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Mercier C, Rollason V, Eshmawey M, Mendes A, Frisoni GB. The treatment of behavioural and psychological symptoms in dementia: pragmatic recommendations. Psychogeriatrics 2024; 24:968-982. [PMID: 38638077 DOI: 10.1111/psyg.13116] [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: 11/15/2023] [Revised: 02/20/2024] [Accepted: 03/19/2024] [Indexed: 04/20/2024]
Abstract
Behavioural and psychological symptoms of dementia (BPSD) are a clinical challenge for the lack of a sound taxonomy, frequent presentation with comorbid BPSD, lack of specific pharmacologic interventions, poor base of methodologically sound evidence with randomized clinical trials, contamination from the treatment of behavioural disturbances of young and adult psychiatric conditions, and small efficacy window of psychotropic drugs. We present here a treatment workflow based on a concept-driven literature review based on the notions that (i) the aetiology of BPSD can be mainly neurobiological (so-called 'primary' symptoms) or mainly environmental and functional ('secondary' symptoms) and that this drives treatment; (ii) the clinical efficacy of psychotropic drugs is driven by their specific profile of receptor affinity; (iii) drug treatment should follow the rules of 'start low-go slow, prescribe and revise'. This article argues in support of the distinction between primary and secondary BPSD, as well as their characteristics, which until now have been just sketchily described in the literature. It also offers comprehensive and pragmatic clinician-oriented recommendations for the treatment of BPSD.
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Affiliation(s)
- Camille Mercier
- Laboratory of Neuroimaging of Aging (LANVIE), University of Geneva, Geneva, Switzerland
- Memory Center, Department of Rehabilitation and Geriatrics, University Hospitals of Geneva, Geneva, Switzerland
| | - Victoria Rollason
- Department of Acute Medicine, Clinical Pharmacology and Toxicology Service, University Hospitals of Geneva, Geneva, Switzerland
| | - Mohamed Eshmawey
- Department of Psychiatry, Geriatric Psychiatry Service, University Hospitals of Geneva, Geneva, Switzerland
| | - Aline Mendes
- Geriatrics and Rehabilitation Department, Department of Rehabilitation and Geriatrics, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland
| | - Giovanni B Frisoni
- Laboratory of Neuroimaging of Aging (LANVIE), University of Geneva, Geneva, Switzerland
- Memory Center, Department of Rehabilitation and Geriatrics, University Hospitals of Geneva, Geneva, Switzerland
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Kobayashi S, Sugama N, Nagano H, Miyamori A, Takahashi M, Kushiyama A. Analysis of Adverse Events of Cholinesterase Inhibitors and NMDA Receptor Antagonists on Arrhythmias Using the Japanese Adverse Drug Event Report Database. Drugs Real World Outcomes 2023:10.1007/s40801-023-00362-6. [PMID: 37086360 DOI: 10.1007/s40801-023-00362-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2023] [Indexed: 04/23/2023] Open
Abstract
BACKGROUND The association between anti-dementia drugs and arrhythmia is uncertain. In addition, the effects of certain drug combinations are not yet well known. OBJECTIVE We investigated the association between anti-dementia drugs and arrhythmia. Furthermore, we investigated the effects of anti-dementia drugs both alone and in combination on the likelihood of arrhythmia in patients with dementia. METHODS We examined the Japanese Adverse Drug Event Report database (JADER) from April 2004 to May 2022 for dementia drug users aged ≥ 60 years. We calculated the unadjusted reported odds ratio (ROR) and adjusted ROR for confounding factors. Furthermore, we examined the association of various combinations of anti-dementia drugs with the development of arrhythmias. RESULTS There were 6718 arrhythmia cases identified out of 333,702 reported cases. The unadjusted ROR results were as follows: donepezil alone (ROR 4.39, 95% confidence interval [CI] 3.89-4.95), rivastigmine alone (2.10, 1.53-2.87), galantamine alone (3.87, 3.04-4.94), memantine alone (2.25, 1.59-3.20), and combination of choline esterase inhibitor and memantine (2.56, 1.84-3.57). In a multivariate analysis, the RORs remained significant. CONCLUSIONS Regardless of whether anti-dementia drugs were used alone or in combination, attention should be paid to the occurrence of arrhythmias.
