Review of Pharmacotherapeutic Targets in Alzheimer's Disease and Its Management Using Traditional Medicinal Plants

Alzheimer's disease (AD) is a progressive neurodegenerative disorder characterized by cognitive decline, memory loss, and impaired daily functioning. While there is currently no cure for AD, several pharmacotherapeutic targets and management strategies have been explored. Additionally, traditional medicinal plants have gained attention for their potential role in AD management. Pharmacotherapeutic targets in AD include amyloid-beta (Aβ) aggregation, tau protein hyperphosphorylation, neuroinflammation, oxidative stress, and cholinergic dysfunction. Traditional medicinal plants, such as Ginkgo biloba, Huperzia serrata, Curcuma longa (turmeric), and Panax ginseng, have demonstrated the ability to modulate these targets through their bioactive compounds. Ginkgo biloba, for instance, contains flavonoids and terpenoids that exhibit neuroprotective effects by reducing Aβ deposition and enhancing cerebral blood flow. Huperzia serrata, a natural source of huperzine A, has acetylcholinesterase-inhibiting properties, thus improving cholinergic function. Curcuma longa, enriched with curcumin, exhibits anti-inflammatory and antioxidant effects, potentially mitigating neuroinflammation and oxidative stress. Panax ginseng's ginsenosides have shown neuroprotective and anti-amyloidogenic properties. The investigation of traditional medicinal plants as a complementary approach to AD management offers several advantages, including a lower risk of adverse effects and potential multi-target interactions. Furthermore, the cultural knowledge and utilization of these plants provide a rich source of information for the development of new therapies. However, further research is necessary to elucidate the precise mechanisms of action, standardize preparations, and assess the safety and efficacy of these natural remedies. Integrating traditional medicinal-plant-based therapies with modern pharmacotherapies may hold the key to a more comprehensive and effective approach to AD treatment. This review aims to explore the pharmacotherapeutic targets in AD and assess the potential of traditional medicinal plants in its management.

Extemporaneous combination of donepezil and memantine to treat dementia in Alzheimer disease: evidence from Italian real-world data

OBJECTIVE

Providing evidence on donepezil and memantine administration as extemporaneous combination (DM-EXT) to treat Alzheimer Disease (AD) in Italy, and describing demographic and clinical features of AD patients prescribed DM-EXT.

METHODS

Retrospective observational study using IQVIA Italian LifeLink Treatment Dynamics (LRx) and Longitudinal Patient Database (LPD). Prevalent users of DM-EXT were identified on the databases (cohorts DMp_LRx and DMp_LPD) including patients with donepezil and memantine overlapping prescriptions during the selection period (DMp_LRx: "July 2018-June 2021"; DMp_LPD: "July 2012-June 2021"). Demographic and clinical profiles of patients were provided. Starting from cohort DMp_LPD, new users of DM-EXT were selected to calculate treatment adherence. Three additional cohorts of prevalent users of DM-EXT were identified on IQVIA LRx over subsequent 12-month periods, from July 2018 to June 2021, to get national-level yearly estimates accounting for database representativeness.

RESULTS

Cohorts DMp_LRx and DMp_LPD included 9862 and 708 patients, respectively. For both cohorts, two-third of patients were female, and more than half were aged 80+. Concomitant conditions and co-treatments prevalence was very high; most frequent comorbidities included psychiatric and cardiovascular diseases. An intermediate-to-high adherence was observed in 57% of DM-EXT new users. National-level yearly estimates showed an increasing trend (+4%) in DM-EXT prescription, which led to estimate about 10,000 patients being treated during the period "July 2020-June 2021".

CONCLUSIONS

Prescription of DM-EXT is a common practice in Italy. Because the administration of fixed-dose (FDCs) instead of extemporaneous combinations improves treatment adherence, the introduction of an FDC containing donepezil and memantine might enhance AD patients' management and reduce caregiver burden.

