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Sloane KL, Hamilton RH. Transcranial Direct Current Stimulation to Ameliorate Post-Stroke Cognitive Impairment. Brain Sci 2024; 14:614. [PMID: 38928614 PMCID: PMC11202055 DOI: 10.3390/brainsci14060614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 06/04/2024] [Accepted: 06/12/2024] [Indexed: 06/28/2024] Open
Abstract
Post-stroke cognitive impairment is a common and disabling condition with few effective therapeutic options. After stroke, neural reorganization and other neuroplastic processes occur in response to ischemic injury, which can result in clinical improvement through spontaneous recovery. Neuromodulation through transcranial direct current stimulation (tDCS) is a promising intervention to augment underlying neuroplasticity in order to improve cognitive function. This form of neuromodulation leverages mechanisms of neuroplasticity post-stroke to optimize neural reorganization and improve function. In this review, we summarize the current state of cognitive neurorehabilitation post-stroke, the practical features of tDCS, its uses in stroke-related cognitive impairment across cognitive domains, and special considerations for the use of tDCS in the post-stroke patient population.
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Affiliation(s)
- Kelly L. Sloane
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Physical Medicine and Rehabilitation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Roy H. Hamilton
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Physical Medicine and Rehabilitation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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2
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Zhao X, Li J, Xue C, Li Y, Lu T. Effects of exercise dose based on the ACSM recommendations on patients with post-stroke cognitive impairment: a systematic review and meta-analyses. Front Physiol 2024; 15:1364632. [PMID: 38887320 PMCID: PMC11180945 DOI: 10.3389/fphys.2024.1364632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 05/10/2024] [Indexed: 06/20/2024] Open
Abstract
Purpose This review aimed to assess the impact of different exercise dosages on cognitive function in individuals with post-stroke cognitive impairment (PSCI). Methods Four electronic databases-Embase, PubMed, Web of Science, and Cochrane Library-were systematically searched from inception to 01 January 2024, focusing on the impact of exercise therapy on cognitive function in individuals with PSCI. Only randomized controlled trials meeting the criteria were included. The exercise therapy dose and adherence were evaluated following the American College of Sports Medicine (ACSM) guidelines, categorized into a high compliance group with ACSM recommendations and a low or uncertain compliance group. A random-effects model compared the effect of ACSM compliance on cognitive function in individuals with PSCI, with the effect size represented by the standardized mean difference (SMD) and a 95% confidence interval (CI). Results In total, 18 studies meeting the criteria were included, with data from 1,742 participants. The findings suggested a beneficial effect of exercise on cognitive function in individuals with PSCI [SMD = 0.42, 95% CI (0.20, 0.65)]. Ten studies were categorized as the "high adherence group" and eight in the "low or uncertain adherence group" based on the ACSM recommendations. The subgroup analysis revealed that the SMD of the high compliance group was 0.46 (95% CI: 0.10, 0.82) (p = 0.01), while the SMD of the low or uncertain compliance group was 0.38 (95% CI: 0.07, 0.70) (p = 0.02). Conclusion Our study indicates the beneficial impact of exercise for patients with PSCI over no exercise. Furthermore, high adherence to the exercise dose recommended by ACSM guidelines demonstrated a more substantial improvement in cognitive function than low or uncertain adherence in patients with PSCI. Systematic Review Registration: https:// www.crd.york.ac.uk/prospero/#myprospero, identifier CRD42023487915.
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Affiliation(s)
- Xuejiao Zhao
- School of Nursing, Guizhou University of Traditional Chinese Medicine, Guiyang, Guizhou, China
- Department of Nursing, Guizhou Provincial People’s Hospital, Guiyang, Guizhou, China
| | - Juan Li
- Department of Nursing, Guizhou Provincial People’s Hospital, Guiyang, Guizhou, China
| | - Chao Xue
- School of Nursing, Guizhou University of Traditional Chinese Medicine, Guiyang, Guizhou, China
| | - Yujie Li
- School of Nursing, Guizhou University of Traditional Chinese Medicine, Guiyang, Guizhou, China
| | - Ting Lu
- School of Nursing, Guizhou University of Traditional Chinese Medicine, Guiyang, Guizhou, China
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van der Veen R, Königs M, Bakker S, van Iperen A, Peerdeman S, Bet PM, Oosterlaan J. Pharmacotherapy to Improve Cognitive Functioning After Acquired Brain Injury: A Meta-Analysis and Meta-Regression. Clin Pharmacol Ther 2024; 115:971-987. [PMID: 38294196 DOI: 10.1002/cpt.3186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 01/10/2024] [Indexed: 02/01/2024]
Abstract
Cognitive impairments, common sequelae of acquired brain injury (ABI), significantly affect rehabilitation and quality of life. Currently, there is no solid evidence-base for pharmacotherapy to improve cognitive functioning after ABI, nevertheless off-label use is widely applied in clinical practice. This meta-analysis and meta-regression aims to quantitatively aggregate the available evidence for the effects of pharmacological agents used in the treatment of cognitive impairments following ABI. We conducted a comprehensive search of Embase, Medline Ovid, and Cochrane Controlled Trials Register databases for randomized controlled and crossover trials. Meta-analytic effects were calculated for each pharmaceutical agent and targeted neuromodulator system. Cognitive outcome measures were aggregated across cognitive domains. Of 8,216 articles, 41 studies (4,434 patients) were included. The noradrenergic agent methylphenidate showed a small, significant positive effect on cognitive functioning in patients with traumatic brain injury (TBI; k = 14, d = 0.34, 95% confidence interval: 0.12-0.56, P = 0.003). Specifically, methylphenidate was found to improve cognitive functions related to executive memory, baseline speed, inhibitory control, and variability in responding. The cholinergic drug donepezil demonstrated a large effect size, albeit based on a limited number of studies (k = 3, d = 1.68, P = 0.03). No significant effects were observed for other agents. Additionally, meta-regression analysis did not identify significant sources of heterogeneity in treatment response. Our meta-analysis supports the use of methylphenidate for enhancing cognitive functioning in patients with TBI. Although donepezil shows potential, it warrants further research. These results could guide clinical decision making, inform practice guidelines, and direct future pharmacotherapeutic research in ABI.