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Affiliation(s)
- Shotaro Kobayashi
- Department of Pharmacy, Sonoda Daiichi Hospital, Tokyo, Japan
- Department of Pharmacotherapy, Meiji Pharmaceutical University, Kiyose, Tokyo, 204-8588, Japan
| | - Norio Sugama
- Department of Pharmacy, Sonoda Daiichi Hospital, Tokyo, Japan
| | - Hiroyuki Nagano
- Department of Pharmacy, Saitama Medical University Hospital, Saitama, Japan
- Department of Pharmacotherapy, Meiji Pharmaceutical University, Kiyose, Tokyo, 204-8588, Japan
| | - Ayaka Miyamori
- Department of Pharmacotherapy, Meiji Pharmaceutical University, Kiyose, Tokyo, 204-8588, Japan
- Department of Pharmacy, National Hospital Organization Chiba Medical Center, Chiba, Japan
| | - Masahiro Takahashi
- Department of Pharmacotherapy, Meiji Pharmaceutical University, Kiyose, Tokyo, 204-8588, Japan
| | - Akifumi Kushiyama
- Department of Pharmacotherapy, Meiji Pharmaceutical University, Kiyose, Tokyo, 204-8588, Japan.
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Levin OS, Zakharov VV, Khacheva KK, Vladykin AL, Globenko AA. [Pathogenetic therapy of cognitive impairment: results of a multicenter placebo-controlled clinical trial of the efficacy and safety of Miladean]. Zh Nevrol Psikhiatr Im S S Korsakova 2023; 123:60-68. [PMID: 37966441 DOI: 10.17116/jnevro202312310160] [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: 11/16/2023]
Abstract
OBJECTIVE Evaluation of the efficacy and safety of the use of the drug Miladean in the treatment of patients with cognitive disorders (CDs) of vascular genesis. MATERIAL AND METHODS In during the double-blind multicenter prospective randomized placebo-controlled phase III clinical trial, 300 patients with CDs and chronic cerebral ischemia were randomized into 3 groups: group 1 (n=100) received Miladean (daily dose: memantine 10 mg + melatonin 6 mg), group 2 (n=101) - memantine (10 mg/day), group 3 - placebo (n=99) for 8 weeks. The dynamics of the overall score (the primary criterion of effectiveness) and the proportion of patients with improvement on the Alzheimer's Disease Assessment Scale-Cognitive (ADAS-Cog), the dynamics of visual-spatial orientation disorders (Benton test), sleep quality (Pittsburgh Sleep Quality Index scale) and the safety of therapy were evaluated. RESULTS Miladean demonstrated efficacy in the treatment of CDs: a statistically and clinically significant decrease in the overall score on the ADAS-Sod scale was shown (by 6.1 versus 4.7 and 3.5 points in the 2nd (p=0.009) and 3rd (p<0.05) groups) and an increase in the proportion of patients (96.9%) with clinically and statistically a significant improvement compared to the 2nd and 3rd groups (p=0.019 and p<0.001 respectively). Miladean significantly improved the performance in the Benton test (1.20±1.66 vs. 0.64±1.69 points in group 3, p=0.026) and sleep quality (84.7% of patients with CDs), compared to placebo (63.9%) and memantine (64.3%) (p=0.002 in both cases). Miladean was well tolerated, there were no cases of interaction with basic therapy drugs. CONCLUSION The combination of many different pathogenetic effects of Miladean suggests that it has the ability to slow down the rate of progression of CDs and stabilize the condition of patients. The unique combination of active substances in Miladean has been proven to be effective and safe in the treatment of patients with CDs.
