICIPANTS IPA panel of international experts on agitation. INTERVENTION Integration of available information into a comprehensive algorithm. MEASUREMENTS None. RESULTS The IPA Agitation Work Group recommends the Investigate, Plan, and Act (IPA) approach to agitation reduction and prevention. A thorough investigation of the behavior is followed by planning and acting with an emphasis on shared decision-making; the success of the plan is evaluated and adjusted as needed. The process is repeated until agitation is reduced to an acceptable level and prevention of recurrence is optimized. Psychosocial interventions are part of every plan and are continued throughout the process. Pharmacologic interventions are organized into panels of choices for nocturnal/circadian agitation; mild-moderate agitation or agitation with prominent mood features; moderate-severe agitation; and severe agitation with threatened harm to the patient or others. Therapeutic alternatives are presented for each panel. The occurrence of agitation in a variety of venues-home, nursing home, emergency department, hospice-and adjustments to the therapeutic approach are presented. CONCLUSIONS The IPA definition of agitation is operationalized into an agitation management algorithm that emphasizes the integration of psychosocial and pharmacologic interventions, reiterative assessment of response to treatment, adjustment of therapeutic approaches to reflect the clinical situation, and shared decision-making.
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Affiliation(s)
- Jeffrey Cummings
- Joy Chambers-Grundy Professor of Brain Science, Director, Chambers-Grundy Center for Transformative Neuroscience, Co-Director, Pam Quirk Brain Health and Biomarker Laboratory, Department of Brain Health, School of Integrated Health Sciences. University of Nevada Las Vegas (UNLV)
| | - Mary Sano
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, NYC NY and James J. Peters VAMC, Bronx NY
| | - Stefanie Auer
- Centre for Dementia Studies, University for Continuing Education Krems, Austria
| | - Sverre Bergh
- The research centre for age-related functional decline and disease, Innlandet hospital trust, Ottestad, Norway
| | - Corinne E. Fischer
- Faculty of Medicine, Department of Psychiatry, University of Toronto, Canada
| | - Debby Gerritsen
- Department of Primary and Community Care, Radboud university medical center, Radboud Institute for Health Sciences, Radboud Alzheimer Center, Nijmegen, the Netherlands
| | - George Grossberg
- Department of Psychiatry & Behavioral Neuroscience, Division of Geriatric Psychiatry St Louis University School of Medicine
| | - Zahinoor Ismail
- Departments Psychiatry, Neurology, Epidemiology, and Pathology, Hotchkiss Brain Institute & O’Brien Institute for Public Health University of Calgary
| | - Krista Lanctôt
- Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute; and Departments of Psychiatry and Pharmacology/Toxicology, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Maria I Lapid
- Mayo Clinic Department of Psychiatry and Psychology, Rochester, MN, USA
| | - Jacobo Mintzer
- Psychiatrist, Ralph. H. Johnson VA Medical Center, Charleston, SC and Professor, College of Health Professions, Medical University of South Carolina, Charleston, SC
| | - Rebecca Palm
- Department of Nursing Science, Faculty of Health, Witten/Herdecke University, 58455 Witten, Germany
| | - Paul B. Rosenberg
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
| | - Michael Splaine
- Owner Splaine Consulting, Managing Partner, Recruitment Partners LLC
| | - Kate Zhong
- Department of Brain Health, School of Integrated Health Sciences, University of Nevada, Las Vegas
| | - Carolyn W. Zhu
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, NYC, NY and James J. Peters VAMC, Bronx NY
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Ticinesi A, Parise A, Delmonte D, Coppi C, Prati B, Cerundolo N, Guerra A, Nouvenne A, Meschi T. Factors associated with delirium in a real-world acute-care setting: analysis considering the interdependence of clinical variables with the frailty syndrome. Eur Geriatr Med 2024; 15:411-421. [PMID: 38329618 PMCID: PMC10997727 DOI: 10.1007/s41999-024-00934-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 01/04/2024] [Indexed: 02/09/2024]
Abstract
PURPOSE Delirium risk assessment in the acute-care setting generally does not account for frailty. The objective of this retrospective study was to identify factors associated with delirium, considering the interdependency of clinical variables with frailty syndrome in complex older patients. METHODS The clinical records of 587 participants (248 M, median age 84) were reviewed, collecting clinical, anamnestic and pharmacological data. Frailty syndrome was assessed with the Clinical Frailty Scale (CFS). Delirium was the main study endpoint. The correlations of the considered anamnestic and clinical variables with delirium and its subtypes were investigated selecting only those variables not showing a high overlap with frailty. Correlations associated with a 25% excess of frequency of delirium in comparison with the average of the population were considered as statistically significant. RESULTS Delirium was detected in 117 (20%) participants. The presence of one among age > 85 years old, CFS > 4 and invasive devices explained 95% of delirium cases. The main factors maximizing delirium incidence at the individual level were dementia, other psychiatric illness, chronic antipsychotic treatment, and invasive devices. The coexistence of three of these parameters was associated with a peak frequency of delirium, ranging from 57 to 61%, mostly hypoactive forms. CONCLUSIONS In acute-care wards, frailty exhibited a strong association with delirium during hospitalization, while at the individual level, dementia and the use of antipsychotics remained important risk factors. Modern clinical prediction tools for delirium should account for frailty syndrome.
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Affiliation(s)
- Andrea Ticinesi
- Department of Medicine and Surgery, University of Parma, Via Antonio Gramsci 14, 43126, Parma, Italy.
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Via Antonio Gramsci 14, 43126, Parma, Italy.
| | - Alberto Parise
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Via Antonio Gramsci 14, 43126, Parma, Italy
| | - Davide Delmonte
- Institute of Materials for Electronics and Magnetism, National Research Council (CNR), Parco Area delle Scienze 7/A, 43124, Parma, Italy
| | - Chiara Coppi
- Doctoral School in Material Science, Department of Chemistry, Life Science and Environmental Sustainability, University of Parma, Parco Area delle Scienze 7/A, 43124, Parma, Italy
| | - Beatrice Prati
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Via Antonio Gramsci 14, 43126, Parma, Italy
| | - Nicoletta Cerundolo
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Via Antonio Gramsci 14, 43126, Parma, Italy
| | - Angela Guerra
- Department of Medicine and Surgery, University of Parma, Via Antonio Gramsci 14, 43126, Parma, Italy
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Via Antonio Gramsci 14, 43126, Parma, Italy
| | - Antonio Nouvenne
- Department of Medicine and Surgery, University of Parma, Via Antonio Gramsci 14, 43126, Parma, Italy
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Via Antonio Gramsci 14, 43126, Parma, Italy
| | - Tiziana Meschi
- Department of Medicine and Surgery, University of Parma, Via Antonio Gramsci 14, 43126, Parma, Italy
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Via Antonio Gramsci 14, 43126, Parma, Italy
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Azab M, Novella A, Ianes A, Pasina L. Potentially Inappropriate Psychotropic Drugs in Nursing Homes: An Italian Observational Study. Drugs Aging 2024; 41:187-197. [PMID: 38036916 DOI: 10.1007/s40266-023-01083-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND AND OBJECTIVES Physicians often face difficulties in selecting appropriate medications for older adults with multiple comorbidities. As people age, they are more likely to be living with a number of chronic conditions (multimorbidity) and be prescribed a high number of medications (polypharmacy). Multimorbidity is frequent in nursing home (NH) residents and the use of potentially inappropriate medications, especially psychotropic drugs, is widespread. This retrospective cross-sectional cohort study examined the frequency of potentially inappropriate psychotropic drugs using the Beers, Screening Tool of Older Persons' Prescriptions/Screening Tool to Alert doctors to Right Treatment (STOPP/START) and Fit fOR The Aged (FORTA) criteria, and their association with mortality. METHODS This retrospective cross-sectional cohort study was conducted on a sample of long-term care NHs across Italy. Of the 34 NHs with an electronic medical records system, 27 met the inclusion criteria, with complete web-based case report forms (CRFs). Residents under the age of 65 years were excluded. We calculated the prevalence of potentially inappropriate psychotropics drugs (antipsychotics, antidepressants and anxiolytics/hypnotics) according to three criteria for prescriptive appropriateness. Univariate and multivariate correlations were examined, taking into account age, sex, comorbidities, and the number of psychotropic drugs, to analyse the relationship between inappropriate psychotropic use and mortality rates. The rate of inappropriate psychotropic prescriptions was calculated with the prevalence of residents receiving potentially inappropriate psychotropic drugs according to the three criteria. We used a logistic model to check for a possible predictive relationship between inappropriate use of psychotropics and mortality. The study evaluated differences in prescriptive appropriateness among NHs by analysing the proportions of potentially inappropriately treated residents at the last visit. Differences were compared with the overall sample mean using confidence intervals (CIs) calculated using Wald's method. RESULTS This study involved 2555 residents, of whom 1908 (74.7% of the total) were treated with psychotropic drugs; 186 (7.3% of the total) were exposed to at least one psychotropic drug considered potentially inappropriate according to the FORTA criteria. Analysis using the Beers criteria showed that 1616 residents (63.2% of the total) received at least one psychotropic drug considered potentially inappropriate. In line with the Beers recommendation, patients receiving at least three psychotropic drugs were also included and 440 were identified (17.2% of the total sample). According to the STOPP criteria, 1451 residents (56.8% of the total sample) were prescribed potentially inappropriate psychotropic drugs. No correlation was found between potentially inappropriate use of psychotropic drugs and mortality, in either univariate analysis or in a multivariate model adjusted for age, sex and comorbidity index. CONCLUSIONS Different criteria for appropriate drug prescription identify very different percentages of patients in NHs exposed to psychotropics considered potentially inappropriate. The Beers and STOPP/START criteria identified a larger percentage of patients exposed in NHs than FORTA.
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Affiliation(s)
- Marina Azab
- Laboratory of Clinical Pharmacology and Appropriateness of Drug Prescription, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156, Milan, Italy.
| | - Alessio Novella
- Laboratory of Clinical Pharmacology and Appropriateness of Drug Prescription, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156, Milan, Italy
| | | | - Luca Pasina
- Laboratory of Clinical Pharmacology and Appropriateness of Drug Prescription, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156, Milan, Italy
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Perreault S, Boivin Proulx LA, Brouillette J, Jarry S, Dorais M. Antipsychotics and Risks of Cardiovascular and Cerebrovascular Diseases and Mortality in Dwelling Community Older Adults. Pharmaceuticals (Basel) 2024; 17:178. [PMID: 38399393 PMCID: PMC10892683 DOI: 10.3390/ph17020178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 01/24/2024] [Accepted: 01/26/2024] [Indexed: 02/25/2024] Open
Abstract
This study aims to investigate the effect of antipsychotic agents on cardiovascular and cerebrovascular diseases (CVD/CEV) and mortality risks in the older population living in a community. A cohort of 42,650 new users of antipsychotic agents was built using Quebec healthcare databases (1998-2011). The outcomes were CVD/CEV and mortality incidence in 5 years of follow-up in the total cohort, sub-cohort of patients with no schizophrenia/dementia, sub-cohort with schizophrenia, and sub-cohort with dementia. Comparisons were made between the new users who continued the treatment (adherent level ≥ 60%) vs. those ceasing treatment (adherence level < 60%) using inverse probability of treatment weighting and Cox models. Comparing high adherence vs. low levels, CVD/CEV risk was increased by 36% in the sub-cohort with schizophrenia for atypical antipsychotic users and by 25% in the sub-cohort with dementia for typical antipsychotic users. An increasing mortality risk of 2- to 3-fold was linked with the typical antipsychotic use in all cohorts except the sub-cohort with schizophrenia; in addition, mortality risk is linked with the use of high vs. low doses. Antipsychotics were not linked with CVD/CEV risk, except for atypical antipsychotics in patients with schizophrenia and typical antipsychotics in patients with dementia. The mortality risk was linked with the use of typical antipsychotics and the dose used.
