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

Targets, trials and tribulations in Alzheimer therapeutics

Alzheimer's disease (AD) is a progressive neurodegenerative disorder characterized by abnormal accumulation of extracellular amyloid beta senile plaques and intracellular neurofibrillary tangles in the parts of the brain responsible for cognition. The therapeutic burden for the management of AD relies solely on cholinesterase inhibitors that provide only symptomatic relief. The urgent need for disease-modifying drugs has resulted in intensive research in this domain, which has led to better understanding of the disease pathology and identification of a plethora of new pathological targets. Currently, there are over a hundred and seventy clinical trials exploring disease modification, cognitive enhancement, and reduction of neuro-psychiatric complications. However, the path to developing safe and efficacious AD therapeutics has not been without challenges. Several clinical trials have been terminated in advanced stages due to lack of therapeutic translation or increased incidence of adverse events. This review presents an in-depth look at the various therapeutic targets of AD and the lessons learnt during their clinical assessment. Comprehensive understanding of the implication of modulating various aspects of Alzheimer brain pathology is crucial for development of drugs with potential to halt disease progression in Alzheimer therapeutics.

Psychiatric Adverse Events of Acetylcholinesterase Inhibitors in Alzheimer's Disease and Parkinson's Dementia: Systematic Review and Meta-Analysis

BACKGROUND

The acetylcholinesterase inhibitors (AChEIs) donepezil, galantamine, and rivastigmine are commonly used in the management of various forms of dementia.

OBJECTIVES

While these drugs are known to induce classic cholinergic adverse events such as diarrhea, their potential to cause psychiatric adverse events has yet to be thoroughly examined.

METHODS

We sought to determine the risk of psychiatric adverse events associated with the use of AChEIs through a systematic review and meta-analysis of double-blind randomized controlled trials involving patients with Alzheimer's dementia and Parkinson's dementia.

RESULTS

A total of 48 trials encompassing 22,845 patients were included in our analysis. Anorexia was the most commonly reported psychiatric adverse event, followed by agitation, insomnia, and depression. Individuals exposed to AChEIs had a greater risk of experiencing appetite disorders, insomnia, or depression compared with those who received placebo (anorexia: odds ratio [OR] 2.93, 95% confidence interval [CI] 2.29-3.75; p < 0.00001; decreased appetite: OR 1.93, 95% CI 1.33-2.82; p = 0.0006; insomnia: OR 1.55, 95% CI 1.25-1.93; p < 0.0001; and depression: OR 1.59, 95% CI 1.23-2.06, p = 0.0004). Appetite disorders were also more frequent with high-dose versus low-dose therapy. A subgroup analysis revealed that the risk of insomnia was higher for donepezil than for galantamine.

CONCLUSIONS

Our findings suggest that AChEI therapy may negatively impact psychological health, and careful monitoring of new psychiatric symptoms is warranted. Lowering the dose may resolve some psychiatric adverse events, as may switching to galantamine in the case of insomnia.

CLINICAL TRIAL REGISTRATION

The study was pre-registered on PROSPERO (CRD42021258376).

An Update on Apathy in Alzheimer's Disease

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.

The Effect of Multimodal Non-pharmacological Interventions on Cognitive Function Improvement for People With Dementia: A Systematic Review

Introduction

Dementia is a progressive brain degeneration characterized by a progressive deterioration in cognition and independent living capacity. Since dementia is a complex syndrome, multimodal non-pharmacological interventions (MNPIs) are highly recommended. Currently, there is less available evidence to describe the content, length, and frequency of multimodal interventions for cognitive function improvement for people with dementia (PWD).

Method

A comprehensive search was performed in PubMed, EMBASE, CINAHL, Web of Science, and Medline international databases. The quality appraisal of the studies was done by the Cochrane risk of bias assessment tools.

Results

A total of 19 controlled trial studies were included. Most of the included studies reported that MNPIs resulted in improvement, stability, or attenuation of decline in cognitive function of PWD. The reported effectiveness of MNPIs on cognitive function ranged from medium (0.29 Cohen's d) to large (2.02 Cohen's d) effect sizes. The median duration of intervention was 12 weeks for a 1-h session.

Conclusion

This systematic review showed that MNPIs might improve people's cognitive functions for PWD. Physical exercise, music, and cognitive interventions were used in the content of multimodal interventions in a majority of the studies. Therefore, high-quality randomized controlled trial (RCT) studies with repeated-measured design on the combined effect of physical exercise, music, and cognitive intervention on cognitive function for PWD are recommended.

Systematic Review Registration

http://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42020222065.

Emotional and Neuropsychiatric Disorders Associated with Alzheimer's Disease

Alzheimer's disease is associated with impairments in emotional communication including comprehension and production of facial emotional expressions, comprehension of affective prosody, and alexithymia. It is also associated with disorders of emotional experience including mood disorders (depression and anxiety), agitation/aggression, and psychosis. Agitation/aggression and psychosis are particularly disruptive, are associated with earlier institutionalization, and pose a major challenge to institutional management. Treatment of disorders of emotional experience has been primarily pharmacologic (reviewed here in detail) and has relied heavily on antipsychotic medications despite the small effect sizes demonstrated in a large number of randomized controlled trials and the prevalence of serious side effects associated with these drugs. Recent studies suggest that treatment with pimavanserin, an antipsychotic without activity at dopamine receptors, may represent an important advance for treatment of psychotic manifestations, even as the drug appears to pose significant risk. Dextromethorphan/quinidine may represent an important advance in the treatment of agitation/aggression. There is also compelling evidence that sleep disorders, which are common among patients with Alzheimer's disease and are readily treatable, may potentiate psychotic manifestations and agitation/aggression, but further studies are needed.

[Non-cognitive psychopathological symptoms in mild cognitive impairment]

Noncognitive psychopathological symptoms (NPS) in elderly patients are increasingly attracting the attention of researchers in the field of neurodegenerative diseases. The question is raised whether these symptoms are risk factors or initial manifestations of the neurodegeneration process. This article provides information on the prevalence of late-onset NPS together with mild cognitive impairment (MCI), combination of which reflects the risk of developing dementia. The characteristic of mild behavioral impairment syndrome, which is currently used along with the concept of MCI, is given. The authors summarized data of the studies published over the past 10 years on the effect of NPS on the progression of cognitive impairment. Topics related to the differential diagnosis of these disorders, as well as existing approaches to treatment, are considered.

Prescription Patterns of Antidementia and Psychotropic Drugs in People Living With Dementia: Findings From the Clinical Pathway Study of Alzheimer's Disease in China

OBJECTIVES

Evidence about prescribing patterns of dementia medication in China is lacking. This study aimed to examine prescribing rates of antidementia and psychotropic drugs and factors associated with drug prescription for dementia in China.

DESIGN

A multicenter observational study.

SETTING AND PARTICIPANTS

This study employed cross-sectional data from the Clinical Pathway for Alzheimer's Disease in China study that was conducted in 28 memory clinics at tertiary hospitals across 14 provinces between 2012 and 2013. Patients aged ≥45 years with a diagnosis of dementia were included.

