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Michael AE, Michael N, Erfurth A, Kujovic M. Clozapine for the treatment of aggressiveness and agitation in advanced dementia. Psychogeriatrics 2023; 23:963-972. [PMID: 37673659 DOI: 10.1111/psyg.13017] [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: 06/12/2023] [Revised: 08/05/2023] [Accepted: 08/16/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Distressing behavioural symptoms, particularly agitation and aggressiveness, remain a difficult problem in everyday clinical practice in the treatment of multimorbid patients with dementia. Clozapine may be an effective therapeutic alternative in this context. METHODS In a retrospective study, patients who had a diagnosis of dementia and had been treated in a specialized geriatric psychiatry unit with clozapine between August 2018 and February 2022 were included, and medical records were systematically reviewed. The Clinical Global Impressions Scale was used to assess improvement, and the Pittsburgh Agitation Scale for symptom reduction. In addition, side effects and clinical features were documented in detail. RESULTS A total of 31 patients (median age 82 years) were identified with a mean clozapine dose of 47.2 (SD 35.6) mg. A total of 13 patients tolerated clozapine very well, 10 showed tolerable side effects, and in 10 patients side effects were the reason for stopping clozapine. Behavioural symptoms improved significantly, as indicated by the assessment scores. CONCLUSIONS In summary, clozapine was effective and well tolerated in 23 patients, suggesting that low-dose clozapine may help to alleviate the suffering of difficult-to-treat multimorbid patients with advanced dementia and their caregivers. However, particular attention should be paid to adverse drug reactions, especially in patients with cardiovascular and pulmonary impairment.
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Affiliation(s)
- Arwed E Michael
- Department of Radiology, Neuroradiology and Nuclear Medicine, Johannes Wesling University Hospital, Ruhr University Bochum, Bochum, Germany
| | - Nikolaus Michael
- Department of Psychiatry, Psychotherapy and Psychosomatic Medicine, Elbroich Hospital, Düsseldorf, Germany
- University of Münster, Münster, Germany
| | - Andreas Erfurth
- University of Münster, Münster, Germany
- 1st Department of Psychiatry and Psychotherapeutic Medicine, Klinik Hietzing, Vienna, Austria
| | - Milenko Kujovic
- Department of Psychiatry and Psychotherapy, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
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Romanova Z, Hlavacova N, Jezova D. Psychotropic Drug Effects on Steroid Stress Hormone Release and Possible Mechanisms Involved. Int J Mol Sci 2022; 23:ijms23020908. [PMID: 35055090 PMCID: PMC8779609 DOI: 10.3390/ijms23020908] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 01/07/2022] [Accepted: 01/12/2022] [Indexed: 12/16/2022] Open
Abstract
There is no doubt that chronic stress accompanied by adrenocortical stress hormone release affects the development and treatment outcome of several mental disorders. Less attention has been paid to the effects of psychotropic drugs on adrenocortical steroids, particularly in clinical studies. This review focuses on the knowledge related to the possible modulation of cortisol and aldosterone secretion under non-stress and stress conditions by antipsychotic drugs, which are being used in the treatment of several psychotic and affective disorders. The molecular mechanisms by which antipsychotic drugs may influence steroid stress hormones include the modulation of central and/or adrenocortical dopamine and serotonin receptors, modulation of inflammatory cytokines, influence on regulatory mechanisms in the central part of the hypothalamic-pituitary axis, inhibition of corticotropin-releasing hormone gene promoters, influencing glucocorticoid receptor-mediated gene transcription, indirect effects via prolactin release, alteration of signaling pathways of glucocorticoid and mineralocorticoid actions. Clinical studies performed in healthy subjects, patients with psychosis, and patients with bipolar disorder suggest that single and repeated antipsychotic treatments either reduce cortisol concentrations or do not affect its secretion. A single and potentially long-term treatment with dopamine receptor antagonists, including antipsychotics, has a stimulatory action on aldosterone release.
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Affiliation(s)
- Zuzana Romanova
- Institute of Experimental Endocrinology, Biomedical Research Center, Slovak Academy of Sciences, 84505 Bratislava, Slovakia; (Z.R.); (N.H.)
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Comenius University Bratislava, 83232 Bratislava, Slovakia
| | - Natasa Hlavacova
- Institute of Experimental Endocrinology, Biomedical Research Center, Slovak Academy of Sciences, 84505 Bratislava, Slovakia; (Z.R.); (N.H.)
| | - Daniela Jezova
- Institute of Experimental Endocrinology, Biomedical Research Center, Slovak Academy of Sciences, 84505 Bratislava, Slovakia; (Z.R.); (N.H.)
- Correspondence:
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3
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Prins AJ, Scherder EJA, van Straten A, Zwaagstra Y, Milders MV. Sensory Stimulation for Nursing-Home Residents: Systematic Review and Meta-Analysis of Its Effects on Sleep Quality and Rest-Activity Rhythm in Dementia. Dement Geriatr Cogn Disord 2021; 49:219-234. [PMID: 32920562 DOI: 10.1159/000509433] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 06/02/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Disrupted sleep-wake cycles might be associated with an exacerbation of behavioural disturbances and accelerate disease progression in dementia. The effect of sensory stimulation for improving sleep quality is unclear. METHODS A systematic literature search was performed and all studies examining the effects of a sensory stimulation intervention (i.e. bright light, massage, acupuncture, animal-assisted interventions) on rest-activity rhythm (RAR) and/or nocturnal restlessness in nursing-home residents with dementia were included. RESULTS Sensory stimulation was shown to improve nocturnal behavioural restlessness as well as sleep duration and continuation, but the effect on the number of awakenings, RAR, and daytime sleep was negligible. Notable was the high heterogeneity between studies regarding treatments and patients' characteristics and sleep parameters. CONCLUSION Sleep quality and nocturnal restlessness in nursing-home residents with dementia may benefit from sensory stimulation. An environment with sensory stimulation may prevent or improve sleep disturbances in nursing homes, and thereby contribute to a better quality of life for their patients.
