The cholinergic approach for the treatment of vascular dementia: evidence from pre-clinical and clinical studies

Ligustilide ameliorates cognitive impairment via AMPK/SIRT1 pathway in vascular dementia rat

Vascular dementia (VaD) is the second cause of dementia after Alzheimer's disease. Ligustilide (LIG) is one of the main active ingredients of traditional Chinese medicines, such as Angelica. Studies have reported that LIG could protect against VaD. However, the mechanism is still confused. In this study, we employed a bilateral common carotid artery occlusion rat model to study. LIG (20 or 40 mg/kg/day) and Nimodipine (20 mg/kg) were orally administered to the VaD rats for four weeks. Morris water maze test showed that LIG effectively ameliorated learning and memory impairment in VaD rats. LIG obviously reduced neuronal oxidative stress damage and the level of homocysteine in the brain of VaD rats. Western blot results showed that pro-apoptotic protein Bax and cleaved caspase 3 increased and anti-apoptotic protein Bcl-2 decreased in the hippocampi of VaD rats. But after LIG treatment, these changes were reversed. Moreover, Nissl staining result showed that LIG could reduce neuronal degeneration in VaD rats. Furthermore, LIG enhanced the expressions of P-AMPK and Sirtuin1(SIRT1) in VaD rats. In conclusion, these studies indicated that LIG could ameliorate cognitive impairment in VaD rats, which might be related to AMPK/SIRT1 pathway activation.

Roflumilast Reduces Pathological Symptoms of Sporadic Alzheimer's Disease in Rats Produced by Intracerebroventricular Streptozotocin by Inhibiting NF-κB/BACE-1 Mediated Aβ Production in the Hippocampus and Activating the cAMP/BDNF Signalling Pathway

Alzheimer's disease (AD) is a neurological disease that gradually causes memory loss and cognitive impairment. The intracellular secondary messenger cyclic nucleotide cAMP helps in memory acquisition and consolidation. In several models of AD, increasing their levels using phosphodiesterase (PDE) inhibitors improved cognitive performance and prevent memory loss. Thus, the current investigation was undertaken to investigate the therapeutic potential of the PDE-4 inhibitor roflumilast (RFM) against intracerebroventricular (ICV) streptozotocin (STZ)-induced sporadic AD in rats. STZ (3 mg/kg) was given to rats via the ICV route on the stereotaxic apparatus, followed by RFM (0.51 mg/kg/oral) treatment for 15 days, and donepezil (5 mg/kg/oral) was employed as a reference standard drug. Subsequently, we observed that RFM dramatically increased rats learning and memory capacities as measured by the Morris water maze and a novel object recognition task. RFM enhanced the levels of cAMP and brain-derived neurotrophic factors (BDNFs) while decreasing the expression of nuclear factor kappa B (NF-κB) and glial fibrillary acidic protein (GFAP) in the hippocampus of ICV-STZ-infused rats. RFM was found to significantly reduce ICV-STZ-induced neuroinflammation, amyloidogenesis, oxidative stress cholinergic impairments, GSK-3β, and phosphorylated tau levels in the rat hippocampus. Supporting these, histopathological study using Cresyl violet and Congo red demonstrated that RFM reduced neuronal alterations and Aβ deposition in the hippocampus of AD rats. These findings suggest that RFM could be a promising candidate for the management of AD by inhibiting NF-κB/BACE-1 mediated Aβ production in the hippocampus and activating the cAMP/BDNF signalling pathway.

[Molecular and clinical aspects of the effect of cytidyndiphosphocholine on cognitive functions]

OBJECTIVE

Systematization of the array of publications on cytidyldiphosphocholine (CDP-choline).

MATERIAL AND METHODS

Systematic computer analysis of all currently available publications on CDP-choline (1750 publications in PUBMED) using the topological theory of big data analysis.

RESULTS

CDP-choline is essential for acetylcholine biosynthesis, phospholipid metabolism, and DNA methylation. The article describes the effects of CDP-choline on acetylcholinergic and other types of neurotransmission, anti-inflammatory, neuroprotective and neurotrophic effects of CDP-choline. Also, the paper presents the effects of the molecule on lipid metabolism and gene expression within the post-genomic paradigm (in particular, an increase in the expression of nicotinic and muscarinic acetylcholine receptors). The results of fundamental and clinical studies of CDP-choline in the treatment of cognitive impairments associated with cerebral ischemia and neurodegeneration are presented.