Network pharmacology and bioinformatics approach reveals the therapeutic mechanism of action of curcumin in Alzheimer disease

Curcumin is a natural anti-inflammatory and antioxidant substance which plays a major role in reducing the amyloid plaques formation, which is the major cause of Alzheimer's disease (AD). Consequently, a methodical approach was used to select the potential protein targets of curcumin in AD through network pharmacology. In this study, through integrative methods, AD targets of curcumin through SwissTargetPrediction database, STITCH database, BindingDB, PharmMapper, Therapeutic Target Database (TTD), Online Mendelian Inheritance in Man (OMIM) database were predicted followed by gene enrichment analysis, network construction, network topology, and docking studies. Gene ontology analysis facilitated identification of a list of possible AD targets of curcumin (74 targets genes). The correlation of the obtained targets with AD was analysed by using gene ontology (GO) pathway enrichment analyses and Kyoto Encyclopaedia of Genes and Genomes (KEGG). We have incorporated the applied network pharmacological approach to identify key genes. Furthermore, we have performed molecular docking for analysing the mechanism of curcumin. In order to validate the temporospatial expression of key genes in human central nervous system (CNS), we searched the Human Brain Transcriptome (HBT) dataset. We identified top five key genes namely, PPARγ, MAPK1, STAT3, KDR and APP. Further validated the expression profiling of these key genes in publicly available brain data expression profile databases. In context to a valuable addition in the treatment of AD, this study is concluded with novel insights into the therapeutic mechanisms of curcumin, will ease the treatment of AD with the clinical application of curcumin.

Antibiotic use and associated factors in adult outpatients from 2000 to 2019

The aims of the study were to assess the changes in 19-years use of antibiotics (overall, by age, sex and geographical area) and of those classes deemed to be quality indicators for their consumption and to evaluate factors associated to antibiotic use. We analyzed drug prescription data collected in the administrative database of the Lombardy Region (Northern Italy) for outpatients aged 40+ years from 2000 to 2019. Logistic regression analyses were performed to evaluate the association between receiving at least one antibiotic prescription and year of observation, gender, age groups, area of residence, polypharmacy and hospitalizations in the index year. The prevalence of patients prescribed with antibiotics remained high from 2000 (33.8%) to 2019 (32.6%). Prevalence of use of second-line choice antibiotics (penicillin combinations with beta-lactamase inhibitors, third and fourth generation cephalosporins, macrolides) continued to increase, only fluoroquinolones decreased in 2019 (19%) comparing to 2018 (26%), at the time when the Italian Medicines Agency promulgated safety warnings. Females (OR 1.28, 95%CI 1.27-1.28), people living in Brescia (OR 1.24, 95%CI 1.24-1.25), those exposed to polypharmacy (OR 2.57, 95%CI 2.56-2.57) and those hospitalized 1 to 3 (OR 1.86, 95%CI 1.85-1.86) or more than 3 (OR 2.02, 95%CI 2.01-2.03) times a year had a statistically significant higher risk of receiving antibiotics. The high use of antibiotics over the study period further reinforces the need of impactful interventions, in order to improve the rational use of antibiotics and to reduce the risks of antimicrobial resistance. The differences outlined should be considered when monitoring and planning these interventions.

Traditional Oriental Medicines and Alzheimer's Disease

Alzheimer’s disease (AD), which is the most major cause of dementia, is a progressive neurodegenerative disease that affects cognitive functions. Even though the prevalence of AD is continuously increasing, few drugs including cholinesterase inhibitors and N-methyl D-aspartate-receptor antagonists were approved to treat AD. Because the clinical trials of AD drugs with single targets, such as β-amyloid and tau, have failed, the development of multi-target drugs that ameliorate many of the symptoms of AD is needed. Thus, recent studies have investigated the effects and underlying mechanisms of herbal formulae consisting of various herb combinations used to treat AD. This review discusses the results of clinical and nonclinical studies of the therapeutic efficacy in AD and underlying mechanisms of the herbal formulae of traditional Oriental medicines and bioactive compounds of medicinal plants.