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Affiliation(s)
- Angela Joanna Prins
- Atlant (Elderly Care), Beekbergen, The Netherlands, .,Department of Clinical Neuropsychology, VU University Amsterdam, Amsterdam, The Netherlands,
| | - Erik J Anton Scherder
- Department of Clinical Neuropsychology, VU University Amsterdam, Amsterdam, The Netherlands
| | - Annemieke van Straten
- Department of Clinical Psychology, VU University Amsterdam, Amsterdam, The Netherlands
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4
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Moon E, Lavin P, Storch KF, Linnaranta O. Effects of antipsychotics on circadian rhythms in humans: a systematic review and meta-analysis. Prog Neuropsychopharmacol Biol Psychiatry 2021; 108:110162. [PMID: 33152385 DOI: 10.1016/j.pnpbp.2020.110162] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 10/05/2020] [Accepted: 10/28/2020] [Indexed: 01/08/2023]
Abstract
Antipsychotics are widely used to treat psychiatric illness and insomnia. However, the etiology of insomnia is multifactorial, including disrupted circadian rhythms. Several studies show that antipsychotics might modulate even healthy circadian rhythms. The purpose of this systematic review is to integrate current knowledge about the effects of antipsychotics on the circadian rhythms in humans, and to conduct a meta- analysis with the available data. Nine electronic databases were searched. We followed the PRISMA guidelines and included randomized controlled trials (RCTs), non-RCTs, case-control studies, case series, and case reports. Of 7,217 articles, 70 were included. The available data was mainly from healthy individuals, or patients having schizophrenia, but the findings showed a transdiagnostic impact on circadian parameters. This was consistently seen as decreased amplitude of cortisol, melatonin, and body temperature. Particularly, a meta-analysis of 16 RCTs measuring cortisol rhythm showed that antipsychotics, especially atypical antipsychotics, decreased the cortisol area under the curve and morning cortisol level, compared to placebo. The data with melatonin or actigraphy was limited. Overall, this evidence about the circadian effect of antipsychotics showed a need for longitudinal, real-time monitoring of specific circadian markers to differentiate a change in amplitude from a shift in phasing, and for knowledge about optimal timing of administration of antipsychotics, according to individual baseline circadian parameters. Standardizing selection criteria and outcome methods could facilitate good quality intervention studies and evidence-based treatment guidelines. This is relevant considering the accumulating evidence of the high prevalence and unfavorable impact of disrupted circadian rhythms in psychiatric disorders.
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Affiliation(s)
- Eunsoo Moon
- Department of Psychiatry, Pusan National University School of Medicine, Yangsan, Republic of Korea; Department of Psychiatry, Medical Research Institute and Pusan National University Hospital, Busan, Republic of Korea; Douglas Mental Health University Institute, Montreal, QC, Canada
| | - Paola Lavin
- Department of Psychiatry, McGill University, Montreal, QC, Canada; Douglas Mental Health University Institute, Montreal, QC, Canada
| | - Kai-Florian Storch
- Department of Psychiatry, McGill University, Montreal, QC, Canada; Douglas Mental Health University Institute, Montreal, QC, Canada
| | - Outi Linnaranta
- Department of Psychiatry, McGill University, Montreal, QC, Canada; Douglas Mental Health University Institute, Montreal, QC, Canada; National institute for Health and Welfare, Helsinki, Finland.
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5
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Ohdo S, Koyanagi S, Matsunaga N. Chronopharmacological strategies focused on chrono-drug discovery. Pharmacol Ther 2019; 202:72-90. [DOI: 10.1016/j.pharmthera.2019.05.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 05/29/2019] [Indexed: 01/21/2023]
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Angulo Sevilla D, Carreras Rodríguez MT, Heredia Rodríguez P, Fernández Sánchez M, Vivancos Mora JA, Gago-Veiga AB. Is There a Characteristic Clinical Profile for Patients with Dementia and Sundown Syndrome? J Alzheimers Dis 2018; 62:335-346. [DOI: 10.3233/jad-170488] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- David Angulo Sevilla
- Department of Neurology, Alzheimer’s Disease and Other Cognitive Disorders Unit, La Princesa Health Research Institute, La Princesa University Hospital, Madrid, Spain
| | - María Teresa Carreras Rodríguez
- Department of Neurology, Alzheimer’s Disease and Other Cognitive Disorders Unit, La Princesa Health Research Institute, La Princesa University Hospital, Madrid, Spain
| | - Patricia Heredia Rodríguez
- Department of Neurology, Alzheimer’s Disease and Other Cognitive Disorders Unit, La Princesa Health Research Institute, La Princesa University Hospital, Madrid, Spain
| | - Marisa Fernández Sánchez
- Department of Neurology, Alzheimer’s Disease and Other Cognitive Disorders Unit, La Princesa Health Research Institute, La Princesa University Hospital, Madrid, Spain
| | - José Aurelio Vivancos Mora
- Department of Neurology, Alzheimer’s Disease and Other Cognitive Disorders Unit, La Princesa Health Research Institute, La Princesa University Hospital, Madrid, Spain
| | - Ana Beatriz Gago-Veiga
- Department of Neurology, Alzheimer’s Disease and Other Cognitive Disorders Unit, La Princesa Health Research Institute, La Princesa University Hospital, Madrid, Spain
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7
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Frohnhofen H, Netzer N. [Sleep disorders in the elderly : Importance in geriatrics]. Z Gerontol Geriatr 2017; 50:702-705. [PMID: 29079870 DOI: 10.1007/s00391-017-1329-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Revised: 10/02/2017] [Accepted: 10/05/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Helmut Frohnhofen
- Fakultät für Gesundheit, Department Humanmedizin, Universität Witten Herdecke, Alfred-Herrhausen-Str. 50, 58456, Witten, Deutschland.