CONCLUSION

The pharmacological effects of CDP-choline are mediated through multiple molecular mechanisms that contribute to the nootropic action of this molecule.

Association between Use of Angiotensin-converting Enzyme Inhibitors or Angiotensin Receptor Blockers and Postoperative Delirium

Background

Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers improve cognitive function. The authors therefore tested the primary hypothesis that preoperative use of angiotensin inhibitors is associated with less delirium in critical care patients. Post hoc, the association between postoperative use of angiotensin system inhibitors and delirium was assessed.

Methods

The authors conducted a single-site cohort study of adults admitted to Cleveland Clinic critical care units after noncardiac procedures between 2013 and 2018 who had at least one Confusion Assessment Method delirium assessment. Patients with preexisting dementia, Alzheimer’s disease or other cognitive decline, and patients who had neurosurgical procedures were excluded. For the primary analysis, the confounder-adjusted association between preoperative angiotensin inhibitor use and the incidence of postoperative delirium was assessed. Post hoc, the confounder-adjusted association between postoperative angiotensin system inhibitor use and the incidence of delirium was assessed.

Results

The incidence of delirium was 39% (551 of 1,396) among patients who were treated preoperatively with angiotensin system inhibitors and 39% (1,344 of 3,468) in patients who were not. The adjusted odds ratio of experiencing delirium during critical care was 0.98 (95% CI, 0.86 to 1.10; P = 0.700) for preoperative use of angiotensin system inhibitors versus control. Delirium was observed in 23% (100 of 440) of patients who used angiotensin system inhibitors postoperatively before intensive care discharge, and in 41% (1,795 of 4,424) of patients who did not (unadjusted P < 0.001). The confounder-adjusted odds ratio for experiencing delirium in patients who used angiotensin system inhibitors postoperatively was 0.55 (95% CI, 0.43 to 0.72; P < 0.001).

Conclusions

Preoperative use of angiotensin system inhibitors is not associated with reduced postoperative delirium. In contrast, treatment during intensive care was associated with lower odds of delirium. Randomized trials of postoperative angiotensin-converting enzymes inhibitors and angiotensin receptor blockers seem justified.

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Contributions by the Brain Renin-Angiotensin System to Memory, Cognition, and Alzheimer's Disease

Alzheimer's disease (AD) is a neurodegenerative disease characterized by progressive neuron losses in memory-associated brain structures that rob patients of their dignity and quality of life. Five drugs have been approved by the FDA to treat AD but none modify or significantly slow disease progression. New therapies are needed to delay the course of this disease with the ultimate goal of preventing neuron losses and preserving memory functioning. In this review we describe the renin-angiotensin II (AngII) system (RAS) with specific regard to its deleterious contributions to hypertension, facilitation of neuroinflammation and oxidative stress, reduced cerebral blood flow, tissue remodeling, and disruption of memory consolidation and retrieval. There is evidence that components of the RAS, AngIV and Ang(1-7), are positioned to counter such damaging influences and these systems are detailed with the goal of drawing attention to their importance as drug development targets. Ang(1-7) binds at the Mas receptor, while AngIV binds at the AT4 receptor subtype, and these receptor numbers are significantly decreased in AD patients, accompanied by declines in brain aminopeptidases A and N, enzymes essential for the synthesis of AngIV. Potent analogs may be useful to counter these changes and facilitate neuronal functioning and reduce apoptosis in memory associated brain structures of AD patients.

Behavioral and psychological symptoms in Alzheimer's dementia and vascular dementia

Behavioral and psychological symptoms of dementia (BPSD) are highly prevalent and represent a significant burden for patients and their caregivers. Early recognition and management of these symptoms is crucial as they are associated with increased risk of institutionalization, impairments in daily functioning, reduced quality of life, and more rapid progression to severe dementia. This chapter will discuss the pathophysiology, proposed diagnostic criteria, clinical features, and management of BPSD, including apathy, depression, agitation/aggression, psychosis, and sleep disturbances. Apathy and depression are the most common overall, and apathy is associated with high symptom severity likely because of its greater persistence. Symptoms such as agitation, aggression, hallucinations, and delusions may be especially distressing and dangerous to patients and caregivers. Nonpharmacologic management should be considered first-line therapy in most cases due to the modest and inconsistent evidence base for pharmacologic agents and greater risk of harm. However, the judicious use of pharmacologic agents may be warranted when symptoms are dangerous and/or severely distressing.

