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Dolphin H, Dyer AH, McHale C, O'Dowd S, Kennelly SP. An Update on Apathy in Alzheimer's Disease. Geriatrics (Basel) 2023; 8:75. [PMID: 37489323 PMCID: PMC10366907 DOI: 10.3390/geriatrics8040075] [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: 05/31/2023] [Revised: 06/21/2023] [Accepted: 07/11/2023] [Indexed: 07/26/2023] Open
Abstract
Apathy is a complex multi-dimensional syndrome that affects up to 70% of individuals with Alzheimer's disease (AD). Whilst many frameworks to define apathy in AD exist, most include loss of motivation or goal-directed behaviour as the central feature. Apathy is associated with significant impact on persons living with AD and their caregivers and is also associated with accelerated cognitive decline across the AD spectrum. Neuroimaging studies have highlighted a key role of fronto-striatial circuitry including the anterior cingulate cortex (ACC), orbito-frontal cortex (OFC) and associated subcortical structures. Importantly, the presence and severity of apathy strongly correlates with AD stage and neuropathological biomarkers of amyloid and tau pathology. Following from neurochemistry studies demonstrating a central role of biogenic amine neurotransmission in apathy syndrome in AD, recent clinical trial data suggest that apathy symptoms may improve following treatment with agents such as methylphenidate-which may have an important role alongside emerging non-pharmacological treatment strategies. Here, we review the diagnostic criteria, rating scales, prevalence, and risk factors for apathy in AD. The underlying neurobiology, neuropsychology and associated neuroimaging findings are reviewed in detail. Finally, we discuss current treatment approaches and strategies aimed at targeting apathy syndrome in AD, highlighting areas for future research and clinical trials in patient cohorts.
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Affiliation(s)
- Helena Dolphin
- Tallaght Institute of Memory and Cognition, Tallaght University Hospital, D24NR0A Dublin, Ireland
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, D08W9RT Dublin, Ireland
| | - Adam H Dyer
- Tallaght Institute of Memory and Cognition, Tallaght University Hospital, D24NR0A Dublin, Ireland
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, D08W9RT Dublin, Ireland
| | - Cathy McHale
- Tallaght Institute of Memory and Cognition, Tallaght University Hospital, D24NR0A Dublin, Ireland
| | - Sean O'Dowd
- Tallaght Institute of Memory and Cognition, Tallaght University Hospital, D24NR0A Dublin, Ireland
- Department of Neurology, Tallaght University Hospital, D24NR0A Dublin, Ireland
- Academic Unit of Neurology, Trinity College Dublin, D02R590 Dublin, Ireland
| | - Sean P Kennelly
- Tallaght Institute of Memory and Cognition, Tallaght University Hospital, D24NR0A Dublin, Ireland
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, D08W9RT Dublin, Ireland
- Department of Clinical Medicine, School of Medicine, Trinity College Dublin, D08W9RT Dublin, Ireland
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2
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Chen K, Li H, Yang L, Jiang Y, Wang Q, Zhang J, He J. Comparative efficacy and safety of antidepressant therapy for the agitation of dementia: A systematic review and network meta-analysis. Front Aging Neurosci 2023; 15:1103039. [PMID: 36936502 PMCID: PMC10020338 DOI: 10.3389/fnagi.2023.1103039] [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: 11/19/2022] [Accepted: 02/13/2023] [Indexed: 03/06/2023] Open
Abstract
Background Dementia is a clinical syndrome commonly seen in the elderly individuals. With the prevalence of dementia, the incidence of neuropsychiatric symptoms in dementia patients is increasing annually. Agitation, as one of the neuropsychiatric symptoms, has a serious impact on the quality of life of patients with dementia. Several antidepressant drugs have been shown to be effective for treating agitated behavior symptoms in patients with dementia, but there are no direct comparisons among those drugs. Therefore, we carried out a network meta-analysis (NMA) to examine the efficacy and safety of those antidepressant drugs. Methods We searched eight databases (PubMed, Cochrane Library, Web of Science, Embase, Wanfang Database, China National Knowledge Infrastructure, VIP Database and China biomedical literature service) from their inception to 6 November 2022. Randomized controlled trials (RCTs) reporting the efficacy and safety of antidepressant drugs in treating agitated behavior symptoms in patients with dementia were included in our analysis. The quality assessment was carried out by two researchers individually and the analysis was based on the frequency method. Results Twelve articles with 1,146 participants were included in our analysis. Based on the outcome of the agitation score, treatment with citalopram (standardized mean difference, SMD = -0.44, 95% confidence interval, 95% CI = -0.72 to -0.16) showed significant benefits over the placebo group. Treatment with trazodone (odds ratio, OR = 4.58, 95% CI = 1.12-18.69) was associated with a higher risk of total adverse events compared with a placebo treatment. Conclusion Among the antidepressant drugs included in this study, treatment with citalopram was probably the only optimal intervention, when considering the improvement from baseline to the end of the intervention, and there was not a statistically significant difference in safety when compared with a placebo treatment. Systematic review registration https://www.crd.york.ac.uk/prospero/#recordDetails, identifier: PROSPERO, CRD42022320932.
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Affiliation(s)
- Kaili Chen
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Haiqi Li
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Le Yang
- Department of Endocrinology, Jilin Province People's Hospital, Changchun, China
| | - Yan Jiang
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Qiaoli Wang
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Jiao Zhang
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Jinting He
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, China
- *Correspondence: Jinting He
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3
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Azhar L, Kusumo RW, Marotta G, Lanctôt KL, Herrmann N. Pharmacological Management of Apathy in Dementia. CNS Drugs 2022; 36:143-165. [PMID: 35006557 DOI: 10.1007/s40263-021-00883-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/21/2021] [Indexed: 12/11/2022]
Abstract
Apathy is a highly prevalent symptom of dementia. Despite its association with faster cognitive and functional decline, decreased quality of life and increased mortality, no therapies are currently approved to treat apathy. The objective of this review was to summarize the drugs that have been studied for apathy treatment in patients with dementia (specifically Alzheimer's disease [AD], Huntington's disease [HD] and Parkinson's disease [PD] dementia; dementia with Lewy bodies [DLB]; vascular dementia [VaD]; and frontotemporal dementia [FTD]) based on their putative mechanisms of action. A search for relevant studies was performed using ClinicalTrials.gov and PubMed. Eligible studies were randomized controlled trials that were available in English and included at least one drug intervention and an apathy measure scale. A total of 52 studies that included patients with AD (n = 33 studies), PD (n = 5), HD (n = 1), DLB (n = 1), FTD (n = 3), VaD (n = 1), VaD and AD (n = 4), VaD and mixed dementia (n = 1), and AD, VaD and mixed dementia (n = 3) were eligible for inclusion. These studies showed that methylphenidate, olanzapine, cholinesterase inhibitors, choline alphoscerate, citalopram, memantine, and mibampator are the only beneficial drugs in AD-related apathy. For PD-related apathy, only methylphenidate, rotigotine and rivastigmine showed benefits. Regarding FTD- and DLB-related apathy, initial studies with agomelatine and rivastigmine showed benefits, respectively. As for HD- and only-VaD-related apathy, no drugs demonstrated benefits. With regards to mixed populations, memantine, galantamine and gingko biloba showed effects on apathy in the AD plus VaD populations and nimodipine in the VaD plus mixed dementia populations. Of the drugs with positive results, some are already prescribed to patients with dementia to target other symptoms, some have characteristics-such as medical contraindications (e.g., cardiovascular) and adverse effects (e.g., gastrointestinal disturbances)-that limit their clinical use and some require further study. Future studies should investigate apathy as a primary outcome, making use of appropriate sample sizes and study durations to ensure durability of results. There should also be a consensus on using scales with high test/retest and interrater reliabilities to limit the inconsistencies between clinical trials. In conclusion, there are currently no US FDA-approved drugs that target apathy in dementia, so there is an ongoing need for the development of such drugs.
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Affiliation(s)
- Laiba Azhar
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
- Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Raphael W Kusumo
- Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Giovanni Marotta
- Geriatric Medicine Division, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Krista L Lanctôt
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
- Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, ON, Canada
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Nathan Herrmann
- Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, ON, Canada.
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.