METHODS

Antidementia and psychotropic drugs were classified according to the Anatomical Therapeutic Chemical codes. Odds ratios (ORs) of putative factors associated with prescription patterns were estimated using logistic regressions.

RESULTS

A total of 751 respondents were included in this study, 77.8% of whom were prescribed antidementia drugs, and 33.0% were prescribed at least 1 psychotropic drug. The concomitant prescription rate of antidementia and psychotropic drugs was 24.1%. Frontotemporal dementia [OR 9.92 (99.17% CI 3.08-42.70)], severe dementia [4.25 (1.88-9.79)], and apathy [1.94 (1.18-3.20)] were significantly associated with an elevated likelihood of memantine prescription. Psychotic symptoms [1.84 (1.02-3.35)], agitation [1.91 (1.08-3.40)], and depressive symptoms [2.10 (1.12-3.94)] were significantly associated with the coprescription of antidementia and psychotropic agents.

CONCLUSIONS AND IMPLICATIONS

The prescribing rate of antidementia drugs in the study sample was higher, whereas the rate of coprescription of psychotropic and antidementia drugs was lower than reported in Western studies. Dementia prescription practice was generally consistent with clinical guidelines in memory clinics in China, whereas the prescription of antidementia and psychotropic medication mainly depended on patients' clinical symptoms.

Cerebrovascular Pathology and Responsiveness to Treatment in Alzheimer's Disease: A Systematic Review

INTRODUCTION

Responsiveness to treatment with cholinesterase inhibitors (ChEIs) is difficult to predict in Alzheimer's disease (AD). In the current review, vascular burden is considered as a potential moderator of treatment responsiveness. Cerebrovascular burden co-occurs in at least 30% of AD brains, although it is debated if vascular pathology plays a causal or synergistic role in AD pathogenesis. Vascular burden, therefore, could potentially limit response to treatment due to limited brain reserve or foster treatment efficacy as those with vascular pathology may represent a subgroup with comparable clinical expression but less progressed AD neurodegeneration.

METHODS

A systematic search of Web of Science, Pubmed, Scopus and EthoS identified 32 papers which met the criteria for inclusion. Association of treatment response and vascular burden across five broad markers are discussed: cerebral hypoperfusion, intima-media thickness, white matter changes, cerebral microbleeds and co-existing diagnosis of cerebrovascular disease.

RESULTS

Analysis of frontal regional cerebral blood flow and intima-media thickness may have predictive ability to distinguish those with AD who may respond optimally to short-term treatment with ChEIs. The impact of white matter changes is less consistent; the majority of studies demonstrates no association with treatment response and those that do implicate changes in executive functioning. There is preliminary evidence that deep cerebral microbleeds limit treatment response in subcortical cognitive domains, but this finding requires replication. The use of diagnosis of co-occurring cerebrovascular disease yields no robust variability in response to ChEIs in AD.

CONCLUSION

There is limited evidence that markers of cerebral hypoperfusion, intima-media thickness and cerebral microbleeds moderate response to ChEIs. Findings for other markers of vascular burden are less consistent and do not support any moderating effect.

New approaches to symptomatic treatments for Alzheimer's disease

BACKGROUND

Successful development of agents that improve cognition and behavior in Alzheimer's disease (AD) is critical to improving the lives of patients manifesting the symptoms of this progressive disorder.

DISCUSSION

There have been no recent approvals of cognitive enhancing agents for AD. There are currently 6 cognitive enhancers in Phase 2 trials and 4 in phase 3. They represent a variety of novel mechanisms. There has been progress in developing new treatments for neuropsychiatric symptoms in AD with advances in treatment of insomnia, psychosis, apathy, and agitation in AD. There are currently 4 AD-related psychotropic agents in Phase 2 trials and 7 in Phase 3 trials. Many novel mechanisms are being explored for the treatment of cognitive and behavioral targets. Progress in trial designs, outcomes measures, and population definitions are improving trial conduct for symptomatic treatment of AD.

CONCLUSIONS

Advances in developing new agents for cognitive and behavioral symptoms of AD combined with enhanced trial methods promise to address the unmet needs of patients with AD for improved cognition and amelioration of neuropsychiatric symptoms.

Psychotropic medication use patterns in home-based primary care: A scoping review

Introduction

Up to a third of patients seen by home-based primary care (HBPC) providers suffer from mental health problems. These conditions tend to be underrecognized and undertreated for patients receiving HBPC. The purpose of this scoping review is to evaluate current psychotropic use patterns for patients receiving HBPC services.

Methods

The following databases were searched for articles reporting on studies conducted in HBPC settings that identified patterns of psychotropic medication prescription and use: Ovid/MEDLINE, Cochrane Library, Embase, Scopus, Web of Science, CINAHL, and PsycInfo. Studies that only reported on patients in hospice, rehabilitation, or long-term care facilities were excluded as were drug trials, opinion pieces, case studies, case series, meeting abstracts, and other reviews.

Results

Of 4542 articles initially identified, 74 were selected for full text screening. Of these, only 2 met full criteria and were included in the data extraction and analysis. In 1 study, 41.7% patients enrolled were prescribed an antidepressant, 21.5% were prescribed an antipsychotic (12.7% prescribed both), and 5% to 7% of patients were prescribed benzodiazepines/hypnotics. In the other study, 9% of patients were prescribed an antipsychotic, and 7% were prescribed a benzodiazepine.

Discussion

There are extremely limited data on psychotropic prescribing patterns in HBPC in published studies. Because a significant number of HBPC patients suffer from mental health conditions in addition to other chronic illnesses, treatment can be complex. More studies are needed on current psychotropic prescribing trends to help determine what type of interventions are needed to promote patient safety in this setting.

Impact of deprescribing AChEIs on aggressive behaviors and antipsychotic prescribing

INTRODUCTION

We evaluated the impact of deprescribing acetylcholinesterase inhibitors (AChEIs) on aggressive behaviors and incident antipsychotic use in nursing home (NH) residents with severe dementia.

METHODS

We conducted a retrospective study of Medicare claims, Part D, Minimum Data Set for NH residents aged 65+ with severe dementia receiving AChEIs in 2016. Aggressive behaviors were measured using the aggressive behavior scale (ABS; n = 30,788). Incident antipsychotic prescriptions were evaluated among antipsychotic non-users (n = 25,188). Marginal structural models and inverse probability of treatment weights were used to evaluate associations of AChEI deprescribing and outcomes.

RESULTS

The severity of aggressive behaviors was low at baseline (mean ABS = 0.5) and was not associated with deprescribing AChEIs (0.002 increase in ABS, P = .90). Incident antipsychotic prescribing occurred in 5.1% of residents and was less likely with AChEI deprescribing (adjusted odds ratio = 0.52 [0.40-0.68], P <.001]).

DISCUSSION

Deprescribing AChEIs was not associated with a worsening of aggressive behaviors or incident antipsychotic prescriptions.