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Affiliation(s)
- Sylvie Perreault
- Faculty of Pharmacy, Université de Montréal, Montreal, QC H3C 3J7, Canada
- Centre de Recherche en Santé Publique (CReSP), Partenaire CIUSSS du Centre-Sud-de-l’Île-de-Montréal et l’Université de Montréal, Montreal, QC H3L 1M3, Canada
| | - Laurie-Anne Boivin Proulx
- Department of Cardiology, Faculty of Medicine, University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7, Canada;
| | - Judith Brouillette
- Department of Psychiatry and Addictology, Université de Montréal, Montreal, QC H3L 1M3, Canada;
| | - Stéphanie Jarry
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, QC H3L 1M3, Canada;
| | - Marc Dorais
- StatSciences Inc., Notre-Dame-de-l’Île-Perrot, QC H3L 1M3, Canada;
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Singh AK, Malviya R, Prakash A, Verma S. Neuropsychiatric Manifestations in Alzheimer's Disease Patients: Genetics and Treatment Options. CNS & NEUROLOGICAL DISORDERS DRUG TARGETS 2024; 23:39-54. [PMID: 36856177 DOI: 10.2174/1871527322666230301111216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 12/03/2022] [Accepted: 12/27/2022] [Indexed: 03/02/2023]
Abstract
BACKGROUND Alzheimer's disease (AD) is characterized by neuropsychiatric symptoms (NPS), which cause great misery to those with dementia and those who care for them and may lead to early institutionalization. OBJECTIVE The present systematic review aims to discuss the various aspects of Alzheimer's, including treatment options. METHODS The databases Embase, PubMed, and Web of Science were searched to collect data. RESULTS Incipient cognitive deterioration is commonly accompanied by these early warning signals of neurocognitive diseases. The neurobiology of NPSs in Alzheimer's disease, as well as particular symptoms, including psychosis, agitation, apathy, sadness, and sleep disorders, will be examined in this review. For NPSs in Alzheimer's disease, clinical trial designs, as well as regulatory issues, were also addressed. A fresh wave of research, however, is helping to push the discipline ahead. For medication development and repurposing, we highlight the most recent results in genetics, neuroimaging, and neurobiology. Even though identifying and treating psychosis in adults with dementia is still a challenging endeavor, new options are coming up that give the field fresh focus and hope. Conclsuion: It can be concluded from the complete literature survey that Alzheimer's-related psychosis as well as other symptoms that are not psychotic, have made significant progress in the last decade. These milestones in the development of safer, more effective treatments have been achieved as a consequence of great focus on non-pharmacological interventions like DICE or WHELD; the investigation into ways to improve existing drugs like aripiprazole, risperidone, amisulpride, and Escitalopram for safer precision-based treatment; and the development of a clinical trial program for pimavanserin.
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Affiliation(s)
- Arun Kumar Singh
- Department of Pharmacy, School of Medical and Allied Sciences, Galgotias University Greater Noida, Uttar Pradesh, India
| | - Rishabha Malviya
- Department of Pharmacy, School of Medical and Allied Sciences, Galgotias University Greater Noida, Uttar Pradesh, India
| | - Anuj Prakash
- Reference Standard Division, Indian Pharmacopoeia Commission, Sec-23, Raj Nagar, Ghaziabad, Uttar Pradesh, India
| | - Swati Verma
- Department of Pharmacy, School of Medical and Allied Sciences, Galgotias University Greater Noida, Uttar Pradesh, India
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Ruíz-González C, González-López MDC, García-Ramón MJ, Ruiz-Fernández MD, Rebollo-Lavado B, Andújar-Rodríguez E, Ventura-Miranda MI. A description of risk associated with use of antipsychotics among community dwelling older adults: A descriptive cross-sectional study. Geriatr Nurs 2024; 55:362-367. [PMID: 38171187 DOI: 10.1016/j.gerinurse.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 12/11/2023] [Accepted: 12/14/2023] [Indexed: 01/05/2024]
Abstract
The objective of this research was to analyze the risk of adverse effects in patients older than 65 years with dementia and in concomitant treatment with antidementia and antipsychotic drugs and who are cared for by community nurses. A retrospective cross-sectional descriptive study was carried out. A total of 332 patients who were cared for by primary care teams participated. Most of the patients were women, totally dependent for the basic activities of daily living and residing in the family home. They were polymedicated and there was poor therapeutic adherence. The risk of adverse effects was higher in polymedicated patients who had been taking antipsychotics for longer periods and in those who had a main caregiver. However, those patients who had been assessed by the community nurse were protected from suffering adverse effects. This study demonstrates how integrated and continuous nursing care can reduce adverse effects in this type of patient.
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Affiliation(s)
- Carlos Ruíz-González
- Primary Health Care District of Almeria, Andalusian Health Service, 04006 Almería, Spain
| | | | | | - María Dolores Ruiz-Fernández
- Department of Nursing, Physiotherapy and Medicine, University of Almería, Almería, Spain; Facultad de Ciencias de la Salud, Universidad Autónoma de Chile, Providencia, Chile.
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Thunell JA, Joyce GF, Ferido PM, Chen Y, Guadamuz JS, Qato DM, Zissimopoulos JM. Diagnoses and Treatment of Behavioral and Psychological Symptoms of Dementia Among Racially and Ethnically Diverse Persons Living with Dementia. J Alzheimers Dis 2024; 99:513-523. [PMID: 38669535 DOI: 10.3233/jad-231266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Abstract
Background Behavioral and psychological symptoms of dementia (BPSD) and prescribed central nervous system (CNS) active drugs to treat them are prevalent among persons living with Alzheimer's disease and related dementias (PLWD) and lead to negative outcomes for PLWD and their caregivers. Yet, little is known about racial/ethnic disparities in diagnosis and use of drugs to treat BPSD. Objective Quantify racial/ethnic disparities in BPSD diagnoses and CNS-active drug use among community-dwelling PLWD. Methods We used a retrospective cohort of community-dwelling Medicare Fee-for-Service beneficiaries with dementia, continuously enrolled in Parts A, B and D, 2017-2019. Multivariate logistic models estimated rates of BPSD diagnosis and, conditional on diagnosis, CNS-active drug use. Results Among PLWD, 67.1% had diagnoses of an affective, psychosis or hyperactivity symptom. White (68.3%) and Hispanic (63.9%) PLWD were most likely, Blacks (56.6%) and Asians (52.7%) least likely, to have diagnoses. Among PLWD with BPSD diagnoses, 78.6% took a CNS-active drug. Use was highest among whites (79.3%) and Hispanics (76.2%) and lowest among Blacks (70.8%) and Asians (69.3%). Racial/ethnic differences in affective disorders were pronounced, 56.8% of white PLWD diagnosed; Asians had the lowest rates (37.8%). Similar differences were found in use of antidepressants. Conclusions BPSD diagnoses and CNS-active drug use were common in our study. Lower rates of BPSD diagnoses in non-white compared to white populations may indicate underdiagnosis in clinical settings of treatable conditions. Clinicians' review of prescriptions in this population to reduce poor outcomes is important as is informing care partners on the risks/benefits of using CNS-active drugs.
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Affiliation(s)
- Johanna A Thunell
- USC Schaeffer Center for Health Policy and Economics, Los Angeles, CA, USA
- USC Sol Price School of Public Policy, Los Angeles, CA, USA
| | - Geoffrey F Joyce
- USC Schaeffer Center for Health Policy and Economics, Los Angeles, CA, USA
- USC School of Pharmacy, Los Angeles, CA, USA
| | - Patricia M Ferido
- USC Schaeffer Center for Health Policy and Economics, Los Angeles, CA, USA
| | - Yi Chen
- Rush Alzheimer's Disease Center, Chicago, IL, USA
| | - Jenny S Guadamuz
- USC Schaeffer Center for Health Policy and Economics, Los Angeles, CA, USA
- USC School of Pharmacy, Los Angeles, CA, USA
| | - Dima M Qato
- USC Schaeffer Center for Health Policy and Economics, Los Angeles, CA, USA
- USC School of Pharmacy, Los Angeles, CA, USA
| | - Julie M Zissimopoulos
- USC Schaeffer Center for Health Policy and Economics, Los Angeles, CA, USA
- USC Sol Price School of Public Policy, Los Angeles, CA, USA
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Teixeira AL, Rocha NP, Gatchel J. Behavioral or neuropsychiatric symptoms of Alzheimer's disease: from psychopathology to pharmacological management. ARQUIVOS DE NEURO-PSIQUIATRIA 2023; 81:1152-1162. [PMID: 38157881 PMCID: PMC10756775 DOI: 10.1055/s-0043-1777774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 11/08/2023] [Indexed: 01/03/2024]
Abstract
Neuropsychiatric or behavioral symptoms of dementia encompass a series of disorders, such as anxiety, depression, apathy, psychosis, and agitation, all commonly present in individuals living with dementia. While they are not required for the diagnosis of Alzheimer's disease (AD), they are ubiquitously present in all stages of the disease, contributing to negative clinical outcomes, including cognitive decline, functional disability, and caregiver burden. Neuropsychiatric symptoms have been conceptualized not only as risk factors but as clinical markers of decline along the AD spectrum. The concept of "mild behavioral impairment", the behavioral correlate of mild cognitive impairment, has been proposed within this framework. The first steps in the management of behavioral symptoms in AD involve defining the target and investigating potential causes and/or aggravating factors. Once these factors are addressed, non-pharmacological approaches are preferred as first-line interventions. Following the optimization of anticholinesterase treatments, specific pharmacological approaches (e.g., antidepressants, antipsychotics) can be considered weighing potential side effects.
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Affiliation(s)
- Antonio Lucio Teixeira
- University of Texas University of Texas Health Science Center, McGovern Medical School, Department of Psychiatry and Behavioral Sciences, Neuropsychiatry Program, Houston, Texas, United States.
- Faculdade Santa Casa Belo Horizonte, Belo Horizonte MG, Brazil.
| | - Natalia Pessoa Rocha
- University of Texas Health Science Center, McGovern Medical School, Department of Neurology, Houston, Texas, United States.
| | - Jennifer Gatchel
- Massachusetts General Hospital, Department of Psychiatry, Boston, Massachusetts, United States.