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4
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Carrarini C, Russo M, Dono F, Barbone F, Rispoli MG, Ferri L, Di Pietro M, Digiovanni A, Ajdinaj P, Speranza R, Granzotto A, Frazzini V, Thomas A, Pilotto A, Padovani A, Onofrj M, Sensi SL, Bonanni L. Agitation and Dementia: Prevention and Treatment Strategies in Acute and Chronic Conditions. Front Neurol 2021; 12:644317. [PMID: 33935943 PMCID: PMC8085397 DOI: 10.3389/fneur.2021.644317] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 03/12/2021] [Indexed: 01/11/2023] Open
Abstract
Agitation is a behavioral syndrome characterized by increased, often undirected, motor activity, restlessness, aggressiveness, and emotional distress. According to several observations, agitation prevalence ranges from 30 to 50% in Alzheimer's disease, 30% in dementia with Lewy bodies, 40% in frontotemporal dementia, and 40% in vascular dementia (VaD). With an overall prevalence of about 30%, agitation is the third most common neuropsychiatric symptoms (NPS) in dementia, after apathy and depression, and it is even more frequent (80%) in residents of nursing homes. The pathophysiological mechanism underlying agitation is represented by a frontal lobe dysfunction, mostly involving the anterior cingulate cortex (ACC) and the orbitofrontal cortex (OFC), respectively, meaningful in selecting the salient stimuli and subsequent decision-making and behavioral reactions. Furthermore, increased sensitivity to noradrenergic signaling has been observed, possibly due to a frontal lobe up-regulation of adrenergic receptors, as a reaction to the depletion of noradrenergic neurons within the locus coeruleus (LC). Indeed, LC neurons mainly project toward the OFC and ACC. These observations may explain the abnormal reactivity to weak stimuli and the global arousal found in many patients who have dementia. Furthermore, agitation can be precipitated by several factors, e.g., the sunset or low lighted environments as in the sundown syndrome, hospitalization, the admission to nursing residencies, or changes in pharmacological regimens. In recent days, the global pandemic has increased agitation incidence among dementia patients and generated higher distress levels in patients and caregivers. Hence, given the increasing presence of this condition and its related burden on society and the health system, the present point of view aims at providing an extensive guide to facilitate the identification, prevention, and management of acute and chronic agitation in dementia patients.
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Affiliation(s)
- Claudia Carrarini
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Mirella Russo
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Fedele Dono
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Filomena Barbone
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Marianna G Rispoli
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Laura Ferri
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Martina Di Pietro
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Anna Digiovanni
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Paola Ajdinaj
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Rino Speranza
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Alberto Granzotto
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy.,Behavioral Neurology and Molecular Neurology Units, Center for Advanced Studies and Technology-CAST, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy.,Institute for Mind Impairments and Neurological Disorders-iMIND, University of California, Irvine, Irvine, CA, United States
| | - Valerio Frazzini
- Behavioral Neurology and Molecular Neurology Units, Center for Advanced Studies and Technology-CAST, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy.,Institut du Cerveau et de la Moelle épinière, ICM, INSERM UMRS 1127, CNRS UMR 7225, Pitié Salpêtrière Hospital, Paris, France.,AP-HP, GH Pitie-Salpêtrière-Charles Foix, Epilepsy Unit and Neurophysiology Department, Paris, France
| | - Astrid Thomas
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Andrea Pilotto
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Parkinson's Disease Rehabilitation Centre, FERB ONLUS-S. Isidoro Hospital, Trescore Balneario, Italy
| | - Alessandro Padovani
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Marco Onofrj
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy.,Behavioral Neurology and Molecular Neurology Units, Center for Advanced Studies and Technology-CAST, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Stefano L Sensi
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy.,Behavioral Neurology and Molecular Neurology Units, Center for Advanced Studies and Technology-CAST, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Laura Bonanni
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy.,Behavioral Neurology and Molecular Neurology Units, Center for Advanced Studies and Technology-CAST, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
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5
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The Psychopharmacology Algorithm Project at the Harvard South Shore Program: An update on management of behavioral and psychological symptoms in dementia. Psychiatry Res 2021; 295:113641. [PMID: 33340800 DOI: 10.1016/j.psychres.2020.113641] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 12/09/2020] [Indexed: 12/27/2022]
Abstract
Geriatric patients with dementia frequently present with agitation, aggression, psychosis, and other behavioral and psychological symptoms of dementia (BPSD). We present an update of our previously published algorithms for the use of psychopharmacologic agents in these patients taking into account more recent studies and findings in meta-analyses, reviews, and other published algorithms. We propose three algorithms: BPSD in an emergent, urgent, and non-urgent setting. In the emergent setting when intramuscular (IM) administration is necessary, the first-line recommendation is for olanzapine (since IM aripiprazole, previously favored, is no longer available) and haloperidol injection is the second choice, followed by possible consideration of an IM benzodiazepine. In the urgent setting, the first line would be oral second-generation antipsychotics (SGAs) aripiprazole and risperidone. Perhaps next could be then prazosin, and lastly electroconvulsive therapy is a consideration. There are risks associated with these agents, and adverse effects can be severe. Dosing strategies, discontinuation considerations, and side effects are discussed. In the non-emergent setting, medications are proposed for use in the following order: trazodone, donepezil and memantine, antidepressants such as escitalopram and sertraline, SGAs, prazosin, and carbamazepine. Other options with less support but potential future promise are discussed.
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6
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Ruthirakuhan M, Herrmann N, Andreazza AC, Verhoeff NPLG, Gallagher D, Black SE, Kiss A, Lanctôt KL. 24S-Hydroxycholesterol Is Associated with Agitation Severity in Patients with Moderate-to-Severe Alzheimer's Disease: Analyses from a Clinical Trial with Nabilone. J Alzheimers Dis 2020; 71:21-31. [PMID: 31322567 PMCID: PMC6839471 DOI: 10.3233/jad-190202] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background: Agitation is a prevalent and difficult-to-treat symptom of Alzheimer’s disease (AD). The endocannabinoid system (ECS) has been a target of interest for the treatment of agitation. However, ECS signaling may interact with AD-related changes in brain cholesterol metabolism. Elevated brain cholesterol, reflected by reduced serum 24-S-hydroxycholesterol (24S-OHC), is associated with reduced membrane fluidity, preventing ligand binding to cannabinoid receptor 1. Objective: To assess whether 24S-OHC was associated with agitation severity and response to nabilone. Methods: 24S-OHC was collected from AD patients enrolled in a clinical trial on nabilone at the start and end of each phase. This allowed for the cross-sectional and longitudinal investigation between 24S-OHC and agitation (Cohen Mansfield Agitation Inventory, CMAI). Post-hoc analyses included adjustments for baseline standardized Mini-Mental Status Exam (sMMSE), and analyses with CMAI subtotals consistent with the International Psychogeriatric Association (IPA) definition for agitation (physical aggression and nonaggression, and verbal aggression). Results: 24S-OHC was not associated with CMAI scores cross-sectionally or longitudinally, before and after adjusting for baseline sMMSE. However, 24S-OHC was associated with greater CMAI IPA scores at baseline (F(1,36) = 4.95, p = 0.03). In the placebo phase only, lower 24S-OHC at baseline was associated with increases in CMAI IPA scores (b = –35.2, 95% CI –65.6 to –5.0, p = 0.02), and decreases in 24S-OHC were associated with increases in CMAI IPA scores (b = –20.94, 95% CI –57.9 to –4.01, p = 0.03). Conclusion: 24S-OHC was associated with agitation severity cross-sectionally, and longitudinally in patients with AD. However, 24S-OHC did not predict treatment response, and does not change over time with nabilone.
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Affiliation(s)
- Myuri Ruthirakuhan
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Nathan Herrmann
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada.,Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Ana C Andreazza
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | | | - Damien Gallagher
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Sandra E Black
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Department of Medicine (Neurology), University of Toronto and Sunnybrook HSC, Toronto, ON, Canada
| | - Alex Kiss
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Department of Research Design and Biostatistics, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Krista L Lanctôt
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada.,Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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7
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Herrmann N, Ruthirakuhan M, Gallagher D, Verhoeff NPLG, Kiss A, Black SE, Lanctôt KL. Randomized Placebo-Controlled Trial of Nabilone for Agitation in Alzheimer's Disease. Am J Geriatr Psychiatry 2019; 27:1161-1173. [PMID: 31182351 DOI: 10.1016/j.jagp.2019.05.002] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 05/02/2019] [Accepted: 05/03/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To investigate the efficacy and safety of nabilone for agitation in patients with moderate-to-severe Alzheimer's disease (AD). DESIGN This 14-week randomized double-blind crossover trial compared nabilone to placebo (6 weeks each) with a 1-week washout between phases. SETTING Patients were recruited from a long-term care facility and geriatric psychiatry clinics. PARTICIPANTS Patients had AD (standardized Mini-Mental State Examination [sMMSE ≤24]) and agitation (Neuropsychiatric Inventory-Nursing Home version [NPI-NH]-agitation/aggression subscore ≥3). INTERVENTION Nabilone (target 1-2 mg) versus placebo. MEASUREMENTS The primary outcome was agitation (Cohen Mansfield Agitation Inventory [CMAI]). Secondary outcomes included NPI-NH total, NPI-NH caregiver distress, cognition (sMMSE and Severe Impairment Battery [SIB] or Alzheimer's Disease Assessment Scale of Cognition), global impression (Clinician's Global Impression of Change [CGIC]), and adverse events. RESULTS Thirty-nine patients (mean ± SD age = 87 ± 10, sMMSE = 6.5 ± 6.8, CMAI = 67.9 ± 17.6, NPI-NH total = 34.3 ± 15.8, 77% male, nabilone dose = 1.6 ± 0.5 mg) were randomized. There were no crossover or treatment-order effects. Using a linear mixed model, treatment differences (95% CI) in CMAI (b = -4.0 [-6.5 to -1.5], t(30.2) = -3.3, p = 0.003), NPI-NH total (b = -4.6 [-7.5 to -1.6], t(32.9) = -3.1, p = 0.004), NPI-NH caregiver distress (b = -1.7 [-3.4 to -0.07, t(33.7) = -2.1, p = 0.041), and sMMSE (b = 1.1 [0.1-2.0], t(22.6) = 2.4, p = 0.026) all favored nabilone. However, in those who completed the SIB (n = 25) treatment differences favored placebo (b = -4.6 [-7.3 to -1.8], t(20.7) = -4.8, p = 0.003). CGIC improvement during nabilone (47%) and placebo (23%) was not significantly different (McNemar's test, exact p = 0.09). There was more sedation during nabilone (45%) compared to placebo (16%) phases (McNemar's test, exact p = 0.02), but treatment-limiting sedation was not significantly different (McNemar's test, exact p = 0.22). CONCLUSIONS Nabilone may be an effective treatment for agitation. However, sedation and cognition should be closely monitored.