The renin angiotensin system and the brain: New developments

The traditional renin-angiotensin system (RAS) is indispensable system in adjusting sodium homeostasis, body fluid volume, and controlling arterial blood pressure. The key elements are renin splitting inactive angiotensinogen to yield angiotensin (Ang-I). Ang-1 is then changed by angiotensin-1 converting enzyme (ACE) into angiotensin II (Ang-II). Using PubMed, Google Scholar, and other means, we searched the peer-reviewed literature from 1990 to 2013 for articles on newly discovered findings related to the RAS, especially focusing on how the system influences the central nervous system (CNS). The classical RAS is now considered to be only part of the picture; the discovery of additional RAS pathways in the brain and elsewhere has yielded a vastly improved understanding of how the RAS influences the CNS. Newly discovered effects of the RAS on brain tissue include neuroprotection, cognition, and cerebral vasodilation. A number of brain biochemical pathways are influenced by the brain RAS. Within various pathways, there are potential opportunities for classical pharmacologic interventions as well as the possibility of controlling gene expression.

Pterostilbene ameliorates intracerebroventricular streptozotocin induced memory decline in rats

There is strong evidence that mitochondrial dysfunction mediated oxidative stress results in aging and energy metabolism deficits thus playing a prime role in pathogenesis of Alzheimer's disease, neuronal death and cognitive dysfunction. Evidences accrued in empirical studies suggest the antioxidant, anticancer and anti-inflammatory activities of the phytochemical pterostilbene (PTS). PTS also exhibits favourable pharmacokinetic attributes compared to other stilbenes. Hence, in the present study, we explored the neuroprotective role of PTS in ameliorating the intracerebroventricular administered streptozotocin (STZ) induced memory decline in rats. PTS at doses of 10, 30 and 50 mg/kg, was administered orally to STZ administered Sprague-Dawley (SD) rats. The learning and memory tests, Morris water maze test and novel object recognition test were performed which revealed improved cognition on PTS treatment. Further, there was an overall improvement in brain antioxidant parameters like elevated catalase and superoxide dismutase activities, GSH levels, lowered levels of nitrites, lipid peroxides and carbonylated proteins. There was improved cholinergic transmission as evident by decreased acetylcholinesterase activities. The action of ATPases (Na+ K+, Ca2+ and Mg2+) indicating the maintenance of cell membrane potential was also augmented. mRNA expression of battery of genes involved in cellular mitochondrial biogenesis and inflammation showed variations which extrapolate to hike in mitochondrial biogenesis and abated inflammation. The histological findings corroborated the effective role of PTS in countering STZ induced structural aberrations in brain.

Neuromuscular Junction Impairment in Amyotrophic Lateral Sclerosis: Reassessing the Role of Acetylcholinesterase

Amyotrophic Lateral Sclerosis (ALS) is a highly debilitating disease caused by progressive degeneration of motorneurons (MNs). Due to the wide variety of genes and mutations identified in ALS, a highly varied etiology could ultimately converge to produce similar clinical symptoms. A major hypothesis in ALS research is the “distal axonopathy” with pathological changes occurring at the neuromuscular junction (NMJ), at very early stages of the disease, prior to MNs degeneration and onset of clinical symptoms. The NMJ is a highly specialized cholinergic synapse, allowing signaling between muscle and nerve necessary for skeletal muscle function. This nerve-muscle contact is characterized by the clustering of the collagen-tailed form of acetylcholinesterase (ColQ-AChE), together with other components of the extracellular matrix (ECM) and specific key molecules in the NMJ formation. Interestingly, in addition to their cholinergic role AChE is thought to play several “non-classical” roles that do not require catalytic function, most prominent among these is the facilitation of neurite growth, NMJ formation and survival. In all this context, abnormalities of AChE content have been found in plasma of ALS patients, in which AChE changes may reflect the neuromuscular disruption. We review these findings and particularly the evidences of changes of AChE at neuromuscular synapse in the pre-symptomatic stages of ALS.

