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Zhang Z, Zhang X, Xu L. Comparative efficacy and safety of olanzapine and risperidone in the treatment of psychiatric and behavioral symptoms of Alzheimer's disease: Systematic review and meta-analysis. Medicine (Baltimore) 2024; 103:e35663. [PMID: 38968479 PMCID: PMC11224812 DOI: 10.1097/md.0000000000035663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 09/25/2023] [Indexed: 07/07/2024] Open
Abstract
OBJECTIVES Olanzapine and risperidone have emerged as the most widely used drugs as short-term prescription in the treatment of behavioral disturbances in dementia. The present systematic review and meta-analysis was hence performed to investigate the effectiveness and safety profile of olanzapine and risperidone in the treatment of behavioral and psychological symptoms of dementia (BPSD), aiming to provide updated suggestion for clinical physicians and caregivers. DESIGN Prospective controlled clinical studies were included, of which available data was extracted. Outcomes of BEHAVE-AD scores with the variation of grades, specific behaviors variables, as well as safety signals were pooled for the analysis by odds rates and weighted mean differences, respectively. DATA SOURCES Medline, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), and WanFang. ELIGIBILITY CRITERIA Prospective, controlled clinical studies, conducted to compare the effectiveness and safety profile of olanzapine and risperidone in the treatment of BPSD. DATA EXTRACTION AND SYNTHESIS Interested data including baseline characteristics and necessary outcomes from the included studies were extracted independently by 2 investigators. BEHAVE-AD scale was adopted to assess the efficacy in the present study. All behaviors were evaluated at the time of the initiation of the treatment, as well as the completion of drugs courses. Adverse events were assessed with the criteria of Treatment Emergent Symptom Scale, or Coding Symbols for a Thesaurus of Adverse Reaction Terms dictionary. Weighted mean difference was used for the pooled analysis. RESULTS A total of 2427 participants were included in the present meta-analysis. Comparative OR on response rate, and remarkable response rate between olanzapine and risperidone was 0.65 (95% CI: 0.51-0.84; P = .0008), and 0.62 (95% CI: 0.50-0.78; P < .0001), respectively. There were statistical differences observed by olanzapine on the improvement of variables including delusions (WMD, -1.83, 95% CI, -3.20, -0.47), and nighttime behavior disturbances (WMD, -1.99, 95% CI, -3.60, -0.38) when compared to risperidone. CONCLUSION Our results suggested that olanzapine might be statistically superior to risperidone on the reduction of BPSD of Alzheimer's disease, especially in the relief of delusions and nighttime behavior disturbances. In addition, olanzapine was shown statistically lower risks of agitation, sleep disturbance, and extrapyramidal signs.
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Affiliation(s)
- Zhihua Zhang
- Department of Geriatric Psychiatry, Quzhou Third Hospital, Quzhou, China
| | - Xijuan Zhang
- Department of Geriatric Psychiatry, Quzhou Third Hospital, Quzhou, China
| | - Lingyan Xu
- Department of Geriatric Psychiatry, Quzhou Third Hospital, Quzhou, China
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Cummings J, Lanctot K, Grossberg G, Ballard C. Progress in Pharmacologic Management of Neuropsychiatric Syndromes in Neurodegenerative Disorders: A Review. JAMA Neurol 2024; 81:645-653. [PMID: 38558015 PMCID: PMC11164642 DOI: 10.1001/jamaneurol.2024.0586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Importance Neuropsychiatric syndromes (NPSs) are common in neurodegenerative disorders (NDDs); compromise the quality of life of patients and their care partners; and are associated with faster disease progression, earlier need for nursing home care, and poorer quality of life. Advances in translational pharmacology, clinical trial design and conduct, and understanding of the pathobiology of NDDs are bringing new therapies to clinical care. Observations Consensus definitions have evolved for psychosis, agitation, apathy, depression, and disinhibition in NDDs. Psychosocial interventions may reduce mild behavioral symptoms in patients with NDD, and pharmacotherapy is available for NPSs in NDDs. Brexpiprazole is approved for treatment of agitation associated with Alzheimer disease dementia, and pimavanserin is approved for treatment of delusions and hallucinations associated with psychosis of Parkinson disease. Trials are being conducted across several of the NDDs, and a variety of mechanisms of action are being assessed for their effect on NPSs. Conclusions and Relevance Detection and characterization of NPSs in patients with NDDs is the foundation for excellent care. New definitions for NPSs in NDDs may inform choices regarding clinical trial populations and translate into clinical practice. Psychosocial and pharmacologic therapies may reduce behavioral symptoms and improve quality of life for patients and caregivers. Approved agents may establish regulatory precedents, demonstrate successful trial strategies, and provide the foundation for further advances in treatment development.
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Affiliation(s)
- Jeffrey Cummings
- Chambers-Grundy Center for Transformative Neuroscience, Department of Brain Health, School of Integrated Health Sciences, University of Nevada, Las Vegas
| | - Krista Lanctot
- Departments of Psychiatry and Pharmacology, University of Toronto, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - George Grossberg
- Department of Psychiatry and Behavioral Neuroscience, Saint Louis University School of Medicine, St Louis, Missouri
| | - Clive Ballard
- Exeter University Medical School, University of Exeter, Exeter, United Kingdom
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Jørgensen SM, Lech LVJ, Vermehren C, Schiøtz ML, Andersen JT, Karstoft K, Andersen T, Hansen SV, Birke H. Healthcare professionals' experiences with the use of antipsychotics in dementia. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2024; 14:100446. [PMID: 38845613 PMCID: PMC11152969 DOI: 10.1016/j.rcsop.2024.100446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 04/19/2024] [Accepted: 04/19/2024] [Indexed: 06/09/2024] Open
Abstract
Background Antipsychotics are commonly administered to nursing home residents with dementia, despite the associated risk of severe adverse events. Objective This study aimed to explore healthcare professionals' experiences in caring for nursing home residents with dementia, with a focus on rationales behind the use of antipsychotics. Method Twelve semi-structured interviews with healthcare professionals' from Danish nursing homes were conducted and analyzed using the method Systematic Text Condensation. Results Nonpharmacological interventions were reported as the primary approach to care and the first-choice treatment for behavioral and psychological symptoms of dementia (BPSD). Use of antipsychotics was considered to serve as a last resort, reserved for residents with severe symptoms. However, most informants preferred a more limited use. The study identified four main barriers to reduce the use of antipsychotics: "Scarcity of resources", "Perceiving antipsychotic use to provide relieve", "Reluctance towards deprescribing" and "Limited access to medical counseling", and three potential enablers: "Updating knowledge and nonpharmacological competencies", "Management support and clear procedures" and "Regularity in interdisciplinary collaboration". Conclusion The treatment and care were reported as primarily following guidelines in BPSD. Several barriers were perceived to challenge the healthcare professionals' preference of limited use of antipsychotics. To further reduce the use, this study highlights the importance of understanding the adverse effects caused by limited resources, enhancing employee knowledge and competencies and ensuring regular interprofessional collaboration for assessing and reassessing the need to use antipsychotics.
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Affiliation(s)
- Sidsel Maria Jørgensen
- Center for Clinical Research and Prevention, Copenhagen University Hospital - Bispebjerg and Frederiksberg Hospital, Nordre Fasanvej 57, 2000 Frederiksberg, Denmark
| | - Laura Victoria Jedig Lech
- Department of Clinical Pharmacology, Copenhagen University Hospital - Bispebjerg and Frederiksberg Hospital, Bispebjerg Bakke 23, 2400 Copenhagen NV, Denmark
| | - Charlotte Vermehren
- Department of Clinical Pharmacology, Copenhagen University Hospital - Bispebjerg and Frederiksberg Hospital, Bispebjerg Bakke 23, 2400 Copenhagen NV, Denmark
- Department of Drug Design and Pharmacology, Faculty of Health Sciences, University of Copenhagen, Universitetsparken 2, 2100 Copenhagen, Denmark
- Capital Region Pharmacy, Copenhagen University Hospital - Bispebjerg and Frederiksberg hospital, Bispebjerg Bakke 23, 2400 Copenhagen NV, Denmark
| | - Michaela L. Schiøtz
- Center for Clinical Research and Prevention, Copenhagen University Hospital - Bispebjerg and Frederiksberg Hospital, Nordre Fasanvej 57, 2000 Frederiksberg, Denmark
| | - Jon Trærup Andersen
- Department of Clinical Pharmacology, Copenhagen University Hospital - Bispebjerg and Frederiksberg Hospital, Bispebjerg Bakke 23, 2400 Copenhagen NV, Denmark
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark
| | - Kristian Karstoft
- Department of Clinical Pharmacology, Copenhagen University Hospital - Bispebjerg and Frederiksberg Hospital, Bispebjerg Bakke 23, 2400 Copenhagen NV, Denmark
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark
| | - Tina Andersen
- Hillerød Municipality, Hillerød Rådhus, Trollesminde allé 27, 3400 Hillerød, Denmark
| | - Stine Vest Hansen
- Hillerød Municipality, Hillerød Rådhus, Trollesminde allé 27, 3400 Hillerød, Denmark
| | - Hanne Birke
- Center for Clinical Research and Prevention, Copenhagen University Hospital - Bispebjerg and Frederiksberg Hospital, Nordre Fasanvej 57, 2000 Frederiksberg, Denmark
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Singh AK, Malviya R, Prakash A, Verma S. Neuropsychiatric Manifestations in Alzheimer's Disease Patients: Genetics and Treatment Options. CNS & NEUROLOGICAL DISORDERS DRUG TARGETS 2024; 23:39-54. [PMID: 36856177 DOI: 10.2174/1871527322666230301111216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 12/03/2022] [Accepted: 12/27/2022] [Indexed: 03/02/2023]
Abstract
BACKGROUND Alzheimer's disease (AD) is characterized by neuropsychiatric symptoms (NPS), which cause great misery to those with dementia and those who care for them and may lead to early institutionalization. OBJECTIVE The present systematic review aims to discuss the various aspects of Alzheimer's, including treatment options. METHODS The databases Embase, PubMed, and Web of Science were searched to collect data. RESULTS Incipient cognitive deterioration is commonly accompanied by these early warning signals of neurocognitive diseases. The neurobiology of NPSs in Alzheimer's disease, as well as particular symptoms, including psychosis, agitation, apathy, sadness, and sleep disorders, will be examined in this review. For NPSs in Alzheimer's disease, clinical trial designs, as well as regulatory issues, were also addressed. A fresh wave of research, however, is helping to push the discipline ahead. For medication development and repurposing, we highlight the most recent results in genetics, neuroimaging, and neurobiology. Even though identifying and treating psychosis in adults with dementia is still a challenging endeavor, new options are coming up that give the field fresh focus and hope. Conclsuion: It can be concluded from the complete literature survey that Alzheimer's-related psychosis as well as other symptoms that are not psychotic, have made significant progress in the last decade. These milestones in the development of safer, more effective treatments have been achieved as a consequence of great focus on non-pharmacological interventions like DICE or WHELD; the investigation into ways to improve existing drugs like aripiprazole, risperidone, amisulpride, and Escitalopram for safer precision-based treatment; and the development of a clinical trial program for pimavanserin.
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Affiliation(s)
- Arun Kumar Singh
- Department of Pharmacy, School of Medical and Allied Sciences, Galgotias University Greater Noida, Uttar Pradesh, India
| | - Rishabha Malviya
- Department of Pharmacy, School of Medical and Allied Sciences, Galgotias University Greater Noida, Uttar Pradesh, India
| | - Anuj Prakash
- Reference Standard Division, Indian Pharmacopoeia Commission, Sec-23, Raj Nagar, Ghaziabad, Uttar Pradesh, India
| | - Swati Verma
- Department of Pharmacy, School of Medical and Allied Sciences, Galgotias University Greater Noida, Uttar Pradesh, India
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Bhat MA, Dhaneshwar S. Neurodegenerative Diseases: New Hopes and Perspectives. Curr Mol Med 2024; 24:1004-1032. [PMID: 37691199 DOI: 10.2174/1566524023666230907093451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 07/10/2023] [Accepted: 07/27/2023] [Indexed: 09/12/2023]
Abstract
Alzheimer's disease, Parkinson's disease, Amyotrophic lateral sclerosis, Huntington's disease, and Friedrich ataxia are all incurable neurodegenerative diseases defined by the continuous progressive loss of distinct neuronal subtypes. Despite their rising prevalence among the world's ageing population, fewer advances have been made in the concurrent massive efforts to develop newer drugs. Recently, there has been a shift in research focus towards the discovery of new therapeutic agents for neurodegenerative diseases. In this review, we have summarized the recently developed therapies and their status in the management of neurodegenerative diseases.
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Affiliation(s)
- Mohammad Aadil Bhat
- Amity Institute of Pharmacy, Lucknow, Amity University Uttar Pradesh, Noida, UP, India
| | - Suneela Dhaneshwar
- Amity Institute of Pharmacy, Amity University Maharashtra, Mumbai, Maharashtra, India
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Hirschberg Y, Valle‐Tamayo N, Dols‐Icardo O, Engelborghs S, Buelens B, Vandenbroucke RE, Vermeiren Y, Boonen K, Mertens I. Proteomic comparison between non-purified cerebrospinal fluid and cerebrospinal fluid-derived extracellular vesicles from patients with Alzheimer's, Parkinson's and Lewy body dementia. J Extracell Vesicles 2023; 12:e12383. [PMID: 38082559 PMCID: PMC10714029 DOI: 10.1002/jev2.12383] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 10/16/2023] [Accepted: 11/09/2023] [Indexed: 12/18/2023] Open
Abstract
Dementia is a leading cause of death worldwide, with increasing prevalence as global life expectancy increases. The most common neurodegenerative disorders are Alzheimer's disease (AD), dementia with Lewy bodies (DLB) and Parkinson's disease dementia (PDD). With this study, we took an in-depth look at the proteome of the (non-purified) cerebrospinal fluid (CSF) and the CSF-derived extracellular vesicles (EVs) of AD, PD, PD-MCI (Parkinson's disease with mild cognitive impairment), PDD and DLB patients analysed by label-free mass spectrometry. This has led to the discovery of differentially expressed proteins that may be helpful for differential diagnosis. We observed a greater number of differentially expressed proteins in CSF-derived EV samples (N = 276) compared to non-purified CSF (N = 169), with minimal overlap between both datasets. This finding suggests that CSF-derived EV samples may be more suitable for the discovery phase of a biomarker study, due to the removal of more abundant proteins, resulting in a narrower dynamic range. As disease-specific markers, we selected a total of 39 biomarker candidates identified in non-purified CSF, and 37 biomarker candidates across the different diseases under investigation in the CSF-derived EV data. After further exploration and validation of these proteins, they can be used to further differentiate between the included dementias and may offer new avenues for research into more disease-specific pharmacological therapeutics.