- Baylor College of Medicine, Department of Psychiatry, Houston, Texas, United States.
- Michael E. Debakey VA Medical Center, Houston, Texas, United States.
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Lee D, Slomkowski M, Hefting N, Chen D, Larsen KG, Kohegyi E, Hobart M, Cummings JL, Grossberg GT. Brexpiprazole for the Treatment of Agitation in Alzheimer Dementia: A Randomized Clinical Trial. JAMA Neurol 2023; 80:1307-1316. [PMID: 37930669 PMCID: PMC10628834 DOI: 10.1001/jamaneurol.2023.3810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 08/16/2023] [Indexed: 11/07/2023]
Abstract
Importance Agitation is a prevalent, distressing, and burdensome manifestation of Alzheimer dementia in need of an efficacious, safe, and well-tolerated treatment. Objective To confirm the efficacy, safety, and tolerability of brexpiprazole in patients with agitation in Alzheimer dementia. Design, Setting, and Participants This randomized clinical trial was a 12-week, double-blind, placebo-controlled, fixed-dose, parallel-arm trial that ran from May 2018 to June 2022 at 123 clinical trial sites in Europe and the United States. Participants included patients with agitation in Alzheimer dementia in a care facility or community-based setting. Stable Alzheimer disease medications were permitted. Interventions In this 2-arm trial, patients were randomized to receive oral brexpiprazole or placebo (2:1 ratio) for 12 weeks. Within the brexpiprazole arm, patients were further randomized to receive fixed doses of 2 mg/d or 3 mg/d in a 1:2 ratio. Main Outcomes and Measures The primary end point was change in Cohen-Mansfield Agitation Inventory total score (which measures the frequency of 29 agitated behaviors) from baseline to week 12 for brexpiprazole, 2 or 3 mg, vs placebo. Safety was assessed by standard measures, including treatment-emergent adverse events. Results A total of 345 patients were randomized to receive brexpiprazole (n = 228) or placebo (n = 117); completion rates were 198 (86.8%) for brexpiprazole and 104 (88.9%) for placebo. Mean (SD) age was 74.0 (7.5) years, and 195 of 345 patients were female (56.5%). Patients receiving brexpiprazole, 2 or 3 mg (n = 225), demonstrated statistically significantly greater improvement than those taking placebo (n = 116) in Cohen-Mansfield Agitation Inventory total score from baseline to week 12 (brexpiprazole baseline, 80.6, mean change, -22.6; placebo baseline, 79.2, mean change, -17.3; least-squares mean difference, -5.32; 95% CI, -8.77 to -1.87; P = .003; Cohen d effect size, 0.35). No treatment-emergent adverse events had an incidence of 5% or more with brexpiprazole and greater incidence than placebo. The proportion of patients who discontinued because of adverse events was 12 of 226 (5.3%) for brexpiprazole and 5 of 116 (4.3%) for placebo. Conclusions and Relevance In this study, patients with Alzheimer dementia who took brexpiprazole, 2 or 3 mg, showed a statistically significant improvement vs placebo in agitation over 12 weeks. Brexpiprazole was generally well tolerated over 12 weeks in this vulnerable patient population. Trial Registration ClinicalTrials.gov Identifier: NCT03548584.
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Affiliation(s)
- Daniel Lee
- Otsuka Pharmaceutical Development & Commercialization, Princeton, New Jersey
| | - Mary Slomkowski
- Otsuka Pharmaceutical Development & Commercialization, Princeton, New Jersey
| | | | - Dalei Chen
- Otsuka Pharmaceutical Development & Commercialization, Princeton, New Jersey
| | | | - Eva Kohegyi
- Otsuka Pharmaceutical Development & Commercialization, Princeton, New Jersey
| | - Mary Hobart
- Otsuka Pharmaceutical Development & Commercialization, Princeton, New Jersey
| | - Jeffrey L. Cummings
- Chambers-Grundy Center for Transformative Neuroscience, Department of Brain Health, School of Integrated Health Sciences, University of Nevada, Las Vegas
| | - George T. Grossberg
- Department of Psychiatry and Behavioral Neuroscience, St Louis University School of Medicine, St Louis, Missouri
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Chen H, Qiu Y, Yin Z, Wang Z, Tang Y, Ni H, Lu J, Chen Z, Kong Y, Wang Z. Efficacy and safety of the innovative monoclonal antibodies in adults with generalized myasthenia gravis: a Bayesian network analysis. Front Immunol 2023; 14:1280226. [PMID: 38022544 PMCID: PMC10663412 DOI: 10.3389/fimmu.2023.1280226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 10/26/2023] [Indexed: 12/01/2023] Open
Abstract
Background A series of clinical trials support the effectiveness of monoclonal antibodies for generalized myasthenia gravis (MG) compared to the placebo, but the priority among drugs remains unclear. Therefore, we conduct a frequentist network meta-analysis (NMA) to compare the relative effects of different drugs for generalized MG. Methods PubMed, Embase, Cochrane Library, and clinicaltrials.gov were systematically searched for eligible studies up to 1 June 2023. The primary outcome was efficacy (Myasthenia Gravis Activities of Daily Living [MG-ADL] score and Quantitative Myasthenia Gravis [QMG] score) and safety (adverse events [AEs]). Mean difference (MD) and risk ratio (RR) with their 95% credible intervals (95%CrIs) were used to show the effect size of continuous and categorical variables, respectively. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Results Thirteen studies involving 1167 individuals were identified for NMA. For efficacy outcomes, belimumab, efgartigimod, mezagitamab 600mg, and nipocalimab 60mg/kg were inferior to rozanolixzumab 7mg/kg (MD ranged from 2 to 3.69) and rozanolixzumab 10mg/kg (MD ranged from 2.04 to 3.72) in MG-ADL score, and rozanolixzumab had the highest rank probability (83%) according to the subjective surface under the curve ranking area (SUCRA). For QMG score, batoclimab 340mg (MD ranged from 4.32 to 8.52) and batoclimab 680mg (MD ranged from 4.11 to 9.31) were more effective than placebo and other monoclonal antibodies except for rozanolixzumab, with the highest SUCRA value (93% and 97% respectively). For safety outcomes, belimumab achieved the highest SUCRA value (89.8%) with significant statistical difference compared to rozanolixzumab 7mg/kg (RR 0.08, 95%CrI 0.01 to 0.94) and rozanolixzumab 10mg/kg (RR 0.08, 95%CrI 0.01 to 0.86). Conclusion While all monoclonal antibodies were superior to the placebo, rozanolixzumab and batoclimab might be the most effective for generalized MG. However, rozanolixzumab was associated with higher incidence of AEs. Given the limitations inherent in indirect comparisons, further head-to-head and extensive observational studies are necessary to confirm our findings. Systematic review registration https://inplasy.com/?s=202370112, identifier 202370112.
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Affiliation(s)
- Huiru Chen
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Youjia Qiu
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Ziqian Yin
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Zilan Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yanbing Tang
- Suzhou Medical College of Soochow University, Suzhou, Jiangsu, China
| | - Hanyu Ni
- Suzhou Medical College of Soochow University, Suzhou, Jiangsu, China
| | - Jiaye Lu
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Zhouqing Chen
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yan Kong
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Zhong Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
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23
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Cardoso JPH, Vaz Patto MA. Why do we still prescribe quetiapine as a sleep agent for the elderly? J Psychiatr Res 2023; 167:32. [PMID: 37820448 DOI: 10.1016/j.jpsychires.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 07/30/2023] [Accepted: 09/15/2023] [Indexed: 10/13/2023]
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Michael AE, Michael N, Erfurth A, Kujovic M. Clozapine for the treatment of aggressiveness and agitation in advanced dementia. Psychogeriatrics 2023; 23:963-972. [PMID: 37673659 DOI: 10.1111/psyg.13017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 08/05/2023] [Accepted: 08/16/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Distressing behavioural symptoms, particularly agitation and aggressiveness, remain a difficult problem in everyday clinical practice in the treatment of multimorbid patients with dementia. Clozapine may be an effective therapeutic alternative in this context. METHODS In a retrospective study, patients who had a diagnosis of dementia and had been treated in a specialized geriatric psychiatry unit with clozapine between August 2018 and February 2022 were included, and medical records were systematically reviewed. The Clinical Global Impressions Scale was used to assess improvement, and the Pittsburgh Agitation Scale for symptom reduction. In addition, side effects and clinical features were documented in detail. RESULTS A total of 31 patients (median age 82 years) were identified with a mean clozapine dose of 47.2 (SD 35.6) mg. A total of 13 patients tolerated clozapine very well, 10 showed tolerable side effects, and in 10 patients side effects were the reason for stopping clozapine. Behavioural symptoms improved significantly, as indicated by the assessment scores. CONCLUSIONS In summary, clozapine was effective and well tolerated in 23 patients, suggesting that low-dose clozapine may help to alleviate the suffering of difficult-to-treat multimorbid patients with advanced dementia and their caregivers. However, particular attention should be paid to adverse drug reactions, especially in patients with cardiovascular and pulmonary impairment.
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Affiliation(s)
- Arwed E Michael
- Department of Radiology, Neuroradiology and Nuclear Medicine, Johannes Wesling University Hospital, Ruhr University Bochum, Bochum, Germany
| | - Nikolaus Michael
- Department of Psychiatry, Psychotherapy and Psychosomatic Medicine, Elbroich Hospital, Düsseldorf, Germany
- University of Münster, Münster, Germany
| | - Andreas Erfurth
- University of Münster, Münster, Germany
- 1st Department of Psychiatry and Psychotherapeutic Medicine, Klinik Hietzing, Vienna, Austria
| | - Milenko Kujovic
- Department of Psychiatry and Psychotherapy, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
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25
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Seritan AL. Advances in the Diagnosis and Management of Psychotic Symptoms in Neurodegenerative Diseases: A Narrative Review. J Geriatr Psychiatry Neurol 2023; 36:435-460. [PMID: 36941085 PMCID: PMC10578041 DOI: 10.1177/08919887231164357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
Background: Approximately 15% of older adults may experience psychotic phenomena. Primary psychiatric disorders that manifest with psychosis (delusions, hallucinations, and disorganized thought or behavior) account for less than half. Up to 60% of late-life psychotic symptoms are due to systemic medical or neurological conditions, particularly neurodegenerative diseases. A thorough medical workup including laboratory tests, additional procedures if indicated, and neuroimaging studies is recommended. This narrative review summarizes current evidence regarding the epidemiology and phenomenology of psychotic symptoms encountered as part of the neurodegenerative disease continuum (including prodromal and manifest stages). Results: Prodromes are constellations of symptoms that precede the onset of overt neurodegenerative syndromes. Prodromal psychotic features, particularly delusions, have been associated with an increased likelihood of receiving a neurodegenerative disease diagnosis within several years. Prompt prodrome recognition is crucial for early intervention. The management of psychosis associated with neurodegenerative diseases includes behavioral and somatic strategies, although evidence is scarce and mostly limited to case reports, case series, or expert consensus guidelines, with few randomized controlled trials. Conclusion: The complexity of psychotic manifestations warrants management by interprofessional teams that provide coordinated, integrated care.