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Affiliation(s)
- Ruud van der Veen
- Follow Me Program & Emma Neuroscience Group, Department of Pediatrics, Emma Children's Hospital, Amsterdam UMC Location University of Amsterdam, Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
- Daan Theeuwes Center for Intensive Neurorehabilitation, Woerden, The Netherlands
| | - Marsh Königs
- Follow Me Program & Emma Neuroscience Group, Department of Pediatrics, Emma Children's Hospital, Amsterdam UMC Location University of Amsterdam, Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
- Daan Theeuwes Center for Intensive Neurorehabilitation, Woerden, The Netherlands
| | - Simon Bakker
- Reade, Amsterdam Rehabilitation Research Centre, Amsterdam, The Netherlands
| | - Andries van Iperen
- Daan Theeuwes Center for Intensive Neurorehabilitation, Woerden, The Netherlands
| | - Saskia Peerdeman
- Department of Neurosurgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Pierre M Bet
- Department of Clinical Pharmacology and Pharmacy, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Jaap Oosterlaan
- Follow Me Program & Emma Neuroscience Group, Department of Pediatrics, Emma Children's Hospital, Amsterdam UMC Location University of Amsterdam, Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
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Guo X, Phan C, Batarseh S, Wei M, Dye J. Risk factors and predictive markers of post-stroke cognitive decline-A mini review. Front Aging Neurosci 2024; 16:1359792. [PMID: 38414631 PMCID: PMC10896992 DOI: 10.3389/fnagi.2024.1359792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 01/22/2024] [Indexed: 02/29/2024] Open
Abstract
Stroke is one of the top causes of death and disability worldwide. Cognitive impairments are found in more than 70% of individuals who have survived a stroke. Cognitive decline is a major contributor to disability, dependency, and morbidity. The prevalence and severity of dementia vary depending on different characteristics of the stroke and other clinical risk factors. Here we discuss the effects of stroke territory, patients' age, sex, cerebral blood flow, acute reperfusion therapy, and cognitive reserve of post-stroke cognitive decline. Potential predictive molecular and genetic biomarkers of post-stroke cognitive impairments are also discussed.
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Affiliation(s)
- Xiaofan Guo
- Department of Neurology, Loma Linda University, Loma Linda, CA, United States
| | - Cattien Phan
- Department of Neurology, Loma Linda University, Loma Linda, CA, United States
| | - Sanad Batarseh
- Department of Neurology, Loma Linda University, Loma Linda, CA, United States
| | - Miao Wei
- Department of Neurology, Loma Linda University, Loma Linda, CA, United States
| | - Justin Dye
- Department of Neurosurgery, Loma Linda University, Loma Linda, CA, United States
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Zhou J, Fangma Y, Chen Z, Zheng Y. Post-Stroke Neuropsychiatric Complications: Types, Pathogenesis, and Therapeutic Intervention. Aging Dis 2023; 14:2127-2152. [PMID: 37199575 PMCID: PMC10676799 DOI: 10.14336/ad.2023.0310-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 03/10/2023] [Indexed: 05/19/2023] Open
Abstract
Almost all stroke survivors suffer physical disabilities and neuropsychiatric disturbances, which can be briefly divided into post-stroke neurological diseases and post-stroke psychiatric disorders. The former type mainly includes post-stroke pain, post-stroke epilepsy, and post-stroke dementia while the latter one includes post-stroke depression, post-stroke anxiety, post-stroke apathy and post-stroke fatigue. Multiple risk factors are related to these post-stroke neuropsychiatric complications, such as age, gender, lifestyle, stroke type, medication, lesion location, and comorbidities. Recent studies have revealed several critical mechanisms underlying these complications, namely inflammatory response, dysregulation of the hypothalamic pituitary adrenal axis, cholinergic dysfunction, reduced level of 5-hydroxytryptamine, glutamate-mediated excitotoxicity and mitochondrial dysfunction. Moreover, clinical efforts have successfully given birth to many practical pharmaceutic strategies, such as anti-inflammatory medications, acetylcholinesterase inhibitors, and selective serotonin reuptake inhibitors, as well as diverse rehabilitative modalities to help patients physically and mentally. However, the efficacy of these interventions is still under debate. Further investigations into these post-stroke neuropsychiatric complications, from both basic and clinical perspectives, are urgent for the development of effective treatment strategies.
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Affiliation(s)
| | | | - Zhong Chen
- Correspondence should be addressed to: Prof. Zhong Chen () and Dr. Yanrong Zheng (), Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Yanrong Zheng
- Key Laboratory of Neuropharmacology and Translational Medicine of Zhejiang Province, School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China.