Inhibited Expression of α4β2 Nicotinic Acetylcholine Receptor in Blood Leukocytes of Chinese Patients with Vascular Dementia and in Blood Leukocytes as Well as the Hippocampus of Brain from Ischemic Rats

Our present aim was to investigate whether changes in the expression of α₄β₂ nicotinic acetylcholine receptor (nAChR) in patients with vascular dementia (VaD) and ischemic rats are related to cognitive scores. Blood leukocytes for 59 Chinese patients with VaD (diagnosed on the basis of clinical guidelines) and 31 cases as age-matched controls were examined, and the animal model established employing Pulsinelli's four-vessel occlusion. The levels of α₄ and β₂ subunit mRNA in leukocytes and the hippocampus were analyzed by real-time PCR, and the protein level in the hippocampus by Western blotting. The mini-mental state examination was utilized to characterize the intellectual capacity of the patients with reference to the DSM IV diagnosis and Hachinski Ischemic Scale score, and the Morris Water Maze test to assess the ability of learning and memory of the rats. In patients, the level of α₄ mRNA, but not β₂, in blood leukocytes was clearly lowered, which was significantly correlated to their clinical cognitive test scores. Smoking exerted no impact on the level of α₄ mRNA in the present study. In the blood leukocytes and the hippocampus of the brains of the ischemic rats, the levels of both α₄ and β₂ mRNA were lowered, and the proteins of these subunits in the hippocampus were decreased. The changes of α₄ and β₂ mRNA in blood leukocytes, and their protein levels in the hippocampus were significantly correlated with impaired learning and memory. These findings indicate that alterations in expression of the α₄β₂ subtype of nAChR may be involved in the molecular mechanism(s) underlying the cognitive deficit associated with VaD.

Vascular dementia

Vascular dementia is one of the most common causes of dementia after Alzheimer's disease, causing around 15% of cases. However, unlike Alzheimer's disease, there are no licensed treatments for vascular dementia. Progress in the specialty has been difficult because of uncertainties over disease classification and diagnostic criteria, controversy over the exact nature of the relation between cerebrovascular pathology and cognitive impairment, and the paucity of identifiable tractable treatment targets. Although there is an established relation between vascular and degenerative Alzheimer's pathology, the mechanistic link between the two has not yet been identified. This Series paper critiques some of the key areas and controversies, summarises treatment trials so far, and makes suggestions for what progress is needed to advance our understanding of pathogenesis and thus maximise opportunities for the search for new and effective management approaches.

Prevention of cognitive impairment in the midlife women

Forgetfulness is common symptom with age. Especially for midlife women, hormonal cessation by menopausal change is one of the causes in cognitive disorders. And neuropathological changes in brain can lead to mild cognitive impairment (MCI) and eventually dementia. Prevention of MCI is important for decreasing progression to dementia. This article presents therapeutic approaches based on pathophysiologic changes in brain for preventing cognitive decline.

The development of small molecule angiotensin IV analogs to treat Alzheimer's and Parkinson's diseases

Alzheimer's (AD) and Parkinson's (PD) diseases are neurodegenerative diseases presently without effective drug treatments. AD is characterized by general cognitive impairment, difficulties with memory consolidation and retrieval, and with advanced stages episodes of agitation and anger. AD is increasing in frequency as life expectancy increases. Present FDA approved medications do little to slow disease progression and none address the underlying progressive loss of synaptic connections and neurons. New drug design approaches are needed beyond cholinesterase inhibitors and N-methyl-d-aspartate receptor antagonists. Patients with PD experience the symptomatic triad of bradykinesis, tremor-at-rest, and rigidity with the possibility of additional non-motor symptoms including sleep disturbances, depression, dementia, and autonomic nervous system failure. This review summarizes available information regarding the role of the brain renin-angiotensin system (RAS) in learning and memory and motor functions, with particular emphasis on research results suggesting a link between angiotensin IV (AngIV) interacting with the AT4 receptor subtype. Currently there is controversy over the identity of this AT4 receptor protein. Albiston and colleagues have offered convincing evidence that it is the insulin-regulated aminopeptidase (IRAP). Recently members of our laboratory have presented evidence that the brain AngIV/AT4 receptor system coincides with the brain hepatocyte growth factor/c-Met receptor system. In an effort to resolve this issue we have synthesized a number of small molecule AngIV-based compounds that are metabolically stable, penetrate the blood-brain barrier, and facilitate compromised memory and motor systems. These research efforts are described along with details concerning a recently synthesized molecule, Dihexa that shows promise in overcoming memory and motor dysfunctions by augmenting synaptic connectivity via the formation of new functional synapses.