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8
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Zhang F, Zhong R, Li S, Chang RCC, Le W. The missing link between sleep disorders and age-related dementia: recent evidence and plausible mechanisms. J Neural Transm (Vienna) 2017; 124:559-568. [PMID: 28188439 DOI: 10.1007/s00702-017-1696-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 12/30/2016] [Indexed: 12/14/2022]
Abstract
Sleep disorders are among the most common clinical problems and possess a significant concern for the geriatric population. More importantly, while around 40% of elderly adults have sleep-related complaints, sleep disorders are more frequently associated with co-morbidities including age-related neurodegenerative diseases and mild cognitive impairment. Recently, increasing evidence has indicated that disturbed sleep may not only serve as the consequence of brain atrophy, but also contribute to the pathogenesis of dementia and, therefore, significantly increase dementia risk. Since the current therapeutic interventions lack efficacies to prevent, delay or reverse the pathological progress of dementia, a better understanding of underlying mechanisms by which sleep disorders interact with the pathogenesis of dementia will provide possible targets for the prevention and treatment of dementia. In this review, we briefly describe the physiological roles of sleep in learning/memory, and specifically update the recent research evidence demonstrating the association between sleep disorders and dementia. Plausible mechanisms are further discussed. Moreover, we also evaluate the possibility of sleep therapy as a potential intervention for dementia.
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Affiliation(s)
- Feng Zhang
- Liaoning Provincial Clinical Research Center for Neurological Diseases, The First Affiliated Hospital, Dalian Medical University, Dalian, 116021, China.,Liaoning Provincial Key Laboratory for Research on the Pathogenic Mechanisms of Neurological Diseases, The First Affiliated Hospital, Dalian Medical University, Dalian, 116021, China
| | - Rujia Zhong
- Liaoning Provincial Clinical Research Center for Neurological Diseases, The First Affiliated Hospital, Dalian Medical University, Dalian, 116021, China.,Liaoning Provincial Key Laboratory for Research on the Pathogenic Mechanisms of Neurological Diseases, The First Affiliated Hospital, Dalian Medical University, Dalian, 116021, China
| | - Song Li
- Liaoning Provincial Clinical Research Center for Neurological Diseases, The First Affiliated Hospital, Dalian Medical University, Dalian, 116021, China.,Liaoning Provincial Key Laboratory for Research on the Pathogenic Mechanisms of Neurological Diseases, The First Affiliated Hospital, Dalian Medical University, Dalian, 116021, China
| | - Raymond Chuen-Chung Chang
- Laboratory of Neurodegenerative Diseases, LKS Faculty of Medicine, School of Biomedical Sciences, The University of Hong Kong, Hong Kong, China
| | - Weidong Le
- Liaoning Provincial Clinical Research Center for Neurological Diseases, The First Affiliated Hospital, Dalian Medical University, Dalian, 116021, China. .,Liaoning Provincial Key Laboratory for Research on the Pathogenic Mechanisms of Neurological Diseases, The First Affiliated Hospital, Dalian Medical University, Dalian, 116021, China. .,Collaborative Innovation Center for Brain Science, The First Affiliated Hospital, Dalian Medical University, Dalian, 116011, China.
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9
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Naharcı Mİ, Bozoğlu E, Koçak N, Doruk H. Demans Hastalarında Galantamin ve Donepezil'in Uyku Bozukluğu Üzerine Etkinliklerinin İncelenmesi. ACTA ACUST UNITED AC 2016. [DOI: 10.5455/bcp.20110926052514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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10
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Sun HQ, Li SX, Chen FB, Zhang Y, Li P, Jin M, Sun Y, Wang F, Mi WF, Shi L, Yue JL, Yang FD, Lu L. Diurnal neurobiological alterations after exposure to clozapine in first-episode schizophrenia patients. Psychoneuroendocrinology 2016; 64:108-16. [PMID: 26630391 DOI: 10.1016/j.psyneuen.2015.11.013] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Revised: 11/12/2015] [Accepted: 11/13/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND Irregular circadian rhythm and some of its most characteristic symptoms are frequently observed in patients with schizophrenia. However, changes in the expression of clock genes or neuropeptides that are related to the regulation of circadian rhythm may influence the susceptibility to recurrence after antipsychotic treatment in schizophrenia, but this possibility has not been investigated. METHODS Blood samples were collected from 15 healthy male controls and 13 male schizophrenia patients at 4h intervals for 24h before and after treatment with clozapine for 8 weeks. The outcome measures included the relative expression of clock gene mRNA PERIOD1 (PER1), PERIOD2 (PER2), PERIOD3 (PER3) and the levels of plasma cortisol, orexin, and insulin. RESULTS Compared with healthy controls, schizophrenia patients presented disruptions in diurnal rhythms of the expression of PER1, PER3, and NPAS2 and the release of orexin, accompanied by a delayed phase in the expression of PER2, decreases in PER3 and NPAS2 expression, and an increase in cortisol levels at baseline. Several of these disruptions (i.e., in PER1 and PER3 expression) persisted after 8 weeks of clozapine treatment, similar to the decreases in the 24-h expression of PER3 and NPAS2. Clozapine treatment for 8 weeks significantly decreased the 24-h levels of PER2 and increased the 24-h levels of insulin. CONCLUSION These persistent neurobiological changes that occur after 8 weeks of clozapine treatment may contribute to the vulnerability to recurrence and efficacy of long-term maintenance treatment in schizophrenia.