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Ahuja M, Siddhpuria S, Karimi A, Lewis K, Wong E, Lee J, Reppas-Rindlisbacher C, Sood E, Gabor C, Patterson C. Cholinesterase inhibitors and falls, syncope and injuries in patients with cognitive impairment: a systematic review and meta-analysis. Age Ageing 2023; 52:afad205. [PMID: 37993407 DOI: 10.1093/ageing/afad205] [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: 05/09/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND Cholinesterase inhibitors are commonly used to treat patients with neurocognitive disorders, who often have an elevated risk of falling. Effective use of these medications requires a thoughtful assessment of risks and benefits. OBJECTIVE To provide an update on previous reviews and determine the association between cholinesterase inhibitors and falls, syncope, fracture and accidental injuries in patients with neurocognitive disorders. METHODS Embase, MEDLINE, Cochrane Central Register of Controlled Trials, Cumulative Index of Nursing and Allied Health Literature and AgeLine were systematically searched through March 2023 to identify all randomised controlled trials of cholinesterase inhibitors (donepezil, galantamine, rivastigmine) in patients with cognitive impairment. Corresponding authors were contacted for additional data necessary for meta-analysis. Inclusion criteria consisted of adults ≥19 years, with a diagnosis of dementia, Parkinson's disease, mild cognitive impairment or traumatic brain injury. Data were extracted in duplicate for the aforementioned primary outcomes and all outcomes were analysed using random-effects meta-analysis. RESULTS Fifty three studies (30 donepezil, 14 galantamine, 9 rivastigmine) were included providing data on 25, 399 patients. Cholinesterase inhibitors, compared to placebo, were associated with reduced risk of falls (risk ratio [RR] 0.84 [95% confidence interval [CI] = 0.73-0.96, P = 0.009]) and increased risk of syncope (RR 1.50 [95% CI = 1.02-2.21, P = 0.04]). There was no association with accidental injuries or fractures. CONCLUSION In patients with neurocognitive disorders, cholinesterase inhibitors were associated with decreased risk of falls, increased risk of syncope and no association with accidental trauma or fractures. These findings will help clinicians better evaluate risks and benefits of cholinesterase inhibitors.
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Affiliation(s)
- Manan Ahuja
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Shailee Siddhpuria
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Arian Karimi
- Department of Medicine, University of Illinois College of Medicine, Chicago, IL, USA
| | - Kaitlin Lewis
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Eric Wong
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, Canada
| | - Justin Lee
- Division of Geriatric Medicine, Department of Medicine, McMaster University, Hamilton, Canada
| | | | - Emma Sood
- Faculty of Science, Department of Psychology, Neuroscience & Behaviour, McMaster University, Hamilton, Ontario, Canada
| | | | - Christopher Patterson
- Division of Geriatric Medicine, Department of Medicine, McMaster University, Hamilton, Canada
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Dávila G, Torres-Prioris MJ, López-Barroso D, Berthier ML. Turning the Spotlight to Cholinergic Pharmacotherapy of the Human Language System. CNS Drugs 2023; 37:599-637. [PMID: 37341896 PMCID: PMC10374790 DOI: 10.1007/s40263-023-01017-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2023] [Indexed: 06/22/2023]
Abstract
Even though language is essential in human communication, research on pharmacological therapies for language deficits in highly prevalent neurodegenerative and vascular brain diseases has received little attention. Emerging scientific evidence suggests that disruption of the cholinergic system may play an essential role in language deficits associated with Alzheimer's disease and vascular cognitive impairment, including post-stroke aphasia. Therefore, current models of cognitive processing are beginning to appraise the implications of the brain modulator acetylcholine in human language functions. Future work should be directed further to analyze the interplay between the cholinergic system and language, focusing on identifying brain regions receiving cholinergic innervation susceptible to modulation with pharmacotherapy to improve affected language domains. The evaluation of language deficits in pharmacological cholinergic trials for Alzheimer's disease and vascular cognitive impairment has thus far been limited to coarse-grained methods. More precise, fine-grained language testing is needed to refine patient selection for pharmacotherapy to detect subtle deficits in the initial phases of cognitive decline. Additionally, noninvasive biomarkers can help identify cholinergic depletion. However, despite the investigation of cholinergic treatment for language deficits in Alzheimer's disease and vascular cognitive impairment, data on its effectiveness are insufficient and controversial. In the case of post-stroke aphasia, cholinergic agents are showing promise, particularly when combined with speech-language therapy to promote trained-dependent neural plasticity. Future research should explore the potential benefits of cholinergic pharmacotherapy in language deficits and investigate optimal strategies for combining these agents with other therapeutic approaches.