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Affiliation(s)
- O S Levin
- Russian Medical Academy of Continuing Professional Education, Moscow, Russia
| | - V V Zakharov
- Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
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Costa ACS, Brandão AC, Boada R, Barrionuevo VL, Taylor HG, Roth E, Stasko MR, Johnson MW, Assir FF, Roberto MP, Salmona P, Abreu-Silveira G, Bederman I, Prendergast E, Hüls A, Abrishamcar S, Mustacchi Z, Scheidemantel T, Roizen NJ, Ruedrich S. Safety, efficacy, and tolerability of memantine for cognitive and adaptive outcome measures in adolescents and young adults with Down syndrome: a randomised, double-blind, placebo-controlled phase 2 trial. Lancet Neurol 2021; 21:31-41. [PMID: 34942135 DOI: 10.1016/s1474-4422(21)00369-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 10/02/2021] [Accepted: 10/11/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Down syndrome is a chromosomal disorder with considerable neurodevelopmental impact and neurodegenerative morbidity. In a pilot trial in young adults with Down syndrome, memantine (a drug approved for Alzheimer's disease) showed a significant effect on a secondary measure of episodic memory. We aimed to test whether memantine would improve episodic memory in adolescents and young adults with Down syndrome. METHODS We did a randomised, double-blind, placebo-controlled phase 2 trial with a parallel design, stratified by age and sex. Participants (aged 15-32 years) with either trisomy 21 or complete unbalanced translocation of chromosome 21 and in general good health were recruited from the community at one site in Brazil and another in the USA. Participants were randomly assigned (1:1) to receive either memantine (20 mg/day orally) or placebo for 16 weeks. Computer-generated randomisation tables for both sites (allocating a placebo or drug label to each member of a unique pair of participants) were centrally produced by an independent statistician and were shared only with investigational pharmacists at participating sites until unblinding of the study. Participants and investigators were masked to treatment assignments. Neuropsychological assessments were done at baseline (T1) and week 16 (T2). The primary outcome measure was change from baseline to week 16 in the California Verbal Learning Test-second edition short-form (CVLT-II-sf) total free recall score, assessed in the per-protocol population (ie, participants who completed 16 weeks of treatment and had neuropsychological assessments at T1 and T2). Linear mixed effect models were fit to data from the per-protocol population. Safety and tolerability were monitored and analysed in all participants who started treatment. Steady-state concentrations in plasma of memantine were measured at the end of the trial. This study is registered at ClinicalTrials.gov, number NCT02304302. FINDINGS From May 13, 2015, to July 22, 2020, 185 participants with Down syndrome were assessed for eligibility and 160 (86%) were randomly assigned either memantine (n=81) or placebo (n=79). All participants received their allocated treatment. Linear mixed effect models were fit to data from 149 (81%) participants, 73 in the memantine group and 76 in the placebo group, after 11 people (eight in the memantine group and three in the placebo group) discontinued due to COVID-19 restrictions, illness of their caregiver, adverse events, or low compliance. The primary outcome measure did not differ between groups (CVLT-II-sf total free recall score, change from baseline 0·34 points [95% CI -0·98 to 1·67], p=0·61). Memantine was well tolerated, with infrequent mild-to-moderate adverse events, the most common being viral upper respiratory infection (nine [11%] participants in the memantine group and 12 [15%] in the placebo group) and transient dizziness (eight [10%] in the memantine group and six [8%] in the placebo group). No serious adverse events were observed. Amounts of memantine in plasma were substantially lower than those considered therapeutic for Alzheimer's disease. INTERPRETATION Memantine was well tolerated, but cognition-enhancing effects were not recorded with a 20 mg/day dose in adolescents and young adults with Down syndrome. Exploratory analyses point to a need for future work. FUNDING Alana Foundation. TRANSLATION For the Portuguese translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Alberto C S Costa
- Department of Pediatrics, School of Medicine, Case Western Reserve University, Cleveland, OH, USA; Department of Psychiatry, School of Medicine, Case Western Reserve University, Cleveland, OH, USA.
| | - Ana C Brandão
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Richard Boada
- Department of Pediatrics, School of Medicine, University of Colorado Aurora, CO, USA
| | | | - Hudson G Taylor
- Center for Biobehavioral Health, Nationwide Children's Hospital Research Institute, Ohio State University, Columbus, OH, USA
| | - Elizabeth Roth
- Department of Pediatrics, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Melissa R Stasko
- Department of Pediatrics, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Mark W Johnson
- Department of Pediatrics, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | | | | | - Patrícia Salmona
- São Paulo Center for Clinical Studies and Research-CEPEC-SP, São Paulo, Brazil
| | | | - Ilya Bederman
- Department of Genetics and Genome Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Erin Prendergast
- Department of Genetics and Genome Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Anke Hüls
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA; Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Sarina Abrishamcar
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Zan Mustacchi
- São Paulo Center for Clinical Studies and Research-CEPEC-SP, São Paulo, Brazil
| | - Thomas Scheidemantel
- Department of Psychiatry, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Nancy J Roizen
- Department of Pediatrics, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Stephen Ruedrich
- Department of Psychiatry, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
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