Potential therapeutic roles of retinoids for prevention of neuroinflammation and neurodegeneration in Alzheimer's disease

All retinoids, which can be natural and synthetic, are chemically related to vitamin A. Both natural and synthetic retinoids use specific nuclear receptors such as retinoic acid receptors and retinoid X receptors to activate specific signaling pathways in the cells. Retinoic acid signaling is extremely important in the central nervous system. Impairment of retinoic acid signaling pathways causes severe pathological processes in the central nervous system, especially in the adult brain. Retinoids have major roles in neural patterning, differentiation, axon outgrowth in normal development, and function of the brain. Impaired retinoic acid signaling results in neuroinflammation, oxidative stress, mitochondrial malfunction, and neurodegeneration leading to progressive Alzheimer's disease, which is pathologically characterized by extra-neuronal accumulation of amyloid plaques (aggregated amyloid-beta) and intra-neurofibrillary tangles (hyperphosphorylated tau protein) in the temporal lobe of the brain. Alzheimer's disease is the most common cause of dementia and loss of memory in old adults. Inactive cholinergic neurotransmission is responsible for cognitive deficits in Alzheimer's disease patients. Deficiency or deprivation of retinoic acid in mice is associated with loss of spatial learning and memory. Retinoids inhibit expression of chemokines and neuroinflammatory cytokines in microglia and astrocytes, which are activated in Alzheimer's disease. Stimulation of retinoic acid receptors and retinoid X receptors slows down accumulation of amyloids, reduces neurodegeneration, and thereby prevents pathogenesis of Alzheimer's disease in mice. In this review, we described chemistry and biochemistry of some natural and synthetic retinoids and potentials of retinoids for prevention of neuroinflammation and neurodegeneration in Alzheimer's disease.

The Hyperactivity-Impulsivity-Irritiability-Disinhibition-Aggression-Agitation Domain in Alzheimer's Disease: Current Management and Future Directions

Behavioral and psychological symptoms of dementia (BPSD) afflict the vast majority of patients with dementia, especially those with Alzheimer's disease (AD). In clinical settings, patients with BPSD most often do not present with just one symptom. Rather, clusters of symptoms commonly co-occur and can, thus, be grouped into behavioral domains that may ultimately be the result of disruptions in overarching neural circuits. One major BPSD domain routinely identified across patients with AD is the hyperactivity-impulsivity-irritiability-disinhibition-aggression-agitation (HIDA) domain. The HIDA domain represents one of the most difficult sets of symptoms to manage in AD and accounts for much of the burden for caregivers and hospital staff. Although many studies recommend non-pharmacological treatments for HIDA domain symptoms as first-line, they demonstrate little consensus as to what these treatments should be and are often difficult to implement clinically. Certain symptoms within the HIDA domain also do not respond adequately to these treatments, putting patients at risk and necessitating adjunct pharmacological intervention. In this review, we summarize the current literature regarding non-pharmacological and pharmacological interventions for the HIDA domain and provide suggestions for improving treatment. As epigenetic changes due to both aging and AD cause dysfunction in drug-targeted receptors, we propose that HIDA domain treatments could be enhanced by adjunct strategies that modify these epigenetic alterations and, thus, increase efficacy and reduce side effects. To improve the implementation of non-pharmacological approaches in clinical settings, we suggest that issues regarding inadequate resources and guidance for implementation should be addressed. Finally, we propose that increased monitoring of symptom and treatment progression via novel sensor technology and the "DICE" (describe, investigate, create, and evaluate) approach may enhance both pharmacological and non-pharmacological interventions for the HIDA domain.

Factors Associated With Deprescribing Acetylcholinesterase Inhibitors in Older Nursing Home Residents With Severe Dementia

BACKGROUND/OBJECTIVE

Uncertainty regarding benefits and risks associated with acetylcholinesterase inhibitors (AChEIs) in severe dementia means providers do not know if and when to deprescribe. We sought to identify which patient-, provider-, and system-level characteristics are associated with AChEI discontinuation.

DESIGN

Analysis of 2015 to 2016 data from Medicare claims, Part D prescriptions, Minimum Data Set (MDS), version 3.0, Area Health Resource File, and Nursing Home Compare. Cox-proportional hazards models with time-varying covariates were used to identify patient-, provider-, and system-level factors associated with AChEI discontinuation (30-day or more gap in supply).

SETTING

US Medicare-certified nursing homes (NHs).

PARTICIPANTS

Nonskilled NH residents, aged 65 years and older, with severe dementia receiving AChEIs within the first 14 days of an MDS assessment in 2016 (n = 37 106).

RESULTS

The sample was primarily white (78.7%), female (75.5%), and aged 80 years or older (77.4%). The most commonly prescribed AChEIs were donepezil (77.8%), followed by transdermal rivastigmine (14.6%). The cumulative incidence of AChEI discontinuation was 29.7% at the end of follow-up (330 days), with mean follow-up times of 194 days for continuous users of AChEIs and 105 days for those who discontinued. Factors associated with increased likelihood of discontinuation were new admission, older age, difficulty being understood, aggressive behavior, poor appetite, weight loss, mechanically altered diet, limited prognosis designation, hospitalization in 90 days prior, and northeastern region. Factors associated with decreased likelihood of discontinuation included memantine use, use of strong anticholinergics, polypharmacy, rurality, and primary care prescriber vs geriatric specialist.

CONCLUSION

Among NH residents with severe dementia being treated with AChEIs, the cumulative incidence of AChEI discontinuation was just under 30% at 1 year of follow-up. Our findings provide insight into potential drivers of deprescribing AChEIs, identify system-level barriers to deprescribing, and help to inform covariates that are needed to address potential confounding in studies evaluating the potential risks and benefits associated with deprescribing. J Am Geriatr Soc 67:1871-1879, 2019.

What are we trying to prevent in Alzheimer disease?

Within aging societies, the number of individuals suffering from Alzheimer disease (AD) is constistently increasing. This is paralleled by intense research aimed at improving treatment options and potentially even fostering effective prevention. The discussion on relevant outcomes of such interventions is ongoing. Here, different types of currently applied outcomes in the treatment of AD at the dementia stage, but also at the pre-dementia stages of mild cognitive impairment (MCI) and asymptomatic preclinical AD are discussed. Regulatory agencies require effects on the clinical measures of cognition and function. In novel disease-modifying therapy trials, biological markers are used as secondary and exploratory outcomes. Additional outcomes of great relevance for the individual patients are neuropsychiatric symptoms, quality of life, and goal attainment. In addition, costs and cost-benefit ratios are of interest for the reimbursement of interventions.