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Affiliation(s)
- Guadalupe Dávila
- Cognitive Neurology and Aphasia Unit, Centro de Investigaciones Médico-Sanitarias, University of Malaga, Marqués de Beccaria 3, 29010, Malaga, Spain
- Instituto de Investigación Biomédica de Malaga-IBIMA, Malaga, Spain
- Department of Psychobiology and Methodology of Behavioral Sciences, Faculty of Psychology and Speech Therapy, University of Malaga, Malaga, Spain
- Language Neuroscience Research Laboratory, Faculty of Psychology and Speech Therapy, University of Malaga, Malaga, Spain
| | - María José Torres-Prioris
- Cognitive Neurology and Aphasia Unit, Centro de Investigaciones Médico-Sanitarias, University of Malaga, Marqués de Beccaria 3, 29010, Malaga, Spain
- Instituto de Investigación Biomédica de Malaga-IBIMA, Malaga, Spain
- Department of Psychobiology and Methodology of Behavioral Sciences, Faculty of Psychology and Speech Therapy, University of Malaga, Malaga, Spain
- Language Neuroscience Research Laboratory, Faculty of Psychology and Speech Therapy, University of Malaga, Malaga, Spain
| | - Diana López-Barroso
- Cognitive Neurology and Aphasia Unit, Centro de Investigaciones Médico-Sanitarias, University of Malaga, Marqués de Beccaria 3, 29010, Malaga, Spain
- Instituto de Investigación Biomédica de Malaga-IBIMA, Malaga, Spain
- Department of Psychobiology and Methodology of Behavioral Sciences, Faculty of Psychology and Speech Therapy, University of Malaga, Malaga, Spain
- Language Neuroscience Research Laboratory, Faculty of Psychology and Speech Therapy, University of Malaga, Malaga, Spain
| | - Marcelo L Berthier
- Cognitive Neurology and Aphasia Unit, Centro de Investigaciones Médico-Sanitarias, University of Malaga, Marqués de Beccaria 3, 29010, Malaga, Spain.
- Instituto de Investigación Biomédica de Malaga-IBIMA, Malaga, Spain.
- Language Neuroscience Research Laboratory, Faculty of Psychology and Speech Therapy, University of Malaga, Malaga, Spain.
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Gaudreau AS, Macoir J, Hudon C. Normative data for the Color Trails Test in middle-aged and elderly Quebec-French people. APPLIED NEUROPSYCHOLOGY. ADULT 2022:1-9. [PMID: 36548473 DOI: 10.1080/23279095.2022.2156291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Despite the widespread use of the Color Trails Test (CTT) in clinical and research settings, information regarding the impact of sociodemographic variables on test performance in Quebec-French adults and elderly people is non-existent. This study aimed to establish French-Quebec normative data for error scores and completion time on all test trials (CTT1 and CTT2) taking into account the impact of age, education, and sex on test performance. METHOD The sample consisted of 169 community-dwelling and healthy Quebec-French individuals aged between 50 and 90 years and having between 6 and 21 years of formal education. RESULTS Regression analyses indicated that age was associated with completion time on CTT1 and CTT2. Spearman correlations also revealed that age was positively associated with error scores (CTT1 errors, CTT2 number errors, CTT2 near-misses) and index interference. Education was marginally associated with CTT1 but was not associated with CTT2 completion time or interference index. Education was only associated with the number of errors in the CTT2. Finally, sex was not associated with any variables. Equations to calculate Z scores and percentiles are presented. CONCLUSIONS Norms for the CTT will ease the interpretation of executive functioning in Quebec-French adults and the elderly and favor accurate discrimination between normal and pathological cognitive states.
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Affiliation(s)
- Anne-Sophie Gaudreau
- CERVO Brain Research Centre, Quebec, Canada
- School of Psychology, Laval University, Quebec, Canada
| | - Joël Macoir
- CERVO Brain Research Centre, Quebec, Canada
- Department of Rehabilitation, Faculty of Medicine, Laval University, Quebec, Canada
| | - Carol Hudon
- CERVO Brain Research Centre, Quebec, Canada
- School of Psychology, Laval University, Quebec, Canada
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Huang XT, Chen CY, Zhang QF, Lu LH, She YL, Fang XY. Meta-analysis of the efficacy of acupuncture in the treatment of the vascular cognitive impairment associated with cerebral small vessel disease. Explore (NY) 2022:S1550-8307(22)00203-8. [DOI: 10.1016/j.explore.2022.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 10/18/2022] [Accepted: 10/25/2022] [Indexed: 11/08/2022]
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10
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Li Z, Yang L, Qiu H, Wang X, Zhang C, Zhang Y. Comparative efficacy of 5 non-pharmacological therapies for adults with post-stroke cognitive impairment: A Bayesian network analysis based on 55 randomized controlled trials. Front Neurol 2022; 13:977518. [PMID: 36247793 PMCID: PMC9554560 DOI: 10.3389/fneur.2022.977518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 09/13/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundAs a common sequela after stroke, cognitive impairment negatively impacts patients' activities of daily living and overall rehabilitation. Non-pharmacological therapies have recently drawn widespread attention for their potential in improving cognitive function. However, the optimal choice of non-pharmacological therapies for post-stroke cognitive impairment (PSCI) is still unclear. Hence, in this study, we compared and ranked 5 non-pharmacological therapies for PSCI with a Bayesian Network Meta-analysis (NMA), to offer a foundation for clinical treatment decision-making.MethodsPubMed, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials, Chinese Biomedical Medicine, China National Knowledge Infrastructure, Wangfang Database, and China Science and Technology Journal Database were searched from database inception to December 31, 2021, to collect Randomized Controlled Trials for PSCI. All of the studies were assessed (according to Cochrane Handbook for Systematic Reviews) and then data were extracted by two researchers separately. Pairwise meta-analysis for direct comparisons was performed using Revman. NMA of Bayesian hierarchical model was performed by WinBUGS and ADDIS. STATA was used to construct network evidence plots and funnel plots.ResultsA total of 55 trials (53 Two-arm trials and 2 Three-arm trials) with 3,092 individuals were included in this study. In the pair-wise meta-analysis, Transcranial Magnetic Stimulation (TMS), Virtual Reality Exposure Therapy (VR), Computer-assisted cognitive rehabilitation (CA), Transcranial Direct Current Stimulation (tDCS), and Acupuncture were superior to normal cognition training in terms of MoCA, MMSE, and BI outcomes. Bayesian NMA showed that the MoCA outcome ranked Acupuncture (84.7%) as the best therapy and TMS (79.7%) as the second. The MMSE outcome ranked TMS (76.1%) as the best therapy and Acupuncture as the second (72.1%). For BI outcome, TMS (89.1%) ranked the best.ConclusionsTMS and Acupuncture had a better effect on improving cognitive function in post-stroke patients according to our Bayesian NMA. However, this conclusion still needs to be confirmed with large sample size and high-quality randomized controlled trials.Registrationhttps://inplasy.com (No. INPLASY202260036).