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Affiliation(s)
- Yael Hirschberg
- Health UnitFlemish Institute for Technological Research (VITO)MolBelgium
- Centre for Proteomics (CfP)University of AntwerpAntwerpBelgium
| | - Natalia Valle‐Tamayo
- Department of Neurology, Sant Pau Memory Unit, Sant Pau Biomedical Research InstituteHospital de la Santa Creu i Sant Pau, Universitat Autònoma de BarcelonaBarcelonaSpain
- Network Center for Biomedical Research in Neurodegenerative Diseases (CIBERNED)MadridSpain
| | - Oriol Dols‐Icardo
- Department of Neurology, Sant Pau Memory Unit, Sant Pau Biomedical Research InstituteHospital de la Santa Creu i Sant Pau, Universitat Autònoma de BarcelonaBarcelonaSpain
- Network Center for Biomedical Research in Neurodegenerative Diseases (CIBERNED)MadridSpain
| | - Sebastiaan Engelborghs
- Department of Neurology and Bru‐BRAINUniversitair Ziekenhuis Brussel and NEUR Research Group, Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB)BrusselsBelgium
- Department of Biomedical SciencesUniversity of AntwerpAntwerpBelgium
| | - Bart Buelens
- Data Science Hub, Flemish Institute for Technological Research (VITO)MolBelgium
| | - Roosmarijn E. Vandenbroucke
- VIB Center for Inflammation Research, VIBGhentBelgium
- Department of Biomedical Molecular BiologyGhent UniversityGhentBelgium
| | - Yannick Vermeiren
- Faculty of Medicine & Health Sciences, Translational NeurosciencesUniversity of AntwerpAntwerpBelgium
- Division of Human Nutrition and Health, Chair Group of Nutritional BiologyWageningen University & Research (WUR)WageningenThe Netherlands
| | - Kurt Boonen
- Health UnitFlemish Institute for Technological Research (VITO)MolBelgium
- Centre for Proteomics (CfP)University of AntwerpAntwerpBelgium
| | - Inge Mertens
- Health UnitFlemish Institute for Technological Research (VITO)MolBelgium
- Centre for Proteomics (CfP)University of AntwerpAntwerpBelgium
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7
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Ballard C. Brexpiprazole for the Treatment of Agitation and Aggression in Alzheimer Disease. JAMA Neurol 2023; 80:1272-1273. [PMID: 37930677 DOI: 10.1001/jamaneurol.2023.3967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Affiliation(s)
- Clive Ballard
- University of Exeter Medical School, University of Exeter, Exeter, United Kingdom
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8
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Boyanova ST, Lloyd-Morris E, Corpe C, Rahman KM, Farag DB, Page LK, Wang H, Fleckney AL, Gatt A, Troakes C, Vizcay-Barrena G, Fleck R, Reeves SJ, Thomas SA. Interaction of amisulpride with GLUT1 at the blood-brain barrier. Relevance to Alzheimer's disease. PLoS One 2023; 18:e0286278. [PMID: 37874822 PMCID: PMC10597500 DOI: 10.1371/journal.pone.0286278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 09/27/2023] [Indexed: 10/26/2023] Open
Abstract
Blood-brain barrier (BBB) dysfunction may be involved in the increased sensitivity of Alzheimer's disease (AD) patients to antipsychotics, including amisulpride. Studies indicate that antipsychotics interact with facilitated glucose transporters (GLUT), including GLUT1, and that GLUT1 BBB expression decreases in AD. We tested the hypotheses that amisulpride (charge: +1) interacts with GLUT1, and that BBB transport of amisulpride is compromised in AD. GLUT1 substrates, GLUT1 inhibitors and GLUT-interacting antipsychotics were identified by literature review and their physicochemical characteristics summarised. Interactions between amisulpride and GLUT1 were studied using in silico approaches and the human cerebral endothelial cell line, hCMEC/D3. Brain distribution of [3H]amisulpride was determined using in situ perfusion in wild type (WT) and 5xFamilial AD (5xFAD) mice. With transmission electron microscopy (TEM) we investigated brain capillary degeneration in WT mice, 5xFAD mice and human samples. Western blots determined BBB transporter expression in mouse and human. Literature review revealed that, although D-glucose has no charge, charged molecules can interact with GLUT1. GLUT1 substrates are smaller (184.95±6.45g/mol) than inhibitors (325.50±14.40g/mol) and GLUT-interacting antipsychotics (369.38±16.04). Molecular docking showed beta-D-glucose (free energy binding: -15.39kcal/mol) and amisulpride (-29.04kcal/mol) interact with GLUT1. Amisulpride did not affect [14C]D-glucose hCMEC/D3 accumulation. [3H]amisulpride uptake into the brain (except supernatant) of 5xFAD mice compared to WT remained unchanged. TEM revealed brain capillary degeneration in human AD. There was no difference in GLUT1 or P-glycoprotein BBB expression between WT and 5xFAD mice. In contrast, caudate P-glycoprotein, but not GLUT1, expression was decreased in human AD capillaries versus controls. This study provides new details about the BBB transport of amisulpride, evidence that amisulpride interacts with GLUT1 and that BBB transporter expression is altered in AD. This suggests that antipsychotics could potentially exacerbate the cerebral hypometabolism in AD. Further research into the mechanism of amisulpride transport by GLUT1 is important for improving antipsychotics safety.
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Affiliation(s)
- Sevda T. Boyanova
- King’s College London, Institute of Pharmaceutical Science, London, United Kingdom
| | - Ethlyn Lloyd-Morris
- King’s College London, Institute of Pharmaceutical Science, London, United Kingdom
| | - Christopher Corpe
- King’s College London, Department of Nutritional Sciences, School of Life Course Sciences, Faculty of Life Sciences and Medicine, London, United Kingdom
| | | | - Doaa B. Farag
- Faculty of Pharmacy, Misr International University, Cairo, Egypt
| | - Lee K. Page
- King’s College London, Institute of Pharmaceutical Science, London, United Kingdom
| | - Hao Wang
- King’s College London, Institute of Pharmaceutical Science, London, United Kingdom
| | - Alice L. Fleckney
- King’s College London, Institute of Pharmaceutical Science, London, United Kingdom
| | - Ariana Gatt
- King’s College London, Wolfson Centre for Age Related Disease, London, United Kingdom
| | - Claire Troakes
- King’s College London, London Neurodegenerative Diseases Brain Bank, IoPPN, London, United Kingdom
| | - Gema Vizcay-Barrena
- King’s College London, Centre for Ultrastructural Imaging, London, United Kingdom
| | - Roland Fleck
- King’s College London, Centre for Ultrastructural Imaging, London, United Kingdom
| | - Suzanne J. Reeves
- Faculty of Brain Sciences, University College London, London, United Kingdom
| | - Sarah A. Thomas
- King’s College London, Department of Physiology, London, United Kingdom
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9
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Trenaman SC, Quach J, Bowles SK, Kirkland S, Andrew MK. An investigation of psychoactive polypharmacy and related gender-differences in older adults with dementia: a retrospective cohort study. BMC Geriatr 2023; 23:683. [PMID: 37864154 PMCID: PMC10590009 DOI: 10.1186/s12877-023-04353-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 09/26/2023] [Indexed: 10/22/2023] Open
Abstract
BACKGROUND Older adults living with dementia may express challenging responsive behaviours. One management strategy is pharmacologic treatment though these options often have limited benefit, which may lead to multiple treatments being prescribed. METHODS The aim of the present study was to describe psychoactive medication polypharmacy and explore factors associated with psychoactive polypharmacy in a cohort of older adults living with dementia in Nova Scotia, Canada, including a gender-stratified analysis. This was a retrospective cohort study of those aged 65 years or older with a recorded diagnosis of dementia between 2005 and 2015. Medication dispensation data was collected from April 1, 2010, or dementia diagnosis (cohort entry) to either death or March 31, 2015 (cohort exit). Psychoactive medication claims were captured. Psychoactive medication polypharmacy was defined as presence of three or more psychoactive prescription medications dispensed to one subject and overlapping for more than 30 days. Psychoactive polypharmacy episodes were described in duration, quantity, and implicated medications. Regression analysis examined factors associated with experience and frequency of psychoactive polypharmacy. All analysis were stratified by gender. RESULTS The cohort included 15,819 adults living with dementia (mean age 80.7 years; 70.0% female), with 99.4% (n = 15,728) receiving at least one psychoactive medication over the period of follow-up. Psychoactive polypharmacy was present in 19.3% of the cohort. The gender specific logistic regressions demonstrated that for both men and women a younger age was associated with an increased risk of psychoactive polypharmacy (women: OR 0.97, 95%CI[0.96, 0.98], men: OR 0.96, 95%CI[0.95, 0.97]). Men were less likely to experience psychoactive polypharmacy if their location of residence was urban (OR 0.86, 95%CI[0.74, 0.99]). There was no significant association between location of residence (urban or rural) and psychoactive polypharmacy for women living with dementia. Antidepressants were the most dispensed medication class, while quetiapine was the most dispensed medication. CONCLUSIONS This study suggests that of adults living with dementia those of younger ages were more likely to experience psychoactive polypharmacy and that men living with dementia in rural locations may benefit from increased access to non-pharmacological options for dementia management.
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Affiliation(s)
- Shanna C Trenaman
- College of Pharmacy, Faculty of Health, Dalhousie University, 5968 College Street, PO Box 15000, B3H 4R2, Halifax, NS, Canada.
- Division of Geriatric Medicine, Department of Medicine, Dalhousie University, Halifax, Canada.
| | - Jack Quach
- Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | - Susan K Bowles
- College of Pharmacy, Faculty of Health, Dalhousie University, 5968 College Street, PO Box 15000, B3H 4R2, Halifax, NS, Canada
- Division of Geriatric Medicine, Department of Medicine, Dalhousie University, Halifax, Canada
- Nova Scotia Health, Halifax, NS, Canada
| | - Susan Kirkland
- Division of Geriatric Medicine, Department of Medicine, Dalhousie University, Halifax, Canada
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS, Canada
| | - Melissa K Andrew
- Division of Geriatric Medicine, Department of Medicine, Dalhousie University, Halifax, Canada
- Nova Scotia Health, Halifax, NS, Canada
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS, Canada
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10
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Ryan SL, Liu X, McKenna V, Ghanta M, Muniz C, Renwick R, Westover MB, Kimchi EY. Associations between early in-hospital medications and the development of delirium in patients with stroke. J Stroke Cerebrovasc Dis 2023; 32:107249. [PMID: 37536017 PMCID: PMC10529367 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107249] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 06/29/2023] [Accepted: 07/06/2023] [Indexed: 08/05/2023] Open
Abstract
OBJECTIVES Patients hospitalized with stroke develop delirium at higher rates than general hospitalized patients. While several medications are associated with existing delirium, it is unknown whether early medication exposures are associated with subsequent delirium in patients with stroke. Additionally, it is unknown whether delirium identification is associated with changes in the prescription of these medications. MATERIALS AND METHODS We conducted a retrospective cohort study of patients admitted to a comprehensive stroke center, who were assessed for delirium by trained nursing staff during clinical care. We analyzed exposures to multiple medication classes in the first 48 h of admission, and compared them between patients who developed delirium >48 hours after admission and those who never developed delirium. Statistical analysis was performed using univariate testing. Multivariable logistic regression was used further to evaluate the significance of univariately significant medications, while controlling for clinical confounders. RESULTS 1671 unique patients were included in the cohort, of whom 464 (27.8%) developed delirium >48 hours after admission. Delirium was associated with prior exposure to antipsychotics, sedatives, opiates, and antimicrobials. Antipsychotics, sedatives, and antimicrobials remained significantly associated with delirium even after accounting for several clinical covariates. Usage of these medications decreased in the 48 hours following delirium identification, except for atypical antipsychotics, whose use increased. Other medication classes such as steroids, benzodiazepines, and sleep aids were not initially associated with subsequent delirium, but prescription patterns still changed after delirium identification. CONCLUSIONS Early exposure to multiple medication classes is associated with the subsequent development of delirium in patients with stroke. Additionally, prescription patterns changed following delirium identification, suggesting that some of the associated medication classes may represent modifiable targets for future delirium prevention strategies, although future study is needed.
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Affiliation(s)
- Sophia L Ryan
- Department of Neurology, Massachusetts General Hospital, USA; Department of Neurology, Mount Sinai Medical Center, India
| | - Xiu Liu
- Department of Neurology, Massachusetts General Hospital, USA; Lawrence Center for Quality and Safety, Massachusetts General Hospital, USA
| | - Vanessa McKenna
- Department of Neurology, Massachusetts General Hospital, USA
| | - Manohar Ghanta
- Department of Neurology, Massachusetts General Hospital, USA
| | - Carlos Muniz
- Department of Neurology, Massachusetts General Hospital, USA; Department of Neurology, SUNY Upstate Medical University, USA
| | - Rachel Renwick
- Department of Neurology, Massachusetts General Hospital, USA
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, USA; Department of Neurology, Beth Israel Deaconess Medical Center, USA
| | - Eyal Y Kimchi
- Department of Neurology, Massachusetts General Hospital, USA; Department of Neurology, Northwestern University, USA.
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Perez SM, Boley AM, McCoy AM, Lodge DJ. Aberrant Dopamine System Function in the Ferrous Amyloid Buthionine (FAB) Rat Model of Alzheimer's Disease. Int J Mol Sci 2023; 24:7196. [PMID: 37108357 PMCID: PMC10138591 DOI: 10.3390/ijms24087196] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/06/2023] [Accepted: 04/11/2023] [Indexed: 04/29/2023] Open
Abstract
Antipsychotics increase the risk of death in elderly patients with Alzheimer's disease (AD). Thus, there is an immediate need for novel therapies to treat comorbid psychosis in AD. Psychosis has been attributed to a dysregulation of the dopamine system and is associated with aberrant regulation by the hippocampus. Given that the hippocampus is a key site of pathology in AD, we posit that aberrant regulation of the dopamine system may contribute to comorbid psychosis in AD. A ferrous amyloid buthionine (FAB) rodent model was used to model a sporadic form of AD. FAB rats displayed functional hippocampal alterations, which were accompanied by decreases in spontaneous, low-frequency oscillations and increases in the firing rates of putative pyramidal neurons. Additionally, FAB rats exhibited increases in dopamine neuron population activity and augmented responses to the locomotor-inducing effects of MK-801, as is consistent with rodent models of psychosis-like symptomatology. Further, working memory deficits in the Y-maze, consistent with an AD-like phenotype, were observed in FAB rats. These data suggest that the aberrant hippocampal activity observed in AD may contribute to dopamine-dependent psychosis, and that the FAB model may be useful for the investigation of comorbid psychosis related to AD. Understanding the pathophysiology that leads to comorbid psychosis in AD will ultimately lead to the discovery of novel targets for the treatment of this disease.
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Affiliation(s)
- Stephanie M. Perez
- Department of Pharmacology and Center for Biomedical Neuroscience, UT Health San Antonio, San Antonio, TX 78229, USA; (A.M.B.); (D.J.L.)
- South Texas Veterans Health Care System, Audie L. Murphy Division, San Antonio, TX 78229, USA
| | - Angela M. Boley
- Department of Pharmacology and Center for Biomedical Neuroscience, UT Health San Antonio, San Antonio, TX 78229, USA; (A.M.B.); (D.J.L.)
- South Texas Veterans Health Care System, Audie L. Murphy Division, San Antonio, TX 78229, USA
| | - Alexandra M. McCoy
- Department of Pharmacology and Center for Biomedical Neuroscience, UT Health San Antonio, San Antonio, TX 78229, USA; (A.M.B.); (D.J.L.)
- South Texas Veterans Health Care System, Audie L. Murphy Division, San Antonio, TX 78229, USA
| | - Daniel J. Lodge
- Department of Pharmacology and Center for Biomedical Neuroscience, UT Health San Antonio, San Antonio, TX 78229, USA; (A.M.B.); (D.J.L.)
- South Texas Veterans Health Care System, Audie L. Murphy Division, San Antonio, TX 78229, USA
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12
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Chadborn NH, Devi R, Goodman C, Williams CD, Sartain K, Gordon AL. General practitioners' role in improving health care in care homes: a realist review. Fam Pract 2023; 40:119-127. [PMID: 35781333 PMCID: PMC9909664 DOI: 10.1093/fampra/cmac071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Despite recent focus on improving health care in care homes, it is unclear what role general practitioners (GPs) should play. To provide evidence for future practice we set out to explore how GPs have been involved in such improvements. METHODS Realist review incorporated theory-driven literature searches and stakeholder interviews, supplemented by focussed searches on GP-led medication reviews and end-of-life care. Medline, Embase, CINAHL, PsycInfo, Web of Science, and the Cochrane library were searched. Grey literature was identified through internet searches and professional networks. Studies were included based upon relevance. Data were coded to develop and test contexts, mechanisms, and outcomes for improvements involving GPs. RESULTS Evidence was synthesized from 30 articles. Programme theories described: (i) "negotiated working with GPs," where other professionals led improvement and GPs provided expertise; and (ii) "GP involvement in national/regional improvement programmes." The expertise of GPs was vital to many improvement programmes, with their medical expertise or role as coordinators of primary care proving pivotal. GPs had limited training in quality improvement (QI) and care home improvement work had to be negotiated in the context of wider primary care commitments. CONCLUSIONS GPs are central to QI in health care in care homes. Their contributions relate to their specialist expertise and recognition as leaders of primary care but are challenged by available time and resources to develop this role.