Chronic administration of the angiotensin-converting enzyme inhibitor, ramipril, prevents fractionated whole-brain irradiation-induced perirhinal cortex-dependent cognitive impairment

We hypothesized that chronic administration of the angiotensin-converting enzyme inhibitor, ramipril, to young adult male rats would prevent/ameliorate fractionated whole-brain irradiation-induced perirhinal cortex-dependent cognitive impairment. Eighty 12-14-week-old young adult male Fischer 344 rats received either: (1) sham irradiation, (2) 40 Gy of fractionated whole-brain irradiation delivered as two 5 Gy fractions/week for 4 weeks, (3) sham irradiation plus continuous administration of 15 mg/L of ramipril in the drinking water starting 3 days before irradiation, or (4) fractionated whole-brain irradiation plus ramipril. Cognitive function was assessed using a perirhinal cortex-dependent version of the novel object recognition task 26 weeks after irradiation. Microglial activation was determined in the perirhinal cortex and the dentate gyrus of the hippocampus 28 weeks after irradiation using the ED1 antibody. Neurogenesis was assessed in the granular cell layer and subgranular zones of the dentate gyrus using a doublecortin antibody. Fractionated whole-brain irradiation led to: (1) a significant impairment in perirhinal cortex-dependent cognitive function, (2) a significant increase in activated microglia in the dentate gyrus but not in the perirhinal cortex, and (3) a significant decrease in neurogenesis. Continuous administration of ramipril before, during, and after irradiation prevented the fractionated whole-brain irradiation-induced changes in perirhinal cortex-dependent cognitive function, as well as in microglial activation in the dentate gyrus. Thus, as hypothesized, continuous administration of the angiotensin-converting enzyme inhibitor, ramipril, can prevent the fractionated whole-brain irradiation-induced impairment in perirhinal cortex-dependent cognitive function.

The brain RAS and Alzheimer's disease

Alzheimer's disease (AD) has become a major world-wide health problem with ever rising costs associated with the treatment and care of afflicted individuals. As life expectancy has increased the occurrence of dementia has also increased. Hypertension during middle adulthood is correlated with a significantly elevated risk of cognitive impairment later in life. Treatment with antihypertensive drugs, particularly angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs), has been reported to reduce the likelihood and slow the progression of AD; however, the use of ACE inhibitors may be accompanied by an increase in amyloid beta protein(1-42) accumulation. This review summarizes available information regarding the brain renin-angiotensin system (RAS), and specifically the efficacy of ACE inhibitors as anti-dementia agents, and considers the recently discovered AT(4) receptor and associated agonist drugs as potential new therapeutic targets to treat memory impairments associated with AD. We conclude with a description of recent efforts by members of our laboratory to develop blood-brain barrier penetrant angiotensin IV analogue drugs that facilitate cognition in animal models of AD. These efforts have resulted in a small molecule with desirable hydrophobicity characteristics that shows promise with respect to memory facilitation when peripherally administered.

The angiotensin AT4 receptor subtype as a target for the treatment of memory dysfunction associated with Alzheimer's disease

Over recent years antihypertensive drugs, particularly angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs), have been reported to have beneficial effects upon cognitive impairment. Such findings suggest that pharmacological manipulation of angiotensin ligands may be of clinical importance in slowing or halting the cognitive deterioration seen in vascular dementia and Alzheimer's disease. The mechanism(s) underlying these improvements in cognitive function remains unclear; however, important leads are emerging. The angiotensin AT4 receptor subtype, discovered by our laboratory in 1992, influences several important behaviours and physiologies, including learning and memory, and may play a role in this cognitive improvement. This review initially describes the therapeutic drugs approved by the Federal Drug Administration and new approaches presently being developed to treat Alzheimer's disease-induced cognitive impairment. Next, the biologically-active angiotensin ligands and their respective receptor subtypes are discussed, followed by the roles of angiotensin II, angiotensin IV, ACE inhibitors and ARBs in cognitive function. We conclude with a working hypothesis concerning the importance of the AT4 receptor subtype as a new potential drug target for the treatment of Alzheimer's disease-associated memory loss.