Enhancement of the Neuroprotective Effect of Fermented Spirulina maxima Associated with Antioxidant Activities by Ultrasonic Extraction

This study is the first demonstration of the neuroprotective activity of the marine alga, Spirulina maxima, fermented by Lactobacillus plantarum HY-08, which was freshly isolated from fermented vegetables. The combined process of the fermentation with ultrasonic extraction at 40 kHz for 4 hr greatly increased the amounts of β-carotene in the extract up to 1.62 mg/g, along with a high extraction yield of 18.26%, compared to 1.03 mg/g and 12.8% from ultrasonic extraction itself, and even much higher than 0.81 mg/g and 10.6% from conventional water extraction. It was also proved that the neuroprotective activities of the extract were enhanced possibly by higher contents of β-carotene in the extract, compared to those from water extraction or ultrasonic extraction itself. This extract was found to have strong antioxidant properties, with 49.01% 1,1-diphenyl-2-picrylhydrazyl (DPPH) radical scavenging activity, which resulted in 90.30% neuroprotective activity. Specifically, the fermented extract markedly enhanced the brain-derived neurotrophic factor (BDNF)/p-CREB signaling pathways, which can effectively prevent memory impairment in mice caused by oxidative stress. β-Carotene also increased the expression of p-CREB and BDNF, and a mechanism of their upregulation by β-carotene is first proposed in this study. It can be concluded that the strong neuroprotective effect of the extract was markedly influenced by the antioxidant activities, due to the synergistic effects of high amounts of β-carotene and other biologically active substances in the extract that can be obtained by lactic acid fermentation, combined with ultrasonic processing.

Effect of Fermented Spirulina maxima Extract on Cognitive-Enhancing Activities in Mice with Scopolamine-Induced Dementia

This work provides the first demonstration that Spirulina maxima extract fermented with the lactic acid bacterium Lactobacillus planetarium HY-08 has the ability to ameliorate scopolamine-induced memory impairment in mice. The fermented extract exhibited good cognitive-enhancing activities, as demonstrated through Morris water maze and passive avoidance experiments: in these tests, the mice administered the fermented extract at a dose of 400 mg/kg exhibited an escape latency time and a latency time of 88.5 and 76.0 sec, respectively, whereas those administered donepezil, which was used as a positive control, showed an escape latency time and a latency time of 81.3 and 83.3 sec, respectively. However, an extract of 200 mg/kg was considered economically feasible for maintaining relatively high memory-improving activities because only a slight difference in activities was found between 200 and 400 mg/kg. The study also provides the first demonstration that β-carotene, one of the major bioactive substances in S. maxima, has memory-enhancing activity. A detailed analysis of the mechanism for the cognitive-enhancing activities of the fermented extract revealed that the fermented extract effectively increased the phosphorylation of both extracellular signal-regulated kinases (p-ERK) and p-cAMP response element-binding protein (p-CREB) and sequentially upregulated the expression of brain-derived neurotrophic factor (BDNF), whose signaling pathway responds to a reduction in oxidative stress in the brain. The results indicate that the improved efficacy of the fermented extract was likely due to the synergistic effects of β-carotene and other bioactive substances. Therefore, it can be concluded that the fermented extract exerts memory-improving effects in the hippocampus of scopolamine-treated mice through an initial increase in ERK signaling and a sequential induction of the expression of p-CREB and BDNF, and these effects are related to the antioxidant activities of β-carotene and other components.

A cross-sectional examination of the prevalence of psychotropic medications for people living with dementia in Australian long-term care facilities: issues of concern

ABSTRACTBackground:Behavioral and psychological symptoms of dementia (BPSD) are a common problem in long-term care facilities (LTC). Clinical guidelines dictate that first-line treatments for BPSD are psychosocial and behavioral interventions; if these are unsuccessful, psychotropic medications may be trialed at low doses and their effects can be monitored.

METHODS

There have previously been no studies with nationally representative samples to investigate psychotropic administration in LTCs in Australia. This study determines the prevalence of psychotropic administration in a representative stratified random sample of 446 residents living with dementia from 53 Australian LTCs. Questionnaire and medical chart data in this study is drawn from a larger cross-sectional, mixed methods study on quality of life in Australian LTCs.

RESULTS

It was found that 257 (58%) residents were prescribed psychotropic medications including: antipsychotics (n = 160, 36%), benzodiazepines (n = 136, 31%), antidepressants (n = 117, 26%), and anti-dementia medications (n = 9, 2%). BPSD were found to be very common in the sample, with 82% (n = 364) of participants experiencing at least one BPSD. The most prevalent BPSD were depression (n = 286, 70%) and agitation (n = 299, 67%).

CONCLUSIONS

Although detailed background information was not collected on individual cases, the prevalence found is indicative of systematic industry-wide, over-prescription of psychotropic medications as a first-line treatment for BPSD. This study highlights a clear need for further research and interventions in this area.

Treatment effects of Ginkgo biloba extract EGb 761® on the spectrum of behavioral and psychological symptoms of dementia: meta-analysis of randomized controlled trials

ABSTRACTBackground:In randomized controlled trials, Ginkgo biloba extract EGb 761® has been found to be effective in the treatment of behavioral and psychological symptoms of dementia (BPSD).

METHODS

To assess the effects of EGb 761® on specific BPSD, we analyzed data from all randomized, placebo-controlled, at least 20-week, trials of EGb 761® enrolling patients with dementia (probable Alzheimer's disease (AD), probable vascular dementia or probable AD with cerebrovascular disease) who had clinically significant BPSD (Neuropsychiatric Inventory (NPI) total score at least 6). Data were pooled and joint analyses of NPI single item composite and caregiver distress scores were performed by meta-analysis with a fixed effects model.

RESULTS

Four trials involving 1628 patients (EGb 761®, 814; placebo, 814) were identified; treatment duration was 22 or 24 weeks; the daily dose of EGb 761® was 240 mg in all trials. Pooled analyses including data from the full analysis sets of all trials (EGb 761®, 796 patients; placebo, 802 patients) revealed significant superiority of EGb 761® over placebo in total scores and 10 single symptom scores. Regarding caregiver distress scores, EGb 761®-treated patients improved significantly more than those receiving placebo in all symptoms except delusions, hallucinations, and elation/euphoria. The benefit of EGb 761® mainly consists of improvement in symptoms present at baseline, but the incidence of some symptoms was also decreased.

CONCLUSIONS

Twenty two- to twenty four-week treatment with Ginkgo biloba extract EGb 761® improved BPSD (except psychotic-like features) and caregiver distress caused by such symptoms.

The Effect of the Association between Donepezil and Choline Alphoscerate on Behavioral Disturbances in Alzheimer's Disease: Interim Results of the ASCOMALVA Trial

BACKGROUND

Behavioral and psychological symptoms of dementia (BPSD) are a group of psychological reactions, psychiatric symptoms, and behaviors commonly found in Alzheimer's disease (AD). Four clusters of BPSD have been described: mood disorders (depression, anxiety, and apathy), psychotic symptoms (delusions and hallucinations), aberrant motor behaviors (pacing, wandering, and other purposeless behaviors), and inappropriate behaviors (agitation, disinhibition, and euphoria). Most of them are attributed to acetylcholine deficiency.

OBJECTIVE

To evaluate if a higher amount of acetylcholine obtained by associating donepezil and choline alphoscerate might have a favorable effect on BPSD.

METHODS

BPSD were measured at baseline and after 24 months in 113 mild/moderate AD patients, included in the double-blind randomized trial ASCOMALVA, by the Neuropsychiatric Inventory (NPI). Two matched groups were compared: group A treated with donepezil (10 mg/day) plus choline alphoscerate (1200 mg/day), and group B treated with donepezil (10 mg/day) plus placebo.