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Affiliation(s)
- Neil H Chadborn
- Unit of Injury, Inflammation and Recovery Sciences, University of Nottingham, Derby, United Kingdom.,NIHR Applied Research Collaboration-East Midlands (ARC-EM), Nottingham, United Kingdom
| | - Reena Devi
- School of Healthcare, University of Leeds, Leeds, United Kingdom
| | - Claire Goodman
- Centre for Research in Public Health and Community Care, University of Hertfordshire, Hatfield, United Kingdom.,NIHR Applied Research Collaboration-East of England (ARC-EoE), Cambridge, United Kingdom
| | | | - Kate Sartain
- School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Adam L Gordon
- Unit of Injury, Inflammation and Recovery Sciences, University of Nottingham, Derby, United Kingdom.,NIHR Applied Research Collaboration-East Midlands (ARC-EM), Nottingham, United Kingdom.,University Hospitals of Derby and Burton NHS Foundation Trust, Derby, United Kingdom
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13
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McDermid J, Ballard C, Khan Z, Aarsland D, Fox C, Fossey J, Clare L, Moniz‐Cook E, Soto‐Martin M, Sweetnam A, Mills K, Cummings J, Corbett A. Impact of the Covid-19 pandemic on neuropsychiatric symptoms and antipsychotic prescribing for people with dementia in nursing home settings. Int J Geriatr Psychiatry 2023; 38:e5878. [PMID: 36704984 PMCID: PMC10286750 DOI: 10.1002/gps.5878] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/09/2023] [Indexed: 01/18/2023]
Abstract
OBJECTIVES This study aimed to determine the impact of the Covid-19 pandemic on neuropsychiatric symptoms and antipsychotic use in people with dementia living in nursing homes. METHODS This was a comparative analysis of baseline data from two large nursing home studies, one conducted during (COVID-iWHELD study) and one prior (WHELD study) to the pandemic. It involves data from 69 and 149 nursing homes, and 1006 and 666 participants respectively. Participants were people with established dementia (score >1 on Clinical Dementia Rating Scale). Resident data included demographics, antipsychotic prescriptions and neuropsychiatric symptoms using the Neuropsychiatric Inventory Nursing Home version. Nursing home data collected were nursing home size and staffing information. RESULTS Overall prevalence of neuropsychiatric symptoms was unchanged from pre-pandemic prevalence. Mean antipsychotic use across the sample was 32.0%, increased from 18% pre-pandemic (Fisher's exact test p < 0.0001). At a nursing home level, the medians for the low, medium and high tertiles for antipsychotic use were 7%, 20% and 59% respectively, showing a disproportionate rise in tertile three. Residents in these homes also showed a small but significant increase in agitation. CONCLUSION There has been a significant increase in antipsychotic prescribing in nursing homes since the COVID-19 pandemic, with a disproportionate rise in one third of homes, where median prescription rates for antipsychotics were almost 60%. Strategies are urgently needed to identify these nursing homes and introduce pro-active support to bring antipsychotic prescription rates back to pre-pandemic levels.
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Affiliation(s)
- Joanne McDermid
- University of Exeter Medical SchoolUniversity of ExeterExeterUK
- Institute of Psychiatry, Psychology and NeuroscienceKing's College LondonLondonUK
| | - Clive Ballard
- University of Exeter Medical SchoolUniversity of ExeterExeterUK
| | - Zunera Khan
- Institute of Psychiatry, Psychology and NeuroscienceKing's College LondonLondonUK
| | - Dag Aarsland
- Institute of Psychiatry, Psychology and NeuroscienceKing's College LondonLondonUK
| | - Chris Fox
- University of Exeter Medical SchoolUniversity of ExeterExeterUK
| | - Jane Fossey
- University of Exeter Medical SchoolUniversity of ExeterExeterUK
| | - Linda Clare
- University of Exeter Medical SchoolUniversity of ExeterExeterUK
- NIHR Applied Research Collaboration South‐West PeninsulaExeterUK
| | | | | | | | - Kathryn Mills
- University of Exeter Medical SchoolUniversity of ExeterExeterUK
| | - Jeffrey Cummings
- Chambers‐Grundy Center for Transformative NeuroscienceDepartment of Brain HealthSchool of Integrated Health SciencesUniversity of Nevada Las Vegas (UNLV)Las VegasNevadaUSA
| | - Anne Corbett
- University of Exeter Medical SchoolUniversity of ExeterExeterUK
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14
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Malik R, Kalra S, Bhatia S, Harrasi AA, Singh G, Mohan S, Makeen HA, Albratty M, Meraya A, Bahar B, Tambuwala MM. Overview of therapeutic targets in management of dementia. Biomed Pharmacother 2022; 152:113168. [PMID: 35701303 DOI: 10.1016/j.biopha.2022.113168] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 05/17/2022] [Accepted: 05/18/2022] [Indexed: 11/16/2022] Open
Abstract
Dementia is defined as a gradual cognitive impairment that interferes with everyday tasks, and is a leading cause of dependency, disability, and mortality. According to the current scenario, millions of individuals worldwide have dementia. This review provides with an overview of dementia before moving on to its subtypes (neurodegenerative and non-neurodegenerative) and pathophysiology. It also discusses the incidence and severity of dementia, focusing on Alzheimer's disease with its different hypotheses such as Aβ cascade hypothesis, Tau hypothesis, inflammatory hypothesis, cholinergic and oxidative stress hypothesis. Alzheimer's disease is the most common type and a progressive neurodegenerative illness distinct by neuronal loss and resulting cognitive impairment, leading to dementia. Alzheimer's disease (AD) is considered the most familiar neurodegenerative dementias that affect mostly older population. There are still no disease-modifying therapies available for any dementias at this time, but there are various methods for lowering the risk to dementia patients by using suitable diagnostic and evaluation methods. Thereafter, the management and treatment of primary risk elements of dementia are reviewed. Finally, the future perspectives of dementia (AD) focusing on the impact of the new treatment are discussed.
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Affiliation(s)
- Rohit Malik
- Department of Pharmaceutical Sciences, Maharshi Dayanand University, Rohtak, Haryana, India
| | - Sunishtha Kalra
- Department of Pharmaceutical Sciences, Maharshi Dayanand University, Rohtak, Haryana, India
| | - Saurabh Bhatia
- School of Health Sciences, University of Petroleum and Energy Studies, Dehradun, Uttarakhand, India; Natural & Medical Sciences Research Centre, University of Nizwa, Birkat Al Mauz, Oman
| | - Ahmed Al Harrasi
- Natural & Medical Sciences Research Centre, University of Nizwa, Birkat Al Mauz, Oman
| | - Govind Singh
- Department of Pharmaceutical Sciences, Maharshi Dayanand University, Rohtak, Haryana, India.
| | - Syam Mohan
- School of Health Sciences, University of Petroleum and Energy Studies, Dehradun, Uttarakhand, India; Substance Abuse and Toxicology Research Centre, Jazan University, Jazan, Saudi Arabia
| | - Hafiz A Makeen
- Pharmacy Practice Research Unit, Clinical Pharmacy Department, College of Pharmacy, Jazan University, Jazan, Saudi Arabia
| | - Mohammed Albratty
- Department of Pharmaceutical Chemistry, College of Pharmacy, Jazan University, Jazan, Saudi Arabia
| | - Abdulkarim Meraya
- Substance Abuse and Toxicology Research Centre, Jazan University, Jazan, Saudi Arabia
| | - Bojlul Bahar
- Nutrition Sciences and Applied Food Safety Studies, Research Centre for Global Development, School of Sport & Health Sciences, University of Central Lancashire, Preston, UK
| | - Murtaza M Tambuwala
- School of Pharmacy and Pharmaceutical Science, Ulster University, Coleraine, UK.
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15
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Agüera-Ortiz L, Babulal GM, Bruneau MA, Creese B, D'Antonio F, Fischer CE, Gatchel JR, Ismail Z, Kumar S, McGeown WJ, Mortby ME, Nuñez NA, de Oliveira FF, Pereiro AX, Ravona-Springer R, Rouse HJ, Wang H, Lanctôt KL. Psychosis as a Treatment Target in Dementia: A Roadmap for Designing Interventions. J Alzheimers Dis 2022; 88:1203-1228. [PMID: 35786651 PMCID: PMC9484097 DOI: 10.3233/jad-215483] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Psychotic phenomena are among the most severe and disruptive symptoms of dementias and appear in 30% to 50% of patients. They are associated with a worse evolution and great suffering to patients and caregivers. Their current treatments obtain limited results and are not free of adverse effects, which are sometimes serious. It is therefore crucial to develop new treatments that can improve this situation. We review available data that could enlighten the future design of clinical trials with psychosis in dementia as main target. Along with an explanation of its prevalence in the common diseases that cause dementia, we present proposals aimed at improving the definition of symptoms and what should be included and excluded in clinical trials. A review of the available information regarding the neurobiological basis of symptoms, in terms of pathology, neuroimaging, and genomics, is provided as a guide towards new therapeutic targets. The correct evaluation of symptoms is transcendental in any therapeutic trial and these aspects are extensively addressed. Finally, a critical overview of existing pharmacological and non-pharmacological treatments is made, revealing the unmet needs, in terms of efficacy and safety. Our work emphasizes the need for better definition and measurement of psychotic symptoms in dementias in order to highlight their differences with symptoms that appear in non-dementing diseases such as schizophrenia. Advances in neurobiology should illuminate the development of new, more effective and safer molecules for which this review can serve as a roadmap in the design of future clinical trials.
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Affiliation(s)
- Luis Agüera-Ortiz
- Department of Psychiatry, Instituto de Investigación Sanitaria (imas12), Hospital Universitario 12 de Octubre, & Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Instituto de Salud Carlos III, Madrid, Spain
| | - Ganesh M Babulal
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA.,Department of Clinical Research and Leadership, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA.,Department of Psychology, Faculty of Humanities, University of Johannesburg, South Africa
| | - Marie-Andrée Bruneau
- Department of Psychiatry and Addictology, Faculty of Medicine, University of Montreal, Quebec, Canada.,Geriatric Institute of Montreal Research Center, Montreal, Quebec, Canada
| | - Byron Creese
- Medical School, College of Medicine and Health, University of Exeter, UK
| | | | - Corinne E Fischer
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Ontario, Canada.,University of Toronto, Department of Psychiatry, Toronto, Ontario, Canada
| | - Jennifer R Gatchel
- Harvard Medical School; Massachusetts General Hospital, Boston MA, USA.,McLean Hospital, Belmont MA, USA
| | - Zahinoor Ismail
- Hotchkiss Brain Institute & O'Brien Institute for Public Health, University of Calgary, Calgary, Canada
| | - Sanjeev Kumar
- Adult Neurodevelopmental and Geriatric Psychiatry Division, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - William J McGeown
- School of Psychological Sciences and Health, University of Strathclyde, Glasgow, UK
| | - Moyra E Mortby
- School of Psychology, University of New South Wales, Sydney, Australia & Neuroscience Research Australia, Sydney, Australia
| | - Nicolas A Nuñez
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Fabricio F de Oliveira
- Department of Neurology and Neurosurgery, Escola Paulista de Medicina, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Arturo X Pereiro
- Facultade de Psicoloxía, Universidade de Santiago de Compostela, Spain
| | - Ramit Ravona-Springer
- Sheba Medical Center, Tel Hashomer, Israel & Sackler School of Medicine, Tel Aviv University, Israel
| | - Hillary J Rouse
- School of Aging Studies, University of South Florida, Tampa, FL, USA.,SiteRx, New York, NY, USA
| | - Huali Wang
- Dementia Care and Research Center, Peking University Institute of Mental Health; National & Clinical Research Center for Mental Disorders, Beijing, China
| | - Krista L Lanctôt
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute and Departments of Psychiatry and Pharmacology, University of Toronto, Toronto, Ontario, Canada
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16
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Roßmeier C, Gast J, Riedl L, Hartmann J, Kohl S, Hartmann F, Diehl-Schmid J. [Deprescribing of antipsychotic drugs for dementia : Recommendations for action on dose reduction and discontinuation attempts]. DER NERVENARZT 2022; 93:912-920. [PMID: 35771240 PMCID: PMC9243982 DOI: 10.1007/s00115-022-01343-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 05/02/2022] [Indexed: 11/06/2022]
Abstract
Hintergrund In Leitlinien zur Behandlung von psychischen und Verhaltenssymptomen bei Demenz („Behavioral and Psychological Symptoms of Dementia“ [BPSD]) wird empfohlen, Antipsychotika im Falle einer notwendigen Therapie zeitlich begrenzt und in möglichst geringer Dosis einzusetzen. Fragestellung Um das Bewusstsein für die Risiken einer Antipsychotikabehandlung bei Patient:innen mit Demenz und die dadurch begründete Notwendigkeit einer zeitlich begrenzten und möglichst niedrig dosierten Antipsychotikabehandlung zu schärfen, wurden Handlungsempfehlungen zum Deprescribing von Antipsychotika bei Menschen mit Demenz entwickelt. Material und Methoden Die Entwicklung der Handlungsempfehlungen erfolgte in einem mehrstufigen Prozess: 1. Literaturrecherche unter besonderer Würdigung von konsentierten Leitlinienempfehlungen und Ergebnissen einer eigenen Interventionsstudie (READY-Studie), 2. Diskussion und Konsentierung in einem Expert:innengremium, 3. Onlineumfrage von in Deutschland tätigen ärztlichen Demenzexpert:innen. Ergebnisse Aus 51 im ersten Entwurf zusammengestellten Aussagen wurden nach der Diskussion im multiprofessionellen Expert:innengremium 32 Aussagen zum „Deprescribing“ (Reduktion und Ausschleichen) von Antipsychotika formuliert. 25 der 32 Aussagen wurden nach Konsentierung in einer Onlineumfrage durch ärztliche Demenzexpert:innen final übernommen. Diskussion In Deutschland gibt es bislang keine konkreten Empfehlungen zur Vorgehensweise bei Reduktion und Absetzen von Antipsychotika, die zur Behandlung von BPSD bei Menschen mit Demenz eingesetzt werden. Die vorgelegte Arbeit soll als Handlungsempfehlung für Haus- und Fachärzt:innen dienen. Bei den Empfehlungen handelt es sich um keine Leitlinien, sie ersetzen nicht die Eigenverantwortlichkeit der Behandelnden und das individuell notwendige Vorgehen in Abhängigkeit von der Behandlungssituation. Zusatzmaterial online Die Onlineversion dieses Beitrags (10.1007/s00115-022-01343-w) enthält zusätzliches Material. Beitrag und Zusatzmaterial stehen Ihnen auf www.springermedizin.de zur Verfügung. Bitte geben Sie dort den Beitragstitel in die Suche ein, die Videos finden Sie beim Beitrag unter „Ergänzende Inhalte“.
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Affiliation(s)
- Carola Roßmeier
- Fakultät für Medizin, Klinik und Poliklinik für Psychiatrie und Psychotherapie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland. .,Fachbereich Alterspsychiatrie, kbo-Inn-Salzach-Klinikum GmbH, Gabersee 7, 83512, Wasserburg am Inn, Deutschland.
| | - Jennifer Gast
- Fakultät für Medizin, Klinik und Poliklinik für Psychiatrie und Psychotherapie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - Lina Riedl
- Fakultät für Medizin, Klinik und Poliklinik für Psychiatrie und Psychotherapie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - Julia Hartmann
- Fakultät für Medizin, Klinik und Poliklinik für Psychiatrie und Psychotherapie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - Sarah Kohl
- Fakultät für Medizin, Klinik und Poliklinik für Psychiatrie und Psychotherapie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - Florentine Hartmann
- Fakultät für Medizin, Klinik und Poliklinik für Psychiatrie und Psychotherapie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - Janine Diehl-Schmid
- Fakultät für Medizin, Klinik und Poliklinik für Psychiatrie und Psychotherapie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland.,Fachbereich Alterspsychiatrie, kbo-Inn-Salzach-Klinikum GmbH, Gabersee 7, 83512, Wasserburg am Inn, Deutschland
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17
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Impact of Psychotic Symptoms and Concurrent Neuropsychiatric Symptoms on the Quality of Life of People With Dementia Living in Nursing Homes. J Am Med Dir Assoc 2022; 23:1474-1479.e1. [DOI: 10.1016/j.jamda.2022.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 03/18/2022] [Accepted: 03/26/2022] [Indexed: 11/22/2022]
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18
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Brandt T, Frangiosa T, Biggar V, Taylor A, Valentine J, Keller B, Price M, DeMuro C, Abler V. Symptoms and Treatment Needs of People with Dementia-Related Psychosis: A Mixed-Methods Study of the Patient Experience. Clin Gerontol 2022; 45:681-695. [PMID: 34369313 DOI: 10.1080/07317115.2021.1957050] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES This study describes the person-centered experience and impact of symptoms and the treatment needs of dementia-related psychosis (DRP) from a patient and care partner perspective. METHODS Qualitative interviews and a quantitative survey were used to collect patient experience data from persons with DRP or their care partners. RESULTS Sixteen participants (1 person with DRP, 15 care partners) completed the qualitative interview; 212 participants (26 persons with DRP, 186 care partners) completed the quantitative survey. The most commonly reported symptoms were visual hallucinations, auditory hallucinations, persecutory delusions, and distortion of senses. The most common impacts were difficulty differentiating what is real from what is not real, increased anxiety, and effects on personal relationships. Current treatments were less than moderately helpful, and the ability to distinguish what is real from what is not real and overall symptom improvement were described as the most important benefits of an ideal treatment. CONCLUSIONS Patient experience data provide insights into urgent therapeutic needs of patients by describing the nature, frequency, and severity of symptoms and the impacts they have on individuals' lives. CLINICAL IMPLICATIONS Patient experience data demonstrate an unmet need for treatments to reduce the symptoms and impacts of DRP.