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Affiliation(s)
- Hong-Qiang Sun
- Peking University Sixth Hospital/Institute of Mental Health and Key Laboratory of Mental Health, Ministry of Health, Peking University, Beijing 100191, China
| | - Su-Xia Li
- National Institute on Drug Dependence, Peking University, Beijing 100191, China
| | - Fang-Bin Chen
- 102 Military Hospital of China, Changzhou 213000, China
| | - Yan Zhang
- 102 Military Hospital of China, Changzhou 213000, China
| | - Peng Li
- Peking University Sixth Hospital/Institute of Mental Health and Key Laboratory of Mental Health, Ministry of Health, Peking University, Beijing 100191, China; 102 Military Hospital of China, Changzhou 213000, China
| | - Mei Jin
- 102 Military Hospital of China, Changzhou 213000, China
| | - Yan Sun
- National Institute on Drug Dependence, Peking University, Beijing 100191, China
| | - Fan Wang
- Beijing Hui-Long-Guan Hospital, Peking University, Beijing 100096, China
| | - Wei-Feng Mi
- Peking University Sixth Hospital/Institute of Mental Health and Key Laboratory of Mental Health, Ministry of Health, Peking University, Beijing 100191, China
| | - Le Shi
- Peking University Sixth Hospital/Institute of Mental Health and Key Laboratory of Mental Health, Ministry of Health, Peking University, Beijing 100191, China; National Institute on Drug Dependence, Peking University, Beijing 100191, China
| | - Jing-Li Yue
- Peking University Sixth Hospital/Institute of Mental Health and Key Laboratory of Mental Health, Ministry of Health, Peking University, Beijing 100191, China
| | - Fu-De Yang
- Beijing Hui-Long-Guan Hospital, Peking University, Beijing 100096, China
| | - Lin Lu
- Peking University Sixth Hospital/Institute of Mental Health and Key Laboratory of Mental Health, Ministry of Health, Peking University, Beijing 100191, China; National Clinical Research Center for Mental Disorder, Peking University, Beijing 100191, China.
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11
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Urrestarazu E, Iriarte J. Clinical management of sleep disturbances in Alzheimer's disease: current and emerging strategies. Nat Sci Sleep 2016; 8:21-33. [PMID: 26834500 PMCID: PMC4716729 DOI: 10.2147/nss.s76706] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Sleep and circadian disorders in Alzheimer's disease (AD) are more frequent than in the general population and appear early in the course of the disease. Quality of sleep and quality of life are parallel in these patients, and such disorders also represent a heavy burden for caregivers. Although alterations in melatonin and hypocretins (orexins) seem to play a key role in the origin of these disturbances, the etiology of these disorders is multifactorial, including many factors such as environment, behavior, treatments, and comorbidities, among others. A comprehensive evaluation of sleep in each patient is essential in the design of the treatment that includes nonpharmacological and pharmacological approaches. One particularly interesting point is the possibility of a role of sleep disorders in the pathogenesis of AD, raising the possibility that treating the sleep disorder may alter the course of the disease. In this review, we present an update on the role of sleep disorders in AD, the bidirectional influence of sleep problems and AD, and treatment options. Behavioral measures, bright light therapy (BLT), melatonin, and other drugs are likely well known and correctly managed by the physicians in charge of these patients. In spite of the multiple treatments used, evidence of efficacy is scarce and more randomized double-blind placebo-controlled studies are needed. Future directions for treatment are the establishment of BLT protocols and the development of drugs with new mechanisms of action, especially hypocretin receptor antagonists, melatonin receptor agonists, and molecules that modulate the circadian clock.
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Affiliation(s)
- Elena Urrestarazu
- Sleep Unit, Clinical Neurophysiology, Clínica Universidad de Navarra, Pamplona, Navarra, Spain
| | - Jorge Iriarte
- Sleep Unit, Clinical Neurophysiology, Clínica Universidad de Navarra, Pamplona, Navarra, Spain
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12
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Grippe TC, Gonçalves BSB, Louzada LL, Quintas JL, Naves JOS, Camargos EF, Nóbrega OT. Circadian rhythm in Alzheimer disease after trazodone use. Chronobiol Int 2015; 32:1311-4. [PMID: 26376345 DOI: 10.3109/07420528.2015.1077855] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
A circadian rhythm is a cycle of approximately 24 h, responsible for many physiological adjustments, and ageing of the circadian clock contributes to cognitive decline. Rhythmicity is severely impaired in Alzheimer disease (AD) and few therapeutic attempts succeeded in improving sleep disorders in such context. This study evaluated sleep parameters by actigraphy in 30 AD patients before and after trazodone use for 2 weeks, and we show a significant improvement in relative rhythm amplitude (RRA), compatible with a more stable daytime behavioral pattern. So, trazodone appears to produce a stabilization of the circadian rhythms in individuals with AD.