Jowiseungchungtang Inhibits Amyloid-β Aggregation and Amyloid-β-Mediated Pathology in 5XFAD Mice

Alzheimer's disease (AD) is a neurodegenerative disease, which is accompanied by memory loss and cognitive dysfunction. Although a number of trials to treat AD are in progress, there are no drugs available that inhibit the progression of AD. As the aggregation of amyloid-β (Aβ) peptides in the brain is considered to be the major pathology of AD, inhibition of Aβ aggregation could be an effective strategy for AD treatment. Jowiseungchungtang (JWS) is a traditional oriental herbal formulation that has been shown to improve cognitive function in patients or animal models with dementia. However, there are no reports examining the effects of JWS on Aβ aggregation. Thus, we investigated whether JWS could protect against both Aβ aggregates and Aβ-mediated pathology such as neuroinflammation, neurodegeneration, and impaired adult neurogenesis in 5 five familial Alzheimer's disease mutations (5XFAD) mice, an animal model for AD. In an in vitro thioflavin T assay, JWS showed a remarkable anti-Aβ aggregation effect. Histochemical analysis indicated that JWS had inhibitory effects on Aβ aggregation, Aβ-induced pathologies, and improved adult hippocampal neurogenesis in vivo. Taken together, these results suggest the therapeutic possibility of JWS for AD targeting Aβ aggregation, Aβ-mediated neurodegeneration, and impaired adult hippocampal neurogenesis.

Dementia-specific drug treatment in home care settings: A German multicentre study

AIMS AND OBJECTIVES

The aim of this study was to identify and analyse factors influencing the use of drugs for dementia treatment in home care settings.

BACKGROUND

While the number of care-dependent people with dementia is growing, it is not clear whether their medication follows the state of the art, especially in home care settings where over two-thirds of them are cared for in Germany. Although dementia is not curable, it is possible to reduce cognitive, behavioural and psychological symptoms of dementia with the appropriate use of medication. However, there is a lack of information concerning the drug treatment in home care settings.

METHODS

The study was conducted as a multicentre cross-sectional survey, including 923 participants from 102 home care institutions throughout Germany. Medical diagnosis, medication, consultations with a specialist within the previous 12 weeks of the initial assessment and additional general information were assessed following a standardised study protocol. Data were analysed using univariate and multivariate statistical methods. The manuscript was developed utilising the STROBE checklist for cross-sectional studies.

RESULTS

In home care, one in seven clients (14.8%) is diagnosed with some form of dementia. 52.6% (n = 72) of them were treated with dementia medication: AchEIs 16.1% (n = 22), memantine 9.5% (n = 13), antidepressants 23.4% (n = 32), antipsychotic medication 9.5% (n = 13), tranquilisers 16.8% (n = 23) and anticonvulsant drugs 6.6% (n = 9). Drug treatment for dementia was significantly associated with the consultation of a neurologist/psychiatrist in the previous 12 weeks.

CONCLUSIONS

It has been demonstrated that the use of drugs as a component of home care treatment for dementia depends on many factors and therefore varies.

RELEVANCE TO CLINICAL PRACTICE

It can be assumed that people living with dementia in home care settings are not sufficiently supplied with medication. Their medical care can be improved by establishing interdisciplinary care involving a neurologist/psychiatrist.

Trends and disparities in the use of cholinesterase inhibitors to treat Alzheimer’s disease dispensed by the Brazilian public health system – 2008 to 2014: a nation-wide analysis

ABSTRACT In light of the high cost of dementia treatment, there is legislation authorizing free distribution of cholinesterase inhibitors to those suffering from Alzheimer’s disease in Brazil. However, the existence of this free distribution does not guarantee adequate distribution. Objectives The present study aimed to investigate the trends of prescriptions and the coverage of Alzheimer’s disease treatment using cholinesterase inhibitors from public pharmacies dispensing high-cost drugs in Brazil. Methods This was a retrospective study that collected data from the Brazilian public Unified Health System. All cholinesterase inhibitors distributed at no cost to Brazilians during the year 2014, as well as the estimated number and percentages of patients who used these medications, were evaluated and compared to data from the year 2008. Results Our estimates indicated that 9.7% of the population having dementia syndromes used cholinesterase inhibitors, as well as 16.1% of those with Alzheimer’s disease in Brazil. A clear disparity was noted between the use and distribution of cholinesterase inhibitors, depending on the region in which they were found. Over time, an increase in the distribution of cholinesterase inhibitors has been noted. In 2008, that use was 12.0% whereas, in 2014, it was 16.1%, an increase of 34% in six years. Conclusion It was estimated that 16.1% of patients with Alzheimer’s disease in Brazil use cholinesterase inhibitors. These values have increased and, in spite of not being satisfactory, they indicate a potential for improvement. However, there is still a significant disparity among the regions.