RESULTS

Data of NPI revealed a significant decrease of BPSD severity and distress of the caregiver in patients of group A compared with group B. Mood disorders (depression, anxiety and apathy) were significantly decreased in subjects treated with donepezil and choline alphoscerate, while their severity and frequency was increased in the other group.

CONCLUSIONS

Patients treated with donepezil plus choline alphoscerate showed a lower level of behavioral disturbances than subjects treated with donepezil only, suggesting that the association can have beneficial effects.

Quality of Life in relation to neuropsychiatric symptoms in Alzheimer's disease: 5-year prospective ALSOVA cohort study

OBJECTIVE

To examine the association between neuropsychiatric symptoms (NPS) with self- and caregiver-rated Quality of Life (QoL) for patients with Alzheimer's disease (AD) during a 5-year follow-up.

METHODS

The ALSOVA 5-year follow-up study included, at baseline, 236 patients with either very mild (Clinical Dementia Rating Scale (CDR) 0.5), or mild (CDR 1) AD, together with their caregivers from three Finnish hospital districts. QoL was evaluated using patient self-reported, and caregiver-rated, QoL in AD (QoL-AD) scores. NPS were assessed using the Neuropsychiatric Inventory (NPI), and AD severity was evaluated using the CDR, with cognition tested by the mini-mental state examination. The performance of daily activities was assessed using the Alzheimer's Disease Cooperative Study-Activities of Daily Living Inventory.

RESULTS

Over the 5-year follow-up period, patient self-reported QoL-AD scores did not change significantly (p = 0.245), despite increases in their NPS. However, caregiver-rated patient QoL-AD scores declined significantly (p ≤ 0.001), as total NPI scores increased during follow-up. No NPS at baseline, and only apathy at follow-up, correlated significantly (p = 0.007) with patient self-rated QoL-AD scores. Caregiver-rated patient QoL-AD scores correlated significantly with most NPS, especially (p ≤ 0.001) apathy, agitation, anxiety, irritability, depression, and delusions at baseline, and delusions, hallucinations, apathy, appetite disturbances, and anxiety during follow-up.

CONCLUSIONS

Patient rated QoL-AD scores are an unreliable tool with which to evaluate the success of therapy for NPS. Instead, caregiver-rated scores for patients correlated well with NPI scores, and health care professionals in the clinic should preferentially use these. Copyright © 2017 John Wiley & Sons, Ltd.

Behavioral Emergencies: Special Considerations in the Geriatric Psychiatric Patient

This article reviews psychiatric considerations and common psychiatric emergencies in the elderly. The elderly are vulnerable to medication side-effects because of pharmacokinetic changes from aging, and require lower doses and slower titration. They are a high-risk group for suicide, with more serious intent, fewer warning signs, and more lethality. Prompt diagnosis and treatment of delirium in emergency settings is essential, given association with worse outcomes when undiagnosed. Pharmacologic options with demonstrable efficacy for agitation in dementia are limited to antipsychotics, which are, however, associated with an increased risk of mortality; behavioral interventions are universally recommended as first-line measures.

Systematic Review of Cholinesterase Inhibitors on Cognition and Behavioral Symptoms in Patients of Chinese Descent with Alzheimer's Disease, Vascular Dementia, or Mixed Dementia

Cholinesterase inhibitors (ChEIs) are the primary pharmacologic treatment for dementia. Their efficacy in patients of Chinese descent is not well described. We reviewed how ChEIs could affect cognition and behavioral and psychological symptoms (BPSD) in Chinese patients with Alzheimer’s disease (AD), vascular dementia (VaD), or mixed (AD with vascular component) dementia. MEDLINE, PsycINFO, EMBASE and CINAHL were systematically searched for controlled trials of ChEIs, including donepezil, galantamine, and rivastigmine, for Chinese patients with AD, VaD, or mixed dementia. Outcomes for cognition and BPSD were extracted for discussion. Fifty-four studies were identified. While one larger study found that dementia patients of Chinese descent treated with ChEIs had significantly higher mean Mini-Mental State Examination (MMSE) score, other studies showed no significant difference. Evidence on BPSD after use of ChEIs was also conflicting. ChEIs may be effective in improving cognition among patients of Chinese descent with dementia. Further studies are needed to examine the possible effects of ChEIs on BPSD in Chinese patients with dementia in view of the small number of studies and limitations in their methodologies.

Management of Depression in Patients with Dementia: Is Pharmacological Treatment Justified?

Depression in the context of dementia is common and contributes to poorer outcomes in individuals and those who care for them. Non-pharmacological treatments are the preferred initial approach to managing these symptoms but data in support of these are scarce. There are a number of pharmacological treatment options available to clinicians but efficacy is uncertain and concern about potential side effects in an aging and vulnerable population needs to be taken into consideration. This review aims to provide a concise overview of pharmacological treatments for depression in dementia. Antidepressants are the mainstay of pharmacological treatment for clinically significant depression in the general population but evidence to support their use in dementia is mixed. Trials of antidepressants should generally be reserved for individuals with depression where the symptoms are distressing and surpass the threshold for major depression. Acetylcholinesterase inhibitors and memantine are effective in the symptomatic treatment of Alzheimer's disease but current evidence does not support their use to treat depressive symptoms in dementia. Similarly, antipsychotics and mood stabilizers have no proven efficacy for depression and the risk of adverse effects seems to outweigh any potential benefit. Pain can be a frequent problem in dementia and may have significant effects on behavior and mood. Preliminary evidence supports a role of adequate analgesia in improving mood in people with dementia.

Novel 3-(1,2,3,6-Tetrahydropyridin-4-yl)-1H-indole-Based Multifunctional Ligands with Antipsychotic-Like, Mood-Modulating, and Procognitive Activity

The most troublesome aspects of behavioral and psychological symptoms of dementia (BPSD) are nowadays addressed by antidepressant, anxiolytic, and antipsychotic drugs, often administered off-label. Considering their modest effectiveness in dementia patients, the increased risk of adverse events and cognitive decline, there is an unmet need for well-tolerated and effective therapy of BPSD. We designed and synthesized multifunctional ligands characterized in vitro as high-affinity partial agonists of D₂R, antagonists of 5-HT₆R, and blockers of SERT. Moreover, the molecules activated 5-HT_1AR and blocked 5-HT₇R while having no relevant affinity for off-target M₁R and hERG channel. Compound 16 (N-{2-[4-(5-chloro-1H-indol-3-yl)-1,2,3,6-tetrahydropyridin-1-yl]ethyl}-3-methylbenzene-1-sulfonamide) exhibited a broad antipsychotic-, antidepressant-, and anxiolytic-like activity, not eliciting motor impairments in mice. Most importantly, 16 showed memory-enhancing properties and it ameliorated memory deficits induced by scopolamine. The molecule outperformed most important comparators in selected tests, indicating its potential in the treatment of both cognitive and noncognitive (behavioral and psychological) symptoms of dementia.