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Affiliation(s)
- Zhendong Li
- Department of Nursing, The First Affiliated Hospital of Hunan University of Chinese Medicine, Changsha, China
| | - Lei Yang
- Department of Nursing, The First Affiliated Hospital of Hunan University of Chinese Medicine, Changsha, China
| | - Hangjian Qiu
- School of Nursing, Hunan University of Chinese Medicine, Changsha, China
| | - Xiaoqian Wang
- School of Nursing, Hunan University of Chinese Medicine, Changsha, China
| | - Chengcheng Zhang
- Department of Nursing, The First Affiliated Hospital of Hunan University of Chinese Medicine, Changsha, China
| | - Yuejuan Zhang
- Department of Nursing, The First Affiliated Hospital of Hunan University of Chinese Medicine, Changsha, China
- *Correspondence: Yuejuan Zhang
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Caramelli P, Marinho V, Laks J, Coletta MVD, Stella F, Camargos EF, Smid J, Barbosa BJAP, Schilling LP, Balthazar MLF, Frota NAF, Souza LCD, Vale FAC, Chaves MLF, Brucki SMD, Nitrini R, Durgante HB, Bertolucci PHF. Treatment of dementia: recommendations of the Scientific Department of Cognitive Neurology and Aging of the Brazilian Academy of Neurology. Dement Neuropsychol 2022. [DOI: 10.1590/1980-5764-dn-2022-s106en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
ABSTRACT There is currently no cure for neurodegenerative or vascular dementias, but some pharmacological and non-pharmacological interventions may contribute to alleviate symptoms, slow disease progression and improve quality of life. Current treatment approaches are based on etiology, symptom profile and stage of dementia. This manuscript presents recommendations on pharmacological and non-pharmacological treatments of dementia due to Alzheimer’s disease, vascular cognitive impairment, frontotemporal dementia, Parkinson’s disease dementia, and dementia with Lewy bodies.
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Affiliation(s)
| | | | - Jerson Laks
- Universidade Federal do Rio de Janeiro, Brasil; Universidade do Estado do Rio de Janeiro, Brasil
| | | | - Florindo Stella
- Universidade Estadual Paulista, Brasil; Universidade de São Paulo, Brasil
| | | | | | - Breno José Alencar Pires Barbosa
- Universidade de São Paulo, Brasil; Universidade Federal de Pernambuco, Brasil; Instituto de Medicina Integral Prof. Fernando Figueira, Brasil
| | - Lucas Porcello Schilling
- Pontifícia Universidade do Rio Grande do Sul, Brasil; Pontifícia Universidade do Rio Grande do Sul, Brasil; Pontifícia Universidade do Rio Grande do Sul, Brasil
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Caramelli P, Marinho V, Laks J, Coletta MVD, Stella F, Camargos EF, Smid J, Barbosa BJAP, Schilling LP, Balthazar MLF, Frota NAF, Souza LCD, Vale FAC, Chaves MLF, Brucki SMD, Nitrini R, Durgante HB, Bertolucci PHF. Tratamento da demência: recomendações do Departamento Científico de Neurologia Cognitiva e do Envelhecimento da Academia Brasileira de Neurologia. Dement Neuropsychol 2022; 16:88-100. [DOI: 10.1590/1980-5764-dn-2022-s106pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 04/27/2022] [Accepted: 04/27/2022] [Indexed: 11/30/2022] Open
Abstract
RESUMO Atualmente não há tratamento curativo para as demências neurodegenerativas ou para a demência vascular, mas algumas intervenções farmacológicas e não farmacológicas podem contribuir para aliviar os sintomas, retardar a progressão da doença e melhorar a qualidade de vida. As abordagens terapêuticas atuais são baseadas na etiologia, no perfil dos sintomas e no estágio da demência. Neste artigo apresentamos recomendações sobre os tratamentos farmacológicos e não farmacológicos da demência devida à doença de Alzheimer, comprometimento cognitivo vascular, demência frontotemporal, demência da doença de Parkinson e demência com corpos de Lewy.