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Affiliation(s)
- Teresa Brandt
- Acadia Pharmaceuticals Inc, San Diego, California, USA
| | | | | | - Angela Taylor
- Lewy Body Dementia Association, Lilburn, Georgia, USA
| | - James Valentine
- Hyman, Phelps & McNamara, P.C, Washington, DC, USA.,Carey School of Law, University of Maryland, Baltimore, Maryland, USA
| | - Bill Keller
- Acadia Pharmaceuticals Inc, San Diego, California, USA
| | - Mark Price
- RTI Health Solutions, Research Triangle Park, North Carolina, USA
| | - Carla DeMuro
- RTI Health Solutions, Research Triangle Park, North Carolina, USA
| | - Victor Abler
- Acadia Pharmaceuticals Inc, San Diego, California, USA
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19
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Drewitt L, Martin K, Atkinson C, Marczak M. Providing music therapy for people with dementia in an acute mental health setting. Nurs Stand 2022; 37:77-82. [PMID: 35466659 DOI: 10.7748/ns.2022.e11796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2022] [Indexed: 11/09/2022]
Abstract
As global figures for dementia are set to rise significantly, there has been a shift towards using non-pharmacological interventions such as music therapy to enhance the quality of life for people with the condition. Research into music therapy interventions for this patient group in acute mental health inpatient settings, however, is limited. This article describes a service evaluation that explored whether group music therapy was effective for people with dementia in such settings. Open group music therapy sessions were hosted weekly in two acute wards and the researchers examined the social and behavioural outcomes of participants pre and post-intervention. The results indicated that music therapy significantly improved patient outcomes following participation. The outcome measure developed for this service evaluation was found to be a reliable tool for measuring the effectiveness of music therapy on patient outcomes.
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Affiliation(s)
- Leah Drewitt
- School of Psychological, Social and Behavioural Sciences, Coventry University, Coventry, England
| | - Kate Martin
- Coventry and Warwick Partnership NHS Trust, Coventry, England
| | - Chris Atkinson
- Coventry and Warwick Partnership NHS Trust, Coventry, England
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20
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Ismail Z, Creese B, Aarsland D, Kales HC, Lyketsos CG, Sweet RA, Ballard C. Psychosis in Alzheimer disease - mechanisms, genetics and therapeutic opportunities. Nat Rev Neurol 2022; 18:131-144. [PMID: 34983978 PMCID: PMC9074132 DOI: 10.1038/s41582-021-00597-3] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2021] [Indexed: 12/14/2022]
Abstract
Psychosis is a common and distressing symptom in people with Alzheimer disease, and few safe and effective treatments are available. However, new approaches to symptom assessment and treatment are beginning to drive the field forward. New nosological perspectives have been provided by incorporating the emergence of psychotic symptoms in older adults - even in advance of dementia - into epidemiological and neurobiological frameworks as well as into diagnostic and research criteria such as the International Psychogeriatric Association criteria for psychosis in neurocognitive disorders, the Alzheimer's Association International Society to Advance Alzheimer's Research and Treatment (ISTAART) research criteria for psychosis in neurodegenerative disease, and the ISTAART criteria for mild behavioural impairment. Here, we highlight the latest findings in genomics, neuroimaging and neurobiology that are informing approaches to drug discovery and repurposing. Current pharmacological and non-pharmacological treatment options are discussed, with a focus on safety and precision medicine. We also explore trial data for pimavanserin, a novel agent that shows promise for the treatment of psychosis in people with dementia, and discuss existing agents that might be useful but need further exploration such as escitalopram, lithium, cholinesterase inhibitors and vitamin D. Although the assessment and management of psychosis in people with dementia remain challenging, new opportunities are providing direction and hope to the field.
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Affiliation(s)
- Zahinoor Ismail
- Departments of Psychiatry, Clinical Neurosciences, Community Health Sciences, and Pathology, Hotchkiss Brain Institute and O'Brien Institute of Public Health, University of Calgary, Calgary, AB, Canada
| | - Byron Creese
- University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Dag Aarsland
- Department of Old Age Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Helen C Kales
- Department of Psychiatry and Behavioral Sciences, UC Davis School of Medicine, University of California, Sacramento, CA, USA
| | - Constantine G Lyketsos
- Department of Psychiatry and Behavioral Science, Johns Hopkins Bayview, Johns Hopkins University, Baltimore, MD, USA
| | - Robert A Sweet
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Clive Ballard
- Department of Old Age Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
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21
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Pearce D, Gould RL, Roughley M, Reynolds G, Ward EV, Bhome R, Reeves S. Paranoid and misidentification subtypes of psychosis in dementia. Neurosci Biobehav Rev 2022; 134:104529. [PMID: 35032536 DOI: 10.1016/j.neubiorev.2022.104529] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 10/22/2021] [Accepted: 01/09/2022] [Indexed: 11/24/2022]
Abstract
This study aimed to review the neurobiological and neuropsychological correlates of paranoid (persecutory delusions) and misidentification (misidentification delusions and/or hallucinations) subtypes of psychosis in dementia, to establish if they represent distinct subphenotypes. Nine studies were eligible, all included patients with Alzheimer's disease. Greater global cognitive deficits and an accelerated global cognitive decline were observed in the misidentification subtype. Neuroimaging studies showed more marked volume loss in multiple regions in patients with the misidentification subtype, including those involved in object recognition and the processing of information on spatial and temporal context. A single study found greater impairment in visual sustained attention and object recognition in the misidentification subtype. The small number of studies and methodological heterogeneity limit interpretation of the findings. Nevertheless, these findings would tentatively suggest that there may be additional or accelerated pathological change in functional networks involved in visuoperceptual processing in the misidentification subtype. This should be further explored in prospective studies and the investigation extended to other forms of dementia, to gain a transdiagnostic perspective.
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Affiliation(s)
- Danielle Pearce
- Division of Psychiatry, University College London, W1T 7NF, UK
| | - Rebecca L Gould
- Division of Psychiatry, University College London, W1T 7NF, UK
| | | | - Gemma Reynolds
- Middlesex University, The Burroughs, London, NW4 4BT, UK
| | - Emma V Ward
- Middlesex University, The Burroughs, London, NW4 4BT, UK
| | - Rohan Bhome
- Division of Psychiatry, University College London, W1T 7NF, UK
| | - Suzanne Reeves
- Division of Psychiatry, University College London, W1T 7NF, UK.
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Rashid N, Wetmore JB, Irfan M, Abler V. Adverse Outcomes Associated With Off-Label Agents Used to Treat Dementia Patients With Psychosis: A Case-Control Medicare Database Study. Am J Alzheimers Dis Other Demen 2022; 37:15333175221081374. [PMID: 35331005 PMCID: PMC10623966 DOI: 10.1177/15333175221081374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Currently, there are no Food and Drug Administration-approved therapies to treat dementia-related psychosis (DRP). This study investigated the association between using antipsychotics and the anticonvulsant divalproex (sodium valproate) to manage DRP and adverse outcomes. METHODS A retrospective case/control matching study evaluated the risk of mortality, extrapyramidal symptoms (EPS), ischemic stroke, and cardiac arrest/ventricular arrhythmia (CA/VA) with ever-use of antipsychotics/divalproex in patients with DRP vs never-use. RESULTS 49 509 patients were included; 76.8% used an antipsychotic/divalproex. Treatment ever-use was associated with an increased risk of all-cause mortality (odds ratio, 1.14; 95% CI, 1.10-1.18) and a smaller increase in the risk of EPS (1.10; 1.00-1.19) relative to never-use (adjusted for matching demographic variables, comorbid conditions, and disability). CONCLUSIONS Current agents used for DRP were associated with increased risk of death and adverse outcomes. An increased risk of death was evident within 3 months of antipsychotic/divalproex initiation and persisted with long-term use.
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Affiliation(s)
| | - James B. Wetmore
- Division of Nephrology, Hennepin County Medical Center, Minneapolis, MN, USA
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Muna Irfan
- University of Minnesota and Veterans Affairs Medical Center, Minneapolis, MN, USA
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23
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Kristensson JH, Zahirovic I, Londos E, Modig S. Medications causing potential cognitive impairment are common in nursing home dementia units – A cross-sectional study. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2021; 3:100054. [PMID: 35480606 PMCID: PMC9031036 DOI: 10.1016/j.rcsop.2021.100054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 07/14/2021] [Accepted: 08/03/2021] [Indexed: 11/26/2022] Open
Abstract
Background With advancing age the brain becomes more sensitive to centrally acting drugs thus increasing the risk of cognitive side-effects. The Swedish National Board of Health and Welfare developed indicators to measure and follow quality in older people's drug therapy, one being “Potentially Inappropriate Medications risking Cognitive impairment (PIMcogn)”. Associations between anticholinergics and cognitive impairment are described, especially in persons with Alzheimer's disease or Lewy Body Dementia/Parkinson's disease dementia, due to degenerated cholinergic pathways. Objectives To examine the prevalence of PIMcogn and if it differed between nursing home residents with and without a dementia diagnosis and between residents with different dementia aetiologias. Methods Descriptive cross-sectional study, based on residents ≥65 years in nursing home dementia units in Malmö, Sweden, in 2012–2013 (N = 574). Results The study population consisted of 76% women, the mean age was 86 years and a dementia diagnosis was registered in 92%. A total of 74% were prescribed at least one PIMcogn. Benzodiazepines were prevalent in 59%, opioids in 27%, antipsychotics in 20% and anticholinergics in 13%. Opioids used regularly and antiepileptics were more common in residents without a dementia diagnosis. The lowest proportion of anticholinergics was seen in the oldest age group, 11.0%. There was no difference seen in anticholinergics between dementia types with considerable cholinergic deficit and other dementia diagnoses. Conclusions Treatment with at least one PIMcogn was common. Usage of benzodiazepines and antipsychotics was, despite the knowledge of alarming side-effects, high. An awareness of the inappropriateness in prescribing anticholinergics to the oldest old seems to be apparent, but not to persons with cholinergic deficit. Benzodiazepine use was alarmingly high, despite the knowledge of increased risk of sedation, cognitive impairment, delirium and fall in older people. Antipsychotics were common in residents with dementia. This is worrying since alarming side-effects are seen in these persons and treatment effects of antipsychotics are modest in BPSD. An awareness of the inappropriateness in prescribing anticholinergics to the oldest old seem to be apparent, but not to persons with cholinergic deficit due to Alzheimer's disease or LBD/PDD.
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24
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Habiger TF, Achterberg WP, Flo-Groeneboom E, Mannseth J, Husebo BS. Managing Pain and Psychosis Symptoms in Nursing Home Patients: Results from a Cluster-Randomized Controlled Trial (COSMOS). J Am Med Dir Assoc 2021; 22:1692-1698. [PMID: 34087225 DOI: 10.1016/j.jamda.2021.05.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 04/22/2021] [Accepted: 05/02/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVES In nursing homes (NHs), 30% to 60% of patients experience daily pain and >80% have dementia. This can lead to neuropsychiatric symptoms, including psychosis symptoms such as delusion. We investigated if there was a relationship between pain and psychosis symptoms over time. We also aimed to investigate the effect of a multicomponent intervention (COSMOS) on pain, psychosis symptoms, and analgesic prescription. DESIGN COSMOS is a cluster-randomized, single blinded, controlled trial. Each NH unit was defined as a cluster and randomized to either the COSMOS intervention or care as usual. The COSMOS intervention is a multicomponent intervention, consisting of staff training in communication, pain treatment, medication review, organization of activities, and safety. The intervention lasted for 4 months with a follow-up at month 9. SETTING AND PARTICIPANTS Sixty-seven units from 33 Norwegian NHs in 8 municipalities. The study included 723 patients aged ≥65 years, residing at the NH ≥2 weeks before inclusion. Patients with a life expectancy <6 months were excluded. MEASURES Pain was measured using the Mobilization-Observation-Behavior-Intensity-Dementia Pain Scale. Psychosis symptoms were measured using the Neuropsychiatric Inventory-NH version. Measurements were performed at baseline, and months 4 and 9. RESULTS Multilevel Mixed-Effect statistical analysis found that psychosis symptoms as a group (odds ratio [OR] 2.03, P = .009), and delusion (OR 2.12, P = .007) were associated with pain over time. No significant intervention effect on psychosis symptoms was observed. Compared with the control group, people with dementia in the intervention group experienced less musculoskeletal pain (β: -0.47, P = .047). Analgesic prescription was not affected by the intervention. CONCLUSION AND IMPLICATIONS Pain is associated with psychosis symptoms, and pain assessment should be done when making treatment decisions on psychosis symptoms in NH patients. The COSMOS intervention improved musculoskeletal pain in people with dementia, but not psychosis symptoms, and there is need for further studies on treatment of psychosis symptoms in NH patients.
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Affiliation(s)
- Torstein F Habiger
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway.
| | - Wilco P Achterberg
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway; Department of Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, Leiden University Medical Centre, Netherlands
| | - Elisabeth Flo-Groeneboom
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway; Department of Clinical Psychology, Faculty of Psychology, University of Bergen, Bergen, Norway
| | - Janne Mannseth
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway
| | - Bettina S Husebo
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway; Municipality of Bergen, Bergen, Norway
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25
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Burstein ES. Relevance of 5-HT 2A Receptor Modulation of Pyramidal Cell Excitability for Dementia-Related Psychosis: Implications for Pharmacotherapy. CNS Drugs 2021; 35:727-741. [PMID: 34224112 PMCID: PMC8310514 DOI: 10.1007/s40263-021-00836-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/09/2021] [Indexed: 01/05/2023]
Abstract
Psychosis occurs across a wide variety of dementias with differing etiologies, including Alzheimer's dementia, Parkinson's dementia, Lewy body dementia, frontotemporal dementia, and vascular dementia. Pimavanserin, a selective serotonin 5-HT2A receptor (5-HT2AR) inverse agonist, has shown promising results in clinical trials by reducing the frequency and/or severity of hallucinations and delusions and the risk of relapse of these symptoms in patients with dementia-related psychosis. A literature review was conducted to identify mechanisms that explain the role of 5-HT2ARs in both the etiology and treatment of dementia-related psychosis. This review revealed that most pathological changes commonly associated with neurodegenerative diseases cause one or more of the following events to occur: reduced synaptic contact of gamma aminobutyric acid (GABA)-ergic interneurons with glutamatergic pyramidal cells, reduced cortical innervation from subcortical structures, and altered 5-HT2AR expression levels. Each of these events promotes increased pyramidal cell hyperexcitability and disruption of excitatory/inhibitory balance, facilitating emergence of psychotic behaviors. The brain regions affected by these pathological changes largely coincide with areas expressing high levels of 5-HT2ARs. At the cellular level, 5-HT2ARs are most highly expressed on cortical glutamatergic pyramidal cells, where they regulate pyramidal cell excitability. The common effects of different neurodegenerative diseases on pyramidal cell excitability together with the close anatomical and functional connection of 5-HT2ARs to pyramidal cell excitability may explain why suppressing 5-HT2AR activity could be an effective strategy to treat dementia-related psychosis.
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Affiliation(s)
- Ethan S. Burstein
- Acadia Pharmaceuticals Inc, 12830 El Camino Real, Suite 400, San Diego, CA 92130 USA
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26
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RCL1 copy number variants are associated with a range of neuropsychiatric phenotypes. Mol Psychiatry 2021; 26:1706-1718. [PMID: 33597717 PMCID: PMC8159744 DOI: 10.1038/s41380-021-01035-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 12/29/2020] [Accepted: 01/15/2021] [Indexed: 12/18/2022]
Abstract
Mendelian and early-onset severe psychiatric phenotypes often involve genetic variants having a large effect, offering opportunities for genetic discoveries and early therapeutic interventions. Here, the index case is an 18-year-old boy, who at 14 years of age had a decline in cognitive functioning over the course of a year and subsequently presented with catatonia, auditory and visual hallucinations, paranoia, aggression, mood dysregulation, and disorganized thoughts. Exome sequencing revealed a stop-gain mutation in RCL1 (NM_005772.4:c.370 C > T, p.Gln124Ter), encoding an RNA 3'-terminal phosphate cyclase-like protein that is highly conserved across eukaryotic species. Subsequent investigations across two academic medical centers identified eleven additional cases of RCL1 copy number variations (CNVs) with varying neurodevelopmental or psychiatric phenotypes. These findings suggest that dosage variation of RCL1 contributes to a range of neurological and clinical phenotypes.