Effect of treatment with choline alphoscerate on hippocampus microanatomy and glial reaction in spontaneously hypertensive rats

The influence of long term treatment with choline alphoscerate on microanatomy of hippocampus and glial reaction was assessed in spontaneously hypertensive rats (SHR) used as an animal model of cerebrovascular disease. Choline alphoscerate is a cholinergic precursor, which has shown to be effective in countering cognitive symptoms in forms of dementia disorders of degenerative, vascular or combined origin. Male spontaneously hypertensive rats (SHR) aged 6 months and age-matched normotensive Wistar-Kyoto (WKY) rats were treated for 8 weeks with an oral daily dose of 100 mg/kg of choline alphoscerate, 285 mg/kg of phosphatidylcholine (lecithin) or vehicle. On the hippocampus of different animal groups, nerve cell number and GFAP-immunoreactive astrocytes were assessed by neuroanatomical, immunochemical and immunohistochemical techniques associated with quantitative analysis. Treatment with choline alphoscerate countered nerve cell loss and glial reaction primarily in the CA1 subfields and in the dentate gyrus of the hippocampus of SHR. Phosphatidylcholine did not affect hypertension-dependent changes in hippocampal microanatomy. Both compounds did not affect blood pressure values in SHR. These data suggest that choline alphoscerate may play a role in the countering hippocampal changes induced by cerebrovascular involvement. The observation that treatment with choline alphoscerate attenuates the extent of glial reaction in the hippocampus of SHR suggests also that the compound may afford neuroprotection in this animal model of vascular brain damage.

Association with the cholinergic precursor choline alphoscerate and the cholinesterase inhibitor rivastigmine: An approach for enhancing cholinergic neurotransmission

The effects of association of cholinergic precursors choline or choline alphoscerate with the cholinesterase inhibitor rivastigmine on acetylcholine levels and [(3)H]hemicholinium-3 binding were assessed in rat frontal cortex, hippocampus and striatum. Acetylcholine immunoreactivity was also evaluated in cerebrocortical cholinergic fibers by immunohistochemistry. Choline alphoscerate or rivastigmine, but not choline increased acetylcholine levels as well as [(3)H]hemicholinium-3 binding used as a marker of high affinity cholinergic transporter. The association of choline alphoscerate with rivastigmine dose-dependently increased both acetylcholine levels and [(3)H]hemicholinium-3 binding. Rivastigmine alone or in association with either choline or choline alphoscerate decreased acetylcholinesterase (AChE), whereas choline or choline alphoscerate alone did not affect AChE activity. Choline alphoscerate or rivastigmine alone or in association, but not choline increased acetylcholine immunoreactivity in nerve fibers supplying cerebral cortex. These data suggest that combination of a suitable precursor of brain acetylcholine such as choline alphoscerate and of a cholinesterase inhibitor may represent an association worthwhile of being further investigated as a cholinergic replacement therapy in pathologies characterized by altered cholinergic neurotransmission.

Rivastigmine in vascular dementia

Patients with vascular dementia (VaD) show cholinergic deficits that may result in characteristic clinical syndromes for different subtypes of the condition. Subcortical VaD is characterised by executive dysfunction and behavioural problems, reflecting deterioration of the frontal lobe. Based on limited open-labelled controlled studies of rivastigmine in VaD, this article aims to determine whether rivastigmine, a dual inhibitor of acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE), has any effects on the typical symptoms of subcortical VaD. Long-term rivastigmine treatment is safe and effective. Improvements in domains that characterise subcortical VaD were observed, indicating that rivastigmine may have provided targeted treatment in areas of the brain that are particularly affected in this patient population. A large, double-blind study of rivastigmine in patients with VaD is clearly warranted.

Donepezil: in vascular dementia

Vascular dementia (VaD), caused by stroke or small vessel disease, is the second most common form of dementia after Alzheimer's disease (AD). Donepezil, an acetylcholinesterase inhibitor currently indicated for use in patients with mild to moderate AD, has recently been evaluated in VaD. Donepezil 5 or 10mg once daily provided significant improvements in cognition, as determined by the Alzheimer's Disease Assessment Scale-cognitive subscale (ADAS-cog), relative to placebo, after 24 weeks in patients with VaD. Pooled data from two, randomised, double-blind, phase III trials showed that the least-squares mean change from baseline score effect size for the ADAS-cog was -1.79 for donepezil 5mg once daily (p < 0.001) and -2.28 for donepezil 10mg once daily (p < 0.001) at 24 weeks (observed cases). Significant improvement in global functioning occurred with donepezil 5mg once daily compared with placebo (p = 0.003), but not with donepezil 10mg once daily, as measured by the Clinician's Interview-Based Impression of Change-plus version score (pooled data, observed cases). Donepezil was generally well tolerated in patients with VaD. Most adverse events were mild to moderate in nature, with diarrhoea and nausea being the most common.