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Affiliation(s)
- Talyta C Grippe
- a Geriatric Medical Centre, Brasilia University Hospital, University of Brasilia , Brasília , Brazil
| | - Bruno S B Gonçalves
- b Department of Physiology , Bioscience Center, Federal University of Rio Grande do Norte , Natal , Brazil
| | - Luciana L Louzada
- a Geriatric Medical Centre, Brasilia University Hospital, University of Brasilia , Brasília , Brazil
| | - Juliana L Quintas
- a Geriatric Medical Centre, Brasilia University Hospital, University of Brasilia , Brasília , Brazil
| | - Janeth O S Naves
- a Geriatric Medical Centre, Brasilia University Hospital, University of Brasilia , Brasília , Brazil .,c Graduation Program in Health Sciences, Pharmacy School , and
| | - Einstein F Camargos
- a Geriatric Medical Centre, Brasilia University Hospital, University of Brasilia , Brasília , Brazil .,d Graduation Program in Medical Sciences, University of Brasilia , Brasília , Brazil
| | - Otávio T Nóbrega
- a Geriatric Medical Centre, Brasilia University Hospital, University of Brasilia , Brasília , Brazil .,d Graduation Program in Medical Sciences, University of Brasilia , Brasília , Brazil
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13
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Cipriani G, Lucetti C, Danti S, Nuti A. Sleep disturbances and dementia. Psychogeriatrics 2015; 15:65-74. [PMID: 25515641 DOI: 10.1111/psyg.12069] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Revised: 08/15/2014] [Accepted: 08/18/2014] [Indexed: 12/20/2022]
Abstract
Sleep is a complex behavioural state, the ultimate functions of which remain poorly understood. It becomes more fragmented as we age, with more night-time awakenings and greater tendency for daytime sleep. The magnitude of disordered sleep among individuals affected by dementia has been clearly demonstrated, and disturbed sleep is a major clinical problem in dementia. Comorbid insomnia and other sleep disturbances are common in patients with neurodegenerative disorders, such Alzheimer's disease and other dementing disorders. How and when sleep problems manifest themselves can depend on the type of dementia involved as well as the stage of the dementia. However, differences in sleep pattern presentation show more variation during the initial stages of dementias than they do during the later stages. Effective, pragmatic interventions are largely anecdotal and untested.
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14
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Coogan AN, Schutová B, Husung S, Furczyk K, Baune BT, Kropp P, Häßler F, Thome J. The circadian system in Alzheimer's disease: disturbances, mechanisms, and opportunities. Biol Psychiatry 2013; 74:333-9. [PMID: 23273723 DOI: 10.1016/j.biopsych.2012.11.021] [Citation(s) in RCA: 132] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Revised: 11/20/2012] [Accepted: 11/20/2012] [Indexed: 12/18/2022]
Abstract
Alzheimer's disease (AD) is a devastating neurodegenerative condition associated with severe cognitive and behavioral impairments. Circadian rhythms are recurring cycles that display periods of approximately 24 hours and are driven by an endogenous circadian timekeeping system centered on the suprachiasmatic nucleus of the hypothalamus. We review the compelling evidence that circadian rhythms are significantly disturbed in AD and that such disturbance is of significant clinical importance in terms of behavioral symptoms. We also detail findings from neuropathological studies of brain areas associated with the circadian system in postmortem studies, the use of animal models of AD in the investigation of circadian processes, and the evidence that chronotherapeutic approaches aimed at bolstering weakened circadian rhythms in AD produce beneficial outcomes. We argue that further investigation in such areas is warranted and highlight areas for future research that might prove fruitful in ultimately providing new treatment options for this most serious and intractable of conditions.
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Affiliation(s)
- Andrew N Coogan
- Department of Psychology, National University of Ireland, Maynooth, Republic of Ireland
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15
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Coogan AN, Papachatzaki MM, Clemens C, Baird A, Donev RM, Joosten J, Zachariou V, Thome J. Haloperidol alters circadian clock gene product expression in the mouse brain. World J Biol Psychiatry 2011; 12:638-44. [PMID: 21250933 DOI: 10.3109/15622975.2010.543149] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Circadian rhythms are patterns in behavioural and physiological measures that recur on a daily basis and are driven by an endogenous circadian timekeeping system whose molecular machinery consists of a number of clock genes. The typical anti-psychotic haloperidol has previously been shown to induce significant deficiencies in circadian timing in patients. In this study we examined the impact of haloperidol treatment on molecular components of the circadian clock in the mouse brain. METHODS We examined how haloperidol treatment, either acute (both at day and night) or chronically over 14 days, alters the expression of three clock gene protein products (PER1, PER2, BMAL1) across the mouse brain by means of immunohistochemistry. RESULTS Chronic haloperidol treatment significantly decreases the expression levels of PER1 in a number of brain areas, including the hippocampus, the prefrontal and cingulate cerebral cortex and the paraventricular nucleus of the hypothalamus. PER2 expression was only altered in the dentate gyrus and the CA3, and BMAL1 expression was only altered in the paraventricular nucleus of the hypothalamus. CONCLUSION These data indicate that haloperidol has the potential to alter circadian rhythms via modulation of circadian clock gene expression.
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Affiliation(s)
- Andrew N Coogan
- Department of Psychology, National University of Ireland Maynooth, Co. Kildare, Republic of Ireland.