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Affiliation(s)
| | | | - Jerson Laks
- Universidade Federal do Rio de Janeiro, Brasil; Universidade do Estado do Rio de Janeiro, Brasil
| | | | - Florindo Stella
- Universidade Estadual Paulista, Brasil; Universidade de São Paulo, Brasil
| | | | | | - Breno José Alencar Pires Barbosa
- Universidade de São Paulo, Brasil; Universidade Federal de Pernambuco, Brasil; Instituto de Medicina Integral Prof. Fernando Figueira, Brasil
| | - Lucas Porcello Schilling
- Pontifícia Universidade do Rio Grande do Sul, Brasil; Pontifícia Universidade do Rio Grande do Sul, Brasil; Pontifícia Universidade do Rio Grande do Sul, Brasil
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Lee JH. The listed, delisted, and sustainability of therapeutic medicines for dementia patients: the study is specific to South Korea. Naunyn Schmiedebergs Arch Pharmacol 2022; 395:535-546. [PMID: 35122115 PMCID: PMC8989833 DOI: 10.1007/s00210-022-02209-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 01/19/2022] [Indexed: 01/02/2023]
Abstract
The Dementia Management Act (DMA) came into effect on August 4, 2011, in South Korea. Diagnosis and medication were rapidly performed for dementia in a short time. We investigated the cardiac effects of increased drug prescription following DMA. We observed a correlation between Alzheimer’s disease (AD) and anti-AD drug (AAD) groups from 2010 to 2019 on the National Health Insurance System (NHIS) of South Korea. This study investigated the increase and decrease in deaths of AD patients with AAD. We analysed the mortality per 100,000 population with the R2 Calculator. Moreover, we made the up or down datum line for the simple decision on the listed, delisted, and sustainable drug examined by a linear equation and R2. We observed that life expectancy was diminished by AAD in Sorokdo National Hospital. In the NHIS, donepezil and rivastigmine increased the number of deaths decided on R2 > 0.75. Memantine was sustainable. We could not decide on galantamine because it is one of the other groups. We made a straightforward decision-maker of delisted, listed, or sustainable criteria based on mortality and datum line.
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Affiliation(s)
- Jong Hoon Lee
- Science & Research Center, Seoul National University College of Medicine, Seoul, South Korea.
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14
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Rost NS, Brodtmann A, Pase MP, van Veluw SJ, Biffi A, Duering M, Hinman JD, Dichgans M. Post-Stroke Cognitive Impairment and Dementia. Circ Res 2022; 130:1252-1271. [PMID: 35420911 DOI: 10.1161/circresaha.122.319951] [Citation(s) in RCA: 212] [Impact Index Per Article: 106.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Poststroke cognitive impairment and dementia (PSCID) is a major source of morbidity and mortality after stroke worldwide. PSCID occurs as a consequence of ischemic stroke, intracerebral hemorrhage, or subarachnoid hemorrhage. Cognitive impairment and dementia manifesting after a clinical stroke is categorized as vascular even in people with comorbid neurodegenerative pathology, which is common in elderly individuals and can contribute to the clinical expression of PSCID. Manifestations of cerebral small vessel disease, such as covert brain infarcts, white matter lesions, microbleeds, and cortical microinfarcts, are also common in patients with stroke and likewise contribute to cognitive outcomes. Although studies of PSCID historically varied in the approach to timing and methods of diagnosis, most of them demonstrate that older age, lower educational status, socioeconomic disparities, premorbid cognitive or functional decline, life-course exposure to vascular risk factors, and a history of prior stroke increase risk of PSCID. Stroke characteristics, in particular stroke severity, lesion volume, lesion location, multiplicity and recurrence, also influence PSCID risk. Understanding the complex interaction between an acute stroke event and preexisting brain pathology remains a priority and will be critical for developing strategies for personalized prediction, prevention, targeted interventions, and rehabilitation. Current challenges in the field relate to a lack of harmonization of definition and classification of PSCID, timing of diagnosis, approaches to neurocognitive assessment, and duration of follow-up after stroke. However, evolving knowledge on pathophysiology, neuroimaging, and biomarkers offers potential for clinical applications and may inform clinical trials. Preventing stroke and PSCID remains a cornerstone of any strategy to achieve optimal brain health. We summarize recent developments in the field and discuss future directions closing with a call for action to systematically include cognitive outcome assessment into any clinical studies of poststroke outcome.
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Affiliation(s)
- Natalia S Rost
- J. Philip Kistler Stroke Research Center (N.S.R., S.J.v.V., A. Biffi), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Amy Brodtmann
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Australia (A. Brodtmann).,Turner Institute for Brain and Mental Health, Monash University, Melbourne, Australia (A. Brodtmann. M.P.P.)
| | - Matthew P Pase
- Turner Institute for Brain and Mental Health, Monash University, Melbourne, Australia (A. Brodtmann. M.P.P.).,Harvard T.H. Chan School of Public Health, Boston (M.P.P.)
| | - Susanne J van Veluw
- MassGeneral Institute for Neurodegenerative Disease, Massachusetts General Hospital, Charlestown (S.J.v.V.)
| | - Alessandro Biffi
- J. Philip Kistler Stroke Research Center (N.S.R., S.J.v.V., A. Biffi), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston.,Divisions of Memory Disorders and Behavioral Neurology (A. Biffi), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Marco Duering
- J. Philip Kistler Stroke Research Center (N.S.R., S.J.v.V., A. Biffi), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston.,Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Germany (M. Duering, M. Dichgans).,Medical Image Analysis Center and Department of Biomedical Engineering, University of Basel, Switzerland (M. Duering)
| | - Jason D Hinman
- Department of Neurology, David Geffen School of Medicine, University of California Los Angeles (J.D.H.).,Department of Neurology, West Los Angeles VA Medical Center, CA (J.D.H.)