Pharmacotherapy for Dementia: A Practical Approach to the Use of Cholinesterase Inhibitors and Memantine

Cholinesterase inhibitors and memantine are the only classes of drugs approved for the treatment of dementia due to Alzheimer's disease. This article provides evidence-based recommendations to address the issues regarding the use of cholinesterase inhibitors and memantine in clinical practice. It includes their efficacy, timing, assessment, use in institutionalized patients, combined use, and use in other dementia types. However, most of the studies are of short duration (<1 year) and are mainly focused on cognitive and global improvement, whereas the practical issue of their use in daily practice such as optimal duration of treatment, long-term efficacy and delaying institutionalization are limited.

Making a Difference: A Study of Cognitive Stimulation Therapy for Persons with Dementia

Affecting nearly 5.4 million older adults in the United States and 35.6 million individuals worldwide, dementia is one of the greatest public health crises of our time. As a result, helping professionals, clients, and care partners seek effective and affordable treatment. Developed in the United Kingdom by Spector and colleagues, Cognitive Stimulation Therapy (CST) is a non-pharmacologic psychosocial group intervention for persons with dementia. To expand upon and fill the gaps within existing research, the authors developed a descriptive study to assess the impact of CST on cognition, quality of life, and depression, among six CST groups (n = 40). A paired sample t-test was run among pre- and post-test measures. There was a statistically significant difference in Saint Louis University Mental Status Exam (SLUMS) scores after CST (t = 2.80, p = 0.008). There was also a statistically significant difference in Cornell Scale for Depression in Dementia scores (t = -3.36, p = 0.002). There was no statistically significant difference in Quality of Life scores.

Yokukansan and Yokukansankachimpihange Ameliorate Aggressive Behaviors in Rats with Cholinergic Degeneration in the Nucleus Basalis of Meynert

Yokukansan (YKS) and yokukansankachimpihange (YKSCH) are traditional Japanese Kampo medicines. The latter comprises YKS along with the medicinal herbs Citrus unshiu peel and Pinellia tuber. Both of these Kampo medicines are indicated for the treatment of night crying and irritability in children and for neurosis and insomnia in adults. In recent clinical trials, YKS exhibited ameliorative effects on the behavioral and psychological symptoms of dementia, such as aggressiveness, excitement, and irritability. In the present study, we aimed to clarify the involvement of cholinergic degeneration in the nucleus basalis of Meynert (NBM) in the development of aggressiveness in rats. Subsequently, using this animal model, the effects of YKS and YKSCH on aggressiveness were compared and the mechanisms underlying these effects were investigated. L-Glutamic acid (Glu) was injected into the right NBM of rats to induce deterioration of cholinergic neurons. On day 8 after Glu injection, aggressive behaviors were evaluated using resident–intruder tests. After the evaluation, YKS or YKSCH was administered to rats with aggressive behaviors daily for 7 days. In some groups, the 5-HT_1A receptor antagonist WAY-100635 was coadministered with YKS or YKSCH over the same period. In other groups, locomotor activity was measured on days 12–14 after Glu injection. On day 15, immunohistochemistry was then performed to examine choline acetyltransferase (ChAT) activities in the NBM. Aggressive behaviors had developed on day 8 after Glu injection and were maintained until day 15. YKS and YKSCH significantly ameliorated the aggressive behaviors. These suppressive effects were entirely abolished following coadministration of WAY-100635. Finally, the number of ChAT-positive cells in the right NBM was significantly reduced on day 15 after Glu injection, and treatment with YKS or YKSCH did not ameliorate these reduced cell numbers. Our results show that unilateral Glu injections into the NBM of rats leads to the development of aggressive behaviors, which is thought to reflect cholinergic degeneration. YKS and YKSCH treatments ameliorated Glu-induced aggressive behaviors, and these effects were suggested to be mediated by 5-HT_1A receptor stimulation, but not by improvement of cholinergic degeneration.

Pharmacological Therapy for Apathy in Alzheimer’s Disease: A Systematic Review and Meta-Analysis

Introduction:Apathy is highly prevalent in Alzheimer’s disease (AD), but whether pharmacotherapy is effective in managing apathy is unclear.Methods:To assess the efficacy of pharmacotherapy for apathy in AD we searched for randomized controlled trials (RCT) and aggregate data reporting on apathy in several search engines, reference lists of articles, and reviews. Demographic characteristics and relevant data were extracted to assess apathy.Results:Fifteen RCTs’ were examined, and 11 were used in aggregate meta-analytic statistics. Drugs included were cholinesterase inhibitors, memantine, and psycho-stimulants. We found no significant treatment effect in favour of any of the drugs, and the effect-size estimates under a random effect model were heterogeneous. Most RCTs had a high attrition rate and used the NPI apathy subscale to measure apathy.Conclusion:The lack of an effect could be explained by methodological limitations, publication bias, and heterogeneity.

Management of Neuropsychiatric Symptoms in Neurocognitive Disorders

Dementias, renamed neurocognitive disorders (NCDs) in the DSM-5, are defined by acquired decline in cognitive and functional abilities. DSM-5 now also includes mild NCD, which incorporates the previous diagnosis of mild cognitive impairment. DSM-5 recognizes the following etiologies for NCDs: NCD due to Alzheimer's disease, vascular NCD, NCD with Lewy bodies, frontotemporal NCD, substance-/medication-induced NCD, NCD due to traumatic brain injury, NCD due to Huntington's disease, NCD due to HIV infection, NCD due to prion disease, and NCD due to other medical conditions. In this review, the authors discuss a wide variety of interventions that have been studied for the treatment and management of neuropsychiatric symptoms of patients with NCDs. In addition to nonpharmacological interventions, several classes of medications-including antipsychotics, antidepressants, anticonvulsants, and cholinesterase inhibitors-have been studied for this indication.

Efficacy of Ginkgo biloba extract EGb 761® in dementia with behavioural and psychological symptoms: A systematic review

OBJECTIVES

To review current evidence of efficacy of Ginkgo biloba extract EGb 761^® in dementia with behavioural and psychological symptoms (BPSD).

METHODS

Randomized, placebo-controlled trials assessing the effects of EGb 761^® in dementia patients with BPSD were included if the diagnosis was made in accordance with internationally accepted criteria, the treatment period was at least 22 weeks, outcome measures covered BPSD and at least two of the following domains of assessment, i.e. cognition, activities of daily living and clinical global assessment, and methodological quality was adequate. An analysis of covariance (ANCOVA) model was used to calculate the pooled effect estimates and to compare effects of EGb 761^® and placebo; furthermore, combined risk differences of response rates were calculated.

RESULTS

Four published trials were identified, involving altogether 1,628 outpatients with mild to moderate dementia. Least-square mean differences for change from baseline in cognition, BPSD (including caregiver distress rating), activities of daily living, clinical global impression, and quality of life favoured EGb 761^® (P < 0.001 for all comparisons).

CONCLUSIONS

The pooled analyses provide evidence of efficacy of EGb 761^® at a daily dose of 240 mg in the treatment of out-patients suffering from Alzheimer's, vascular or mixed dementia with BPSD.