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Affiliation(s)
- Nathan Herrmann
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Myuri Ruthirakuhan
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Damien Gallagher
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Alex Kiss
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Sandra E Black
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Krista L Lanctôt
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada.
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8
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Current Agents in Development for Treating Behavioral and Psychological Symptoms Associated with Dementia. Drugs Aging 2019; 36:589-605. [PMID: 30957198 DOI: 10.1007/s40266-019-00668-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Behavioral and psychological symptoms associated with dementia are highly prevalent and are associated with an increased risk of institutionalization and mortality. Current pharmacological treatments for these symptoms include cholinesterase inhibitors, antipsychotics, and selective serotonin reuptake inhibitors. When used for treating behavioral and psychological symptoms associated with dementia, they are associated with limited efficacy and/or serious adverse events. As such, there has been extensive research into novel agents with varying mechanisms of action targeting behavioral and psychological symptoms associated with dementia. In this article, we present the results of a comprehensive literature search and review that evaluates current agents that have completed or are currently in clinical trials for treating behavioral and psychological symptoms associated with dementia as a primary outcome. We highlight novel agents from miscellaneous drug classes, such as dextromethorphan/quinidine, bupropion/dextromethorphan, lumateperone, deudextromethorphan/quinidine, methylphenidate and scyllo-inositol, and drugs from various therapeutic classes (including atypical antipsychotics, selective serotonin reuptake inhibitors, and cannabinoids) that have demonstrated promising results and were generally well tolerated. Future research with large appropriately powered studies using validated outcome measures for behavioral and psychological symptoms associated with dementia should be conducted to further establish the clinical utility of these agents.
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9
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Investigating the safety and efficacy of nabilone for the treatment of agitation in patients with moderate-to-severe Alzheimer's disease: Study protocol for a cross-over randomized controlled trial. Contemp Clin Trials Commun 2019; 15:100385. [PMID: 31338476 PMCID: PMC6627000 DOI: 10.1016/j.conctc.2019.100385] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 05/03/2019] [Accepted: 05/22/2019] [Indexed: 12/14/2022] Open
Abstract
Agitation is a prevalent and difficult-to-treat symptom in patients with moderate-to-severe Alzheimer's disease (AD). Though there are nonpharmacological and pharmacological interventions recommended for the treatment of agitation, the efficacy of these are modest and not always consistent. Furthermore, the safety profiles of currently prescribed medications are questionable. Nabilone, a synthetic cannabinoid, has a distinct pharmacological profile that may provide a safer and more effective treatment for agitation, while potentially having benefits for weight and pain. Additionally, emerging evidence suggests nabilone may have neuroprotective effects. We describe a clinical trial investigating the safety and efficacy of nabilone for the treatment of agitation in patients with moderate-to-severe AD. This will be a double-blind, randomized cross-over study comparing 6 weeks of nabilone (0.5-2 mg) and placebo, with a 1-week washout preceding each phase. Study outcomes will be measured at baseline and end of treatment for each treatment phase. The primary outcome measure will be agitation as assessed by the Cohen-Mansfield Agitation Inventory. The secondary outcomes include safety, behaviour (Neuropsychiatric Inventory), cognition (standardized Mini Mental Status Exam and either Severe Impairment Battery or Alzheimer's disease Assessment Scale-Cognitive subscale) and global impression (Clinician's Global Impression of Change). Exploratory outcomes include pain (Pain Assessment in Advanced AD), nutritional status (Mini-Nutritional Assessment-Short Form), caregiver distress (NPI caregiver distress), and blood-based biomarkers. A safe and efficacious pharmacological intervention for agitation, with effects on pain and weight loss in patients with moderate-to-severe AD could increase quality-of-life, reduce caregiver stress and avoid unnecessary institutionalization and related increases in health care costs. Clinical trials number NCT02351882.
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Key Words
- AD, Alzheimer's disease
- Agitation
- Alzheimer's disease
- CB, cannabinoids
- CB1, cannabinoid receptor 1
- CB2, cannabinoid receptor 2
- CGIC, Clinician's Global Impression of Change
- CMAI, Cohen Mansfield Agitation Inventory
- Cannabinoid
- Clinical trial
- EC50, half maximal effective concentration
- FDA, Food and Drug Administration
- IPA, International Psychogeriatric Association
- LTC, long-term care
- MAR, Medication Administration Record
- MNA-SF, Mini-Nutritional Assessment-Short form
- NPI-NH, Neuropsychiatric Inventory-Nursing home version
- NPS, neuropsychiatric symptoms
- Neuropsychiatric symptoms
- PAINAD, Pain Assessment in Advanced AD
- RCT, randomized controlled trial
- SIB, Severe Impairment Battery
- THC, tetrahydrocannabinol
- sMMSE, standardized Mini-Mental Status Examination
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Balta G, Dalla C, Kokras N. Women's Psychiatry. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2019; 1192:225-249. [PMID: 31705497 DOI: 10.1007/978-981-32-9721-0_11] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Brain disorders and mental diseases, in particular, are common and considered as a top global health challenge for the twenty-first century. Interestingly, women suffer more frequently from mental disorders than men. Moreover, women may respond to psychotropic drugs differently than men, and, through their lifespan, they endure sex-orientated social stressors. In this chapter, we present how women may differ in the development and manifestation of mental health issues and how they differ from men in pharmacokinetics and pharmacodynamics. We discuss issues in clinical trials regarding women participation, issues in the use of psychotropic medications in pregnancy, and challenges that psychiatry faces as a result of the wider use of contraceptives, of childbearing at older age, and of menopause. Such issues, among others, demand further women-oriented psychiatric research that can improve the care for women during the course of their lives. Indeed, despite all these known sex differences, psychiatry for both men and women patients uses the same approach. Thereby, a modified paradigm for women's psychiatry, which takes into account all these differences, emerges as a necessity, and psychiatric research should take more vigorously into account sex differences.
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Affiliation(s)
- Georgia Balta
- Department of Pharmacology, Medical School, National and Kapodistrian University of Athens, Mikras Asias 75, Goudi, 11527, Athens, Greece
| | - Christina Dalla
- Department of Pharmacology, Medical School, National and Kapodistrian University of Athens, Mikras Asias 75, Goudi, 11527, Athens, Greece
| | - Nikolaos Kokras
- Department of Pharmacology, Medical School, National and Kapodistrian University of Athens, Mikras Asias 75, Goudi, 11527, Athens, Greece. .,First Department of Psychiatry, Eginition Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece.