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Affiliation(s)
- Andreea L. Seritan
- University of California, San Francisco Department of Psychiatry and UCSF Weill Institute for Neurosciences, CA, USA
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26
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Yokoyama A, Jo T, Sakamoto Y, Urushiyama H, Tamiya H, Tanaka G, Kumazawa R, Matsui H, Fushimi K, Yasunaga H, Nagase T. Effectiveness and safety of the co-administration of Yokukan-San (Japanese herbal medicine) with antipsychotics in hospitalized older patients with pneumonia. Geriatr Gerontol Int 2023; 23:849-854. [PMID: 37804182 DOI: 10.1111/ggi.14696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 09/13/2023] [Accepted: 09/21/2023] [Indexed: 10/09/2023]
Abstract
AIM Behavioral and psychological symptoms and delirium frequently occur in hospitalized older patients with pneumonia and are associated with longer hospital stays. Yokukan-San (YKS, traditional Japanese [Kampo] medicine) and antipsychotics are often used to treat delirium and behavioral and psychological symptoms in Japan. Hence, this study aimed to assess the effectiveness and safety of the co-administration of YKS with atypical antipsychotics in older patients with pneumonia. METHODS We used the Japanese Diagnosis Procedure Combination inpatient database to retrospectively identify older patients (≥65 years) hospitalized for pneumonia who received antipsychotics within 3 days of hospitalization. The patients were divided into two groups: those who received atypical antipsychotics alone (control group) and those who received both atypical antipsychotics and YKS (YKS group). We compared length of hospital stay, in-hospital mortality, bone fractures, and administration of potassium products between the two groups using propensity score overlap weighting. RESULT We identified 4789 patients in the YKS group and 61 641 in the control group. After propensity score overlap weighting, length of hospital stay was statistically significantly shorter in the YKS group (percentage difference -3.0%; 95% confidence interval -5.8% to -0.3%). The proportion of patients who received potassium products was higher in the YKS group (odds ratio 1.34; 95% confidence interval 1.15-1.55). In-hospital death and bone fractures were not significantly different. CONCLUSION Co-administration of YKS with atypical antipsychotics could be a reasonable treatment option for hospitalized older patients with pneumonia and aggressive psychiatric symptoms. Geriatr Gerontol Int 2023; 23: 849-854.
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Affiliation(s)
- Akira Yokoyama
- Department of Respiratory Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Taisuke Jo
- Department of Respiratory Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
- Department of Health Services Research, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Yukiyo Sakamoto
- Department of Respiratory Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Hirokazu Urushiyama
- Department of Respiratory Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Hiroyuki Tamiya
- Department of Respiratory Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
- Division for Health Service Promotion, University of Tokyo, Tokyo, Japan
| | - Goh Tanaka
- Department of Respiratory Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Ryosuke Kumazawa
- Department of Clinical Epidemiology and Health Economics, School of Public Health, University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University, Graduate School of Medicine, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, University of Tokyo, Tokyo, Japan
| | - Takahide Nagase
- Department of Respiratory Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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27
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Korkatti-Puoskari N, Tiihonen M, Caballero-Mora MA, Topinkova E, Szczerbińska K, Hartikainen S. Therapeutic dilemma's: antipsychotics use for neuropsychiatric symptoms of dementia, delirium and insomnia and risk of falling in older adults, a clinical review. Eur Geriatr Med 2023; 14:709-720. [PMID: 37495836 PMCID: PMC10447285 DOI: 10.1007/s41999-023-00837-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 07/06/2023] [Indexed: 07/28/2023]
Abstract
PURPOSE Because of the common and increasing use of antipsychotics in older adults, we aim to summarize the current knowledge on the causes of antipsychotic-related risk of falls in older adults. We also aim to provide information on the use of antipsychotics in dementia, delirium and insomnia, their adverse effects and an overview of the pharmacokinetic and pharmacodynamic mechanisms associated with antipsychotic use and falls. Finally, we aim to provide information to clinicians for weighing the benefits and harms of (de)prescribing. METHODS A literature search was executed in CINAHL, PubMed and Scopus in March 2022 to identify studies focusing on fall-related adverse effects of the antipsychotic use in older adults. We focused on the antipsychotic use for neuropsychiatric symptoms of dementia, insomnia, and delirium. RESULTS Antipsychotics increase the risk of falls through anticholinergic, orthostatic and extrapyramidal effects, sedation, and adverse effects on cardio- and cerebrovascular system. Practical resources and algorithms are available that guide and assist clinicians in deprescribing antipsychotics without current indication. CONCLUSIONS Deprescribing of antipsychotics should be considered and encouraged in older people at risk of falling, especially when prescribed for neuropsychiatric symptoms of dementia, delirium or insomnia. If antipsychotics are still needed, we recommend that the benefits and harms of antipsychotic use should be reassessed within two to four weeks of prescription. If the use of antipsychotic causes more harm than benefit, the deprescribing process should be started.
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Affiliation(s)
| | - Miia Tiihonen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland.
| | | | - Eva Topinkova
- Geriatric Department, First Faculty of Medicine, Charles University, General Faculty Hospital, Prague and Faculty of Health and Social Sciences, South Bohemian University, Ceske Budejovice, Czech Republic
| | - Katarzyna Szczerbińska
- Medical Faculty, Epidemiology and Preventive Medicine Chair, Laboratory for Research on Ageing Society, Jagiellonian University Medical College, Kraków, Poland
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28
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Li L, Wang A, Fang Q, Moosbrugger ME. Physical Activity Interventions for Improving Cognitive Functions in Children With Autism Spectrum Disorder: Protocol for a Network Meta-Analysis of Randomized Controlled Trials. JMIR Res Protoc 2023; 12:e40383. [PMID: 37379078 PMCID: PMC10365605 DOI: 10.2196/40383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 04/09/2023] [Accepted: 04/10/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Autism spectrum disorder (ASD) is a neurodevelopmental disorder that affects millions of children worldwide, with a current prevalence of approximately 1 in 54 children in the United States. Although the precise mechanisms underlying ASD remain unclear, research has shown that early intervention can have a significant impact on cognitive development and outcomes in children with ASD. Physical activity interventions have emerged as a promising intervention for children with ASD, but the efficacy of different types of interventions remains unclear. OBJECTIVE This study protocol aims to update the knowledge on extant literature and explore the efficacy of physical activity intervention strategies on cognitive functions in children with ASD. METHODS A systematic review and network meta-analysis (NMA) will be conducted following the PRISMA-NMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols for Network Meta-Analyses) statement. A total of 9 bibliographic databases (APA PsycInfo, CENTRAL, Dimensions, ERIC, MEDLINE Complete, PubMed, Scopus, SPORTDiscus, and Web of Science) will be systematically searched to screen eligible articles based on a series of inclusion and exclusion criteria. A study will be considered for inclusion if it is not classified as a systematic review with or without meta-analysis, was published from inception to present, includes children aged 0 to 12 years with ASD, quantitively measures cognitive outcomes, and examines treatment comprising at least 1 physical activity intervention strategy. The internal validity and quality of evidence will be evaluated using the Grading of Recommendations Assessment, Development, and Evaluation framework. Statistical analyses will be performed in the RStudio software (version 3.6; RStudio Inc) with the BUGSnet package and the Comprehensive Meta-Analysis software (version 3.3; Biostat Inc). The results of our NMA will be illustrated through network diagrams accompanied by geometry and league tables. Further, to rank the interventions based on their efficacy, we will use the surface under the cumulative ranking curve. RESULTS Our preliminary search identified 3778 potentially relevant studies. The screening of the studies based on the inclusion and exclusion criteria is ongoing, and we anticipate that the final number of eligible studies will be in the range of 30 to 50. CONCLUSIONS This study will provide a comprehensive review of the literature on physical activity interventions for children with ASD and will use NMA to compare the efficacy of different types of interventions on cognitive outcomes. Our findings will have important implications for clinical practice and future research in this area and will contribute to the growing body of evidence supporting the use of physical activity interventions as a key component of early intervention for children with ASD. TRIAL REGISTRATION PROSPERO CRD42021279054; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=279054. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/40383.
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Affiliation(s)
- Longxi Li
- Center for Leadership in Athletics, University of Washington, Seattle, WA, United States
| | - Anni Wang
- College of Education, Michigan State University, East Lansing, MI, United States
| | - Qun Fang
- School of Physical Education, Qingdao University, Qingdao, China
| | - Michelle E Moosbrugger
- Department of Physical Education and Health Education, Springfield College, Springfield, MA, United States
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29
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Palm A, Talaslahti T, Vataja R, Ginters M, Kautiainen H, Elonheimo H, Suvisaari J, Lindberg N, Koponen H. Antipsychotic Use and Mortality in Persons with Alcohol-Related Dementia or Wernicke-Korsakoff Syndrome: A Nationwide Register Study in Finland. J Clin Med 2023; 12:4263. [PMID: 37445298 DOI: 10.3390/jcm12134263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 06/19/2023] [Accepted: 06/21/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND Research on the use of psychotropic drugs in people with alcohol-related neurocognitive disorders is virtually nonexistent. We examined the prevalence of antipsychotic drug use and its effect on mortality among patients with Wernicke-Korsakoff syndrome (WKS) or alcohol-related dementia (ARD). METHODS In this nationwide register study, we collected data on the medication use and mortality of all persons aged ≥40 diagnosed with WKS (n = 1149) or ARD (n = 2432) between 1998 and 2015 in Finland. We calculated the prevalence of antipsychotic use within one year of diagnosis and the adjusted cumulative mortality of antipsychotic users versus non-users in relation to the age-, sex-, and calendar year-matched general population. RESULTS Of the WKS and ARD patients, 35.9% and 38.5%, respectively, purchased one or more antipsychotic drugs in the year following diagnosis. The adjusted cumulative mortality of the antipsychotic users was significantly lower than that of non-users in both the WKS and ARD groups, where the adjusted hazard ratios (95% CI) were 0.85 (0.72-0.99) and 0.73 (0.65-0.81), respectively. WKS and ARD patients using antipsychotics were less likely to die of alcohol-related causes than antipsychotic non-users, but the difference was significant only in the ARD group. CONCLUSIONS This population-based study shows that antipsychotic use is common in patients with WKS or ARD. In contrast to other dementia studies, our results indicate that the mortality of antipsychotic users is significantly lower than that of non-users. The lower mortality could be explained by decreased alcohol use and better healthcare coverage in antipsychotic users.