Inappropriate behaviors and hypersexuality in individuals with dementia: An overview of a neglected issue

Behavioral and psychological symptoms of dementia are very common in patients affected by dementia, and are associated with high rates of institutionalization. Behavioral and psychological symptoms of dementia consist of aggressive behavior, delusions, hallucinations, depression, apathy, wandering, stereotyped and inappropriate sexual behavior. Interestingly, the latter has been reported to be relatively uncommon, but causing immense distress to patients and their caregivers. The genesis of inappropriate behavior is considered a combination of neurological, psychological and social factors. Although assessment is mainly carried out by clinical observation and interviews with caregivers, the most appropriate management of behavioral and psychological symptoms of dementia, including hypersexuality, is a combination of pharmacological and non-pharmacological interventions, according to specific symptoms, degree of cognitive dysfunction and subtype of dementia. The present narrative review will mainly focus on aggressiveness, disinhibition, aberrant motor, and sexually inappropriate behavior diagnostic work-up and treatment, in an attempt to provide both the patients and their caregivers with useful information to better manage these symptoms and improve their quality of life. Space is particularly dedicated to inappropriate sexual behavior, which is still considered a neglected issue. Geriatr Gerontol Int 2017; 17: 865-874.

The comparative efficacy and safety of cholinesterase inhibitors in patients with mild-to-moderate Alzheimer's disease: a Bayesian network meta-analysis

BACKGROUND

Comparative evidence for efficacy and safety of second-generation cholinesterase inhibitors (ChEIs) is still sparse.

OBJECTIVES

The purpose of this research is to compare three ChEIs, donepezil, galantamine and rivastigmine, in patients with mild-to-moderate Alzheimer's disease (AD).

METHODS

We conducted a systematic review for published articles and included randomised, double-blind, placebo-controlled trials and head-to-head randomised trials evaluating the efficacy and safety of ChEIs in patients with AD. We examined Alzheimer's Disease Assessment Scale, cognitive subscale (ADAS-Cog), Neuropsychiatric Inventory (NPI), Clinician's Interview-Based Impression of Change plus caregiver's input (CIBIC+) and Clinical Global Impression of Change (CGIC) as efficacy endpoints. Withdrawals due to adverse events and number of patients experiencing nausea, vomiting, diarrhoea and dizziness were examined as safety profiles. Network meta-analyses were sequentially performed for efficacy and safety outcomes based on drug/dose treatment conditions.

RESULTS

Among the 21 trials included, network meta-analysis showed that all treatments were significantly more efficacious than placebo in cognition measured by ADAS-Cog. All treatments except galantamine were significantly more efficacious than placebo in global change in CIBIC+ or CGIC. Across all conditions, no significant efficacy was observed in neuropsychiatric symptoms measured by NPI. Derived hierarchies in the efficacy of treatment conditions were variables across efficacy and safety.

CONCLUSIONS

Our analysis is the first attempt to incorporate available direct and indirect evidence. The results suggest that ChEIs should have significant efficacy for cognition and global change assessment, but the efficacy on neuropsychiatric symptoms is questionable in patients with mild-to-moderate AD.

Effects on agitation with rivastigmine patch monotherapy and combination therapy with memantine in mild to moderate Alzheimer's disease: a multicenter 24-week prospective randomized open-label study (the Korean EXelon Patch and combination with mEmantine Comparative Trial study)

AIM

Memantine is known to be effective in the treatment of the behavioral symptoms of dementia, especially agitation in moderate to severe Alzheimer's disease (AD). However, memantine and rivastigmine patch combination therapy has not been well studied in determining treatment effectiveness with mild to moderate AD patients.

METHODS

This was a multicenter, 24-week, prospective, randomized, open-label study design. A total 147 AD patients with Mini-Mental State Examination scores from 10 to 20 were randomly assigned to rivastigmine patch monotherapy and combination therapy with memantine groups. Agitation symptoms, using the Korean Version of the Cohen Mansfield Agitation Inventory were evaluated at baseline and at study end. Suppression and emergence of agitation symptoms were also evaluated. We carried out factor analyses to evaluate the interrelationship of agitation symptoms and to investigate treatment response in these symptoms.

RESULTS

Factor analyses showed two symptom clusters: factor A - aggressive agitated behaviors - versus factor B - non-aggressive agitated behaviors. The rivastigmine patch monotherapy group showed significantly decreased factor B scores and had a tendency of decreased Korean Version of the Cohen Mansfield Agitation Inventory total scores and factor A scores. Conversely, the combination therapy group showed significantly increased Korean Version of the Cohen Mansfield Agitation Inventory total scores and factor B scores. Neither monotherapy nor combination therapy reduced the emergence of new agitation symptoms.

CONCLUSIONS

In this trial of mild to moderate AD patients, the rivastigmine patch monotherapy group experienced a reduction of non-aggressive agitated behaviors. However, combination therapy with memantine did not show any benefit on the agitation associated with mild to moderate AD. Geriatr Gerontol Int 2017; 17: 494-499.

Mortality risk in current and new antipsychotic Alzheimer's disease users: Large scale Japanese study

INTRODUCTION

We studied the mortality risk of long term and new antipsychotic drug use in Alzheimer's disease (AD) patients in Japan to determine improved treatment protocols.

METHODS

This 24-week prospective cohort study included 10,079 Japanese AD patients (female, 69%; average age, 81 years) under routine clinical care in 357 medical sites. The antipsychotic medication history was varied (63.7% were long-term users). Mortality rates and odds ratio were analyzed (initial 10 weeks and from 11-24 weeks).

RESULTS

The antipsychotic exposed group with shorter treatment periods had a higher mortality risk compared to controls. The newly prescribed users (antipsychotic treatment started during the follow-up) showed increased mortality (9.4% during the 11-24 week period).

CONCLUSIONS

New use of antipsychotic drugs represents a distinct risk for mortality; those on long-term antipsychotic therapy seem to be at less risk. The warning issued 10 years earlier on antipsychotics use for AD patients should be reviewed.

Agitation and aggression in Alzheimer's disease: an update on pharmacological and psychosocial approaches to care

Agitation and aggression are prevalent in Alzheimer's disease and have significant consequences for the patient, caregiver and care system more generally. We briefly discuss the epidemiology and etiology of agitation and aggression in Alzheimer's disease and provide an overview of assessment and approaches to care. We then review the evidence for and against a number of pharmacological and psychosocial approaches to care. There has been a growth in the evidence base for psychosocial interventions and nonpharmacological approaches to care should ordinarily be the first option. Antipsychotics remain the pharmacological agents with most evidence to support their use while there is more limited evidence for other agents such as carbamazepine and selective serotonin reuptake inhibitors such as citalopram.

Progresses in treating agitation: a major clinical challenge in Alzheimer's disease

INTRODUCTION

Treatment of neuropsychiatric symptoms (NPS) represents a major clinical challenge in Alzheimer's disease (AD). Agitation and aggression are frequently seen during institutionalization and increase patient morbidity and mortality and caregiver burden. Off-label use of atypical antipsychotics for treating agitation in AD showed only modest clinical benefits, with high side-effect burden and risk of mortality. Non-pharmacological treatment approaches have become the preferred first-line option. When such treatment fails, pharmacological options are often used. Therefore, there is an urgent need to identify effective and safe pharmacological treatments for efficiently treating agitation and aggression in AD and dementia.