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Ruthirakuhan M, Lanctôt KL, Di Scipio M, Ahmed M, Herrmann N. Biomarkers of agitation and aggression in Alzheimer's disease: A systematic review. Alzheimers Dement 2018; 14:1344-1376. [DOI: 10.1016/j.jalz.2018.04.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 04/12/2018] [Accepted: 04/26/2018] [Indexed: 01/24/2023]
Affiliation(s)
- Myuri Ruthirakuhan
- Hurvitz Brain Sciences ProgramSunnybrook Research InstituteTorontoONCanada
- Department of Pharmacology and ToxicologyUniversity of TorontoTorontoONCanada
| | - Krista L. Lanctôt
- Hurvitz Brain Sciences ProgramSunnybrook Research InstituteTorontoONCanada
- Department of Pharmacology and ToxicologyUniversity of TorontoTorontoONCanada
- Geriatric PsychiatrySunnybrook Health Sciences CentreTorontoONCanada
- Department of PsychiatryUniversity of TorontoTorontoONCanada
| | - Matteo Di Scipio
- Hurvitz Brain Sciences ProgramSunnybrook Research InstituteTorontoONCanada
| | - Mehnaz Ahmed
- Hurvitz Brain Sciences ProgramSunnybrook Research InstituteTorontoONCanada
- Department of Pharmacology and ToxicologyUniversity of TorontoTorontoONCanada
| | - Nathan Herrmann
- Hurvitz Brain Sciences ProgramSunnybrook Research InstituteTorontoONCanada
- Geriatric PsychiatrySunnybrook Health Sciences CentreTorontoONCanada
- Department of PsychiatryUniversity of TorontoTorontoONCanada
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Ruthirakuhan MT, Herrmann N, Abraham EH, Chan S, Lanctôt KL. Pharmacological interventions for apathy in Alzheimer's disease. Cochrane Database Syst Rev 2018; 5:CD012197. [PMID: 29727467 PMCID: PMC6494556 DOI: 10.1002/14651858.cd012197.pub2] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Despite the high prevalence of apathy in Alzheimer's disease (AD), and its harmful effects, there are currently no therapies proven to treat this symptom. Recently, a number of pharmacological therapies have been investigated as potential treatments for apathy in AD. OBJECTIVES Objective 1: To assess the safety and efficacy of pharmacotherapies for the treatment of apathy in Alzheimer's disease (AD).Objective 2: To assess the effect on apathy of pharmacotherapies investigated for other primary outcomes in the treatment of AD. SEARCH METHODS We searched the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (ALOIS), MEDLINE, Embase, CINAHL, PsycINFO, LILACS, ClinicalTrials.gov and the World Health Organization (WHO) portal, ICTRP on 17 May 2017. SELECTION CRITERIA Eligible studies were double-blind, randomized, placebo-controlled trials (RCTs) investigating apathy as a primary or secondary outcome in people with AD. DATA COLLECTION AND ANALYSIS Three review authors extracted data. We assessed the risks of bias of included studies using Cochrane methods, and the overall quality of evidence for each outcome using GRADE methods. We calculated mean difference (MD), standardized mean difference (SMD) or risk ratio (RR) with 95% confidence intervals on an intention-to-treat basis for all relevant outcome measures. MAIN RESULTS We included 21 studies involving a total of 6384 participants in the quantitative analyses. Risk of bias is very low to moderate. All studies reported appropriate methods of randomization and blinding. Most studies reported appropriate methods of allocation concealment. Four studies, three with methylphenidate and one with modafinil, had a primary aim of improving apathy. In these studies, all participants had clinically significant apathy at baseline. Methylphenidate may improve apathy compared to placebo. This finding was present when apathy was assessed using the apathy evaluation scale (AES), which was used by all three studies investigating methylphenidate: MD -4.99, 95% CI -9.55 to -0.43, n = 145, 3 studies, low quality of evidence, but not when assessed with the neuropsychiatric inventory (NPI)-apathy subscale, which was used by two of the three studies investigating methylphenidate: MD -0.08, 95% CI -3.85 to 3.69, n = 85, 2 studies, low quality of evidence. As well as having potential benefits for apathy, methylphenidate probably also slightly improves cognition (MD 1.98, 95% CI 1.06 to 2.91, n = 145, 3 studies, moderate quality of evidence), and probably improves instrumental activities of daily living (MD 2.30, 95% CI 0.74 to 3.86, P = 0.004, n = 60, 1 study, moderate quality of evidence), compared to placebo. There may be no difference between methylphenidate and placebo in the risk of developing an adverse event: RR 1.28, 95% CI 0.67 to 2.42, n = 145, 3 studies, low quality of evidence. There was insufficient evidence from one very small study of modafinil to determine the effect of modafinil on apathy assessed with the FrSBe-apathy subscale: MD 0.27, 95% CI -3.51 to 4.05, n = 22, 1 study, low quality of evidence. In all other included studies, apathy was a secondary outcome and participants were not selected on the basis of clinically significant apathy at baseline. We considered the evidence on apathy from these studies to be indirect and associated with publication bias. There was low or very low quality of evidence on cholinesterase inhibitors (ChEIs) (six studies), ChEI discontinuation (one study), antipsychotics (two studies), antipsychotic discontinuation (one study), antidepressants (two studies), mibampator (one study), valproate (three studies) and semagacestat (one study). AUTHORS' CONCLUSIONS Methylphenidate may demonstrate a benefit for apathy and may have slight benefits for cognition and functional performance in people with AD, but this finding is associated with low-quality evidence. Our meta-analysis is limited by the small number of studies within each drug class, risk of bias, publication bias, imprecision and inconsistency between studies. Additional studies should be encouraged targeting people with AD with clinically significant apathy which investigate apathy as a primary outcome measure, and which have a longer duration and a larger sample size. This could increase the quality of evidence for methylphenidate, and may confirm whether or not it is an effective pharmacotherapy for apathy in AD.
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Affiliation(s)
- Myuri T Ruthirakuhan
- Sunnybrook Research InstituteHurvitz Brain Sciences Research Program2075 Bayview AvenueTorontoONCanadaM4N 3M5
- University of TorontoDepartment of Pharmacology and Toxicology2075 Bayview AvenueTorontoCanada
| | - Nathan Herrmann
- Sunnybrook Research InstituteHurvitz Brain Sciences Research Program2075 Bayview AvenueTorontoONCanadaM4N 3M5
- University of TorontoDepartment of Psychiatry2075 Bayview Avenue, Room H‐185TorontoONCanada
- Sunnybrook Health Sciences CentreGeriatric PsychiatryTorontoCanada
| | - Eleenor H Abraham
- Sunnybrook Research InstituteHurvitz Brain Sciences Research Program2075 Bayview AvenueTorontoONCanadaM4N 3M5
| | - Sarah Chan
- Sunnybrook Health Sciences CentreNeuropsychopharmacology Research Group2075 Bayview AvenueTorontoCanadaM4N 3M5
| | - Krista L Lanctôt
- Sunnybrook Research InstituteHurvitz Brain Sciences Research Program2075 Bayview AvenueTorontoONCanadaM4N 3M5
- University of TorontoDepartment of Pharmacology and Toxicology2075 Bayview AvenueTorontoCanada
- University of TorontoDepartment of Psychiatry2075 Bayview Avenue, Room H‐185TorontoONCanada
- Sunnybrook Health Sciences CentreGeriatric PsychiatryTorontoCanada
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Liu KY, Stringer AE, Reeves SJ, Howard RJ. The neurochemistry of agitation in Alzheimer's disease: a systematic review. Ageing Res Rev 2018. [PMID: 29524596 DOI: 10.1016/j.arr.2018.03.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To provide an up-to-date systematic review of the characteristics, methodology and findings of studies that have investigated the neurochemistry of agitation in Alzheimer's disease (AD). METHODS Electronic databases were searched for published peer-reviewed articles which provided data on any neurotransmitter system in relation to agitation in AD. Screening of titles and abstracts and data extraction from full texts were conducted in duplicate. RESULTS Forty-five studies were included. Monoamines (serotonin, dopamine and noradrenaline) were most commonly investigated. A variety of methods were used to investigate the neurochemistry underlying agitation in AD and, although there were several conflicting findings, there was evidence of serotonergic deficit, relatively preserved dopaminergic function and compensatory overactivity of postsynaptic noradrenergic neurons in agitation in AD. CONCLUSIONS Disruption of the dynamic balance between multiple neurotransmitter systems could impair functional neural networks involved in affective regulation and executive function. Differences in study design and methodology may have contributed to conflicting findings. Future studies that overcome these limitations (e.g. using standardized criteria to define agitation) and employ neuroimaging methods such as MRI/PET to investigate specific neural networks are needed to clarify the role of neurotransmitter alterations in these patients.
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Affiliation(s)
- Kathy Y Liu
- Division of Psychiatry, University College London, UK.
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Abstract
BACKGROUND New onset of mood and behavioral changes in middle-aged patients are frequently the first manifestations of an unrecognized neurocognitive disorder. Impairment of social cognition, the cognitive ability to process social information coming from others, such as emotions, to attribute mental states to others, and to respond appropriately to them, is often at the origin of behavioral manifestations in neurodegenerative disorders. METHODS This paper reviews the current literature on social cognition impairment in neurocognitive disorders, particularly in prodromal stages of behavioral-variant frontotemporal dementia (bvFTD), Alzheimer's disease (AD), idiopathic Parkinson's disease (IPD), and Lewy body dementia (LBD). The concepts of social cognition will be reviewed, including its impairment and neural basis, its clinical assessment, and the different therapeutic interventions available clinically. RESULTS Socially inappropriate behaviors, such as loss of empathy, inappropriateness of affect, and disinhibition are frequently reported in prodromal bvFTD and in prodromal AD. Lack of self-control, reduced perception of social cues, such as recognition of facial emotions and sarcastic speech, and impaired Theory of Mind all contribute to the neuropsychiatric symptoms and are secondary to neurodegeneration in specific brain regions. In contrasts to bvFTD and AD, deficits in social cognition in IPD occur later in the course of the disease and are often multifactorial in origin. CONCLUSIONS Through various manifestations, social inappropriateness is frequently the first clinical sign of a neurodegenerative process, especially in AD and bvFTD, years before noticeable impairment on classical neuropsychological assessment and brain atrophy on imaging.