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27
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Wiels WA, Wittens MMJ, Zeeuws D, Baeken C, Engelborghs S. Neuropsychiatric Symptoms in Mild Cognitive Impairment and Dementia Due to AD: Relation With Disease Stage and Cognitive Deficits. Front Psychiatry 2021; 12:707580. [PMID: 34483998 PMCID: PMC8415837 DOI: 10.3389/fpsyt.2021.707580] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 07/09/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The interaction between neuropsychiatric symptoms, mild cognitive impairment (MCI), and dementia is complex and remains to be elucidated. An additive or multiplicative effect of neuropsychiatric symptoms such as apathy or depression on cognitive decline has been suggested. Unraveling these interactions may allow the development of better prevention and treatment strategies. In the absence of available treatments for neurodegeneration, a timely and adequate identification of neuropsychiatric symptom changes in cognitive decline is highly relevant and can help identify treatment targets. Methods: An existing memory clinic-based research database of 476 individuals with MCI and 978 individuals with dementia due to Alzheimer's disease (AD) was reanalyzed. Neuropsychiatric symptoms were assessed in a prospective fashion using a battery of neuropsychiatric assessment scales: Middelheim Frontality Score, Behavioral Pathology in Alzheimer's Disease Rating Scale (Behave-AD), Cohen-Mansfield Agitation Inventory, Cornell Scale for Depression in Dementia (CSDD), and Geriatric Depression Scale (30 items). We subtyped subjects suffering from dementia as mild, moderate, or severe according to their Mini-Mental State Examination (MMSE) score and compared neuropsychiatric scores across these groups. A group of 126 subjects suffering from AD with a significant cerebrovascular component was examined separately as well. We compared the prevalence, nature, and severity of neuropsychiatric symptoms between subgroups of patients with MCI and dementia due to AD in a cross-sectional analysis. Results: Affective and sleep-related symptoms are common in MCI and remain constant in prevalence and severity across dementia groups. Depressive symptoms as assessed by the CSDD further increase in severe dementia. Most other neuropsychiatric symptoms (such as agitation and activity disturbances) progress in parallel with severity of cognitive decline. There are no significant differences in neuropsychiatric symptoms when comparing "pure" AD to AD with a significant vascular component. Conclusion: Neuropsychiatric symptoms such as frontal lobe symptoms, psychosis, agitation, aggression, and activity disturbances increase as dementia progresses. Affective symptoms such as anxiety and depressive symptoms, however, are more frequent in MCI than mild dementia but otherwise remain stable throughout the cognitive spectrum, except for an increase in CSDD score in severe dementia. There is no difference in neuropsychiatric symptoms when comparing mixed dementia (defined here as AD + significant cerebrovascular disease) to pure AD.
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Affiliation(s)
- Wietse A Wiels
- Department of Neurology, Universitair Ziekenhuis Brussel, Brussels, Belgium.,Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Mandy M J Wittens
- Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Brussels, Belgium.,Department of Biomedical Sciences, University of Antwerp, Antwerp, Belgium
| | - Dieter Zeeuws
- Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Brussels, Belgium.,Department of Psychiatry, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Chris Baeken
- Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Brussels, Belgium.,Department of Psychiatry, Universitair Ziekenhuis Brussel, Brussels, Belgium.,Ghent Experimental Psychiatry (GHEP) Lab, Department of Psychiatry and Medical Psychology, Ghent University Hospital, Ghent University, Ghent, Belgium.,Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Sebastiaan Engelborghs
- Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Brussels, Belgium.,Department of Biomedical Sciences, University of Antwerp, Antwerp, Belgium
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28
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Howard R, Burns A, Schneider L. Antipsychotic prescribing to people with dementia during COVID-19. Lancet Neurol 2020; 19:892. [PMID: 33098796 PMCID: PMC7577650 DOI: 10.1016/s1474-4422(20)30370-7] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 09/14/2020] [Accepted: 09/23/2020] [Indexed: 01/10/2023]
Affiliation(s)
- Robert Howard
- Division of Psychiatry, University College London, London W1T 7NF, UK.
| | - Alistair Burns
- School of Psychiatry and Behavioural Sciences, University of Manchester, Manchester, UK
| | - Lon Schneider
- University of Southern California, Los Angeles, California, USA
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29
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Ballard C, Kales HC, Lyketsos C, Aarsland D, Creese B, Mills R, Williams H, Sweet RA. Psychosis in Alzheimer's Disease. Curr Neurol Neurosci Rep 2020; 20:57. [PMID: 33048274 PMCID: PMC7554014 DOI: 10.1007/s11910-020-01074-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW To review the incidence, treatment and genetics of psychosis in people with mild cognitive impairment (MCI) and Alzheimer's disease (AD). RECENT FINDINGS Psychosis in Alzheimer's disease (AD) has an incidence of ~ 10% per year. There is limited evidence regarding psychological interventions. Pharmacological management has focused on atypical antipsychotics, balancing modest benefits with evidence of long-term harms. The 5HT2A inverse agonist pimavanserin appears to confer benefit in PD psychosis with initial evidence of benefit in AD. Cholinesterase inhibitors give modest benefits in DLB psychosis. The utility of muscarinic agonists, lithium, glutamatergic and noradrenergic modulators needs further study. Recent work has confirmed the importance of psychosis in MCI as well as AD. The lack of evidence regarding psychological therapies is an urgent knowledge gap, but there is encouraging evidence for emerging pharmacological treatments. Genetics will provide an opportunity for precision medicine and new treatment targets.
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Affiliation(s)
- Clive Ballard
- The University of Exeter Medical School, College of Medicine and Health, The University of Exeter, St Luke's Campus, Magdalen Road, Exeter, EX1 2LU, UK.
| | | | | | - Dag Aarsland
- University Hospital Stavanger, Stavanger, Norway
- King's College London, London, UK
| | - Byron Creese
- The University of Exeter Medical School, College of Medicine and Health, The University of Exeter, St Luke's Campus, Magdalen Road, Exeter, EX1 2LU, UK
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30
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Frederiksen KS, Cooper C, Frisoni GB, Frölich L, Georges J, Kramberger MG, Nilsson C, Passmore P, Mantoan Ritter L, Religa D, Schmidt R, Stefanova E, Verdelho A, Vandenbulcke M, Winblad B, Waldemar G. A European Academy of Neurology guideline on medical management issues in dementia. Eur J Neurol 2020; 27:1805-1820. [PMID: 32713125 PMCID: PMC7540303 DOI: 10.1111/ene.14412] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/12/2020] [Accepted: 06/13/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND PURPOSE Dementia is one of the most common disorders and is associated with increased morbidity, mortality and decreased quality of life. The present guideline addresses important medical management issues including systematic medical follow-up, vascular risk factors in dementia, pain in dementia, use of antipsychotics in dementia and epilepsy in dementia. METHODS A systematic review of the literature was carried out. Based on the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework, we developed a guideline. Where recommendations based on GRADE were not possible, a good practice statement was formulated. RESULTS Systematic management of vascular risk factors should be performed in patients with mild to moderate dementia as prevention of cerebrovascular pathology may impact on the progression of dementia (Good Practice statement). Individuals with dementia (without previous stroke) and atrial fibrillation should be treated with anticoagulants (weak recommendation). Discontinuation of opioids should be considered in certain individuals with dementia (e.g. for whom there are no signs or symptoms of pain or no clear indication, or suspicion of side effects; Good Practice statement). Behavioral symptoms in persons with dementia should not be treated with mild analgesics (weak recommendation). In all patients with dementia treated with opioids, assessment of the individual risk-benefit ratio should be performed at regular intervals. Regular, preplanned medical follow-up should be offered to all patients with dementia. The setting will depend on the organization of local health services and should, as a minimum, include general practitioners with easy access to dementia specialists (Good Practice statement). Individuals with dementia and agitation and/or aggression should be treated with atypical antipsychotics only after all non-pharmacological measures have been proven to be without benefit or in the case of severe self-harm or harm to others (weak recommendation). Antipsychotics should be discontinued after cessation of behavioral disturbances and in patients in whom there are side effects (Good Practice statement). For treatment of epilepsy in individuals with dementia, newer anticonvulsants should be considered as first-line therapy (Good Practice statement). CONCLUSION This GRADE-based guideline offers recommendations on several important medical issues in patients with dementia, and thus adds important guidance for clinicians. For some issues, very little or no evidence was identified, highlighting the importance of further studies within these areas.
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Affiliation(s)
- K. S. Frederiksen
- Department of NeurologyDanish Dementia Research CenterRigshospitaletUniversity of CopenhagenCopenhagenDenmark
| | - C. Cooper
- Department of Clinical Educational and Health PsychologyUniversity College LondonLondonUK
| | - G. B. Frisoni
- Memory ClinicUniversity Hospital of GenevaUniversity of GenevaGenevaSwitzerland
| | - L. Frölich
- Department of Geriatric PsychiatryZentralinstitut für Seelische Gesundheit MannheimMedical Faculty MannheimUniversity of HeidelbergMannheimGermany
| | | | - M. G. Kramberger
- Department of NeurologyCenter for Cognitive ImpairmentsUniversity Medical Center Ljubljana, and Medical facultyUniversity of LjubljanaLjubljanaSlovenia
| | - C. Nilsson
- Department of Neurology and Rehabilitation MedicineSkåne University HospitalLundSweden
- Clinical Memory Research UnitDepartment of Clinical SciencesLund UniversityMalmöSweden
| | | | - L. Mantoan Ritter
- Epilepsy CentreKing's College NHS Foundation TrustKing´s College LondonLondonUK
| | - D. Religa
- Division of Clinical GeriatricsDepartment of Neurobiology, Care Sciences and SocietyKarolinska InstitutetNeo, StockholmSweden
- Karolinska University HospitalTheme AgingHuddingeSweden
| | - R. Schmidt
- University Clinic for NeurologyMedical University of GrazGrazAustria
| | - E. Stefanova
- Medical FacultyNeurology clinic CCSUniversity of BelgradeBelgradeSerbia
| | - A. Verdelho
- Department of Neurosciences and Mental HealthCHLNorte‐Hospital de Santa MariaIMMISAMBFaculty of MedicineUniversity of LisbonLisbonPortugal
| | - M. Vandenbulcke
- Department of NeurosciencesKU LeuvenGeriatric PsychiatryUniversity Hospitals LeuvenLeuvenBelgium
| | - B. Winblad
- Karolinska University HospitalTheme AgingHuddingeSweden
- Division of NeurogeriatricsDepartment of Neurobiology, Care Sciences and SocietyKarolinska InstitutetBioClinicumSolnaSweden
| | - G. Waldemar
- Department of NeurologyDanish Dementia Research CenterRigshospitaletUniversity of CopenhagenCopenhagenDenmark
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Dhuny S, Foley T, Jennings A. General practitioners' knowledge of and attitudes towards prescribing psychoactive drugs in dementia care: a cross-sectional questionnaire study. Ir J Med Sci 2020; 190:667-675. [PMID: 32897448 PMCID: PMC7477732 DOI: 10.1007/s11845-020-02356-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 08/31/2020] [Indexed: 11/25/2022]
Abstract
Background Despite their adverse effects, antipsychotics are frequently prescribed to manage behavioural and psychological symptoms of dementia (BPSD). At present, we do not have a good understanding of general practitioners’ (GPs) current management of BPSD. Aims To explore the knowledge, attitudes, and opinions of GPs regarding the prescribing of psychoactive drugs in managing BPSD. Methods This was a descriptive cross-sectional study. A questionnaire was adapted from a previous study and piloted with three GPs and was posted to a census sample of all GPs working in counties Cork and Kerry, Ireland. We collected and analysed both quantitative and qualitative data. Results Of the 456 eligible GPs who received the questionnaire, 168 GPs returned completed questionnaires (response rate 36.8%). All respondents (100%, 168/168) believed that antipsychotics did not benefit all patients with BPSD. The majority of GPs (69%, 116/168) routinely recommended non-pharmacological interventions before medication to manage BPSD. Most GPs (60.7%, 102/168) welcomed more training and experience to improve their management of BPSD. The qualitative comments provided by GPs described a pressure to prescribe from nursing home staff. GPs highlighted that the management of BPSD is difficult in daily practice and felt that antipsychotics still have a role to play. Conclusions This study identified several factors influencing the prescription of antipsychotics for patients with BPSD as well as the prescribing dilemmas faced by GPs in their daily practice. These findings can be used to guide future interventions aimed at reducing inappropriate prescribing in dementia care. Electronic supplementary material The online version of this article (10.1007/s11845-020-02356-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sheefah Dhuny
- Department of General Practice, Western Gateway Building, University College Cork, Cork, Ireland.
| | - Tony Foley
- Department of General Practice, Western Gateway Building, University College Cork, Cork, Ireland
| | - Aisling Jennings
- Department of General Practice, Western Gateway Building, University College Cork, Cork, Ireland
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32
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Malekizadeh Y, Williams G, Kelson M, Whitfield D, Mill J, Collier DA, Ballard C, Jeffries AR, Creese B. Whole transcriptome in silico screening implicates cardiovascular and infectious disease in the mechanism of action underlying atypical antipsychotic side effects. ALZHEIMER'S & DEMENTIA (NEW YORK, N. Y.) 2020; 6:e12078. [PMID: 32864416 PMCID: PMC7443741 DOI: 10.1002/trc2.12078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 07/09/2020] [Accepted: 07/28/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND Stroke/thromboembolic events, infections, and death are all significantly increased by antipsychotics in dementia but little is known about why they can be harmful. Using a novel application of a drug repurposing paradigm, we aimed to identify potential mechanisms underlying adverse events. METHODS Whole transcriptome signatures were generated for SH-SY5Y cells treated with amisulpride, risperidone, and volinanserin using RNA sequencing. Bioinformatic analysis was performed that scored the association between antipsychotic signatures and expression data from 415,252 samples in the National Center for Biotechnology Information Gene Expression Omnibus (NCBI GEO) repository. RESULTS Atherosclerosis, venous thromboembolism, and influenza NCBI GEO-derived samples scored positively against antipsychotic signatures. Pathways enriched in antipsychotic signatures were linked to the cardiovascular and immune systems (eg, brain derived neurotrophic factor [BDNF], platelet derived growth factor receptor [PDGFR]-beta, tumor necrosis factor [TNF], transforming growth factor [TGF]-beta, selenoamino acid metabolism, and influenza infection). CONCLUSIONS These findings for the first time mechanistically link antipsychotics to specific cardiovascular and infectious diseases which are known side effects of their use in dementia, providing new information to explain related adverse events.
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Affiliation(s)
- Yasaman Malekizadeh
- College of Medicine and HealthUniversity of Exeter Medical SchoolUniversity of ExeterExeterUK
| | - Gareth Williams
- College of Engineering Mathematics and Physical SciencesUniversity of ExeterExeterUK
| | - Mark Kelson
- Wolfson Centre for Age‐Related DiseaseInstitute of Psychiatry, Psychology and NeuroscienceKing's College LondonLondonUK
| | - David Whitfield
- College of Medicine and HealthUniversity of Exeter Medical SchoolUniversity of ExeterExeterUK
| | - Jonathan Mill
- College of Medicine and HealthUniversity of Exeter Medical SchoolUniversity of ExeterExeterUK
| | | | - Clive Ballard
- College of Medicine and HealthUniversity of Exeter Medical SchoolUniversity of ExeterExeterUK
| | - Aaron R. Jeffries
- College of Medicine and HealthUniversity of Exeter Medical SchoolUniversity of ExeterExeterUK
| | - Byron Creese
- College of Medicine and HealthUniversity of Exeter Medical SchoolUniversity of ExeterExeterUK
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Srinivasan S, Tampi RR, Balaram K, Kapoor A. Pimavanserin for the treatment of psychosis in Alzheimer’s disease: A literature review. World J Psychiatry 2020; 10:162-174. [PMID: 32844093 PMCID: PMC7418577 DOI: 10.5498/wjp.v10.i7.162] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 05/25/2020] [Accepted: 06/10/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Alzheimer’s disease (AD) is among the most prevalent forms of dementia in the world and neuropathological studies suggest similar high prevalence of mixed (AD + vascular) dementias. Approximately 25%-50% of individuals with AD develop psychosis sometime during their illness. The presence of psychosis in AD worsens outcomes. Currently there are no United States Food and Drug Administration (FDA) approved medications for the treatment of psychosis in AD. Pimavanserin, a novel atypical antipsychotic medication, was approved by the FDA for the treatment of hallucinations and delusions associated with Parkinson disease psychosis and is currently in clinical trials for the treatment of psychosis in AD.
AIM To evaluate the existing literature regarding the use of pimavanserin for treating psychosis among individuals with AD.
METHODS A literature review of clinical studies of pimavanserin treatment for psychosis in individuals with AD was performed using the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Trials were identified by systematically searching PubMed, MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science, and Scopus through October 2019. The 5-point Jadad scoring system was used to assess the methodologic quality of the randomized placebo-controlled trials.