AREAS COVERED

Emerging evidence on the neurobiological substrates of agitation in AD has led to several recent clinical trials of repositioned and novel therapeutics for these NPS in dementia as an alternative to antipsychotics. We operated a comprehensive literature search for published articles evaluating pharmacological interventions for agitation in AD, with a review of recent clinical trials on mibampator, dextromethorphan/quinidine, cannabinoids, and citalopram.

EXPERT OPINION

Notwithstanding the renewed interest for the pharmacological treatment of agitation in AD, progresses have been limited. A small number and, sometimes methodologically questionable, randomized controlled trials (RCTs) have produced disappointing results. However, recently completed RCTs on novel or repositioned drugs (mibampator, dextromethorphan/quinidine, cannabinoids, and citalopram) showed some promise in treating agitation in AD, but still with safety concerns. Further evidence will come from ongoing Phase II and III trials on promising novel drugs for treating these distressing symptoms in patients with AD and dementia.

Molecular Docking and Pharmacological Investigations of Rivastigmine-Fluoxetine and Coumarin-Tacrine hybrids against Acetyl Choline Esterase

The present AChE inhibitors have been successful in the treatment of Alzheimer׳s Diseases however suffers serious side effects. Therefore in this view, the present study was sought to identify compounds with appreciable pharmacological profile targeting AChE. Analogue of Rivastigmine and Fluoxetine hybrid synthesized by Toda et al, 2003 (dataset1), and Coumarin-Tacrine hybrids synthesized by Qi Sun et al (dataset2) formed the test compounds for the present pharmacological evaluation. p-cholorophenyl substituted Rivastigmine and Fluoxetine hybrid compound (26d) from dataset 1 and -OCH3 substitute Coumarin-Tacrine hybrids (1h) from dataset 2 demonstrated superior pharmacological profile. 26 d showed superior pharmacological profile comparison to the entire compounds in either dataset owing to its better electrostatic interactions and hydrogen bonding patterns. In order to identify still better compound with pharmacological profile than 26 d and 1h, virtual screening was performed. The best docked compound (PubCId: PubCid: 68874404) showed better affinity than its parent 26 d, however showed poor ADME profile and AMES toxicity. CHEMBL2391475 (PubCid: 71699632) similar to 1h had reduced affinity in comparison to its parent compound 1h. From, our extensive analysis involving binding affinity analysis, ADMET properties predictions and pharmacophoric mappings, we report p-cholorophenyl substituted rivastigmine and fluoxetine hybrid (26d) to be a potential candidate for AcHE inhibition which in addition can overcome narrow therapeutic window of present AChE inhibitors in clinical treatment of Alzheimer׳s disease.

ABBREVIATIONS

AD - Alzheimer׳s Disease, AChE - Acetyl Choline Estarase, OPLS - Optimized Potentials for Liquid Simulations, PDB - Protein Data Bank.

Antiepileptic drugs for the treatment of agitation and aggression in dementia: do they have a place in therapy?

Antiepileptic drugs (AEDs) are a class of medications that have received considerable attention as possible treatments for agitation and aggression in patients with dementia. This attention has been driven in equal measure by promising findings from limited trial and observational data and the desire to find treatments with improved tolerability. Their use, to date, has been largely confined to circumstances where first-line treatments have proven inadequate or are poorly tolerated. In recent years there has been some growth in the evidence base, and we can now make more informed recommendations regarding a number of older AEDs. Carbamazepine continues to have the best evidence to support its use, although the evidence base remains relatively small and concerns regarding tolerability limit its use. There is now more consistent evidence that valproate preparations should not be used for agitation and aggression in dementia. Despite a lack of high-quality data, some results have been reported for several newer medications, including levetiracetam, oxcarbazepine, gabapentin, topiramate and lamotrigine, and a number of these warrant further investigation. Recent findings and implications for clinical practice are discussed.

Depressive symptoms in neurodegenerative diseases

Depressive symptoms are very common in chronic conditions. This is true so for neurodegenerative diseases. A number of patients with cognitive decline and dementia due to Alzheimer’s disease and related conditions like Parkinson’s disease, Lewy body disease, vascular dementia, frontotemporal degeneration amongst other entities, experience depressive symptoms in greater or lesser grade at some point during the course of the illness. Depressive symptoms have a particular significance in neurological disorders, specially in neurodegenerative diseases, because brain, mind, behavior and mood relationship. A number of patients may develop depressive symptoms in early stages of the neurologic disease, occurring without clear presence of cognitive decline with only mild cognitive deterioration. Classically, depression constitutes a reliable diagnostic challenge in this setting. However, actually we can recognize and evaluate depressive, cognitive or motor symptoms of neurodegenerative disease in order to establish their clinical significance and to plan some therapeutic strategies. Depressive symptoms can appear also lately, when the neurodegenerative disease is fully developed. The presence of depression and other neuropsychiatric symptoms have a negative impact on the quality-of-life of patients and caregivers. Besides, patients with depressive symptoms also tend to further decrease function and reduce cognitive abilities and also uses to present more affected clinical status, compared with patients without depression. Depressive symptoms are treatable. Early detection of depressive symptoms is very important in patients with neurodegenerative disorders, in order to initiate the most adequate treatment. We review in this paper the main neurodegenerative diseases, focusing in depressive symptoms of each other entities and current recommendations of management and treatment.

Use of anti-dementia drugs in home care and residential care and associations with neuropsychiatric symptoms: a cross-sectional study

Background

The number of people with dementia is increasing alongside the aging population, and most of these patients manifest with neuropsychiatric symptoms (NPS). The objective of this study was to investigate anti-dementia drug use and its associations with NPS.

Methods

Questionnaires on demographic information, current drug use, activities of daily living and NPS were sent to all municipal home care producers and to all institutions providing long-term residential care in the South Savo Hospital District, Finland.

Results

The study population comprised 2821 persons. Their mean age was 81 years and 68 % were female. Dementia had been diagnosed in 31 % (n = 410) in home care and in 56 % (n = 774) in residential care. Anti-dementia drugs were used by 69 % of patients with dementia. Hyperactivity symptoms were common in residential care patients (n = 456, 33 %), while problems with mood and apathy dominated in home care patients (n = 486, 54 %). In multivariate regression analysis, the mood symptoms and apathy subgroup was associated with use of an acetylcholinesterase inhibitor (AChEI) (OR 1.44; 95 % Cl 1.03–2.02), memantine (OR 1.77, 95 % Cl 1.15–2.72) or their combinations (OR 1.56, 95 % Cl 1.03-2.34). Hyperactivity symptoms were associated with combination therapy of this type (OR 2.03, 95 % Cl 1.36–2.34).

Conclusions

The use of anti-dementia drugs was common in both care settings. The use of any anti-dementia drug or combination was associated with the mood and apathy subgroup. The hyperactivity subgroup was associated with combination use of memantine and AChEI.