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Affiliation(s)
- Anniina Palm
- Department of Psychiatry, Helsinki University Hospital, 00029 Helsinki, Finland
- University of Helsinki, 00014 Helsinki, Finland
| | - Tiina Talaslahti
- Department of Psychiatry, Helsinki University Hospital, 00029 Helsinki, Finland
- University of Helsinki, 00014 Helsinki, Finland
| | - Risto Vataja
- Department of Psychiatry, Helsinki University Hospital, 00029 Helsinki, Finland
- University of Helsinki, 00014 Helsinki, Finland
| | - Milena Ginters
- Department of Psychiatry, Helsinki University Hospital, 00029 Helsinki, Finland
- University of Helsinki, 00014 Helsinki, Finland
| | - Hannu Kautiainen
- Primary Health Care Unit, Kuopio University Hospital, 70210 Kuopio, Finland
- Folkhälsan Research Center, 00250 Helsinki, Finland
| | - Henrik Elonheimo
- Finnish Institute for Health and Welfare, 00271 Helsinki, Finland
| | - Jaana Suvisaari
- Finnish Institute for Health and Welfare, 00271 Helsinki, Finland
| | - Nina Lindberg
- Department of Psychiatry, Helsinki University Hospital, 00029 Helsinki, Finland
- University of Helsinki, 00014 Helsinki, Finland
| | - Hannu Koponen
- Department of Psychiatry, Helsinki University Hospital, 00029 Helsinki, Finland
- University of Helsinki, 00014 Helsinki, Finland
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30
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Huang YY, Teng T, Giovane CD, Wang RZ, Suckling J, Shen XN, Chen SD, Huang SY, Kuo K, Cai WJ, Chen KL, Feng L, Zhang C, Liu CY, Li CB, Zhao QH, Dong Q, Zhou XY, Yu JT. Pharmacological treatment of neuropsychiatric symptoms of dementia: a network meta-analysis. Age Ageing 2023; 52:afad091. [PMID: 37381843 DOI: 10.1093/ageing/afad091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND Pharmacological treatments are very common to be used for alleviating neuropsychiatric symptoms (NPS) in dementia. However, decision on drug selection is still a matter of controversy. AIMS To summarise the comparative efficacy and acceptability of currently available monotherapy drug regimens for reducing NPS in dementia. METHOD We searched PubMed, MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials between inception and 26 December 2022 without language restrictions; and reference lists scanned from selected studies and systematic reviews. Double-blind randomised controlled trials were identified from electronic databases for reporting NPS outcomes in people with dementia. Primary outcomes were efficacy and acceptability. Confidence in the evidence was assessed using Confidence in Network Meta-Analysis (CINeMA). RESULTS We included 59 trials (15,781 participants; mean age, 76.6 years) and 15 different drugs in quantitative syntheses. Risperidone (standardised mean difference [SMD] -0.20, 95% credible interval [CrI] -0.40 to -0.10) and galantamine (-0.20, -0.39 to -0.02) were more effective than placebo in short-term treatment (median duration: 12 weeks). Galantamine (odds ratio [OR] 1.95, 95% CrI 1.38-2.94) and rivastigmine (1.87, 1.24-2.99) were associated with more dropouts than placebo, and some active drugs. Most of the results were rated as low or very low according to CINeMA. CONCLUSIONS Despite the scarcity of high-quality evidence, risperidone is probably the best pharmacological option to consider for alleviating NPS in people with dementia in short-term treatment when considering the risk-benefit profile of drugs.
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Affiliation(s)
- Yu-Yuan Huang
- Department of Neurology and Institute of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Shanghai Medical College, Fudan University, National Center for Neurological Disorders, Shanghai, China
| | - Teng Teng
- Department of Psychiatry, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Cinzia D Giovane
- Institute of Primary Health Care, University of Bern, Bern, Switzerland
| | - Rong-Ze Wang
- Department of Neurology and Institute of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Shanghai Medical College, Fudan University, National Center for Neurological Disorders, Shanghai, China
| | - John Suckling
- Department of Psychiatry, Medical Research Council and Wellcome Trust Behavioural and Clinical Neuroscience Institute, University of Cambridge, Cambridge, UK
| | - Xue-Ning Shen
- Department of Neurology and Institute of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Shanghai Medical College, Fudan University, National Center for Neurological Disorders, Shanghai, China
| | - Shi-Dong Chen
- Department of Neurology and Institute of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Shanghai Medical College, Fudan University, National Center for Neurological Disorders, Shanghai, China
| | - Shu-Yi Huang
- Department of Neurology and Institute of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Shanghai Medical College, Fudan University, National Center for Neurological Disorders, Shanghai, China
| | - Kevin Kuo
- Department of Neurology and Institute of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Shanghai Medical College, Fudan University, National Center for Neurological Disorders, Shanghai, China
| | - Wen-Jie Cai
- Department of Neurology and Institute of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Shanghai Medical College, Fudan University, National Center for Neurological Disorders, Shanghai, China
| | - Ke-Liang Chen
- Department of Neurology and Institute of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Shanghai Medical College, Fudan University, National Center for Neurological Disorders, Shanghai, China
| | - Lei Feng
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Can Zhang
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
| | - Cai-Yan Liu
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Chun-Bo Li
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qian-Hua Zhao
- Department of Neurology and Institute of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Shanghai Medical College, Fudan University, National Center for Neurological Disorders, Shanghai, China
| | - Qiang Dong
- Department of Neurology and Institute of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Shanghai Medical College, Fudan University, National Center for Neurological Disorders, Shanghai, China
| | - Xin-Yu Zhou
- Department of Psychiatry, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jin-Tai Yu
- Department of Neurology and Institute of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Shanghai Medical College, Fudan University, National Center for Neurological Disorders, Shanghai, China
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Hung YH, Wang WF, Chang MC, Jhang KM. Case Management-based Collaborative Care Model Associated with improvement in neuropsychiatric outcomes in community-dwelling people living with dementia. BMC Geriatr 2023; 23:339. [PMID: 37259035 DOI: 10.1186/s12877-023-04024-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 05/07/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND This study aimed to explore the association between adherence of collaborative care model and short-term deterioration of BPSD after controlling patient and caregiver factors. METHODS This retrospective case-control study enrolled 276 participants who were newly diagnosed with dementia and BPSD. A dementia collaborative care team interviewed patients and caregivers to form a care plan and provided individualized education or social resource referrals. A multivariate logistic regression model with backward selection was used to test factors associated with BPSD deterioration, defined as worse neuropsychiatric inventory (NPI) scores 1 year after joining the care model. RESULTS Male sex (odds ratio [OR] = 0.45; 95% confidence interval [CI] = 0.25-0.84) and higher clinical dementia rating scale sum of boxes scores (CDR-SOB) (OR = 0.90; 95% CI = 0.83-0.98) were protective factors, whereas spouse caregivers and withdrawals from the care model (OR = 3.42; 95% CI = 1.28-9.15) were risk factors for BPSD deterioration. CONCLUSIONS Our study showed that both patient and caregiver factors were associated with deterioration of BPSD. The case manager-centered dementia collaborative care model is beneficial for the management of BPSD. Healthcare systems may consider implementing a case management model in clinical dementia care practice.
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Affiliation(s)
- Yu-Hsuan Hung
- School of Medicine, Department of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Medical Education, Changhua Christian Hospital, Changhua, Taiwan
| | - Wen-Fu Wang
- Department of Neurology, Changhua Christian Hospital, Changhua, Taiwan
| | - Ming-Che Chang
- Department of Nuclear Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Kai-Ming Jhang
- Department of Neurology, Changhua Christian Hospital, Changhua, Taiwan.
- , No. 135 Nanxiao St, Changhua City, 500, Taiwan.
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Lee D, Clark ED, Antonsdottir IM, Porsteinsson AP. A 2023 update on the advancements in the treatment of agitation in Alzheimer's disease. Expert Opin Pharmacother 2023; 24:691-703. [PMID: 36958727 DOI: 10.1080/14656566.2023.2195539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
INTRODUCTION Neuropsychiatric symptoms (NPS) in Alzheimer's Disease (AD) are associated with negative outcomes for patients and their care partners. Agitation is one of the most common and distressing NPS, yet we lack safe and effective treatment options. While nonpharmacologic interventions are considered first line treatment, these may not be effective or appropriate for every patient. Our current approaches to the pharmacologic treatment of agitation in AD consist of the off-label use of antipsychotics, sedative/hypnotics, anxiolytics, mood-stabilizing anticonvulsants, acetylcholinesterase inhibitors, NMDA receptor antagonists, and antidepressants. Despite their prevalent use, they have questionable efficacy and significant safety concerns. AREAS COVERED Advances in the understanding of neurobiological mechanisms of agitation have fueled recent clinical trials. This article is an update to our 2017 review. A comprehensive search of ClinicalTrials.gov was completed from January 2017 to June 2022 using the search terms "Alzheimer's Disease" and "Agitation". A subsequent scoping review was completed in PubMed and Google Scholar. Several agents were identified for promise in treating agitation, including: brexpiprazole, cannabinoids, dexmedetomidine, dextromethorphan, escitalopram, masupirdine, and prazosin. EXPERT OPINION Clinical trials remain underway utilizing both novel and repurposed agents to address symptoms of agitation in AD. With increasing understanding of the neurobiological mechanisms that fuel the development of agitation in AD, the use of enhanced trial design and conduct, advanced statistical approaches, and accelerated pathways for regulatory approval, we are advancing closer to having safe and efficacious treatment options for agitation in AD.
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Affiliation(s)
- Daniel Lee
- Alzheimer's Disease Care, Research and Education (AD-CARE), Department of Psychiatry, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Rochester, NY 14642
| | - Emily D Clark
- Alzheimer's Disease Care, Research and Education (AD-CARE), Department of Psychiatry, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Rochester, NY 14642
| | - Inga M Antonsdottir
- Johns Hopkins School of Nursing, 525 N. Wolfe Street, 21205, Baltimore, MD, USA
- Richman Family Precision Medicine Center of Excellence in Alzheimer's Disease, Department of Psychiatry and Behavioral Sciences, Johns Hopkins Bayview, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Anton P Porsteinsson
- Alzheimer's Disease Care, Research and Education (AD-CARE), Department of Psychiatry, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Rochester, NY 14642
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Rodriguez G, Fisher DW, McClarty B, Montalvo-Ortiz J, Cui Q, Chan CS, Dong H. Histone deacetylase inhibitors mitigate antipsychotic risperidone-induced motor side effects in aged mice and in a mouse model of Alzheimer's disease. Front Psychiatry 2023; 13:1020831. [PMID: 36684015 PMCID: PMC9852991 DOI: 10.3389/fpsyt.2022.1020831] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 12/12/2022] [Indexed: 01/07/2023] Open
Abstract
Antipsychotic drugs are still widely prescribed to control various severe neuropsychiatric symptoms in the elderly and dementia patients although they are off-label use in the United States. However, clinical practice shows greater side effects and lower efficacy of antipsychotics for this vulnerable population and the mechanisms surrounding this aged-related sensitivity are not well understood. Our previous studies have shown that aging-induced epigenetic alterations may be involved in the increasing severity of typical antipsychotic haloperidol induced side effects in aged mice. Still, it is unknown if similar epigenetic mechanisms extend to atypical antipsychotics, which are most often prescribed to dementia patients combined with severe neuropsychiatric symptoms. In this study, we report that atypical antipsychotic risperidone also causes increased motor side effect behaviors in aged mice and 5xFAD mice. Histone deacetylase (HDAC) inhibitor Valproic Acid and Entinostat can mitigate the risperidone induced motor side effects. We further showed besides D2R, reduced expression of 5-HT2A, one of the primary atypical antipsychotic targets in the striatum of aged mice that are also mitigated by HDAC inhibitors. Finally, we demonstrate that specific histone acetylation mark H3K27 is hypoacetylated at the 5htr2a and Drd2 promoters in aged mice and can be reversed with HDAC inhibitors. Our work here establishes evidence for a mechanism where aging reduces expression of 5-HT2A and D2R, the key atypical antipsychotic drug targets through epigenetic alteration. HDAC inhibitors can restore 5-HT2A and D2R expression in aged mice and decrease the motor side effects in aged and 5xFAD mice.