RESULTS A total of 499 citations were retrieved and pooled in EndNote and de-duplicated to 258 citations. This set was uploaded to Covidence for screening. Two separate screeners (Srinivasan S and Tampi RR) evaluated the titles, abstracts, and full text of eligible articles. Of the identified 258 abstracts, 98 articles underwent full text review and 2 publications from 1 randomized controlled trial (RCT) were included in the final analysis. The quality of evidence was assessed to be of good methodologic quality, scoring 4 out of 5 using the 5-point Jadad questionnaire with the Jadad Scoring calculation. This systematic review found only one RCT that evaluated the use of pimavanserin for the treatment of psychosis among individuals with AD. This phase 2 trial resulted in two publications, the second of which was a subgroup analysis from the original study. The evidence from these two publications showed that pimavanserin improves psychotic symptoms among individuals with AD when compared to placebo at week 6.
CONCLUSION Pimavanserin may be a pharmacologic consideration for the treatment for psychosis in AD. Additional RCTs are needed to assess the evidence of effectiveness before pimavanserin is considered a standard treatment.
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Affiliation(s)
- Shilpa Srinivasan
- Department of Neuropsychiatry and Behavioral Science, Palmetto Health USC Medical Group, University of South Carolina School of Medicine, Columbia, SC 29203, United States
| | - Rajesh R Tampi
- Department of Psychiatry and Behavioral Sciences, Cleveland Clinic Akron General, Akron, OH 44307, United States
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH 44195, United States
| | - Kripa Balaram
- MD, Department of Psychiatry, MetroHealth, Cleveland, OH 44109, United States
| | - Arushi Kapoor
- Penn Memory Center at the Penn Neuroscience Center, Perelman Center for Advanced Medicine, Philadelphia, PA 19104, United States
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Caraci F, Santagati M, Caruso G, Cannavò D, Leggio GM, Salomone S, Drago F. New antipsychotic drugs for the treatment of agitation and psychosis in Alzheimer's disease: focus on brexpiprazole and pimavanserin. F1000Res 2020; 9. [PMID: 32695312 PMCID: PMC7344175 DOI: 10.12688/f1000research.22662.1] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/03/2020] [Indexed: 12/17/2022] Open
Abstract
Behavioral and psychological symptoms of dementia are symptoms of disturbed perception, mood, behavior, and thought content that occurred frequently. These symptoms, which include apathy, depression, anxiety, psychosis, agitation, and aggression, can serve as predictors of and early clinical diagnostic markers for Alzheimer's disease (AD) and are common precipitants of institutional care. Agitation and psychosis are associated with accelerated disease progression and increased tau phosphorylation in patients with AD. Current guidelines recommend the use of second-generation antipsychotics for the treatment of agitation and psychosis in AD, but only after first-line non-pharmacological interventions and for no longer than 12 weeks because long-term use of these drugs is associated with an increased risk of mortality and an increased frequency of cerebrovascular events. Therefore, new antipsychotic drugs with improved efficacy and safety are needed as an alternative to current antipsychotic drugs. In this report, we discuss some of the most relevant advances in the field of agitation and psychosis in AD and focus on the recent positive clinical evidence observed with two new antipsychotics drugs: brexpiprazole and pimavanserin. Brexpiprazole is a receptor partial agonist (D2, D3, 5-HT1A), receptor antagonist (5-HT2A/B, α1B/α2C) according to the neuroscience-based nomenclature. Two recent phase III clinical trials have shown that brexpiprazole 2 mg/day is effective for the treatment of agitation in patients with AD and has an improved tolerability and safety profile compared with currently available second-generation antipsychotics. Pimavanserin is a receptor antagonist (5-HT2A, 5-HT2C) that has been given market authorization for psychosis occurring in Parkinson's disease. Recent phase II studies suggest that this drug is effective in AD patients with more severe psychosis, although further long-term studies are needed to better define the efficacy and long-term safety profile of pimavanserin for the treatment of psychosis in AD.
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Affiliation(s)
- Filippo Caraci
- Department of Drug Sciences, University of Catania, Viale Andrea Doria 6, 95125, Catania, Italy.,Oasi Research Institute - IRCCS, Via Conte Ruggero 73, 94018, Troina, Italy
| | - Mario Santagati
- ASP3 Catania, Department of Mental Health, Alzheimer Psychogeriatric Center Corso Italia 234, 95127, Catania, Italy
| | - Giuseppe Caruso
- Oasi Research Institute - IRCCS, Via Conte Ruggero 73, 94018, Troina, Italy
| | - Dario Cannavò
- ASP3 Catania, Department of Mental Health, Alzheimer Psychogeriatric Center Corso Italia 234, 95127, Catania, Italy
| | - Gian Marco Leggio
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via S. Sofia 89, 95123, Catania, Italy
| | - Salvatore Salomone
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via S. Sofia 89, 95123, Catania, Italy
| | - Filippo Drago
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via S. Sofia 89, 95123, Catania, Italy
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Kheirbek RE, Fokar A, Little JT, Balish M, Shara NM, Boustani MA, Llorente M. Association Between Antipsychotics and All-Cause Mortality Among Community-Dwelling Older Adults. J Gerontol A Biol Sci Med Sci 2020; 74:1916-1921. [PMID: 30753301 DOI: 10.1093/gerona/glz045] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Accepted: 02/08/2019] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Antipsychotics are prescribed to treat various symptoms in older adults, however, their safety in this context has not been fully evaluated. The objective was to evaluate mortality risks associated with off-label use of antipsychotics among older adults with no preexisting mental illness or dementia relative to those with diagnosis of dementia. METHODS Data (2007-2015) were derived from Department of Veterans Affairs registries for 730,226 patients (≥65 years) with no baseline serious mental illness, dementia). We estimated the cumulative incidence of antipsychotics prescription and 10-year all-cause mortality. The extended Cox models were used to estimate Hazard Ratios (HRs) associated with antipsychotics prescription, adjusted for time-varying covariates, dementia diagnosis, comorbidity index score, and age at time of first exposure to antipsychotics. RESULTS The study included 98% males, 13% African Americans, and 81% Caucasian. Patients with dementia and antipsychotics had the highest risk of mortality (78.0%), followed by (73.0%) for patients with dementia alone and compared with patients without dementia or antipsychotics exposure who had the lowest mortality risk (42.0%). Exposure to typical antipsychotics was associated with (HR: 2.1, confidence interval [CI] 2.0-2.2) compared with atypical antipsychotics (HR: 1.5, CI 1.4-1.5, p = <.0001). CONCLUSION In a large cohort of older adults, antipsychotics were associated with an increased risk of all-cause mortality. While significant increase in mortality was attributable to the diagnosis of dementia, the addition of antipsychotics resulted in added mortality risk among all patients. Antipsychotic medications should be used cautiously in all older adults, not only those with dementia.
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Affiliation(s)
- Raya Elfadel Kheirbek
- Veterans Affairs Medical Center, Washington, District of Columbia.,George Washington University School of Medicine and Health Sciences, Washington, District of Columbia.,University of Maryland School of Medicine, Baltimore
| | - Ali Fokar
- Veterans Affairs Medical Center, Washington, District of Columbia
| | - John T Little
- Veterans Affairs Medical Center, Washington, District of Columbia.,Georgetown University School of Medicine, Washington, District of Columbia
| | - Marshall Balish
- Veterans Affairs Medical Center, Washington, District of Columbia.,Georgetown University School of Medicine, Washington, District of Columbia
| | - Nawar M Shara
- MedStar Health Research Institute, Washington, District of Columbia
| | - Malaz A Boustani
- Indiana University Center for Aging Research, Indianapolis.,Regenstrief Institute, Inc., Indianapolis, Indiana.,Indiana University School of Medicine, Indianapolis
| | - Maria Llorente
- Veterans Affairs Medical Center, Washington, District of Columbia.,Georgetown University School of Medicine, Washington, District of Columbia
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Sultana J, Fontana A, Giorgianni F, Tillati S, Cricelli C, Pasqua A, Patorno E, Ballard C, Sturkenboom M, Trifirò G. Measuring the Effectiveness of Safety Warnings on the Risk of Stroke in Older Antipsychotic Users: A Nationwide Cohort Study in Two Large Electronic Medical Records Databases in the United Kingdom and Italy. Drug Saf 2020; 42:1471-1485. [PMID: 31556019 DOI: 10.1007/s40264-019-00860-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Safety warnings relating to antipsychotic-associated stroke among older persons in the UK and Italy were issued. However, the impact of these safety warnings on stroke risk has not been measured to date. OBJECTIVE The aim of this study was to measure the change in stroke incidence after two safety warnings in both the UK and Italy. METHOD A cohort study was conducted using electronic medical records representative of the UK (The Health Improvement Network) and Italy (Health Search-IQVIA Health LPD), containing data on 11 million and 1 million patients, respectively. After each drug safety warning, elderly antipsychotic new initiators were propensity-score matched 1:1:1 on antipsychotic initiators before any safety warning. Stroke incidence within 6 months of antipsychotic initiation, using an intention-to-treat approach, was the main outcome. RESULTS In the UK and Italy, 6342 and 7587 elderly antipsychotic initiators were identified, respectively. A 42% stroke incidence reduction was seen in the UK after the first safety warning [42.3 (95% confidence interval (CI) 35.2-50.8) vs. 24.4 [95% CI 19.0-31.2] events per 1000 person-years (PYs)], while there was a 60% stroke incidence reduction after the second warning (16.9 [95% CI 12.2-23.4] events per 1000 PYs) compared to before the first warning. There was no significant reduction in stroke incidence in Italy. CONCLUSION Antipsychotic safety warnings were followed by a reduction in stroke incidence among older antipsychotic users in the UK, but not Italy.
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Affiliation(s)
- Janet Sultana
- Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, University of Messina, 1, Consolare Valeria Street, 98125, Messina, Italy.,Department of Medical Informatics, Erasmus Medical Centre, Rotterdam, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Andrea Fontana
- Fondazione IRCCS Casa Sollievo della Sofferenza, Unit of Biostatistics, Viale Cappuccini, 2, 71013, San Giovanni Rotondo, FG, Italy
| | - Francesco Giorgianni
- Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, University of Messina, 1, Consolare Valeria Street, 98125, Messina, Italy
| | - Silvia Tillati
- Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, University of Messina, 1, Consolare Valeria Street, 98125, Messina, Italy
| | - Claudio Cricelli
- Health Search, Italian College of General Practitioners, Sestese Street, 61, 50141, Florence, Italy
| | - Alessandro Pasqua
- Health Search, Italian College of General Practitioners, Sestese Street, 61, 50141, Florence, Italy
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, 1620 Tremont Street, Suite 3030, Boston, MA, 02120, USA
| | - Clive Ballard
- University of Exeter Medical School, Medical School Building, St Luke's Campus, Magdalen Road, Exeter, EX1 2LU, UK
| | - Miriam Sturkenboom
- Julius Centre for Global Health, Utrecht University Medical Centre, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Gianluca Trifirò
- Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, University of Messina, 1, Consolare Valeria Street, 98125, Messina, Italy. .,Department of Medical Informatics, Erasmus Medical Centre, Rotterdam, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.
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Jafari Z, Kolb BE, Mohajerani MH. Prepulse inhibition of the acoustic startle reflex and P50 gating in aging and alzheimer's disease. Ageing Res Rev 2020; 59:101028. [PMID: 32092463 DOI: 10.1016/j.arr.2020.101028] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 01/20/2020] [Accepted: 02/17/2020] [Indexed: 02/07/2023]
Abstract
Inhibition plays a crucial role in many functional domains, such as cognition, emotion, and actions. Studies on cognitive aging demonstrate changes in inhibitory mechanisms are age- and pathology-related. Prepulse inhibition (PPI) is the suppression of an acoustic startle reflex (ASR) to an intense stimulus when a weak prepulse stimulus precedes the startle stimulus. A reduction of PPI is thought to reflect dysfunction of sensorimotor gating which normally suppresses excessive behavioral responses to disruptive stimuli. Both human and rodent studies show age-dependent alterations of PPI of the ASR that are further compromised in Alzheimer's disease (AD). The auditory P50 gating, an index of repetition suppression, also is characterized as a putative electrophysiological biomarker of prodromal AD. This review provides the latest evidence of age- and AD-associated impairment of sensorimotor gating based upon both human and rodent studies, as well as the AD-related disruption of P50 gating in humans. It begins with a concise review of neural networks underlying PPI regulation. Then, evidence of age- and AD-related dysfunction of both PPI and P50 gating is discussed. The attentional/ emotional aspects of sensorimotor gating and the neurotransmitter mechanisms underpinning PPI and P50 gating are also reviewed. The review ends with conclusions and research directions.
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Affiliation(s)
- Zahra Jafari
- Department of Neuroscience, Canadian Centre for Behavioural Neuroscience, University of Lethbridge, Lethbridge, T1K 3M4 AB, Canada; Department of Basic Sciences in Rehabilitation, School of Rehabilitation Sciences, Iran University of Medical Science (IUMS), Tehran, Iran
| | - Bryan E Kolb
- Department of Neuroscience, Canadian Centre for Behavioural Neuroscience, University of Lethbridge, Lethbridge, T1K 3M4 AB, Canada.
| | - Majid H Mohajerani
- Department of Neuroscience, Canadian Centre for Behavioural Neuroscience, University of Lethbridge, Lethbridge, T1K 3M4 AB, Canada.
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Husebo BS, Heintz HL, Berge LI, Owoyemi P, Rahman AT, Vahia IV. Sensing Technology to Monitor Behavioral and Psychological Symptoms and to Assess Treatment Response in People With Dementia. A Systematic Review. Front Pharmacol 2020; 10:1699. [PMID: 32116687 PMCID: PMC7011129 DOI: 10.3389/fphar.2019.01699] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 12/31/2019] [Indexed: 01/28/2023] Open
Abstract
Background The prevalence of dementia is expected to rapidly increase in the next decades, warranting innovative solutions improving diagnostics, monitoring and resource utilization to facilitate smart housing and living in the nursing home. This systematic review presents a synthesis of research on sensing technology to assess behavioral and psychological symptoms and to monitor treatment response in people with dementia. Methods The literature search included medical peer-reviewed English language publications indexed in Embase, Medline, Cochrane library and Web of Sciences, published up to the 5th of April 2019. Keywords included MESH terms and phrases synonymous with "dementia", "sensor", "patient", "monitoring", "behavior", and "therapy". Studies applying both cross sectional and prospective designs, either as randomized controlled trials, cohort studies, and case-control studies were included. The study was registered in PROSPERO 3rd of May 2019. Results A total of 1,337 potential publications were identified in the search, of which 34 were included in this review after the systematic exclusion process. Studies were classified according to the type of technology used, as (1) wearable sensors, (2) non-wearable motion sensor technologies, and (3) assistive technologies/smart home technologies. Half of the studies investigated how temporarily dense data on motion can be utilized as a proxy for behavior, indicating high validity of using motion data to monitor behavior such as sleep disturbances, agitation and wandering. Further, up to half of the studies represented proof of concept, acceptability and/or feasibility testing. Overall, the technology was regarded as non-intrusive and well accepted. Conclusions Targeted clinical application of specific technologies is poised to revolutionize precision care in dementia as these technologies may be used both by patients and caregivers, and at a systems level to provide safe and effective care. To highlight awareness of legal regulations, data risk assessment, and patient and public involvement, we propose a necessary framework for sustainable ethical innovation in healthcare technology. The success of this field will depend on interdisciplinary cooperation and the advance in sustainable ethic innovation. Systematic Review Registration PROSPERO, identifier CRD42019134313.