| | - Martin Dichgans
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Germany (M. Duering, M. Dichgans).,German Center for Neurodegenerative Diseases (DZNE), Munich, Germany (M. Dichgans).,Munich Cluster for Systems Neurology (SyNergy), Munich, Germany (M. Dichgans)
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15
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Shi X, Ren G, Cui Y, Xu Z. Comparative efficacy and acceptability of cholinesterase inhibitors and memantine based on dosage in patients with vascular cognitive impairment: a network meta-analysis. Curr Alzheimer Res 2022; 19:133-145. [PMID: 35048806 DOI: 10.2174/1567205019666220120112301] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 11/27/2021] [Accepted: 12/16/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Considering the lack of direct comparison between cholinesterase inhibitors and memantine in patients with vascular cognitive impairment (VCI), determining how to choose the best treatment plan remains inconclusive. Hence, we conducted the network meta-analysis to compare the efficacy and acceptability of these drugs. METHODS PubMed, the Cochrane Central Register of Controlled Trials, Embase and Web of Science were searched for double-blind randomized controlled trials (RCTs) for the treatment of VCI, which involved donepezil, galantamine, rivastigmine, and memantine, from database inception to January 1, 2020. Then, a network meta-analysis based on the frequency method was conducted. RESULTS Eleven RCTs were included. Compared with the placebo, in terms of efficacy donepezil 5 mg (standardized mean difference = -1.11, 95% confidence interval = -1.88 to -0.34), donepezil 10 mg (-1.44, -2.31 to -0.56), galantamine 24 mg (-1.99, -3.03 to -0.95), and memantine 20 mg (-1.89, -2.93 to -0.86) were more effective on the cognition of ADAS-cog; and donepezil 5 mg (0.46, 0.12 to 0.81), donepezil 10 mg (0.76, 0.34 to 1.17), and rivastigmine 12mg (0.60, 0.10 to 1.10) exhibited superior benefits on the cognition of MMSE. Donepezil 10 mg (-0.25, -0.44 to -0.06; -1.47, -2.79 to -0.15) exhibited improvements on CDR-SB and EXIT25, respectively. In terms of acceptability, the memantine behaved as the best. CONCLUSIONS Donepezil 5 mg, donepezil 10 mg, galantamine 24 mg, memantine 20 mg, and rivastigmine 12 mg have beneficial effects on cognition, and donepezil 10mg provides beneficial effects on executive function and global status. Based on the network meta-analysis, donepezil 10 mg might be the best choice, considering the benefits on cognition function, executive function and global status, but dose-related adverse reactions need to be noted. In the meantime, memantine is a better comprehensive choice, in terms of efficacy and safety acceptability.
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Affiliation(s)
- Xinxiu Shi
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - GuangHao Ren
- Department of Vascular Surgery, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - Yang Cui
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - ZhongXin Xu
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
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16
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Lyukmanov R, Rimkevichus A, Gnedovskaya E, Suponeva N. Pharmacotherapy in post-stroke rehabilitation. Zh Nevrol Psikhiatr Im S S Korsakova 2022; 122:40-47. [DOI: 10.17116/jnevro202212206140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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17
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Rundek T, Tolea M, Ariko T, Fagerli EA, Camargo CJ. Vascular Cognitive Impairment (VCI). Neurotherapeutics 2022; 19:68-88. [PMID: 34939171 PMCID: PMC9130444 DOI: 10.1007/s13311-021-01170-y] [Citation(s) in RCA: 66] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2021] [Indexed: 01/03/2023] Open
Abstract
Vascular cognitive impairment (VCI) is predominately caused by vascular risk factors and cerebrovascular disease. VCI includes a broad spectrum of cognitive disorders, from mild cognitive impairment to vascular dementia caused by ischemic or hemorrhagic stroke, and vascular factors alone or in a combination with neurodegeneration including Alzheimer's disease (AD) and AD-related dementia. VCI accounts for at least 20-40% of all dementia diagnosis. Growing evidence indicates that cerebrovascular pathology is the most important contributor to dementia, with additive or synergistic interactions with neurodegenerative pathology. The most common underlying mechanism of VCI is chronic age-related dysregulation of CBF, although other factors such as inflammation and cardiovascular dysfunction play a role. Vascular risk factors are prevalent in VCI and if measured in midlife they predict cognitive impairment and dementia in later life. Particularly, hypertension, high cholesterol, diabetes, and smoking at midlife are each associated with a 20 to 40% increased risk of dementia. Control of these risk factors including multimodality strategies with an inclusion of lifestyle modification is the most promising strategy for treatment and prevention of VCI. In this review, we present recent developments in age-related VCI, its mechanisms, diagnostic criteria, neuroimaging correlates, vascular risk determinants, and current intervention strategies for prevention and treatment of VCI. We have also summarized the most recent and relevant literature in the field of VCI.