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Affiliation(s)
- Guadalupe Rodriguez
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Daniel W. Fisher
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, United States
| | - Bryan McClarty
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Janitza Montalvo-Ortiz
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Qiaoling Cui
- Department of Neuroscience, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - C. Savio Chan
- Department of Neuroscience, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Hongxin Dong
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
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Elefante C, Brancati GE, Torrigiani S, Amadori S, Ricciardulli S, Pistolesi G, Lattanzi L, Perugi G. Bipolar Disorder and Manic-Like Symptoms in Alzheimer's, Vascular and Frontotemporal Dementia: A Systematic Review. Curr Neuropharmacol 2023; 21:2516-2542. [PMID: 35794767 PMCID: PMC10616925 DOI: 10.2174/1570159x20666220706110157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 06/13/2022] [Accepted: 06/13/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND An increased risk of manic episodes has been reported in patients with neurodegenerative disorders, but the clinical features of bipolar disorder (BD) in different subtypes of dementia have not been thoroughly investigated. OBJECTIVES The main aim of this study is to systematically review clinical and therapeutic evidence about manic syndromes in patients with Alzheimer's disease (AD), vascular dementia (VaD), and frontotemporal dementia (FTD). Since manic-mixed episodes have been associated to negative outcomes in patients with dementia and often require medical intervention, we also critically summarized selected studies with relevance for the treatment of mania in patients with cognitive decline. METHODS A systematic review of the literature was conducted according to PRISMA guidelines. PubMed, Scopus, and Web of Science databases were searched up to February 2022. Sixty-one articles on patients with AD, VaD, or FTD and BD or (hypo) mania have been included. RESULTS Manic symptoms seem to be associated to disease progression in AD, have a greatly variable temporal relationship with cognitive decline in VaD, and frequently coincide with or precede cognitive impairment in FTD. Overall, mood stabilizers, and electroconvulsive therapy may be the most effective treatments, while the benefits of short-term treatment with antipsychotic agents must be balanced with the associated risks. Importantly, low-dose lithium salts may exert neuroprotective activity in patients with AD. CONCLUSION Prevalence, course, and characteristics of manic syndromes in patients with dementia may be differentially affected by the nature of the underlying neurodegenerative conditions.
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Affiliation(s)
- Camilla Elefante
- Department of Clinical and Experimental Medicine, University of Pisa, Psychiatry Unit, Pisa, Italy
| | - Giulio Emilio Brancati
- Department of Clinical and Experimental Medicine, University of Pisa, Psychiatry Unit, Pisa, Italy
| | - Samuele Torrigiani
- Department of Clinical and Experimental Medicine, University of Pisa, Psychiatry Unit, Pisa, Italy
| | - Salvatore Amadori
- Department of Clinical and Experimental Medicine, University of Pisa, Psychiatry Unit, Pisa, Italy
| | - Sara Ricciardulli
- Department of Clinical and Experimental Medicine, University of Pisa, Psychiatry Unit, Pisa, Italy
| | - Gabriele Pistolesi
- Department of Clinical and Experimental Medicine, University of Pisa, Psychiatry Unit, Pisa, Italy
| | - Lorenzo Lattanzi
- Psychiatry Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Giulio Perugi
- Department of Clinical and Experimental Medicine, University of Pisa, Psychiatry Unit, Pisa, Italy
- G. De Lisio Institute of Behavioral Sciences, Pisa, Italy
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Moebius HJ, Church KJ. The Case for a Novel Therapeutic Approach to Dementia: Small Molecule Hepatocyte Growth Factor (HGF/MET) Positive Modulators. J Alzheimers Dis 2023; 92:1-12. [PMID: 36683507 PMCID: PMC10041442 DOI: 10.3233/jad-220871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
An estimated 6.5 million Americans aged 65 years or older have Alzheimer's disease (AD), which will grow to 13.8 million Americans by 2060. Despite the growing burden of dementia, no fundamental change in drug development for AD has been seen in > 20 years. Currently approved drugs for AD produce only modest symptomatic improvements in cognition with small effect sizes. A growing mismatch exists between the urgent need to develop effective drugs for symptomatic AD and the largely failed search for disease modification. The failure rate of clinical trials in AD is high overall, and in particular for disease-modifying therapies. Research efforts in AD have focused predominantly on amyloid-β and tau pathologies, but limiting clinical research to these "classical hallmarks" of the disease does not address the most urgent patient, caregiver, or societal needs. Rather, clinical research should consider the complex pathophysiology of AD. Innovative approaches are needed that provide outside-the-box thinking, and re-imagine trial design, interventions, and outcomes as well as progress in proteomics and fluid biomarker analytics for both diagnostics and disease monitoring. A new approach offering a highly specific, yet multi-pronged intervention that exerts positive modulation on the HGF/MET neurotrophic system is currently being tested in mid-to-late-stage clinical trials in mild to moderate AD. Findings from such trials may provide data to support novel approaches for development of innovative drugs for treating AD at various disease stages, including among patients already symptomatic, and may offer benefits for other neurodegenerative diseases.
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Rogowska M, Thornton M, Creese B, Velayudhan L, Aarsland D, Ballard C, Tsamakis K, Stewart R, Mueller C. Implications of Adverse Outcomes Associated with Antipsychotics in Older Patients with Dementia: A 2011-2022 Update. Drugs Aging 2023; 40:21-32. [PMID: 36513918 PMCID: PMC9747539 DOI: 10.1007/s40266-022-00992-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2022] [Indexed: 12/15/2022]
Abstract
Neuropsychiatric symptoms affect most patients with dementia over the course of the disease. They include a wide variety of symptoms from apathy and depression to psychosis, irritability, impulsivity and agitation. These symptoms are associated with significant distress to the patient and caregivers, as well as more rapid progression of dementia, institutionalisation and higher mortality. The first-line management of the neuropsychiatric symptoms of dementia should be non-pharmacological. If medications are required, antipsychotics are commonly chosen. Second-generation antipsychotics such as risperidone, olanzapine, quetiapine and aripiprazole are prescribed more often than first-generation antipsychotics, such as haloperidol. The aim of this review is to provide an update on findings on adverse outcomes and clinical implications of antipsychotic use in dementia. These medications may increase mortality and can be associated with adverse events including pneumonia, cerebrovascular events, parkinsonian symptoms or higher rates of venous thromboembolism. Risks related to antipsychotic use in dementia are moderated by a number of modifiable and non-modifiable factors such as co-prescribing of other medications, medical and psychiatric co-morbidities, and demographics such as age and sex, making individualised treatment decisions challenging. Antipsychotics have further been associated with an increased risk of reliance on long-term care and institutionalisation, and they might not be cost-effective for healthcare systems. Many of these risks can potentially be mitigated by close physical health monitoring of antipsychotic treatment, as well as early withdrawal of pharmacotherapy when clinically possible.
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Affiliation(s)
- Marianna Rogowska
- South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, London, UK.
| | - Mary Thornton
- South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, London, UK
| | - Byron Creese
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- University of Exeter Medical School, Exeter, UK
| | - Latha Velayudhan
- South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, London, UK
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Dag Aarsland
- South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, London, UK
- Stavanger University Hospital, Stavanger, Norway
| | - Clive Ballard
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Stavanger University Hospital, Stavanger, Norway
| | - Konstantinos Tsamakis
- South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, London, UK
- Second Department of Psychiatry, National and Kapodistrian University of Athens, School of Medicine, University General Hospital 'ATTIKON', Athens, Greece
| | - Robert Stewart
- South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, London, UK
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Christoph Mueller
- South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, London, UK
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Maziero MP, Rocha NP, Teixeira AL. Antipsychotics in Alzheimer's Disease: Current Status and Therapeutic Alternatives. Curr Alzheimer Res 2023; 20:682-691. [PMID: 38409713 DOI: 10.2174/0115672050287534240215052417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 01/26/2024] [Accepted: 01/31/2024] [Indexed: 02/28/2024]
Abstract
Psychosis and hyperactive behaviors, such as agitation and wandering, affect a significant proportion of patients with Alzheimer's disease (AD). These symptoms are often treated with antipsychotics, usually in an off-label approach. This mini-review provides an updated perspective on the pharmacological approach for the neuropsychiatric symptoms (NPS) in AD. The results of new studies have provided a better understanding of AD-related NPS management, but high-quality evidence still needs to be obtained. Herein, we argue for a more cautious approach to the use of antipsychotics in AD and highlight the importance of exploring alternative treatments for NPS. By doing so, we can ensure that patients with AD receive optimal care that is both effective and safe.
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Affiliation(s)
- Maria Paula Maziero
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Texas 77030, USA
| | - Natalia P Rocha
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Texas 77030, USA
| | - Antonio L Teixeira
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Texas 77030, USA
- The Glenn Biggs Institute for Alzheimer's & Neurodegenerative Diseases, The University of Texas Health Science Center at San Antonio, TX, USA
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Hølmkjær P, Vermehren C, Holm A, Rozing MP, Høj K, Overbeck G. Tailoring a complex intervention to reduce antidepressants in institutionalized older persons with dementia. BMC Health Serv Res 2022; 22:1582. [PMID: 36572903 PMCID: PMC9791154 DOI: 10.1186/s12913-022-08961-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 12/12/2022] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION First-line treatment for behavioral and psychiatric symptoms of dementia is non-pharmacological. Still, psychotropic medication is widely used, despite its limited effect and harmful side-effects. More than half of all nursing home residents with dementia receive antidepressants, even though deprescribing is safe and feasible. Interventions to promote deprescribing of antidepressants in nursing homes are few and complex. To optimize the deprescribing process through an intervention, transparency for the development of the intervention is needed. We aim to describe the steps in the development and tailoring of an intervention targeting GPs, nursing home staff, and relatives to enhance collaboration on reducing the use of antidepressants in institutionalized older persons with dementia in Denmark. METHOD A step-wise process guided by the core elements in the Medical Research Council constituted the tailoring process. Five steps were included; 1) a literature search, 2) interviews with stakeholders, 3) drafting the intervention prototype, 4) professionals' assessment of the intervention, and 5) refinement of the intervention. The steps were conducted from June 2020 to June 2022. RESULTS Based on the literature search, interviews with stakeholders, and professionals' assessment of the intervention, four main themes were identified; 1) focusing on antidepressants, 2) importance of professional qualifications, 3) collaboration and communication, and 4) patient and relative involvement. They guided intervention development and refinement of the final intervention, which included 1) a case-based training course and 2) a dialog tool including a symptom assessment scale to be used in a structured consultation at the nursing home. CONCLUSION This study presents a detailed account of the tailoring process for a complex intervention to optimize deprescribing of antidepressants for older persons with dementia at nursing homes. By presenting a thorough development process, we expect to achieve increased adherence to the intervention which is currently being tested in an ongoing cluster randomized controlled trial. The transparency of the process will also increase the future development of other similar complex interventions.