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Affiliation(s)
- Bettina S Husebo
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway.,Department of Nursing Home Medicine, Municipality of Bergen, Bergen, Norway
| | - Hannah L Heintz
- Division of Geriatric Psychiatry, McLean Hospital, Belmont, MA, United States
| | - Line I Berge
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway.,NKS Olaviken Gerontopsychiatric Hospital, Bergen, Norway
| | - Praise Owoyemi
- Division of Geriatric Psychiatry, McLean Hospital, Belmont, MA, United States
| | - Aniqa T Rahman
- Division of Geriatric Psychiatry, McLean Hospital, Belmont, MA, United States
| | - Ipsit V Vahia
- Division of Geriatric Psychiatry, McLean Hospital, Belmont, MA, United States.,Department of Psychiatry, Harvard Medical School, Boston, MA, United States
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Zöllner R, Hübener AF, Dannlowski U, Kircher T, Sommer J, Zavorotnyy M. Theta-Burst Stimulation for Auditory-Verbal Hallucination in Very-Late-Onset Schizophrenia-Like Psychosis-A Functional Magnetic Resonance Imaging Case Study. Front Psychiatry 2020; 11:294. [PMID: 32425822 PMCID: PMC7212466 DOI: 10.3389/fpsyt.2020.00294] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 03/25/2020] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Treating very-late-onset (>60 years) schizophrenia-like psychosis (VLOSLP) is challenging. Age-related factors in elderly individuals (e.g., metabolism, medication side effects, drug-interaction, somatic morbidity) may adversely affect treatment. Novel therapeutic approaches are needed to ensure the favorable therapeutic outcome in geriatric patients. Previously, theta-burst stimulation (TBS), a novel form of repetitive transcranial magnetic stimulation, was reported being beneficial in the treatment for auditory-verbal hallucination (AVH) in young and middle-aged schizophrenia (SZ) patients. CASE PRESENTATION Here we present a case of a male patient aged 73. His first psychotic episode manifested with paranoid delusions, auditory-verbal and tactile hallucinations at the age of 66, and first remitted following a second-generation antipsychotics (SGA). Years later, after a relapse the AVH did not respond to previously effective olanzapine, whereas its augmentation with an inhibitory TBS over the left temporal lobe led to a stable remission. During his second relapse, TBS was again capable of facilitating therapeutic action of SGA in the same patient. Extending to our clinical observation, a series of functional MRI scans employing a tonal activation paradigm depicted altered auditory processing during AVH as well as brain activation change during remission. CONCLUSIONS The current case might indicate to favorable effects of combining conventional medicament therapy and non-invasive brain stimulation techniques for elderly patients. Also, we speculate that despite obviously distinct etiologies, the present functional imaging and clinical observation may also demonstrate a possible common pathophysiological pathway underlying AVH in VLOSLP and SZ.
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Affiliation(s)
- Rebecca Zöllner
- Department of Psychiatry and Psychotherapy, University of Marburg, Marburg, Germany.,Marburg Center for Mind, Brain and Behavior - MCMBB, University of Marburg, Marburg, Germany.,Health Protection Authority, Frankfurt am Main, Germany
| | - Anne-Friederike Hübener
- Department of Social Psychiatry, University of Applied Science Niederrhein, Krefeld, Germany
| | - Udo Dannlowski
- Department of Psychiatry and Psychotherapy, University of Marburg, Marburg, Germany.,Department of Psychiatry and Psychotherapy, University of Muenster, Muenster, Germany
| | - Tilo Kircher
- Department of Psychiatry and Psychotherapy, University of Marburg, Marburg, Germany
| | - Jens Sommer
- Marburg Center for Mind, Brain and Behavior - MCMBB, University of Marburg, Marburg, Germany.,Core-Unit Brainimaging, Faculty of Medicine, University of Marburg, Marburg, Germany
| | - Maxim Zavorotnyy
- Department of Psychiatry and Psychotherapy, University of Marburg, Marburg, Germany.,Marburg Center for Mind, Brain and Behavior - MCMBB, University of Marburg, Marburg, Germany.,Department of Psychiatry and Psychotherapy, Psychiatric Services Aargau, Academic Hospital of the University of Zurich, Brugg, Switzerland
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40
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Sekhar GN, Fleckney AL, Boyanova ST, Rupawala H, Lo R, Wang H, Farag DB, Rahman KM, Broadstock M, Reeves S, Thomas SA. Region-specific blood-brain barrier transporter changes leads to increased sensitivity to amisulpride in Alzheimer's disease. Fluids Barriers CNS 2019; 16:38. [PMID: 31842924 PMCID: PMC6915870 DOI: 10.1186/s12987-019-0158-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 12/02/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Research into amisulpride use in Alzheimer's disease (AD) implicates blood-brain barrier (BBB) dysfunction in antipsychotic sensitivity. Research into BBB transporters has been mainly directed towards the ABC superfamily, however, solute carrier (SLC) function in AD has not been widely studied. This study tests the hypothesis that transporters for organic cations contribute to the BBB delivery of the antipsychotics (amisulpride and haloperidol) and is disrupted in AD. METHODS The accumulation of [3H]amisulpride (3.7-7.7 nM) and [3H]haloperidol (10 nM) in human (hCMEC/D3) and mouse (bEnd.3) brain endothelial cell lines was explored. Computational approaches examined molecular level interactions of both drugs with the SLC transporters [organic cation transporter 1 (OCT1), plasma membrane monoamine transporter (PMAT) and multi-drug and toxic compound extrusion proteins (MATE1)] and amisulpride with the ABC transporter (P-glycoprotein). The distribution of [3H]amisulpride in wildtype and 3×transgenic AD mice was examined using in situ brain perfusion experiments. Western blots determined transporter expression in mouse and human brain capillaries . RESULTS In vitro BBB and in silico transporter studies indicated that [3H]amisulpride and [3H]haloperidol were transported by the influx transporter, OCT1, and efflux transporters MATE1 and PMAT. Amisulpride did not have a strong interaction with OCTN1, OCTN2, P-gp, BCRP or MRP and could not be described as a substrate for these transporters. Amisulpride brain uptake was increased in AD mice compared to wildtype mice, but vascular space was unaffected. There were no measurable changes in the expression of MATE1, MATE2, PMAT OCT1, OCT2, OCT3, OCTN1, OCTN2 and P-gp in capillaries isolated from whole brain homogenates from the AD mice compared to wildtype mice. Although, PMAT and MATE1 expression was reduced in capillaries obtained from specific human brain regions (i.e. putamen and caudate) from AD cases (Braak stage V-VI) compared to age matched controls (Braak stage 0-II). CONCLUSIONS Together our research indicates that the increased sensitivity of individuals with Alzheimer's to amisulpride is related to previously unreported changes in function and expression of SLC transporters at the BBB (in particular PMAT and MATE1). Dose adjustments may be required for drugs that are substrates of these transporters when prescribing for individuals with AD.
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Affiliation(s)
- Gayathri Nair Sekhar
- Faculty of Life Sciences and Medicine, School of Cancer and Pharmaceutical Sciences, King's College London, Franklin-Wilkins Building, 150 Stamford Street, Waterloo, London, SE1 9NH, UK
| | - Alice L Fleckney
- Faculty of Life Sciences and Medicine, School of Cancer and Pharmaceutical Sciences, King's College London, Franklin-Wilkins Building, 150 Stamford Street, Waterloo, London, SE1 9NH, UK
| | - Sevda Tomova Boyanova
- Faculty of Life Sciences and Medicine, School of Cancer and Pharmaceutical Sciences, King's College London, Franklin-Wilkins Building, 150 Stamford Street, Waterloo, London, SE1 9NH, UK
| | - Huzefa Rupawala
- Faculty of Life Sciences and Medicine, School of Cancer and Pharmaceutical Sciences, King's College London, Franklin-Wilkins Building, 150 Stamford Street, Waterloo, London, SE1 9NH, UK
| | - Rachel Lo
- Faculty of Life Sciences and Medicine, School of Cancer and Pharmaceutical Sciences, King's College London, Franklin-Wilkins Building, 150 Stamford Street, Waterloo, London, SE1 9NH, UK
| | - Hao Wang
- Faculty of Life Sciences and Medicine, School of Cancer and Pharmaceutical Sciences, King's College London, Franklin-Wilkins Building, 150 Stamford Street, Waterloo, London, SE1 9NH, UK
| | - Doaa B Farag
- Faculty of Life Sciences and Medicine, School of Cancer and Pharmaceutical Sciences, King's College London, Franklin-Wilkins Building, 150 Stamford Street, Waterloo, London, SE1 9NH, UK
- Faculty of Pharmacy, Misr International University, Cairo, 11431, Egypt
| | - Khondaker Miraz Rahman
- Faculty of Life Sciences and Medicine, School of Cancer and Pharmaceutical Sciences, King's College London, Franklin-Wilkins Building, 150 Stamford Street, Waterloo, London, SE1 9NH, UK
| | - Martin Broadstock
- Wolfson Centre for Age-Related Diseases, King's College London, Guy's Campus, London, SE1 1UL, UK
- Maurice Wohl Clinical Neuroscience Institute, King's College London, 125 Coldharbour Lane, Camberwell, London, SE5 9N, UK
| | - Suzanne Reeves
- Division of Psychiatry, Faculty of Brain Sciences, University College London, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Sarah Ann Thomas
- Faculty of Life Sciences and Medicine, School of Cancer and Pharmaceutical Sciences, King's College London, Franklin-Wilkins Building, 150 Stamford Street, Waterloo, London, SE1 9NH, UK.
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Calsolaro V, Antognoli R, Okoye C, Monzani F. The Use of Antipsychotic Drugs for Treating Behavioral Symptoms in Alzheimer's Disease. Front Pharmacol 2019; 10:1465. [PMID: 31920655 PMCID: PMC6915160 DOI: 10.3389/fphar.2019.01465] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 11/13/2019] [Indexed: 12/20/2022] Open
Abstract
According to the World Alzheimer’s report, dementia was estimated to affect 50 million worldwide in 2018, number expected to increase to more than 150 million within 30 years. Alzheimer’s disease is the most common type of dementia, accounting on its own for 2/3 of all dementia cases. The initial signs and symptoms of Alzheimer’s disease relate to progressive cognitive decline, inexorably progressing until the loss of independence. Neuropsychiatric and behavioral symptoms may occur during the progression of the disease; around 20% of patients without any behavioral symptoms at the diagnosis will experience some of them within 2 years. Consequences are early institutionalization, lower quality of life, of both patients and carers, and more severe cognitive impairment. Treatment options for behavioral symptoms include pharmacological and non-pharmacological approaches. The latter are usually preferred, since antipsychotic therapy is not free from several, and often serious, adverse events. However, behavioral symptoms are not always controllable with non-pharmacological intervention. The psychotropic class of medication more frequently prescribed for behavioral symptoms are atypical antipsychotics; among them, risperidone is the only one licensed for the treatment of aggression, in Europe but not in the USA. On that regard, the use of antipsychotic drugs should be limited, due to the increased risk of mortality, stroke, hallucination, and higher risk of relapse after discontinuation. Some new agents are under evaluation, such as pimavanserin and lumateperone. In this review, we are evaluating the current available pharmacological options to treat behavioral symptoms as well as the forthcoming new agents.
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Affiliation(s)
- Valeria Calsolaro
- Neurology Imaging Unit, Imperial College London, London, United Kingdom.,Geriatrics Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Rachele Antognoli
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Chukwuma Okoye
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Fabio Monzani
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Scuteri D, Rombolá L, Tridico L, Mizoguchi H, Watanabe C, Sakurada T, Sakurada S, Corasaniti MT, Bagetta G, Morrone LA. Neuropharmacological Properties of the Essential Oil of Bergamot for the Clinical Management of Pain-Related BPSDs. Curr Med Chem 2019. [PMID: 29521195 DOI: 10.2174/0929867325666180307115546] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Alzheimer's Disease (AD) accounts for approximately 50% of all cases of dementia and, in spite of the great effort for the development of disease-modifying drugs, a definitive treatment of cognitive impairment is not available yet. A perfect adherence to the current therapy of cognitive decline is needed for a better control of the disease and this is proven to reduce, though not completely abolish, the associated Behavioural and Psychological Symptoms of Dementia (BPSDs) from occurring. This cluster of symptoms, remarkably affecting patients' health-related quality of life (HRQL), is tightly associated with pain states. Antipsychotics are the only treatment for BPSDs. However, these drugs are more effective and safer in the short-term (6-12 weeks), they are able to manage aggression but not agitation and they cannot control pain. Aromatherapy with Melissa officinalis and Lavandula officinalis has been employed to handle BPSDs, but it has not provided strong evidence to offer relief from pain. OBJECTIVE Bergamot Essential Oil (BEO) exerts antinociceptive activity through several pharmacological mechanisms: in particular, it is able to enhance autophagy, a process undergoing derangement in chronic pain. Thus, the sound pharmacological basis for clinical translation of aromatherapy with BEO in the treatment of BPSDs has been pointed out. CONCLUSION The antinociceptive effects elicited by BEO in experimental pain models make it a possible candidate for the pharmacological management of pain-related BPSDs.
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Affiliation(s)
- Damiana Scuteri
- Department of Pharmacy, Health Science and Nutrition, Section of Translational Pharmacology, University of Calabria, 87036 Rende (CS), Italy
| | - Laura Rombolá
- Department of Pharmacy, Health Science and Nutrition, Section of Translational Pharmacology, University of Calabria, 87036 Rende (CS), Italy
| | - Laura Tridico
- Department of Pharmacy, Health Science and Nutrition, Section of Translational Pharmacology, University of Calabria, 87036 Rende (CS), Italy
| | - Hirokazu Mizoguchi
- Department of Physiology and Anatomy, Tohoku Pharmaceutical University, Sendai, Japan
| | - Chizuko Watanabe
- Department of Physiology and Anatomy, Tohoku Pharmaceutical University, Sendai, Japan
| | - Tsukasa Sakurada
- Department of Physiology and Anatomy, Tohoku Pharmaceutical University, Sendai, Japan
| | - Shinobu Sakurada
- First Department of Pharmacology, Daiichi College of Pharmaceutical Sciences, Fukuoka, Japan
| | - Maria T Corasaniti
- Department of Health Science, University Magna Graecia, Catanzaro, Italy
| | - Giacinto Bagetta
- Department of Pharmacy, Health Science and Nutrition, Section of Translational Pharmacology, University of Calabria, 87036 Rende (CS), Italy
| | - Luigi A Morrone
- Department of Pharmacy, Health Science and Nutrition, Section of Translational Pharmacology, University of Calabria, 87036 Rende (CS), Italy
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Creese B, Vassos E, Bergh S, Athanasiu L, Johar I, Rongve A, Medbøen IT, Vasconcelos Da Silva M, Aakhus E, Andersen F, Bettella F, Braekhus A, Djurovic S, Paroni G, Proitsi P, Saltvedt I, Seripa D, Stordal E, Fladby T, Aarsland D, Andreassen OA, Ballard C, Selbaek G. Examining the association between genetic liability for schizophrenia and psychotic symptoms in Alzheimer's disease. Transl Psychiatry 2019; 9:273. [PMID: 31641104 PMCID: PMC6805870 DOI: 10.1038/s41398-019-0592-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 09/06/2019] [Accepted: 09/23/2019] [Indexed: 01/09/2023] Open
Abstract
Psychosis (delusions or hallucinations) in Alzheimer's disease (AD + P) occurs in up to 50% of individuals and is associated with significantly worse clinical outcomes. Atypical antipsychotics, first developed for schizophrenia, are commonly used in AD + P, suggesting shared mechanisms. Despite this implication, little empirical research has been conducted to examine whether there are mechanistic similarities between AD + P and schizophrenia. In this study, we tested whether polygenic risk score (PRS) for schizophrenia was associated with AD + P. Schizophrenia PRS was calculated using Psychiatric Genomics Consortium data at ten GWAS p value thresholds (PT) in 3111 AD cases from 11 cohort studies characterized for psychosis using validated, standardized tools. Association between PRS and AD + P status was tested by logistic regression in each cohort individually and the results meta-analyzed. The schizophrenia PRS was associated with AD + P at an optimum PT of 0.01. The strongest association was for delusions where a one standard deviation increase in PRS was associated with a 1.18-fold increased risk (95% CI: 1.06-1.3; p = 0.001). These new findings point towards psychosis in AD-and particularly delusions-sharing some genetic liability with schizophrenia and support a transdiagnostic view of psychotic symptoms across the lifespan.
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Affiliation(s)
- Byron Creese
- University of Exeter Medical School, Exeter, UK.