Trends in Drug Prescription Rates for Dementia: An Observational Population-Based Study in France, 2006-2014

BACKGROUND

Since the 2011 French guidance updates, cholinesterase inhibitors and memantine are considered optional in the management of dementia and leave physicians free to prescribe based on their clinical expertise.

OBJECTIVES

The aims of this study were to analyze the influence of these recent guidance updates on the prescription rates of these drugs and to quantify the impact of potential changes on healthcare expenditures.

METHODS

Patients over 65 years old from a representative sample of a national administrative claims database, the French national health insurance database, were retrospectively included from 2006 to 2014. Trends of annual prescription rates were tested using adjusted segmented regression analysis. Drug costs with and without prescribers' behavioral changes were estimated.

RESULTS

A total of 119,731 individuals were included and followed during the study period. Among them, 5514 individuals were treated for dementia. According to the unadjusted segmented regression model, there was a significant increase in prescription rates between 2006 and 2010, from 2.23% (95% confidence interval 2.13-2.34) to 2.73% (95% confidence interval 2.62-2.84) of the study population. Since 2011, the trend has reversed with a significant decrease until 2014, from 2.64% (95% confidence interval 2.54-2.75) to 1.92% (95% confidence interval 1.84-2.01). In the multivariate analysis, we also found a gradual decline since 2011, particularly for patients aged 65-69 years and with one or more other chronic diseases. Cost savings associated with prescribers' behavioral changes were estimated at €108 million.

CONCLUSION

Drugs prescribed for dementia are on a declining trend with important cost savings, and this was concomitant with guidance updates that left physicians to rely on their clinical expertise while managing dementia.

Strategic roadmap for an early diagnosis of Alzheimer's disease based on biomarkers

The diagnosis of Alzheimer's disease can be improved by the use of biological measures. Biomarkers of functional impairment, neuronal loss, and protein deposition that can be assessed by neuroimaging (ie, MRI and PET) or CSF analysis are increasingly being used to diagnose Alzheimer's disease in research studies and specialist clinical settings. However, the validation of the clinical usefulness of these biomarkers is incomplete, and that is hampering reimbursement for these tests by health insurance providers, their widespread clinical implementation, and improvements in quality of health care. We have developed a strategic five-phase roadmap to foster the clinical validation of biomarkers in Alzheimer's disease, adapted from the approach for cancer biomarkers. Sufficient evidence of analytical validity (phase 1 of a structured framework adapted from oncology) is available for all biomarkers, but their clinical validity (phases 2 and 3) and clinical utility (phases 4 and 5) are incomplete. To complete these phases, research priorities include the standardisation of the readout of these assays and thresholds for normality, the evaluation of their performance in detecting early disease, the development of diagnostic algorithms comprising combinations of biomarkers, and the development of clinical guidelines for the use of biomarkers in qualified memory clinics.

Toxicological Differences Between NMDA Receptor Antagonists and Cholinesterase Inhibitors

Cholinesterase inhibitors (ChEIs), represented by donepezil, rivastigmine, and galantamine, used to be the only approved class of drugs for the treatment of Alzheimer's disease. After the approval of memantine by the Food and Drug Administration (FDA), N-methyl-d-aspartic acid (NMDA) receptor antagonists have been recognized by authorities and broadly used in the treatment of Alzheimer's disease. Along with complementary mechanisms of action, NMDA antagonists and ChEIs differ not only in therapeutic effects but also in adverse reactions, which is an important consideration in clinical drug use. And the number of patients using NMDA antagonists and ChEIs concomitantly has increased, making the matter more complicated. Here we used the FDA Adverse Event Reporting System for statistical analysis , in order to compare the adverse events of memantine and ChEIs. In general, the clinical evidence confirmed the safety advantages of memantine over ChEIs, reiterating the precautions of clinical drug use and the future direction of antidementia drug development.