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Affiliation(s)
- Pernille Hølmkjær
- grid.5254.60000 0001 0674 042XDepartment of Public Health, Section of General Practice and Research Unit for General Practice, University of Copenhagen, Copenhagen, Denmark
| | - Charlotte Vermehren
- grid.4973.90000 0004 0646 7373Department of Clinical Pharmacology, University Hospital Copenhagen, Capital Region, Copenhagen, Denmark ,grid.5254.60000 0001 0674 042XDepartment of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Anne Holm
- grid.5254.60000 0001 0674 042XDepartment of Public Health, Section of General Practice and Research Unit for General Practice, University of Copenhagen, Copenhagen, Denmark
| | - Maarten Pieter Rozing
- grid.5254.60000 0001 0674 042XDepartment of Public Health, Section of General Practice and Research Unit for General Practice, University of Copenhagen, Copenhagen, Denmark
| | - Kirsten Høj
- grid.7048.b0000 0001 1956 2722Research Unit for General Practice, Aarhus, Denmark ,grid.154185.c0000 0004 0512 597XDepartment of Clinical Pharmacology, Aarhus University Hospital, Aarhus, Denmark ,grid.27530.330000 0004 0646 7349Unit of Clinical Pharmacology, Aalborg University Hospital, Aalborg, Denmark
| | - Gritt Overbeck
- grid.5254.60000 0001 0674 042XDepartment of Public Health, Section of General Practice and Research Unit for General Practice, University of Copenhagen, Copenhagen, Denmark
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Tampi RR, Tampi DJ, Farheen SA, Ochije SI, Joshi P. Propranolol for the management of behavioural and psychological symptoms of dementia. Drugs Context 2022; 11:dic-2022-8-3. [PMID: 36544625 PMCID: PMC9753600 DOI: 10.7573/dic.2022-8-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 10/26/2022] [Indexed: 12/12/2022] Open
Abstract
Propranolol is a β-adrenergic antagonist used in the management of hypertension, cardiac arrhythmia, and angina pectoris. There is some evidence that propranolol may benefit individuals with behavioural and psychological symptoms of dementia (BPSD). A total of three case series, one randomized controlled trial and one case report were identified (from a literature search of three major databases: PubMed, Ovid, and Cochrane collaboration) that assessed the use of propranolol for the management of BPSD. From these studies, it appears that propranolol improves BPSD, including agitation and aggression. Propranolol is also well tolerated with no significant bradycardia or hypotension noted in these studies. Current data on the use of propranolol for the management of BPSD are limited in comparison to other pharmacological agents (atypical antipsychotics, antidepressants, acetylcholinesterase inhibitors, memantine, and cannabinoids) and treatment modalities (repetitive transcranial magnetic stimulation and electroconvulsive therapy). The efficacy and safety of these treatments among individuals with BPSD has been evaluated in multiple controlled studies. In clinical practice, the routine use of propranolol among people with BPSD cannot be recommended at this time given the limited data. However, propranolol can be trialled among individuals with BPSD when symptoms have not responded adequately to other medications. Propranolol may also be used prior to embarking on trials of repetitive transcranial magnetic stimulation and electroconvulsive therapy among people with BPSD given the greater acceptance of this medication in the general population.
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Affiliation(s)
- Rajesh R Tampi
- Department of Psychiatry, Creighton University School of Medicine, Omaha, NE, USA,Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA,Department of Psychiatry & Behavioral Sciences, Cleveland Clinic Akron General, Akron, OH, USA
| | - Deena J Tampi
- Co-Founder and Managing Principal, Behavioral Health Advisory Group, Princeton, NJ, USA
| | - Syeda Arshiya Farheen
- Department of Psychiatry & Behavioral Sciences, Cleveland Clinic Akron General, Akron, OH, USA
| | - Sochima I Ochije
- Department of Psychiatry, Emory University Hospital, Atlanta GA, USA
| | - Pallavi Joshi
- Department of Psychiatry, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
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Fischer CE, Namasivayam A, Crawford-Holland L, Hakobyan N, Schweizer TA, Munoz DG, Pollock BG. Psychotic Disorders in the Elderly: Diagnosis, Epidemiology, and Treatment. Psychiatr Clin North Am 2022; 45:691-705. [PMID: 36396273 DOI: 10.1016/j.psc.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
This review covers the latest advances in our understanding of psychosis in the elderly population with respect to diagnosis, epidemiology, and treatment. Major topics of discussion include late life psychiatric disorders such as schizophrenia, schizoaffective disorder, and delusional disorder as well as dementia-related psychosis. Clinical differences between early-onset and late-onset disorders are reviewed in terms of prevalence, symptomatology, and approach to treatment. Newly revised research and clinical criteria for dementia-related psychosis are referenced. The evidence base for emerging therapies including citalopram and pimavanserin in relation to conventional therapies such as atypical antipsychotics are discussed..
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Affiliation(s)
- Corinne E Fischer
- Keenan Research Centre for Biomedical Science, Room 17044 cc wing, St. Michaels Hospital, #30 Bond St., Toronto, Ontario, M5B1W8, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada.
| | - Andrew Namasivayam
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Lucas Crawford-Holland
- Keenan Research Centre for Biomedical Science, Room 17044 cc wing, St. Michaels Hospital, #30 Bond St., Toronto, Ontario, M5B1W8, Canada
| | - Narek Hakobyan
- Keenan Research Centre for Biomedical Science, Room 17044 cc wing, St. Michaels Hospital, #30 Bond St., Toronto, Ontario, M5B1W8, Canada
| | - Tom A Schweizer
- Keenan Research Centre for Biomedical Science, Room 17044 cc wing, St. Michaels Hospital, #30 Bond St., Toronto, Ontario, M5B1W8, Canada; St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada; Department of Neurosurgery, University of Toronto, Toronto, Canada
| | - David G Munoz
- Keenan Research Centre for Biomedical Science, Room 17044 cc wing, St. Michaels Hospital, #30 Bond St., Toronto, Ontario, M5B1W8, Canada; St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - Bruce G Pollock
- Division of Geriatric Psychiatry, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 250 College Street, Toronto, Ontario, M5T 1R8, Canada; Toronto Dementia Research Alliance, University of Toronto, Toronto, Ontario, Canada
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Agbomi LL, Onuoha CP, Nathaniel SI, Coker-Ayo OO, Bailey-Taylor MJ, Roley LT, Poupore N, Goodwin RL, Nathaniel TI. Gender differences in Parkinson's disease with dementia and dementia with Lewy bodies. AGING AND HEALTH RESEARCH 2022. [DOI: 10.1016/j.ahr.2022.100096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Pérez Palmer N, Trejo Ortega B, Joshi P. Cognitive Impairment in Older Adults: Epidemiology, Diagnosis, and Treatment. Psychiatr Clin North Am 2022; 45:639-661. [PMID: 36396270 DOI: 10.1016/j.psc.2022.07.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Cognitive impairment and dementia affect dozens of millions of people worldwide and cause significant distress to patients and caregivers and a financial burden to families and health care systems. Careful history-taking, cognitive and physical examination, and supplemental neuroimaging and fluid-based biomarkers can accurately diagnose neurocognitive disorders. Management includes non-pharmacological and pharmacological treatments tailored to the etiology and to the individual.
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Affiliation(s)
- Nicolás Pérez Palmer
- Department of Psychiatry, Yale School of Medicine, 300 George Street, Suite 901, New Haven, CT 06511, USA.
| | - Barbara Trejo Ortega
- Department of Psychiatry, Yale School of Medicine, 300 George Street, Suite 901, New Haven, CT 06511, USA
| | - Pallavi Joshi
- Banner Alzheimer's Institute, 901 East Willeta Street, Phoenix, AZ 85006, USA; Department of Psychiatry, University of Arizona College of Medicine-Phoenix, 475 North 5th, Phoenix, AZ 85004, USA
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Forns J, Danysh HE, McQuay LJ, Turner ME, Dempsey C, Anthony MS, Demos G, Layton JB. Clinical outcomes and treatment patterns of older adults with dementia-related psychosis by dementia type in the United States. BMC Geriatr 2022; 22:784. [PMID: 36203129 PMCID: PMC9541053 DOI: 10.1186/s12877-022-03489-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 09/28/2022] [Indexed: 11/28/2022] Open
Abstract
Background Little is known about the incidence of clinical events and treatment patterns among older adults with dementia-related psychosis. Given that dementia-related psychosis comprises various dementia types, this study describes the incidence of clinical events and treatment patterns by dementia type after patients with dementia are diagnosed with psychosis. Methods Adults aged ≥ 65 years with dementia and newly diagnosed with psychosis were identified in US Medicare claims during 2013–2018. Baseline characteristics were evaluated at the time of the psychosis diagnosis. After the initial psychosis diagnosis, incidence rates (IRs) of clinical events (e.g., falls/fractures, infections, healthcare utilization), mortality, and patterns of antipsychotic treatment were described for each dementia type (Alzheimer’s disease [AD], Parkinson’s disease dementia [PDD], dementia with Lewy bodies [DLB], frontotemporal dementia [FTD], vascular dementia [VD], and unspecified dementia). Daily mean cumulative counts were estimated to describe the incidence of recurrent events over time. Mortality was described using Kaplan–Meier survival curves. Results We identified 484,520 patients with dementia-related psychosis: mean age, 84 years (standard deviation, 7.8); female, 66%. At the time of psychosis diagnosis, the most prevalent type of dementia was unspecified dementia (56%), followed by AD (31%), VD (12%), PDD (10%), DLB (3%), and FTD (< 1%), and most patients had scores indicating severe illness on the Charlson Comorbidity Index (71%) and frailty index (62%). Across all dementia types, IRs (per 100 person-years) were high for emergency department visits, oral anti-infective use, and urinary tract infections after the initial psychosis diagnosis. Patients with DLB had the highest incidence of most clinical outcomes. After 1 year of follow-up, the cumulative probability of death was about 30% for all dementia types, and after 5 years, was about 80% among patients with DLB, VD, AD, or PDD and about 60%-65% among patients with FTD or unspecified dementia. Conclusions Patients with dementia-related psychosis had a high burden of comorbidities, frailty, emergency department visits, infections, and death. Specifically, after DRP diagnosis, patients with DLB and VD had the highest burden of clinical events of interest. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03489-3.