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16
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Thome J, Coogan AN, Woods AG, Darie CC, Häßler F. CLOCK Genes and Circadian Rhythmicity in Alzheimer Disease. J Aging Res 2011; 2011:383091. [PMID: 22028968 PMCID: PMC3199059 DOI: 10.4061/2011/383091] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2011] [Accepted: 08/16/2011] [Indexed: 01/06/2023] Open
Abstract
Disturbed circadian rhythms with sleep problems and disrupted diurnal activity are often seen in patients suffering from Alzheimer disease (AD). Both endogenous CLOCK genes and external Zeitgeber are responsible for the maintenance of circadian rhythmicity in humans. Therefore, modifications of the internal CLOCK system and its interactions with exogenous factors might constitute the neurobiological basis for clinically observed disruptions in rhythmicity, which often have grave consequences for the quality of life of patients and their caregivers. Presently, more and more data are emerging demonstrating how alterations of the CLOCK gene system might contribute to the pathophysiology of AD and other forms of dementia. At the same time, the impact of neuropsychiatric medication on CLOCK gene expression is under investigation.
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Affiliation(s)
- J Thome
- Department of Psychiatry, University of Rostock, Gehlsheimerstraße 20, 18147 Rostock, Germany
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17
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Conroy DA, Brower KJ. Alcohol, toxins, and medications as a cause of sleep dysfunction. HANDBOOK OF CLINICAL NEUROLOGY 2011; 98:587-612. [PMID: 21056213 DOI: 10.1016/b978-0-444-52006-7.00038-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Affiliation(s)
- Deirdre A Conroy
- University of Michigan Addiction Resarch Center, Ann Arbor, MI 48109-2700, USA
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Abstract
OBJECTIVES Alzheimer disease (AD) has been associated with diminished function of the biological clock in the suprachiasmatic nuclei (SCN) and pronounced circadian sleep-wake cycle disturbances. Few studies have investigated other dementia etiologies. Because alcohol acts on the SCN and modifies circadian rhythms in animal studies, Korsakoff psychosis (KP) may also be associated with circadian rhythm abnormalities. This pilot study investigated the rest-activity cycle of KP to see whether there were sleep-wake cycle disturbances similar to those that the authors had observed in patients with AD. DESIGN AND SETTING Cross-sectional observational study in a single academic medical center. PARTICIPANTS, MEASUREMENTS: The authors investigated the circadian rest-activity cycle of six moderately demented patients with KP who wore an activity/lux monitor for 10-26 days and compared these patterns with those of six home-living healthy individuals of the same age group. In addition, rest-activity cycle data from previous studies of patients with AD were examined. INTERVENTIONS None. RESULTS The rest-activity cycle of KP was remarkably well entrained, without the marked circadian and sleep disturbances found in patients with AD on the same ward. KP had a >2 hour earlier bedtime and rest onset than healthy subjects and a 30-minute earlier wake-up time, resulting in longer nocturnal rest duration. The major difference was a greatly diminished daytime activity level and extremely low light exposure. CONCLUSION A stably entrained, although low-amplitude and phase-advanced rest-activity cycle may reflect the different neuropathology of demented patients with KP compared with patients with AD.
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Wulff K, Joyce E, Middleton B, Dijk DJ, Foster RG. The suitability of actigraphy, diary data, and urinary melatonin profiles for quantitative assessment of sleep disturbances in schizophrenia: A case report. Chronobiol Int 2009; 23:485-95. [PMID: 16687321 DOI: 10.1080/07420520500545987] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Sleep disruption is a commonly encountered clinical feature in schizophrenic patients, and one important concern is to determine the extent of this disruption under "real" life situations. Simultaneous wrist actigraphy, diary records, and repeated urine collection for urinary 6-sulphatoxymelatonin (aMT6s) profiles are appropriate tools to assess circadian rhythms and sleep patterns in field studies. Their suitability for long-term recordings of schizophrenic patients living in the community has not been evaluated. In this case report, we document long-term simultaneous wrist actigraphy, light detection, repeated urine collection, and diary records as a suitable combination of non-invasive techniques to quantify and assess changes in sleep-wake cycles, light exposure, and melatonin profiles in a schizophrenic patient. The actigraph was well-tolerated by the patient, and compliance to diary records and 48 h urine collection was particularly good with assistance from family members. The data obtained by these techniques are illustrated, and the results reveal remarkable abnormal patterns of rest-activity patterns, light exposure, and melatonin production. We observed various rest-activity patterns, including phase-shifts, highly delayed sleep on- and offsets, and irregular rest-activity phases. The period of the rest-activity rhythm, light-dark cycle, and melatonin rhythm was longer than 24 h. These circadian abnormalities may reinforce the altered sleep patterns and the problems of cognitive function and social engagement associated with schizophrenic.
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Affiliation(s)
- Katharina Wulff
- Department of Visual Neuroscience, Division of Neuroscience and Psychological Medicine, Faculty of Medicine, Imperial College London, Charing Cross Hospital, London, UK.