- Norwegian, Exeter and King's College Consortium for Genetics of Neuropsychiatric Symptoms in Dementia, Exeter, UK.
| | - Evangelos Vassos
- Social Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Sverre Bergh
- Norwegian, Exeter and King's College Consortium for Genetics of Neuropsychiatric Symptoms in Dementia, Exeter, UK
- Research Centre of Age-Related Functional Decline and Disease, Innlandet Hospital Trust, Pb 68, 2312, Ottestad, Norway
- Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway
| | - Lavinia Athanasiu
- NORMENT, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- NORMENT, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | - Iskandar Johar
- Norwegian, Exeter and King's College Consortium for Genetics of Neuropsychiatric Symptoms in Dementia, Exeter, UK
- Department of Old Age Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Arvid Rongve
- Norwegian, Exeter and King's College Consortium for Genetics of Neuropsychiatric Symptoms in Dementia, Exeter, UK
- Department of Research and Innovation, Helse Fonna, Haugesund, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Ingrid Tøndel Medbøen
- Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| | - Miguel Vasconcelos Da Silva
- University of Exeter Medical School, Exeter, UK
- Norwegian, Exeter and King's College Consortium for Genetics of Neuropsychiatric Symptoms in Dementia, Exeter, UK
- Department of Old Age Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Eivind Aakhus
- Research Centre of Age-Related Functional Decline and Disease, Innlandet Hospital Trust, Pb 68, 2312, Ottestad, Norway
| | - Fred Andersen
- Department of Community Medicine, University of Tromsø, Tromsø, Norway
| | - Francesco Bettella
- NORMENT, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- NORMENT, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | - Anne Braekhus
- Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
- Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Srdjan Djurovic
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- NORMENT, Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Medical Genetics, Oslo University Hospital, Oslo, Norway
| | - Giulia Paroni
- Complex Structure of Geriatrics, Department of Medical Sciences, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, FG, Italy
| | - Petroula Proitsi
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Ingvild Saltvedt
- Geriatric Department, St. Olav Hospital, University Hospital of Trondheim, Trondheim, Norway
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Davide Seripa
- Complex Structure of Geriatrics, Department of Medical Sciences, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, FG, Italy
| | - Eystein Stordal
- Department of Mental Health, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Psychiatry, Namsos Hospital, Namsos, Norway
| | - Tormod Fladby
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, Campus Ahus, University of Oslo, Oslo, Norway
| | - Dag Aarsland
- Norwegian, Exeter and King's College Consortium for Genetics of Neuropsychiatric Symptoms in Dementia, Exeter, UK
- Department of Old Age Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Centre for Age-Related Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Ole A Andreassen
- NORMENT, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- NORMENT, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | - Clive Ballard
- University of Exeter Medical School, Exeter, UK
- Norwegian, Exeter and King's College Consortium for Genetics of Neuropsychiatric Symptoms in Dementia, Exeter, UK
| | - Geir Selbaek
- Norwegian, Exeter and King's College Consortium for Genetics of Neuropsychiatric Symptoms in Dementia, Exeter, UK
- Research Centre of Age-Related Functional Decline and Disease, Innlandet Hospital Trust, Pb 68, 2312, Ottestad, Norway
- Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
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Tonda-Turo C, Origlia N, Mattu C, Accorroni A, Chiono V. Current Limitations in the Treatment of Parkinson's and Alzheimer's Diseases: State-of-the-Art and Future Perspective of Polymeric Carriers. Curr Med Chem 2019; 25:5755-5771. [PMID: 29473493 DOI: 10.2174/0929867325666180221125759] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 09/18/2017] [Accepted: 02/06/2018] [Indexed: 12/18/2022]
Abstract
Alzheimer's and Parkinson's diseases are the most common neurodegenerative diseases worldwide and their incidence is increasing due to the aging population. At the moment, the available therapies are not disease modifying and have several limitations, some of which are discussed in this review. One of the main limitations of these treatments is the low concentration that drugs reach in the central nervous system after systemic administration. Indeed, the presence of biological barriers, particularly the blood-brain barrier (BBB), hinders the effective drug delivery to the brain, reducing the potential benefit coming from the administration of the medication. In this review, the mechanisms of transport across the BBB and new methods to improve drug passage across the BBB are discussed. These methods include non-invasive solutions such as intranasal and intravitreal administration, and the use of nanotechnology solutions based on polymeric carriers when the drug is intravenously injected, orally taken for intestine adsorption or delivered through the dermal mucosa. Also, it provides an analysis of more invasive solutions that include intracranially injected hydrogels and implanted devices for local drug delivery. Efforts in finding new therapeutic drugs blocking neurodegenerative disease progression or reverting their course should be coupled with efforts addressed to efficient drug delivery systems. Hence, new pharmacology discoveries together with advancements in nanotechnologies and biomaterials for regenerative medicine are required to effectively counteract neurodegenerative diseases.
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Affiliation(s)
- Chiara Tonda-Turo
- Department of Mechanical and Aerospace Engineering, Politecnico di Torino, 10129 Turin, Italy
| | - Nicola Origlia
- CNR, Neuroscience Institute Via G. Moruzzi 1, 56124 Pisa, Italy
| | - Clara Mattu
- Department of Mechanical and Aerospace Engineering, Politecnico di Torino, 10129 Turin, Italy
| | - Alice Accorroni
- CNR, Neuroscience Institute Via G. Moruzzi 1, 56124 Pisa, Italy.,Institute of Life Sciences, Scuola Superiore Sant'Anna, 56127 Pisa, Italy
| | - Valeria Chiono
- Department of Mechanical and Aerospace Engineering, Politecnico di Torino, 10129 Turin, Italy
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Calsolaro V, Antognoli R, Monzani F. Why are so few antipsychotic drugs licensed for Alzheimer's disease related behavioral and psychological symptoms? Expert Rev Neurother 2019; 19:1051-1053. [PMID: 31282774 DOI: 10.1080/14737175.2019.1641407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Valeria Calsolaro
- Geriatrics Unit, Department of Clinical & Experimental Medicine, University of Pisa , Pisa , Italy.,Neurology Imaging Unit, Imperial College , London , UK
| | - Rachele Antognoli
- Geriatrics Unit, Department of Clinical & Experimental Medicine, University of Pisa , Pisa , Italy
| | - Fabio Monzani
- Geriatrics Unit, Department of Clinical & Experimental Medicine, University of Pisa , Pisa , Italy
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46
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Appelhof B, Bakker C, de Vugt ME, van Duinen-van den IJssel JCL, Zwijsen SA, Smalbrugge M, Teerenstra S, Verhey FRJ, Zuidema SU, Koopmans RTCM. Effects of a Multidisciplinary Intervention on the Presence of Neuropsychiatric Symptoms and Psychotropic Drug Use in Nursing Home Residents WithYoung-Onset Dementia: Behavior and Evolution of Young-Onset Dementia Part 2 (BEYOND-II) Study. Am J Geriatr Psychiatry 2019; 27:581-589. [PMID: 30799167 DOI: 10.1016/j.jagp.2018.12.032] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 12/30/2018] [Accepted: 12/31/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The effect of an intervention on neuropsychiatric symptoms (NPS), particularly agitation and aggression, and psychotropic drug use (PDU) in institutionalized people with young-onset dementia (YOD) was evaluated. METHODS A randomized controlled trial was conducted using a stepped wedge design. Thirteen YOD special care units were randomly assigned to three groups, which received the intervention at different time points. Four assessments took place every 6 months during a period of 18 months. Two hundred seventy-four people with YOD who resided in YOD special care units participated, of whom 131 took part in all assessments. The intervention consisted of an educational program combined with a care program, which structured the multidisciplinary process of managing NPS. The care program included the following five steps: evaluation of psychotropic drug prescription, detection, analysis, treatment, and evaluation of treatment of NPS. The Cohen-Mansfield Agitation Inventory and the Neuropsychiatric Inventory-Nursing Home version were used to assess NPS. Data on PDU were retrieved from residents' medical files. Multilevel models were used to evaluate the effect of the intervention, which accounted for clustering of measurements in clients within units. RESULTS No significant differences were found in agitation, aggression, other NPS, or PDU after crossing over to the intervention condition. CONCLUSION We found no evidence that the intervention for management of NPS in nursing home residents with YOD was more effective in reducing agitation, aggression, other NPS, or PDU compared with care as usual.
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Affiliation(s)
- Britt Appelhof
- Department of Primary and Community Care (BA, CB, JCLD, RTCMK), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands; Knowledge Center for Specialized Care (BA), Landrijt Archipel, Eindhoven, The Netherlands; Radboudumc Alzheimer Center (BA, CB, JCLD, RTCMK), Nijmegen, The Netherlands; Send correspondence and reprint requests to Britt Appelhof, M.Sc., Department of Primary and Community Care, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands..
| | - Christian Bakker
- Department of Primary and Community Care (BA, CB, JCLD, RTCMK), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands; Radboudumc Alzheimer Center (BA, CB, JCLD, RTCMK), Nijmegen, The Netherlands; Center for Specialized Care in Young-Onset Dementia (CB), Florence Mariahoeve, The Hague
| | - Marjolein E de Vugt
- Alzheimer Center Limburg (MEV, FRJV), School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jeannette C L van Duinen-van den IJssel
- Department of Primary and Community Care (BA, CB, JCLD, RTCMK), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands; Radboudumc Alzheimer Center (BA, CB, JCLD, RTCMK), Nijmegen, The Netherlands
| | - Sandra A Zwijsen
- Department of General Practice and Elderly Care Medicine/Amsterdam Public Health Research Institute (SAZ, MS), VU University Medical Center, Amsterdam
| | - Martin Smalbrugge
- Department of General Practice and Elderly Care Medicine/Amsterdam Public Health Research Institute (SAZ, MS), VU University Medical Center, Amsterdam
| | - Steven Teerenstra
- Department of Health Evidence (ST), Section Biostatistics, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frans R J Verhey
- Alzheimer Center Limburg (MEV, FRJV), School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Sytse U Zuidema
- Department of General Practice and Elderly Care Medicine (SUZ), University Medical Center Groningen, Groningen, The Netherlands
| | - Raymond T C M Koopmans
- Department of Primary and Community Care (BA, CB, JCLD, RTCMK), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands; Radboudumc Alzheimer Center (BA, CB, JCLD, RTCMK), Nijmegen, The Netherlands; De Waalboog "Joachim en Anna" Center for Specialized Geriatric Care (RTCMK), Nijmegen, The Netherlands
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Howard R, Cort E, Bradley R, Harper E, Kelly L, Bentham P, Ritchie C, Reeves S, Fawzi W, Livingston G, Sommerlad A, Oomman S, Nazir E, Nilforooshan R, Barber R, Fox C, Macharouthu A, Ramachandra P, Pattan V, Sykes J, Curran V, Katona C, Dening T, Knapp M, Romeo R, Gray R. Amisulpride for very late-onset schizophrenia-like psychosis: the ATLAS three-arm RCT. Health Technol Assess 2019; 22:1-62. [PMID: 30507375 DOI: 10.3310/hta22670] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Very late-onset (aged ≥ 60 years) schizophrenia-like psychosis (VLOSLP) occurs frequently but no placebo-controlled, randomised trials have assessed the efficacy or risks of antipsychotic treatment. Most patients are not prescribed treatment. OBJECTIVES The study investigated whether or not low-dose amisulpride is superior to placebo in reducing psychosis symptoms over 12 weeks and if any benefit is maintained by continuing treatment thereafter. Treatment safety and cost-effectiveness were also investigated. DESIGN Three-arm, parallel-group, placebo-controlled, double-blind, randomised controlled trial. Participants who received at least one dose of study treatment were included in the intention-to-treat analyses. SETTING Secondary care specialist old age psychiatry services in 25 NHS mental health trusts in England and Scotland. PARTICIPANTS Patients meeting diagnostic criteria for VLOSLP and scoring > 30 points on the Brief Psychiatric Rating Scale (BPRS). INTERVENTION Participants were randomly assigned to three arms in a two-stage trial: (1) 100 mg of amisulpride in both stages, (2) amisulpride then placebo and (3) placebo then amisulpride. Treatment duration was 12 weeks in stage 1 and 24 weeks (later reduced to 12) in stage 2. Participants, investigators and outcome assessors were blind to treatment allocation. MAIN OUTCOME MEASURES Primary outcomes were psychosis symptoms assessed by the BPRS and trial treatment discontinuation for non-efficacy. Secondary outcomes were extrapyramidal symptoms measured with the Simpson-Angus Scale, quality of life measured with the World Health Organization's quality-of-life scale, and cost-effectiveness measured with NHS, social care and carer work loss costs and EuroQol-5 Dimensions. RESULTS A total of 101 participants were randomised. Ninety-two (91%) participants took the trial medication, 59 (64%) completed stage 1 and 33 (56%) completed stage 2 treatment. Despite suboptimal compliance, improvements in BPRS scores at 12 weeks were 7.7 points (95% CI 3.8 to 11.5 points) greater with amisulpride than with placebo (11.9 vs. 4.2 points; p = 0.0002). In stage 2, BPRS scores improved by 1.1 point in those who continued with amisulpride but deteriorated by 5.2 points in those who switched from amisulpride to placebo, a difference of 6.3 points (95% CI 0.9 to 11.7 points; p = 0.024). Fewer participants allocated to the amisulpride group stopped treatment because of non-efficacy in stages 1 (p = 0.01) and 2 (p = 0.031). The number of patients stopping because of extrapyramidal symptoms and other side effects did not differ significantly between groups. Amisulpride treatment in the base-case analyses was associated with non-significant reductions in combined NHS, social care and unpaid carer costs and non-significant reductions in quality-adjusted life-years (QALYs) in both stages. Including patients who were intensive users of inpatient services in sensitivity analyses did not change the QALY result but resulted in placebo dominance in stage 1 and significant reductions in NHS/social care (95% CI -£8923 to -£122) and societal costs (95% CI -£8985 to -£153) for those continuing with amisulpride. LIMITATIONS The original recruitment target of 300 participants was not achieved and compliance with trial medication was highly variable. CONCLUSIONS Low-dose amisulpride is effective and well tolerated as a treatment for VLOSLP, with benefits maintained by prolonging treatment. Potential adverse events include clinically significant extrapyramidal symptoms and falls. FUTURE WORK Trials should examine the longer-term effectiveness and safety of antipsychotic treatment in this patient group, and assess interventions to improve their appreciation of potential benefits of antipsychotic treatment and compliance with prescribed medication. TRIAL REGISTRATION Current Controlled Trials ISRCTN45593573 and EudraCT2010-022184-35. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 67. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Robert Howard
- Department of Old Age Psychiatry, King's College London, London, UK
| | - Elizabeth Cort
- Department of Old Age Psychiatry, King's College London, London, UK
| | - Rosie Bradley
- Medical Research Council Population Health Research Unit, University of Oxford, Oxford, UK
| | - Emma Harper
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Linda Kelly
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Peter Bentham
- Birmingham and Solihull Mental Health NHS Foundation Trust, Birmingham, UK
| | | | - Suzanne Reeves
- Department of Old Age Psychiatry, King's College London, London, UK
| | | | - Gill Livingston
- Division of Psychiatry, University College London, London, UK
| | | | - Sabu Oomman
- Cheshire and Wirral Partnership NHS Foundation Trust, Chester, UK
| | - Ejaz Nazir
- South Staffordshire and Shropshire Healthcare NHS Foundation Trust, Stafford, UK
| | | | - Robert Barber
- Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Chris Fox
- Norwich Medical School, University of East Anglia, Norwich, UK
| | | | | | | | - John Sykes
- Derbyshire Healthcare NHS Foundation Trust, Derby, UK
| | - Valerie Curran
- Black Country Partnership NHS Foundation Trust, West Bromwich, UK
| | | | - Tom Dening
- Division of Psychiatry and Applied Psychology, University of Nottingham, Nottingham, UK
| | - Martin Knapp
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Renee Romeo
- Health Service and Population Research Department, King's College London, London, UK
| | - Richard Gray
- Medical Research Council Population Health Research Unit, University of Oxford, Oxford, UK
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Ottoboni G, Amici S, Iannizzi P, Di Pucchio A, Vanacore N, Chattat R. Italian revised memory and behavior problems checklist (It-RMBPC): validation and psychometric properties in Alzheimer's disease caregivers. Aging Clin Exp Res 2019; 31:527-537. [PMID: 30066051 DOI: 10.1007/s40520-018-0995-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 06/29/2018] [Indexed: 10/28/2022]
Abstract
Behavioral and psychiatric symptoms (BPSD), common in persons with Alzheimer's disease (AD), are known to be associated with caregiver burdening. Therefore, early recognition of BPSD is necessary to protect these caregivers. The aim of this validation study was to test the internal consistency, test-retest reliability and concurrent validity of an Italian translation of the revised memory and behavior problems checklist (RMBPC), as it demonstrated high plasticity in timely measuring the day-to-day BPSD changes that challenge caregivers. A cohort of 355 dyads composed of AD subjects and their principal caregivers were assessed with the Italian version of RMPBC capitalizing on the information provided by the latter ones. The results were compared with the ones from other predictors (i.e., the Zarit Burben Interview, the Hospital Anxiety and Depression Scale, the EurQuality of Life, the neuropsychiatric symptoms). The validity and stability of the It-RMBPC resulted being solid and concurrent reliability resulted having higher correlations with principal caregiver anxiety level. Future studies on the role of BPSD in fostering anxiety in AD principal caregivers are merited.
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Husebø BS, Ballard C, Aarsland D, Selbaek G, Slettebo DD, Gulla C, Aasmul I, Habiger T, Elvegaard T, Testad I, Flo E. The Effect of a Multicomponent Intervention on Quality of Life in Residents of Nursing Homes: A Randomized Controlled Trial (COSMOS). J Am Med Dir Assoc 2019; 20:330-339. [DOI: 10.1016/j.jamda.2018.11.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 11/02/2018] [Accepted: 11/06/2018] [Indexed: 10/27/2022]
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Guseva E. Art Therapy in Dementia Care: Toward Neurologically Informed, Evidence-Based Practice. ART THERAPY 2019. [DOI: 10.1080/07421656.2019.1564613] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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