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Abstract
Women are more likely than men to experience depression throughout the life span. Sex differences in neurochemistry and brain structure, as well as societal factors may contribute to women's increased likelihood of depression. Pharmacological research targeting depression has historically excluded women, leading to a knowledge gap regarding effective antidepressant treatment in women. Antidepressant pharmacokinetics and pharmacodynamics are clearly different in men and women, necessitating a thoughtful approach to their prescription and management. Hormone changes associated with the menstrual cycle, pregnancy, and menopause also contribute to differences in depression and effective antidepressant use in women. Finally, it is important to consider potential interactions between antidepressant drugs and medications specifically used by women (oral contraceptives, tamoxifen, and estrogen).
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Affiliation(s)
- Christina Bourne
- Department of Psychiatry and Behavioral Sciences, Department of Family Medicine, University of California Davis, Sacramento, CA, USA
| | - Laura Kenkel
- Department of Psychiatry and Behavioral Sciences, University of California Davis, Sacramento, CA, USA.
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Farina N, Morrell L, Banerjee S. What is the therapeutic value of antidepressants in dementia? A narrative review. Int J Geriatr Psychiatry 2017; 32:32-49. [PMID: 27593707 DOI: 10.1002/gps.4566] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 07/17/2016] [Accepted: 07/26/2016] [Indexed: 11/09/2022]
Abstract
OBJECTIVES Antidepressants are commonly used in dementia. Depression is a frequent and important co-morbidity in dementia, and antidepressants are often used to treat depression and more widely. However, there are questions about their utility in depression in dementia and other behavioural and psychological symptoms of dementia. The aim of this narrative review is to summarize the evidence on whether there is therapeutic value in prescribing antidepressants to people with dementia. METHODS A PubMed search was performed to identify randomized controlled trials that prescribed antidepressants to people with dementia, either in the treatment of behavioural and psychological symptoms of dementia (depression, anxiety, agitation/aggression, psychosis and apathy) or for secondary outcomes (quality of life, carer burden, activities of daily living, cognition, clinical severity and adverse events). RESULTS Thirty-six randomized controlled trials were identified (participant n = 3386). A consistent finding in well-designed blinded placebo controlled trials in dementia is the lack of positive effect of antidepressants on outcomes of interest, including depression. One large well-designed study has reported a significant reduction in agitation in people with dementia, but at the expense of clinically significant adverse events. Otherwise, change observed in open trials is also seen in the placebo group, suggesting that any effect is not attributable to the prescription of antidepressants. CONCLUSIONS It is striking how few data there are on indications other than depression. We should question the use of antidepressants in dementia. Definitive trials of clinical effectiveness of specific indications such as anxiety and agitation in dementia and discontinuation of antidepressants in dementia are needed. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Nicolas Farina
- Centre for Dementia Studies, Brighton and Sussex Medical School, Brighton, UK
| | - Lucy Morrell
- Centre for Dementia Studies, Brighton and Sussex Medical School, Brighton, UK
| | - Sube Banerjee
- Centre for Dementia Studies, Brighton and Sussex Medical School, Brighton, UK
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Magierski R, Sobow T. Serotonergic drugs for the treatment of neuropsychiatric symptoms in dementia. Expert Rev Neurother 2016; 16:375-87. [PMID: 26886148 DOI: 10.1586/14737175.2016.1155453] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Behavioral and psychological symptoms of dementia (known also as neuropsychiatric symptoms) are essential features of Alzheimer's disease and related dementias. The near universal presence of neuropsychiatric symptoms in dementia (up to 90% of cases) has brought significant attention of clinicians and experts to the field. Non-pharmacological and pharmacological interventions are recommended for various types of neuropsychiatric symptoms. However, most pharmacological interventions for the treatment of behavioral and psychological symptoms of dementia are used off-label in many countries. Cognitive decline and neuropsychiatric symptoms can be linked to alterations in multiple neurotransmitter systems, so modification of abnormalities in specific systems may improve clinical status of patients with neuropsychiatric symptoms. Use of serotonergic compounds (novel particles acting on specific receptors and widely acting drugs) in the treatment of neuropsychiatric symptoms is reviewed.
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Affiliation(s)
- Radoslaw Magierski
- a Department of Old Age Psychiatry and Psychotic Disorders , Medical University of Lodz , Lodz , Poland
| | - Tomasz Sobow
- b Department of Medical Psychology , Medical University of Lodz , Lodz , Poland
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Buterbaugh WM, Jamrose T, Lazzara J, Honaker L, Thomas CJ. Review of antidepressants in the treatment of behavioral and psychiatric symptoms in dementia (BPSD). Ment Health Clin 2014. [DOI: 10.9740/mhc.n204508] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Behavioral disturbances are commonplace among patients with dementia. Management of these symptoms has proved difficult.1,2 Currently, there are no FDA approved pharmacologic treatments for the treatment of BPSD.3 Traditionally, atypical antipsychotics have been used to treat behavioral disturbances despite modest efficacy and undesirable adverse effects.34,5 Because of the increase in mortality, there is a continued push to reduce antipsychotic utilization in this population.9,10 Thus, many clinicians are using alternative agents such as antidepressants and mood stabilizers to help treat BPSD, while avoiding using antipsychotics. The goal of this review is to review, analyze, and discuss the current literature available on the use of antidepressants to treat BPSD.
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Association between behavioral and psychological symptoms and psychotropic drug use among old people with cognitive impairment living in geriatric care settings. Int Psychogeriatr 2013; 25:1415-23. [PMID: 23782794 DOI: 10.1017/s1041610213000859] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Behavioral and psychological symptoms are common among cognitively impaired individuals and psychotropic drugs are widely used for their treatment. The aim of this study was to describe the prevalence and associated factors of psychotropic and anti-dementia drug use among old people with cognitive impairment living in geriatric care settings. METHODS The study comprised 2,019 cognitively impaired people living in geriatric care units in the county of Västerbotten, Sweden. Data concerning psychotropic and anti-dementia drug use, function in activities of daily living, cognitive function, and prevalence of behavioral and psychological symptoms were collected, using the Multi-Dimensional Dementia Assessment Scale. RESULTS Of the study population, 1,442 individuals (71%) were prescribed at least one psychotropic drug (antidepressants (49%), anxiolytics, hypnotics, and sedatives (36%), antipsychotics (25%)). Furthermore, 363 individuals (18%) received anti-dementia drugs. Associations between various behavioral and psychological symptoms were found for all psychotropic drug classes and anti-dementia drugs. Verbally disruptive/attention-seeking behavior was associated with all psychotropic drugs. Use of antipsychotics was associated with several behavioral and psychological symptoms, including aggressive behavior. CONCLUSION The associations between behavioral and psychological symptoms and psychotropic drug use found in this study indicate that these drugs are prescribed to treat behavioral and psychological symptoms among cognitively impaired individuals despite limited evidence of their efficacy. Given the significant risk of adverse effects among old people with cognitive impairment, it is important to ensure that any medication used is both appropriate and safe.
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Gustafsson M, Karlsson S, Lövheim H. Inappropriate long-term use of antipsychotic drugs is common among people with dementia living in specialized care units. BMC Pharmacol Toxicol 2013; 14:10. [PMID: 23391323 PMCID: PMC3575309 DOI: 10.1186/2050-6511-14-10] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2012] [Accepted: 02/04/2013] [Indexed: 01/12/2023] Open
Abstract
Background Antipsychotic drugs are widely used for the treatment of Behavioral and Psychological Symptoms of Dementia (BPSD), despite their limited efficacy and concerns about safety. The aim of this study was to describe antipsychotic drug therapy among people with dementia living in specialized care units in northern Sweden. Methods This study was conducted in 40 specialized care units in northern Sweden, with a total study population of 344 people with dementia. The study population was described in regard to antipsychotic drug use, ADL function, cognitive function and BPSD, using the Multi-Dimensional Dementia Assessment Scale (MDDAS). These data were collected at baseline and six months later. Detailed data about antipsychotic prescribing were collected from prescription records. Results This study showed that 132 persons (38%) in the study population used antipsychotic drugs at the start of the study. Of these, 52/132 (39%) had prescriptions that followed national guidelines with regard to dose and substance. After six months, there were 111 of 132 persons left because of deaths and dropouts. Of these 111 people, 80 (72%) were still being treated with antipsychotics, 63/111 (57%) with the same dose. People who exhibited aggressive behavior (OR: 1.980, CI: 1.515-2.588), or passiveness (OR: 1.548, CI: 1.150-2.083), or had mild cognitive impairment (OR: 2.284 CI: 1.046-4.988), were at increased risk of being prescribed antipsychotics. Conclusion The prevalence of antipsychotic drug use among people with dementia living in specialized care units was high and inappropriate long-term use of antipsychotic drugs was common.