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Wirz-Justice A, Bromundt V, Cajochen C. Circadian Disruption and Psychiatric Disorders: The Importance of Entrainment. Sleep Med Clin 2009. [DOI: 10.1016/j.jsmc.2009.01.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Wu YH, Swaab DF. Disturbance and strategies for reactivation of the circadian rhythm system in aging and Alzheimer's disease. Sleep Med 2007; 8:623-36. [PMID: 17383938 DOI: 10.1016/j.sleep.2006.11.010] [Citation(s) in RCA: 182] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2006] [Revised: 11/09/2006] [Accepted: 11/11/2006] [Indexed: 12/15/2022]
Abstract
Circadian rhythm disturbances, such as sleep disorders, are frequently seen in aging and are even more pronounced in Alzheimer's disease (AD). Alterations in the biological clock, the suprachiasmatic nucleus (SCN), and the pineal gland during aging and AD are considered to be the biological basis for these circadian rhythm disturbances. Recently, our group found that pineal melatonin secretion and pineal clock gene oscillation were disrupted in AD patients, and surprisingly even in non-demented controls with the earliest signs of AD neuropathology (neuropathological Braak stages I-II), in contrast to non-demented controls without AD neuropathology. Furthermore, a functional disruption of the SCN was observed from the earliest AD stages onwards, as shown by decreased vasopressin mRNA, a clock-controlled major output of the SCN. The observed functional disconnection between the SCN and the pineal from the earliest AD stage onwards seems to account for the pineal clock gene and melatonin changes and underlies circadian rhythm disturbances in AD. This paper further discusses potential therapeutic strategies for reactivation of the circadian timing system, including melatonin and bright light therapy. As the presence of melatonin MT1 receptor in the SCN is extremely decreased in late AD patients, supplementary melatonin in the late AD stages may not lead to clear effects on circadian rhythm disorders.
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Affiliation(s)
- Ying-Hui Wu
- Netherlands Institute for Neuroscience, Meibergdreef 47, 1105 BA Amsterdam, The Netherlands
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22
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Dagan Y, Borodkin K. Behavioral and psychiatric consequences of sleep-wake schedule disorders. DIALOGUES IN CLINICAL NEUROSCIENCE 2006. [PMID: 16416711 PMCID: PMC3181741 DOI: 10.31887/dcns.2005.7.4/ydagan] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Circadian rhythm sleep disorders (CRSDs) arise when an individual's sleep-wake rhythm mismatches the environmental 24-h schedule. Physiological data and genetic studies in patients with CRSDs suggest that these disorders result from abnormal functioning of the circadian timing system. Diagnosis involves recognition of the characteristics of CRSDs, which can be achieved by clinical interview and actigraphic monitoring of rest-activity patterns. Bright-light therapy and melatonin administration have proved to be the most effective treatment modalities of CRSDs. In psychiatric practice, CRSDs can be encountered on various occasions. Some evidence indicates that a deviant sleep-wake schedule might be a predisposing factor to personality disorders. CRSDs can emerge as an iatrogenic effect of certain psychoactive drugs, such as haloperidol and fluvoxamine. It is not uncommon that the daytime functional difficulties that accompany CRSDs are misinterpreted as symptoms of psychopathology. Recognition and awareness of these disorders should prevent years of erroneous diagnosis and treatment in these patients.
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Affiliation(s)
- Yaron Dagan
- Institute for Fatigue and Sleep Medicine, Sheba Medical Center, Tel Hashoma, Israel.
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23
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Abstract
The pineal gland is a central structure in the circadian system which produces melatonin under the control of the central clock, the suprachiasmatic nucleus (SCN). The SCN and the output of the pineal gland, i.e. melatonin, are synchronized to the 24-hr day by environmental light, received by the retina and transmitted to the SCN via the retinohypothalamic tract. Melatonin not only plays an important role in the regulation of circadian rhythms, but also acts as antioxidant and neuroprotector that may be of importance in aging and Alzheimer's disease (AD). Circadian disorders, such as sleep-wake cycle disturbances, are associated with aging, and even more pronounced in AD. Many studies have reported disrupted melatonin production and rhythms in aging and in AD that, as we showed, are taking place as early as in the very first preclinical AD stages (neuropathological Braak stage I-II). Degeneration of the retina-SCN-pineal axis may underlie these changes. Our recent studies indicate that a dysfunction of the sympathetic regulation of pineal melatonin synthesis by the SCN is responsible for melatonin changes during the early AD stages. Reactivation of the circadian system (retina-SCN-pineal pathway) by means of light therapy and melatonin supplementation, to restore the circadian rhythm and to relieve the clinical circadian disturbances, has shown promising positive results.
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Affiliation(s)
- Ying-Hui Wu
- Netherlands Institute for Brain Research, Amsterdam, The Netherlands
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Armitage R, Cole D, Suppes T, Ozcan ME. Effects of clozapine on sleep in bipolar and schizoaffective disorders. Prog Neuropsychopharmacol Biol Psychiatry 2004; 28:1065-70. [PMID: 15610918 DOI: 10.1016/j.pnpbp.2004.05.048] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/10/2004] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Sleep disturbances are strongly associated with mood disorders, although the majority of data have been obtained in patients with major depressive disorder. Studies reporting results in bipolar disorder are few, and results have not been consistent. Clozapine is a prototype of atypical antipsychotics, which is effective in improving symptoms of manic episodes in patients with bipolar disorder, or schizoaffective disorder, bipolar type and has been shown to influence sleep in other psychiatric disorders. The present study evaluated the sleep effects of clozapine in bipolar and schizoaffective disorders. METHODS Participants were 11 women and 4 men (range:28-53 years of age, mean 40.9+/-8.6 years), all with a history of mania by DSM-IV criteria for either bipolar I disorder or schizoaffective disorder, bipolar type. They participated in a sleep study at baseline and again after 6 months initiation of clozapine add-on therapy. RESULTS Sleep latency was longer on clozapine and the number of awakenings were increased, whereas time in bed (TIB) and total sleep period (TSP) were increased (range: F=6.2-17.9; df=l,12; p<0.05). Although none of the individual sleep stage showed significant treatment changes, both Stage 2 and slow-wave sleep were increased and Stage 2 decreased on clozapine. Subjective sleep measures improved on clozapine with a small but significant improvement in how rested patients felt upon awakening (t=-2.1; df=26; p<0.05). CONCLUSION Clozapine prolonged sleep latency, improved restedness, and increased total sleep time. Although lack of a control group limits interpretation of these results, they are in general agreement with studies in other psychiatric populations, and support the view that clozapine is primarily a NREM sleep enhancer. The improvement in restedness may be of positive clinical consequence.