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Affiliation(s)
- Joan Forns
- Pharmacoepidemiology and Risk Management, RTI Health Solutions, Barcelona, Spain.
| | - Heather E Danysh
- Pharmacoepidemiology and Risk Management, RTI Health Solutions, Waltham, MA, USA
| | - Lisa J McQuay
- Pharmacoepidemiology and Risk Management, RTI Health Solutions, Research Triangle Park, NC, USA
| | - Mary Ellen Turner
- Drug Safety and Pharmacovigilance, ACADIA Pharmaceuticals Inc, Princeton, NJ, USA
| | - Colleen Dempsey
- Drug Safety and Pharmacovigilance, ACADIA Pharmaceuticals Inc, Princeton, NJ, USA
| | - Mary S Anthony
- Pharmacoepidemiology and Risk Management, RTI Health Solutions, Research Triangle Park, NC, USA
| | - George Demos
- Drug Safety and Pharmacovigilance, ACADIA Pharmaceuticals Inc, San Diego, CA, USA
| | - J Bradley Layton
- Pharmacoepidemiology and Risk Management, RTI Health Solutions, Research Triangle Park, NC, USA
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Impact of standardizing care for agitation in dementia using an integrated care pathway on an inpatient geriatric psychiatry unit. Int Psychogeriatr 2022; 34:919-928. [PMID: 35546289 DOI: 10.1017/s1041610222000321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES This study examined the effectiveness of an integrated care pathway (ICP), including a medication algorithm, to treat agitation associated with dementia. DESIGN Analyses of data (both prospective and retrospective) collected during routine clinical care. SETTING Geriatric Psychiatry Inpatient Unit. PARTICIPANTS Patients with agitation associated with dementia (n = 28) who were treated as part of the implementation of the ICP and those who received treatment-as-usual (TAU) (n = 28) on the same inpatient unit before the implementation of the ICP. Two control groups of patients without dementia treated on the same unit contemporaneously to the TAU (n = 17) and ICP groups (n = 36) were included to account for any secular trends. INTERVENTION ICP. MEASUREMENTS Cohen Mansfield Agitation Inventory (CMAI), Neuropsychiatric Inventory Questionnaire (NPIQ), and assessment of motor symptoms were completed during the ICP implementation. Chart review was used to obtain length of inpatient stay and rates of psychotropic polypharmacy. RESULTS Patients in the ICP group experienced a reduction in their scores on the CMAI and NPIQ and no changes in motor symptoms. Compared to the TAU group, the ICP group had a higher chance of an earlier discharge from hospital, a lower rate of psychotropic polypharmacy, and a lower chance of having a fall during hospital stay. In contrast, these outcomes did not differ between the two control groups. CONCLUSIONS These preliminary results suggest that an ICP can be used effectively to treat agitation associated with dementia in inpatients. A larger randomized study is needed to confirm these results.
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Ayhan Y, Yoseph SA, Miller BL. Management of Psychiatric Symptoms in Dementia. Neurol Clin 2022; 41:123-139. [DOI: 10.1016/j.ncl.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Brucki SMD, Aprahamian I, Borelli WV, Silveira VCD, Ferretti CEDL, Smid J, Barbosa BJAP, Schilling LP, Balthazar MLF, Frota NAF, Souza LCD, Vale FAC, Caramelli P, Bertolucci PHF, Chaves MLF, Nitrini R, Schultz RR, Morillo LS. Management in severe dementia: recommendations of the Scientific Department of Cognitive Neurology and Aging of the Brazilian Academy of Neurology. Dement Neuropsychol 2022. [DOI: 10.1590/1980-5764-dn-2022-s107en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
ABSTRACT Alzheimer’s disease (AD) and other neurodegenerative dementias have a progressive course, impairing cognition, functional capacity, and behavior. Most studies have focused on AD. Severe dementia is associated with increased age, higher morbidity-mortality, and rising costs of care. It is fundamental to recognize that severe dementia is the longest period of progression, with patients living for many years in this stage. It is the most heterogeneous phase in the process, with different abilities and life expectancies. This practice guideline focuses on severe dementia to improve management and care in this stage of dementia. As it is a long period in the continuum of dementia, clinical practice should consider non-pharmacological and pharmacological approaches. Multidisciplinary interventions (physical therapy, speech therapy, nutrition, nursing, and others) are essential, besides educational and support to caregivers.
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Affiliation(s)
| | - Ivan Aprahamian
- Faculdade de Medicina de Jundiaí, Brasil; University of Groningen, The Netherlands; Universidade de São Paulo, Brasil
| | | | | | | | | | - Breno José Alencar Pires Barbosa
- Universidade de São Paulo, Brazil; Universidade Federal de Pernambuco, Brasil; Instituto de Medicina Integral Prof. Fernando Figueira, Brasil
| | - Lucas Porcello Schilling
- Pontifícia Universidade do Rio Grande do Sul, Brasil; Pontifícia Universidade do Rio Grande do Sul, Brasil; Pontifícia Universidade do Rio Grande do Sul, Brasil
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Polypharmacy in Treatment of Behavioral Issues in Dementia—Use of Atypical Antipsychotics. Clin Geriatr Med 2022; 38:641-652. [DOI: 10.1016/j.cger.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Brucki SMD, Aprahamian I, Borelli WV, Silveira VCD, Ferretti CEDL, Smid J, Barbosa BJAP, Schilling LP, Balthazar MLF, Frota NAF, Souza LCD, Vale FAC, Caramelli P, Bertolucci PHF, Chaves MLF, Nitrini R, Schultz RR, Morillo LS. Manejo das demências em fase avançada: recomendações do Departamento Científico de Neurologia Cognitiva e do Envelhecimento da Academia Brasileira de Neurologia. Dement Neuropsychol 2022; 16:101-120. [DOI: 10.1590/1980-5764-dn-2022-s107pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 10/04/2021] [Accepted: 04/27/2022] [Indexed: 11/29/2022] Open
Abstract
RESUMO A doença de Alzheimer (DA) e outras demências neurodegenerativas têm um curso progressivo com comprometimento da cognição, capacidade funcional e comportamento. A maioria dos estudos enfocou a DA. A demência grave está associada ao aumento da idade, maior morbimortalidade e aumento dos custos de cuidados. É fundamental reconhecer que a demência grave é o período mais longo de progressão, com o paciente vivendo muitos anos nesta fase. É a fase mais heterogênea do processo, com diferentes habilidades e expectativa de vida. Esta diretriz de prática concentra-se na demência grave para melhorar o manejo e o cuidado nessa fase da demência. Como um longo período no continuum da demência, as abordagens não farmacológicas e farmacológicas devem ser consideradas. Intervenções multidisciplinares (fisioterapia, fonoaudiologia, nutrição, enfermagem, entre outras) são essenciais, além de educacionais e de apoio aos cuidadores.
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Affiliation(s)
| | - Ivan Aprahamian
- Faculdade de Medicina de Jundiaí, Brasil; University of Groningen, The Netherlands; Universidade de São Paulo, Brasil
| | | | | | | | | | - Breno José Alencar Pires Barbosa
- Universidade de São Paulo, Brazil; Universidade Federal de Pernambuco, Brasil; Instituto de Medicina Integral Prof. Fernando Figueira, Brasil
| | - Lucas Porcello Schilling
- Pontifícia Universidade do Rio Grande do Sul, Brasil; Pontifícia Universidade do Rio Grande do Sul, Brasil; Pontifícia Universidade do Rio Grande do Sul, Brasil
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Zangani C, Giordano B, Stein HC, Bonora S, Ostinelli EG, D'Agostino A. Efficacy of tiapride in the treatment of psychiatric disorders: A systematic review. Hum Psychopharmacol 2022; 37:e2842. [PMID: 35313032 DOI: 10.1002/hup.2842] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 02/22/2022] [Accepted: 03/08/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Tiapride is an atypical antipsychotic used to treat alcohol withdrawal, aggressiveness and agitation, headache, dyskinesias, tic and Tourette's disorder. More recently, it has been proposed for the treatment of delirium and agitation in hospitalised patients with COVID-19. Although its safety profile makes it suitable for use in vulnerable populations, the use of tiapride for psychiatric disorders is limited. This work aims to systematically review the available evidence on the efficacy and tolerability of tiapride in individuals with a psychiatric disorder. METHODS We searched PubMed, Embase, PsycINFO, GreyLit, OpenGrey, and ProQuest up to March 2020 for randomised controlled trials focussing on the use of tiapride in the treatment of individuals with a psychiatric disorder (e.g., mood disorder, schizophrenia spectrum, substance use disorder). The Risk of Bias 2 was performed for the quality assessment of the included studies. RESULTS We identified 579 records. Of them, six studies (published between 1982 and 2010) were included in the review. Four studies referred to alcohol withdrawal, and two to the management of agitation in elderly patients with dementia. None of the studies reported significant differences between tiapride and other active comparators in terms of efficacy and tolerability. The overall risk of bias was moderate to high. CONCLUSION Tiapride may be considered as a relatively safe treatment option for selected patients with alcohol withdrawal or agitation in dementia. However, solid evidence of its efficacy in the scientific literature is lacking. High-quality trials remain necessary to fully sustain its use in clinical practice.
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Affiliation(s)
- Caroline Zangani
- Department of Psychiatry, University of Oxford, Oxford, UK.,Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK.,Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK.,Department of Health Sciences, University of Milan, Milan, Italy
| | - Barbara Giordano
- Department of Health Sciences, University of Milan, Milan, Italy
| | | | - Stefano Bonora
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Edoardo Giuseppe Ostinelli
- Department of Psychiatry, University of Oxford, Oxford, UK.,Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK.,Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
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Tampi RR, Bhattacharya G, Marpuri P. Managing Behavioral and Psychological Symptoms of Dementia (BPSD) in the Era of Boxed Warnings. Curr Psychiatry Rep 2022; 24:431-440. [PMID: 35781675 DOI: 10.1007/s11920-022-01347-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/08/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW To provide a comprehensive overview on the evaluation and management of behavioral and psychological symptoms of dementia (BPSD) using evidence from literature. RECENT FINDINGS Evidence indicates efficacy for some non-pharmacological techniques including education of caregivers and cognitive stimulation therapy and pharmacological agents like antidepressant and antipsychotics for the management of BPSD. The use of antipsychotics has generated controversy due to the recognition of their serious adverse effect profile including the risk of cerebrovascular adverse events and death. BPSD is associated with worsening of cognition and function among individuals with dementia, greater caregiver burden, more frequent institutionalization, overall poorer quality of life, and greater cost of caring for these individuals. Future management strategies for BPSD should include the use of technology for the provision of non-pharmacological interventions and the judicious use of cannabinoids and interventional procedures like ECT for the management of refractory symptoms.
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Affiliation(s)
- Rajesh R Tampi
- Department of Psychiatry, Creighton University School of Medicine, Omaha, NE, USA. .,Department of Psychiatry &Behavioral Sciences, Cleveland Clinic Akron General, Akron, OH, USA. .,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA. .,Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA. .,Department of Psychiatry, North East Medical University, Rootstown, OH, USA.
| | - Gargi Bhattacharya
- Department of Psychiatry &Behavioral Sciences, Cleveland Clinic Akron General, Akron, OH, USA
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