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Affiliation(s)
- Maria Gustafsson
- Maria Gustafsson, Department of Pharmacology and Clinical Neuroscience, Umeå University, 901 85, Umeå, Sweden.
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Serotonergic function and treatment of behavioral and psychological symptoms of frontotemporal dementia. Am J Geriatr Psychiatry 2012; 20:789-97. [PMID: 21878805 DOI: 10.1097/jgp.0b013e31823033f3] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVES The purposes of this study were first, to evaluate the effectiveness of citalopram in treating behavioral disturbances in frontotemporal dementia (FTD) subjects and second, to determine whether an association exists between serotonergic function, as determined by a neuroendocrine challenge, and treatment response. DESIGN Single-dose citalopram (30 mg per os) challenge followed by a 6-week open-label study. SETTING Outpatients referred to memory clinics. PARTICIPANTS Fifteen patients suffering from FTD with severe behavioral and psychological symptoms of dementia. INTERVENTION Following citalopram challenge, all patients were treated with citalopram titrated to a target dose of 40 mg once daily. MEASUREMENTS Behavioral disturbances, using the Neuropsychiatric Inventory (NPI) (primary outcome) and Frontal Behavioural Inventory (secondary outcome), were assessed. Change in prolactin concentration following citalopram challenge was used as an index of central serotonergic response. RESULTS Citalopram treatment was effective in treating behavioral symptoms, with significant decreases in NPI total score (F[2, 28] = 6.644, p = 0.004), disinhibition (F[2, 28] = 4.030, p = 0.029), irritability (F[2, 28] = 7.497, p = 0.003) and depression (F[2, 28] = 3.467, p = 0.045) scores over the 6 weeks. Significant improvement in Frontal Behavioural Inventory scores suggested that citalopram was also effective in the treatment ofbehaviors specific to FTD. A lower change score in concentration of prolactin was significantly positively correlated with greater improvement in the total NPI score from baseline to endpoint (r = 0.687, p = 0.005). A blunted response to a citalopram challenge, implying a dysfunctional serotonergic system, predicted a more positive treatment outcome. CONCLUSIONS The results suggest that despite the endogenous serotonin deficiency of FTD, citalopram treatment may be effective in targeting the behavioral disturbances characteristic of FTD.
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Abstract
Behavioral disturbances are frequently the most challenging manifestations of dementia and are exhibited in almost all people with dementia. Common behavioral disturbances can be grouped into four categories: mood disorders (e.g., depression, apathy, euphoria); sleep disorders (insomnia, hypersomnia, night-day reversal); psychotic symptoms (delusions and hallucinations); and agitation (e.g., pacing, wandering, sexual disinhibition, aggression). They are often persistent, greatly diminish quality of life of patients and their family caregivers, cause premature institutionalization, and pose a high economic burden on the patient, family, and society. Behavioral disturbances can be prevented and treated with a multifaceted approach that supports dignity and promotes comfort and quality of life of persons with dementia and their family members. Management involves prompt treatment of reversible factors and management of symptoms using primarily individualized nonpharmacological interventions. Pharmacological interventions need to be restricted to behavioral emergencies and for short-term treatment of behavioral disturbances that pose imminent danger to self or others.
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Affiliation(s)
- Abhilash K Desai
- Geriatric Psychiatry, Sheppard Pratt Health Systems, 6501 N Charles St, Baltimore, MD 21285, USA.
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Henry G, Williamson D, Tampi RR. Efficacy and tolerability of antidepressants in the treatment of behavioral and psychological symptoms of dementia, a literature review of evidence. Am J Alzheimers Dis Other Demen 2011; 26:169-83. [PMID: 21429956 PMCID: PMC10845558 DOI: 10.1177/1533317511402051] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The objective of this review is to summarize the current data on the use of antidepressants in the treatment of behavioral and psychological symptoms of dementia (BPSD) and to determine whether these medications can be recommended for routine clinical use. A literature search of six major databases (PubMed, Medline, PsychINFO, Scopus, Web of Science and Cochrane collaboration) trials, 8 using a selective serotonin reuptake inhibitor (SSRI) compound and 3 using trazodone showed benefit in the treatment of BPSD. The antidepressant drug was well tolerated in at least 14 of the 19 trials with information about tolerability in one trial not provided in the study (paroxetine or placebo for FTD). This review indicates that antidepressants can be an effective in the treatment of BPSD and are generally well tolerated in elderly demented patients.
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Affiliation(s)
- Genevieve Henry
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06511, USA
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Bigos KL, Pollock BG, Stankevich BA, Bies RR. Sex differences in the pharmacokinetics and pharmacodynamics of antidepressants: an updated review. ACTA ACUST UNITED AC 2010; 6:522-43. [PMID: 20114004 DOI: 10.1016/j.genm.2009.12.004] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2009] [Indexed: 01/05/2023]
Abstract
BACKGROUND An increasing number of studies have reported differences in the pharmacokinetics and/or pharmacodynamics of antidepressants between women and men. OBJECTIVES This article updates previously published literature describing sex differences in the pharmacokinetics and pharmacodynamics of antidepressants, and examines specific issues that face women with psychiatric illness. METHODS An English-language literature search was performed with the PubMed database (March 2003-December 2008) using combinations of the search terms sex, gender, and antidepressants. In addition, each antidepressant was identified in the 63rd edition of the Physicians' Desk Reference. RESULTS The current data suggest that the pharmacokinetics of antidepressants can be substantially different between women and men. Likewise, the response to antidepressants can be quite variable, including sex differences in adverse effects and time to response. CONCLUSIONS Despite the many sex differences reported, there is still little published work systematically evaluating potential sex differences in antidepressant pharmacokinetics and pharmacodynamics. More research is needed to guide the treatment of depression and other mental illnesses.
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Affiliation(s)
- Kristin L Bigos
- Clinical Brain Disorders Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland 20892, USA.
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Abstract
Alzheimer's disease (AD) is a complex progressive brain degenerative disorder that has effects on multiple cerebral systems. In addition to cognitive and functional decline, diverse behavioral changes manifest with increasing severity over time, presenting significant management challenges for caregivers and health care professionals. Almost all patients with AD are affected by neuropsychiatric symptoms at some point during their illness; in some cases, symptoms occur prior to diagnosis of the dementia syndrome. Further, behavioral factors have been identified, which may have their origins in particular neurobiological processes, and respond to particular management strategies. Improved clarification of causes, triggers, and presentation of neuropsychiatric symptoms will guide both research and clinical decision-making. Measurement of neuropsychiatric symptoms in AD is most commonly by means of the Neuropsychiatric Inventory; its utility and future development are discussed, as are the limitations and difficulties encountered when quantifying behavioral responses in clinical trials. Evidence from clinical trials of both non-pharmacological and pharmacological treatments, and from neurobiological studies, provides a range of management options that can be tailored to individual needs. We suggest that non-pharmacological interventions (including psychosocial/psychological counseling, interpersonal management and environmental management) should be attempted first, followed by the least harmful medication for the shortest time possible. Pharmacological treatment options, such as antipsychotics, antidepressants, anticonvulsants, cholinesterase inhibitors and memantine, need careful consideration of the benefits and limitations of each drug class.
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Are cholinesterase inhibitors effective in the management of the behavioral and psychological symptoms of dementia in Alzheimer's disease? A systematic review of randomized, placebo-controlled trials of donepezil, rivastigmine and galantamine. Int Psychogeriatr 2009; 21:813-24. [PMID: 19538824 DOI: 10.1017/s1041610209990354] [Citation(s) in RCA: 153] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The study aim was to conduct a systematic review of the evidence from randomized, placebo controlled trials related to the efficacy of donepezil, rivastigmine and galantamine in the treatment of behavioral and psychological symptoms of Alzheimer's disease. METHODS Electronic database searches of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials were carried out using multiple search terms. Articles included were original publications of randomized, placebo-controlled trials of monotherapy of donepezil, rivastigmine or galantamine that reported a behavioral outcome measure. RESULTS 14 studies were identified that matched inclusion criteria. Nine were of donepezil, three of galantamine and two of rivastigmine. Median study treatment length was 24 weeks (range 12-170). Most studies used the Neuropsychiatric Inventory as a behavioral outcome measure although three used specific scales for either agitation or apathy. Four studies were specifically designed to assess behavioral outcomes whilst in the majority of studies behavioral outcomes were only secondary measures. Three studies found statistically significant, albeit modest, differences in the change of NPI total score between drug and placebo. The interpretation of the results of many studies is limited by methodological considerations, including generally low NPI scores at baseline and the investigation of behavioral and psychological symptoms of dementia (BPSD) as secondary outcomes. CONCLUSIONS The evidence base regarding the efficacy of cholinesterase inhibitors in BPSD is limited, in part due to methodological considerations. In the absence of alternative safe and effective management options, the use of cholinesterase inhibitors is an appropriate pharmacological strategy for the management of BPSD in Alzheimer's disease.