Temporal trends for donepezil utilization among older people

To examine and characterize overall donepezil and concomitant utilization with β-blockers, yearly, in older New Zealanders. Deidentified data from the Pharmaceutical claims database and the National Minimum Dataset were obtained for 2011 to 2013 from the Ministry of Health. Population-level data were extracted for donepezil and β-blockers utilization, measured by defined daily dose (DDD) per thousand older people per day (TOPD). Donepezil utilization increased from 5.2 to 8.2 DDD/TOPD between 2011 and 2013. In 2011, the number of prevalent users was 4634, the mean age was 79.4±6.6 years and 57.5% were women. Highest use by age for donepezil was in those aged 85 years or older (2.3 DDD/TOPD), followed by those aged 80-84 years (2.2 DDD/TOPD). The mean utilization volumes were significantly lower for donepezil 5 mg (Student t-test=9.86; P<0.05) and 10 mg (10.90; P<0.05) in the 65- to 69-year age group compared with the 80- to 84-year age group, whereas the proportion of concomitant utilization of donepezil with β-blockers decreased (17.9% to 5.1%). Donepezil utilization in DDD/TOPD increased by three-fifths between 2011 and 2013. Prescribers appear to be aware of the potential risk of bradycardia with the concomitant use of donepezil and β-blockers.

Validity of ICD-9-CM codes for breast, lung and colorectal cancers in three Italian administrative healthcare databases: a diagnostic accuracy study protocol

INTRODUCTION

Administrative healthcare databases are useful tools to study healthcare outcomes and to monitor the health status of a population. Patients with cancer can be identified through disease-specific codes, prescriptions and physician claims, but prior validation is required to achieve an accurate case definition. The objective of this protocol is to assess the accuracy of International Classification of Diseases Ninth Revision-Clinical Modification (ICD-9-CM) codes for breast, lung and colorectal cancers in identifying patients diagnosed with the relative disease in three Italian administrative databases.

METHODS AND ANALYSIS

Data from the administrative databases of Umbria Region (910,000 residents), Local Health Unit 3 of Napoli (1,170,000 residents) and Friuli--Venezia Giulia Region (1,227,000 residents) will be considered. In each administrative database, patients with the first occurrence of diagnosis of breast, lung or colorectal cancer between 2012 and 2014 will be identified using the following groups of ICD-9-CM codes in primary position: (1) 233.0 and (2) 174.x for breast cancer; (3) 162.x for lung cancer; (4) 153.x for colon cancer and (5) 154.0-154.1 and 154.8 for rectal cancer. Only incident cases will be considered, that is, excluding cases that have the same diagnosis in the 5 years (2007-2011) before the period of interest. A random sample of cases and non-cases will be selected from each administrative database and the corresponding medical charts will be assessed for validation by pairs of trained, independent reviewers. Case ascertainment within the medical charts will be based on (1) the presence of a primary nodular lesion in the breast, lung or colon-rectum, documented with imaging or endoscopy and (2) a cytological or histological documentation of cancer from a primary or metastatic site. Sensitivity and specificity with 95% CIs will be calculated.

DISSEMINATION

Study results will be disseminated widely through peer-reviewed publications and presentations at national and international conferences.

Patterns and determinants of dementia pharmacotherapy in a population-based cohort of home care clients

BACKGROUND

Little is known about the needs of older home care clients with dementia or their key quality of care issues, including their use of pharmacotherapy for Alzheimer's disease.

OBJECTIVES

The objectives of this study were to (1) describe the sociodemographic, psychosocial, and health characteristics of clients with dementia (relative to two control subgroups) from a population-based home care cohort; and, (2) determine the distribution and associated characteristics of cholinesterase inhibitor (ChEI) and/or memantine use among dementia clients overall and according to medication class, comorbid illness, and year of assessment.

METHODS

This cross-sectional study included all home care clients aged 50 years or older assessed with the Resident Assessment Instrument-Home Care (RAI-HC) in Ontario, Canada from January 2003 to December 2010. Multivariable logistic regression models were used to identify factors associated with receiving a dementia medication (a ChEI and/or memantine).