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Affiliation(s)
- Roseanne Armitage
- Department of Psychiatry, Sleep Study Unit, The University of Texas Southwestern Medical Center, 2201 Inwood Road, Dallas, TX 75235, USA.
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Ohdo S. Changes in toxicity and effectiveness with timing of drug administration: implications for drug safety. Drug Saf 2004; 26:999-1010. [PMID: 14583062 DOI: 10.2165/00002018-200326140-00002] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The effectiveness and toxicity of many drugs can vary depending on the time of administration in relation to 24-hour rhythms of biochemical, physiological and behavioural processes under the control of the circadian clock. Such chronopharmacological phenomena are influenced by not only the pharmacokinetics but also pharmacodynamics of medications. Chronotherapy is especially relevant when the risk and/or intensity of the symptoms of disease vary predictably over time as exemplified by allergic rhinitis, arthritis, asthma, myocardial infarction, congestive heart failure, stroke and peptic ulcer disease. Morning, once-daily administration of corticosteroids results in little adrenocortical suppression, while the same daily dose split into four equal doses to coincide with daily meals and bedtime results in significant hypothalamus-pituitary-adrenal axis suppression. In a randomised, multicentre trial involving patients with previously untreated metastases from colorectal cancer, the chronomodulated infusion of oxaliplatin, fluorouracil and folinic acid was compared with a constant-rate infusion method. Adverse effects such as stomatitis and peripheral sensory neuropathy were lower and objective response was higher with chronotherapy as compared with the fixed-rate infusion. The merit of chronomodulated infusion is supported by the 24-hour rhythm of DNA synthesis and the activity of dehydropyrimidine dehydrogenase, which brings about the intracellular catabolism of fluorouracil. On the other hand, haloperidol and selective serotonin reuptake inhibitors have diverse effects on sleep continuity and nocturnal arousals. Although interferon also alters the clock function, this disruptive effect can be overcome by devising an administration regimen that minimises adverse drug effects on clock function. Thus, one approach to increasing the efficiency of pharmacotherapy is the administration of drugs at times at which they are most effective and/or best tolerated.
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Affiliation(s)
- Shigehiro Ohdo
- Division of Clinical Pharmacy, Department of Medico-Pharmaceutical Sciences, Clinical Pharmacokinetics, Faculty of Pharmaceutical Sciences, Kyushu University, Fukuoka, Japan.
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Grigg-Damberger MM. Sleep in aging and neurodegenerative diseases. SUPPLEMENTS TO CLINICAL NEUROPHYSIOLOGY 2004; 57:508-20. [PMID: 16106652 DOI: 10.1016/s1567-424x(09)70390-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Madeleine M Grigg-Damberger
- Department of Neurology, University of New Mexico School of Medicine, 915 Camino de Salud NE, ACC-2, Albuquerque, NM 87131, USA.
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Werth E, Savaskan E, Knoblauch V, Gasio PF, van Someren EJW, Hock C, Wirz-Justice A. Decline in long-term circadian rest-activity cycle organization in a patient with dementia. J Geriatr Psychiatry Neurol 2002; 15:55-9. [PMID: 11936245 DOI: 10.1177/089198870201500111] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Continuous measurement of the circadian rest-activity cycle for 598 days in a demented patient with probable Alzheimer's disease revealed slow progressive changes in temporal organization until death. Circadian and sleep analysis of the actigraphic data provided objective documentation of the gradual insertion of wakefulness into rest and rest into wake periods. Pacing, a nonphotic zeitgeber strengthening, led to improved synchronization of the rest-activity cycle.
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Affiliation(s)
- Esther Werth
- Centre for Chronobiology and Alzheimer's Research Group, Psychiatric University Clinic Basel, Switzerland
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Ayalon L, Hermesh H, Dagan Y. Case study of circadian rhythm sleep disorder following haloperidol treatment: reversal by risperidone and melatonin. Chronobiol Int 2002; 19:947-59. [PMID: 12405556 DOI: 10.1081/cbi-120014105] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
A patient with Gilles de la Tourette syndrome treated with haloperidol, ingested once daily after awakening from sleep, exhibited an irregular sleep-wake pattern with a free-running component of approximately 48 h. Transfer to risperidone, ingested once daily after awakening from sleep, was beneficial resulting in a sleep-wake cycle more synchronized at the appropriate phase to the external zeitgebers, and fewer nocturnal disturbances. The circadian sleep-wake schedule was fully synchronized when the patient had been subsequently treated with melatonin at 21:00h, before intended nocturnal sleep, in addition to risperidone in the morning. Restoration of the sleep-wake circadian pattern was accompanied by the patient's subjective report of significant improvement in his quality of life, social interactions, and occupational status. This observation suggests that circadian rhythm sleep disorders can be related to the typical neuroleptic haloperidol and restored by the atypical neuroleptic risperidone. Similar findings reported in patients suffering from other disorders support the hypothesis that the described disruption of the sleep-wake schedule is medication rather than illness-related. Therefore, it is very important to realize that circadian rhythm sleep disorders may be a side effect of neuroleptics.
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Affiliation(s)
- Liat Ayalon
- Institute for Fatigue and Sleep Medicine, Sheba Medical Center, Tel Hashomer, Israel.
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