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Abstract
BACKGROUND Apathy is a deficiency in overt behavioural, emotional and cognitive components of goal-directed behaviour. It is a common occurrence after traumatic brain injury (TBI), with widespread impact. We have systematically reviewed studies examining the effectiveness of interventions for apathy in the TBI population. OBJECTIVES To investigate the effectiveness of interventions for apathy in adults who have sustained a TBI. This was evaluated by changes in behavioural, cognitive and emotional measures of apathy. SEARCH STRATEGY We searched the following databases up to January 2008: CENTRAL (The Cochrane Library 2008, Issue 1), Database of Abstracts of Reviews of Effects, ACP Journal Club, MEDLINE (1950 to Jan 2008), EMBASE (1980 to Jan 2008), PsycINFO (1806 to Jan 2008), CINAHL (1982 Jan 2008), PsycBITE, AMED (1985 to Jan 2008), www.controlled-trials.com, www.clinicaltrials.gov and www.actr.org.au.The Cochrane Injuries Group's Specialised Register was searched to Jan 2009. Additionally, we examined key conference proceedings and reference lists of included trials to identify further studies meeting the inclusion criteria. SELECTION CRITERIA Randomised controlled trials (RCTs) of interventions specifically targeting apathy for people with TBI. DATA COLLECTION AND ANALYSIS Two authors (ALB and RLT) independently assessed studies for inclusion. We rated the methodological quality of included studies and extracted data. MAIN RESULTS We identified one trial that satisfied the inclusion criteria for this review. This trial (N = 21) showed that cranial electrotherapy stimulation (CES) decreased inertia, which is a component of apathy, while no changes were seen in the sham treatment or no treatment control groups. Given that no between-group analysis was reported, it was not possible to determine if the CES treatment group improved significantly more than the control group. AUTHORS' CONCLUSIONS No evidence was provided to support the use of CES treatment for inertia, a component of apathy. Between-group statistical analyses were not conducted and it was therefore not possible to determine the efficacy of the treatment relative to no treatment or sham treatment. Results regarding the effectiveness of treatment can only be inferred, and this evidence is based on only one trial with a small sample size. More randomised controlled trials evaluating different ways of treating apathy would be valuable. Trials should have larger sample sizes and use rigorous research designs and statistical analyses appropriate for examining between-group differences.
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Affiliation(s)
- Amanda Lane-Brown
- Rehabilitation Studies Unit, University of Sydney and Royal Rehabilitation Centre Sydney, P.O. Box 6, Ryde, New South Wales, Australia, 1680.
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Passmore MJ, Gardner DM, Polak Y, Rabheru K. Alternatives to atypical antipsychotics for the management of dementia-related agitation. Drugs Aging 2008; 25:381-98. [PMID: 18447403 DOI: 10.2165/00002512-200825050-00003] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Numerous recent studies have challenged the widely held belief that atypical antipsychotics are safe and effective options for the treatment of behavioural problems such as agitation in patients with dementia. Accordingly, there is a need to reconsider the place of atypical antipsychotics in the treatment of patients with dementia. The present article is intended to assist clinicians with the assessment and pharmacological management of agitation in patients with dementia. We review the risk-benefit evidence for the use of atypical antipsychotics in patients with dementia-related agitation (DRA). Emerging evidence indicates that, for patients with dementia, the risks associated with atypical antipsychotics may outweigh the benefits except for patients with severe agitation who require short-term chemical restraint. We then discuss the importance of a careful assessment to rule out potentially reversible factors contributing to DRA. Finally, we summarize the evidence supporting the use of medications other than antipsychotics to treat DRA. There is wide variability in the levels of evidence supporting the use of non-antipsychotic medication for the treatment of DRA. The best evidence currently exists for cholinesterase inhibitors and serotonin-specific reuptake inhibitor antidepressants. Emerging reports suggest that numerous other medications, for example, antiepileptics, lithium, anxiolytics, analgesics, beta-adrenoceptor antagonists, cannabinoid receptor agonists and hormonal agents, may prove to be viable alternatives to antipsychotics for the treatment of severe DRA and more research is urgently needed to help assess the effectiveness of these agents. A comprehensive biopsychosocial assessment and treatment plan is likely the most effective way to manage DRA.
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Affiliation(s)
- Michael J Passmore
- Department of Psychiatry, Division of Geriatric Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada.
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Omerovic M, Hampel H, Teipel SJ, Buerger K. Pharmacological treatment of Alzheimer's dementia: state of the art and current dilemmas. World J Biol Psychiatry 2008; 9:69-75. [PMID: 17886162 DOI: 10.1080/15622970701568412] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Alzheimer's disease (AD) is one of the most frequent disorders of the central nervous system characterised by a progressive cognitive decline. The demographic changes of our aging population lead to increased numbers of patients and a need of early diagnosis and treatment of cognitive and behavioural symptoms of AD. Drugs are available for symptomatic treatment of AD. The pharmacological treatment of behavioural disturbances experienced dynamic changes in the last years. In this paper, we present the current state and future perspectives in the treatment of AD. Furthermore, we discuss current difficulties regarding AD treatment by looking for explanations for a still unsatisfying rate of state-of-the-art treatment of AD-patients.
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Affiliation(s)
- Muamer Omerovic
- Dementia Research Section and Memory Clinic, Alzheimer Memorial Center and Geriatric Psychiatry Branch, Department of Psychiatry, Ludwig-Maximilians-University, Munich, Germany
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Jeste DV, Blazer D, Casey D, Meeks T, Salzman C, Schneider L, Tariot P, Yaffe K. ACNP White Paper: update on use of antipsychotic drugs in elderly persons with dementia. Neuropsychopharmacology 2008; 33:957-70. [PMID: 17637610 PMCID: PMC2553721 DOI: 10.1038/sj.npp.1301492] [Citation(s) in RCA: 218] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
In elderly persons, antipsychotic drugs are clinically prescribed off-label for a number of disorders outside of their Food and Drug Administration (FDA)-approved indications (schizophrenia and bipolar disorder). The largest number of antipsychotic prescriptions in older adults is for behavioral disturbances associated with dementia. In April 2005, the FDA, based on a meta-analysis of 17 double-blind randomized placebo-controlled trials among elderly people with dementia, determined that atypical antipsychotics were associated with a significantly (1.6-1.7 times) greater mortality risk compared with placebo, and asked that drug manufacturers add a 'black box' warning to prescribing information for these drugs. Most deaths were due to either cardiac or infectious causes, the two most common immediate causes of death in dementia in general. Clinicians, patients, and caregivers are left with unclear choices of treatment for dementia patients with psychosis and/or severe agitation. Not only are psychosis and agitation common in persons with dementia but they also frequently cause considerable caregiver distress and hasten institutionalization of patients. At the same time, there is a paucity of evidence-based treatment alternatives to antipsychotics for this population. Thus, there is insufficient evidence to suggest that psychotropics other than antipsychotics represent an overall effective and safe, let alone better, treatment choice for psychosis or agitation in dementia; currently no such treatment has been approved by the FDA for these symptoms. Similarly, the data on the efficacy of specific psychosocial treatments in patients with dementia are limited and inconclusive. The goal of this White Paper is to review relevant issues and make clinical and research recommendations regarding the treatment of elderly dementia patients with psychosis and/or agitation. The role of shared decision making and caution in using pharmacotherapy for these patients is stressed.
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Affiliation(s)
- Dilip V Jeste
- Department of Psychiatry and Neurosciences, University of California, San Diego, CA 92161, USA.
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Herrmann N, Lanctôt KL. Pharmacologic management of neuropsychiatric symptoms of Alzheimer disease. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2007; 52:630-46. [PMID: 18020111 DOI: 10.1177/070674370705201004] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To systematically review published clinical trials of the pharmacotherapy of neuropsychiatric symptoms of Alzheimer disease (AD). METHOD We searched MEDLINE and EMBASE for published English-language medical literature. Our review focused on randomized controlled trials (RCTs) and corresponding metaanalyses. RESULTS The pharmacotherapy of neuropsychiatric symptoms of AD has been studied with numerous RCTs. The largest number of studies has focused on antipsychotics. Data are of reasonably high quality and indicate that risperidone and olanzapine are more effective than placebo for institutionalized patients with severe agitation, aggression, and psychosis. The efficacy of antipsychotics is counterbalanced by safety concerns that include cerebrovascular adverse events and mortality. Cholinesterase inhibitors and memantine appear to have modest benefits for patients with mildly to moderately severe symptoms. Antidepressants are effective for treating depression in AD, but more data are required to determine the efficacy of trazodone and citalopram for agitation and aggression. Carbamazepine appears to be efficacious, although side effects and concerns about drug-drug interactions limit its use. The data do not support the use of valproate. Benzodiazepines should only be used for short-term, as-needed use. There are insufficient data on other pharmacologic interventions, such as beta blockers, buspirone, and estrogen preparations. CONCLUSIONS Although there have been numerous well-designed studies of the pharmacotherapy of neuropsychiatric symptoms in AD, safer and more effective treatments are urgently needed.