RESULTS

There were 104,802 (21.5 %) clients with a diagnosis of dementia, 92,529 (18.9 %) cognitively impaired clients without a dementia diagnosis, and 290,929 (59.6 %) cognitively intact clients. Relative to the comparison groups, dementia clients were more likely to have reported conflicts with others, a distressed caregiver, greater levels of cognitive and functional impairment, and to exhibit wandering, aggressive behaviors, anxiety, hallucinations or delusions, and swallowing problems. Approximately half of dementia clients were taking a dementia medication, most commonly donepezil. Characteristics most strongly associated with use of ChEI monotherapy included age greater than 64 (especially 75-84), absence of economic barriers, availability of a primary caregiver, year of assessment, moderate to severe cognitive impairment, relative independence in function, health stability, no depressive symptoms or hallucinations/delusions, no recent hospitalization, use of at least 9 medications, the absence of chronic health and neurological conditions, and the use of an antipsychotic or antidepressant. For combination therapy, strong positive associations were observed for younger age, year of assessment, increasing cognitive impairment, presence of a primary caregiver, male sex, absence of economic barriers, use of at least 9 medications, and various indicators of positive health status (e.g., stability in health, absence of chronic health and neurological conditions, and no recent hospitalization). The percentage of clients receiving ChEIs increased with cognitive impairment scores but declined slightly at the highest level of impairment, whereas the percentage receiving memantine increased with cognitive impairment level. The number and percentage of dementia clients receiving any pharmacotherapy increased during the study interval.

CONCLUSIONS

We observed a relatively high prevalence of dementia-specific pharmacotherapy among Ontario long-stay home care clients as well as significant variation in utilization patterns by select sociodemographic, functional, and clinical characteristics, and over time. While physicians generally followed recommended guidelines regarding appropriate dementia pharmacotherapy, continued efforts to monitor practice patterns are required among vulnerable older adults across care settings.

Caregivers' perceptions of the therapeutic benefits of drug treatments for dementia

BACKGROUND AND AIMS

To collect opinions, perceptions, and expectations on the therapeutic benefits of drug treatment for dementia and the impact on the care of the patient in a large sample of caregivers. Only few studies deal with this topic in a small number of participants.

METHODS

This used an ad-hoc online questionnaire to collect the opinions of caregivers of patients with dementia and assess their expectations and perceptions of the therapeutic benefits of drug treatments. The questionnaire was accessible for nearly 4 months on the Federazione Alzheimer Italia website and had three sections: (1) information on the patient with dementia; (2) information on the caregiver's perception of the therapeutic benefits of drug treatments; (3) information on caregivers. To evaluate the relationship between the caregiver's expectations of the therapeutic benefits of dementia treatments and some characteristics of the patients and the caregivers, we used the Chi-square test.

RESULTS

During the access time, 439 questionnaires were filled, and 369 were validated for inclusion in the analysis; of these, 329 also had information on caregivers. The expectations of drug treatment effects were not statistically significantly influenced by any variables considered about the patients or the caregivers. Caregivers' beliefs about the effectiveness of dementia treatment, their expectations and changes in their lives were clear.

CONCLUSIONS

This study addresses a gap in knowledge about caregivers' experiences and their views of drug treatments, and highlights the need for a pharmaceutical treatment that helps to resolve the symptoms and outcomes of dementia.

Australian population trends and disparities in cholinesterase inhibitor use, 2003 to 2010

BACKGROUND

The Australian Pharmaceutical Benefits Scheme (PBS) first subsidized cholinesterase inhibitors (CEIs) for Alzheimer's disease in 2001, introducing a novel therapy for a previously untreatable common condition. This study aims to determine Australian rates of CEI use and to assess equality of access to treatment based on socioeconomic status and geographic remoteness.

METHODS

Pharmaceutical claims records were used to identify all Australians prescribed CEIs between January 2003 and December 2010. Age-standardized and sex-adjusted index prescription rates were derived using the total Australian population as the denominator to examine temporal trends and the impacts of socioeconomic and geographic disadvantage on CEI index prescription rates.

RESULTS

Index prescription rates peaked in 2004 at 92.5 per 100,000 person-years, declining to between 70.2 and 73.5 for years 2006 to 2010. Rates were highest in the 85- to 89-year age group and 2.6-fold higher in the least socioeconomic disadvantaged population when compared with the most disadvantaged population. In major cities in Australia, index prescription rates were 1.4 to 1.7 times greater compared with remote areas.