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Abstract
Alzheimer disease is the most common cause of progressive irreversible intellectual loss in aging humans. The number of individuals and families affected by this disorder will continue to grow as society ages worldwide. Our understanding of the biology, underlying pathophysiology, and diagnosis of Alzheimer disease has greatly expanded over the past few years and much has been published in these areas. This review focuses on the primary care of this disorder and addresses the "now what" question. Topics examined include limiting excess disability, responding to commonly raised questions of family members, pharmacologic and nonpharmacologic therapeutic options, long-term planning, and caregiver issues.
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Affiliation(s)
- Craig D Rubin
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas 75390-8889, USA.
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Zarowitz BJ, Stefanacci R, Hollenack K, O'Shea T, Gruber J, Tangalos EG. The application of evidence-based principles of care in older persons (issue 5): Alzheimer's disease. J Am Med Dir Assoc 2006; 8:183-93. [PMID: 17349948 DOI: 10.1016/j.jamda.2006.08.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2006] [Revised: 08/26/2006] [Accepted: 08/28/2006] [Indexed: 11/17/2022]
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Chan KL, Campayo A, Moser DJ, Arndt S, Robinson RG. Aggressive Behavior in Patients With Stroke: Association With Psychopathology and Results of Antidepressant Treatment on Aggression. Arch Phys Med Rehabil 2006; 87:793-8. [PMID: 16731214 DOI: 10.1016/j.apmr.2006.02.016] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2005] [Revised: 01/26/2006] [Accepted: 02/07/2006] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To examine, in a post hoc analysis of an antidepressant treatment trial, correlates of irritability and aggression after stroke and changes in irritability scores associated with antidepressant treatment. DESIGN Aggressive patients (n=23) were compared with nonaggressive patients (n=69) on numerous measures of psychopathology, poststroke impairment, and neuroimaging findings. SETTING All patients were hospitalized at the time of the initial evaluation for acute stroke or for rehabilitation therapy. PARTICIPANTS Ninety-two patients from the Iowa City Stroke Study were classified as aggressive or nonaggressive, based on symptoms elicited by the Present State Examination (PSE) and from family or caretaker reports. INTERVENTION All patients were randomized to receive nortriptyline, fluoxetine, or placebo using a double-blind methodology. MAIN OUTCOME MEASURE The change in aggression score as elicited by the PSE at the beginning and the end of a 12-week treatment trial. RESULTS Twenty-five percent (23/92) of patients reported irritability or aggression. Irritable and aggressive patients had higher total PSE scores, Hamilton Depression Rating Scale scores, Hamilton Anxiety Rating Scale (HAMA) scores, and lower Mini-Mental State Examination scores. They also had lesions that were more proximal to the frontal pole. Stepwise regression analysis showed that HAMA scores and proximity of lesion to the frontal pole were significant independent predictors of irritability. Among irritable and aggressive patients with depression who responded to antidepressants, there was a significantly greater reduction in irritability after treatment, compared with patients whose depression did not lessen with treatment. CONCLUSIONS Several factors, such as severity of impairment, other psychopathology, and neurobiologic factors, appear to contribute to irritable and aggressive behavior in stroke patients. If depression accompanies aggression, the results of this small study suggest that successful treatment of depression may reduce aggressive behavior.
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Affiliation(s)
- Keen-Loong Chan
- Department of Psychological Medicine, Tan Tock Seng Hospital, Singapore
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Bharani N, Snowden M. Evidence-based interventions for nursing home residents with dementia-related behavioral symptoms. Psychiatr Clin North Am 2005; 28:985-1005, x. [PMID: 16325737 DOI: 10.1016/j.psc.2005.09.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Nipali Bharani
- Department of Psychiatry and Behavioral Sciences, University of Washington, Box 359911, Harborview Medical Center, 325 9th Avenue, Seattle, WA 98104, USA.
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Peskind ER, Tsuang DW, Bonner LT, Pascualy M, Riekse RG, Snowden MB, Thomas R, Raskind MA. Propranolol for disruptive behaviors in nursing home residents with probable or possible Alzheimer disease: a placebo-controlled study. Alzheimer Dis Assoc Disord 2005; 19:23-8. [PMID: 15764868 DOI: 10.1097/01.wad.0000155067.16313.5e] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Enhanced behavioral responsiveness to central nervous system (CNS) norepinephrine (NE) in Alzheimer disease (AD) may contribute to the pathophysiology of disruptive behaviors such as aggression, uncooperativeness with necessary care, irritability, and pressured pacing. We evaluated the efficacy of the beta-adrenergic antagonist propranolol for treatment-resistant disruptive behaviors and overall behavioral status in nursing home residents with probable or possible AD. METHODS Thirty-one subjects (age 85 +/- 8 [SD]) with probable or possible AD and persistent disruptive behaviors that interfered with necessary care were randomized to propranolol (n = 17) or placebo (n = 14) in a double-blind study. Stable doses of previously prescribed psychotropics were maintained at pre-study dose during the study. Following a propranolol or placebo dose titration period of up to 9 days (per a dosing algorithm), subjects were maintained on maximum achieved dose for 6 weeks. Primary outcome measures were the Neuropsychiatric Inventory (NPI) and the Clinical Global Impression of Change (CGIC). RESULTS Propranolol augmentation (mean achieved dose 106 +/- 38 mg/d) was significantly more effective than placebo for improving overall behavioral status on the total NPI score and CGIC. Improvement in individual NPI items within propranolol subjects was significant only for "agitation/aggression" and "anxiety," and reached borderline statistical significance favoring propranolol over placebo only for "agitation/aggression." Pressured pacing and irritability did not appear responsive to propranolol. In propranolol subjects rated "moderately improved" or "markedly improved" on the CGIC at the end of the double-blind study phase, improvement of overall behavioral status had diminished substantially after 6 months of open-label propranolol treatment. CONCLUSION Short-term propranolol augmentation treatment appeared modestly effective and well tolerated for overall behavioral status in nursing home residents with probable or possible AD complicated by disruptive behaviors. Propranolol may be helpful specifically for aggression and uncooperativeness (the behaviors assessed by the NPI "agitation/aggressiveness" item). However, the usefulness of propranolol in this very old and frail population was limited by the high frequency of relative contraindications to beta-adrenergic antagonist treatment and diminution of initial behavioral improvements over time.
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Affiliation(s)
- Elaine R Peskind
- Department of Veterans Affairs Northwest Network VISN 20 Mental Illness Research, Education and Clinical Center, Seattle, WA, USA.
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Herrmann N, Lanctôt KL, Eryavec G, Khan LR. Noradrenergic activity is associated with response to pindolol in aggressive Alzheimer's disease patients. J Psychopharmacol 2004; 18:215-20. [PMID: 15260910 DOI: 10.1177/0269881104042625] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Loss of noradrenergic (NE) neurones in the locus ceruleus and compensatory changes in NE activity have been described in Alzheimer's disease (AD), but have never been linked to treatment. The hypothesis of this study was that central NE responsivity would predict aggression response to treatment with a NE medication, pindolol. Fifteen institutionalized AD subjects [Mini-Mental State Examination (MMSE), mean 3.3 +/- 4.6] with significant behavioural disturbances (Neuropsychiatric Inventory Score, mean 30.6 +/- 14.6) were studied. Growth hormone (GH) response to clonidine challenge (5 microg/kg) was used as a measure of central NE responsivity. Subjects were then randomized to 7 weeks of treatment with pindolol, maximum dose 20 mg b.i.d., or an identical placebo capsule in a cross-over design. The primary outcome measure was change on the retrospective Overt Aggression Scale (r-OAS). Five of 11 completers (45%) had decreased total r-OAS scores. There was significant improvement noted on the r-OAS verbal aggression subscale (paired t = -2.5, p = 0.03) compared to placebo, but not r-OAS total. Higher baseline aggression, higher MMSE and lower GH response predicted improvement in aggression, accounting for 82% of the variance (r = 0.91, F = 10.5, p = 0.006). Changes in NE responsivity, as reflected by a blunted GH response to clonidine challenge and more severe aggression, were associated with better response to the NE agent pindolol. Individual patient characteristics, including underlying neurotransmitter changes, may be useful for predicting response to therapy.
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Affiliation(s)
- Nathan Herrmann
- Department of Psychiatry, Sunnybrook and Women's College Health Sciences Centre and University of Toronto, Toronto, Ontario, Canada.
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Affiliation(s)
- Kevin F Gray
- Departments of Psychiatry and Neurology, University of Texas Southwestern medical Center, 5323 Harry Hines Blvd, Dallas, TX 75235-9070, USA.
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Current awareness in geriatric psychiatry. Int J Geriatr Psychiatry 2002; 17:887-94. [PMID: 12369568 DOI: 10.1002/gps.581] [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] [Indexed: 11/08/2022]
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