CONCLUSIONS

Increasing geographic remoteness and socioeconomic disadvantage are associated with lower CEI index prescription rates, indicating inequities in the management of Alzheimer's disease in Australia.

Functional response to cholinesterase inhibitor therapy in a naturalistic Alzheimer's disease cohort

BACKGROUND

Activities of daily living (ADL) are an essential part of the diagnostic criteria for Alzheimer's disease (AD). A decline in ADL affects independent living and has a strong negative impact on caregiver burden. Functional response to cholinesterase inhibitor (ChEI) treatment and factors that might influence this response in naturalistic AD patients need investigating. The aim of this study was to identify the socio-demographic and clinical factors that affect the functional response after 6 months of ChEI therapy.

METHODS

This prospective, non-randomised, multicentre study in a routine clinical setting included 784 AD patients treated with donepezil, rivastigmine or galantamine. At baseline and after 6 months of treatment, patients were assessed using several rating scales, including the Instrumental Activities of Daily Living (IADL) scale, Physical Self-Maintenance Scale (PSMS) and Mini-Mental State Examination (MMSE). Demographic and clinical characteristics were investigated at baseline. The functional response and the relationships of potential predictors were analysed using general linear models.

RESULTS

After 6 months of ChEI treatment, 49% and 74% of patients showed improvement/no change in IADL and in PSMS score, respectively. The improved/unchanged patients exhibited better cognitive status at baseline; regarding improved/unchanged PSMS, patients were younger and used fewer anti-depressants. A more positive functional response to ChEI was observed in younger individuals or among those having the interaction effect of better preserved cognition and lower ADL ability. Patients with fewer concomitant medications or those using NSAIDs/acetylsalicylic acid showed a better PSMS response.

CONCLUSIONS

Critical characteristics that may influence the functional response to ChEI in AD were identified. Some predictors differed from those previously shown to affect cognitive response, e.g., lower cognitive ability and older age predicted better cognitive but worse functional response.

Impact of geriatric comorbidity and polypharmacy on cholinesterase inhibitors prescribing in dementia

BACKGROUND

Although most guidelines recommend the use of cholinesterase inhibitors (ChEIs) for mild to moderate Alzheimer's Disease, only a small proportion of affected patients receive these drugs. We aimed to study if geriatric comorbidity and polypharmacy influence the prescription of ChEIs in patients with dementia in Germany.

METHODS

We used claims data of 1,848 incident patients with dementia aged 65 years and older. Inclusion criteria were first outpatient diagnoses for dementia in at least three of four consecutive quarters (incidence year). Our dependent variable was the prescription of at least one ChEI in the incidence year. Main independent variables were polypharmacy (defined as the number of prescribed medications categorized into quartiles) and measures of geriatric comorbidity (levels of care dependency and 14 symptom complexes characterizing geriatric patients). Data were analyzed by multivariate logistic regression.

RESULTS

On average, patients were 78.7 years old (47.6% female) and received 9.7 different medications (interquartile range: 6-13). 44.4% were assigned to one of three care levels and virtually all patients (92.0%) had at least one symptom complex characterizing geriatric patients. 13.0% received at least one ChEI within the incidence year. Patients not assigned to the highest care level were more likely to receive a prescription (e.g., no level of care dependency vs. level 3: adjusted Odds Ratio [OR]: 5.35; 95% CI: 1.61-17.81). The chance decreased with increasing numbers of symptoms characterizing geriatric patients (e.g., 0 vs. 5+ geriatric complexes: OR: 4.23; 95% CI: 2.06-8.69). The overall number of prescribed medications had no influence on ChEI prescription and a significant effect of age could only be found in the univariate analysis. Living in a rural compared to an urban environment and contacts to neurologists or psychiatrists were associated with a significant increase in the likelihood of receiving ChEIs in the multivariate analysis.

CONCLUSIONS

It seems that not age as such but the overall clinical condition of a patient including care dependency and geriatric comorbidities influences the process of decision making on prescription of ChEIs.