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Affiliation(s)
- Tatjana Rundek
- Department of Neurology and Evelyn F. McKnight Brain Institute, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Magdalena Tolea
- Department of Neurology and Evelyn F. McKnight Brain Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Taylor Ariko
- Department of Neurology and Evelyn F. McKnight Brain Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Eric A Fagerli
- Department of Neurology and Evelyn F. McKnight Brain Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Christian J Camargo
- Department of Neurology and Evelyn F. McKnight Brain Institute, University of Miami Miller School of Medicine, Miami, FL, USA
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18
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Quinn TJ, Richard E, Teuschl Y, Gattringer T, Hafdi M, O'Brien JT, Merriman N, Gillebert C, Huygelier H, Verdelho A, Schmidt R, Ghaziani E, Forchammer H, Pendlebury ST, Bruffaerts R, Mijajlovic M, Drozdowska BA, Ball E, Markus HS. European Stroke Organisation and European Academy of Neurology joint guidelines on post-stroke cognitive impairment. Eur J Neurol 2021; 28:3883-3920. [PMID: 34476868 DOI: 10.1111/ene.15068] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 08/13/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE The optimal management of post-stroke cognitive impairment (PSCI) remains controversial. These joint European Stroke Organisation (ESO) and European Academy of Neurology (EAN) guidelines provide evidence-based recommendations to assist clinicians in decision making regarding prevention, diagnosis, treatment and prognosis. METHODS Guidelines were developed according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews, assessed the quality of the available evidence, and made specific recommendations. Expert consensus statements were provided where insufficient evidence was available to provide recommendations. RESULTS There was limited randomized controlled trial (RCT) evidence regarding single or multicomponent interventions to prevent post-stroke cognitive decline. Lifestyle interventions and treating vascular risk factors have many health benefits, but a cognitive effect is not proven. We found no evidence regarding routine cognitive screening following stroke, but recognize the importance of targeted cognitive assessment. We describe the accuracy of various cognitive screening tests, but found no clearly superior approach to testing. There was insufficient evidence to make a recommendation for use of cholinesterase inhibitors, memantine nootropics or cognitive rehabilitation. There was limited evidence on the use of prediction tools for post-stroke cognition. The association between PSCI and acute structural brain imaging features was unclear, although the presence of substantial white matter hyperintensities of presumed vascular origin on brain magnetic resonance imaging may help predict cognitive outcomes. CONCLUSIONS These guidelines highlight fundamental areas where robust evidence is lacking. Further definitive RCTs are needed, and we suggest priority areas for future research.
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Affiliation(s)
- Terence J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Edo Richard
- Department of Neurology, Donders Institute for Brain, Behaviour and Cognition, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Yvonne Teuschl
- Department for Clinical Neurosciences and Preventive Medicine, Danube University Krems, Krems, Austria
| | - Thomas Gattringer
- Department of Neurology and Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Melanie Hafdi
- Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - John T O'Brien
- Department of Psychiatry, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Niamh Merriman
- Department of Health Psychology, Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Celine Gillebert
- Department Brain and Cognition, Leuven Brain Institute, KU Leuven, Leuven, Belgium.,TRACE, Centre for Translational Psychological Research (TRACE), KU Leuven - Hospital East-Limbourgh, Genk, Belgium
| | - Hanne Huygelier
- Department Brain and Cognition, Leuven Brain Institute, KU Leuven, Leuven, Belgium.,TRACE, Centre for Translational Psychological Research (TRACE), KU Leuven - Hospital East-Limbourgh, Genk, Belgium
| | - Ana Verdelho
- Department of Neurosciences and Mental Health, Hospital de Santa Maria, Lisbon, Portugal
| | - Reinhold Schmidt
- Department of Neurology and Medical University of Graz, Graz, Austria
| | - Emma Ghaziani
- Department of Physical and Occupational Therapy, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | | | - Sarah T Pendlebury
- Departments of Medicine and Geratology and NIHR Oxford Biomedical Research Centre Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Rose Bruffaerts
- Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium
| | - Milija Mijajlovic
- Neurosonology Unit, Neurology Clinic, University Clinical Center of Serbia and Faculty of Medicine University of Belgrade, Belgrade, Serbia
| | - Bogna A Drozdowska
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Emily Ball
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Hugh S Markus
- Stroke Research group, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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19
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Quinn TJ, Richard E, Teuschl Y, Gattringer T, Hafdi M, O’Brien JT, Merriman N, Gillebert C, Huyglier H, Verdelho A, Schmidt R, Ghaziani E, Forchammer H, Pendlebury ST, Bruffaerts R, Mijajlovic M, Drozdowska BA, Ball E, Markus HS. European Stroke Organisation and European Academy of Neurology joint guidelines on post-stroke cognitive impairment. Eur Stroke J 2021; 6:I-XXXVIII. [PMID: 34746430 PMCID: PMC8564156 DOI: 10.1177/23969873211042192] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 08/09/2021] [Indexed: 01/14/2023] Open
Abstract
The optimal management of post-stroke cognitive impairment remains controversial. These joint European Stroke Organisation (ESO) and European Academy of Neurology (EAN) guidelines provide evidence-based recommendations to assist clinicians in decision making around prevention, diagnosis, treatment and prognosis. These guidelines were developed according to ESO standard operating procedure and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and, where possible, meta-analyses of the literature, assessed the quality of the available evidence and made specific recommendations. Expert consensus statements were provided where insufficient evidence was available to provide recommendations based on the GRADE approach. There was limited randomised controlled trial evidence regarding single or multicomponent interventions to prevent post-stroke cognitive decline. Interventions to improve lifestyle and treat vascular risk factors may have many health benefits but a beneficial effect on cognition is not proven. We found no evidence around routine cognitive screening following stroke but recognise the importance of targeted cognitive assessment. We described the accuracy of various cognitive screening tests but found no clearly superior approach to testing. There was insufficient evidence to make a recommendation for use of cholinesterase inhibitors, memantine nootropics or cognitive rehabilitation. There was limited evidence on the use of prediction tools for post-stroke cognitive syndromes (cognitive impairment, dementia and delirium). The association between post-stroke cognitive impairment and most acute structural brain imaging features was unclear, although the presence of substantial white matter hyperintensities of presumed vascular origin on acute MRI brain may help predict cognitive outcomes. These guidelines have highlighted fundamental areas where robust evidence is lacking. Further, definitive randomised controlled trials are needed, and we suggest priority areas for future research.
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Affiliation(s)
- Terence J Quinn
- Institute of Cardiovascular and
Medical Sciences, University of Glasgow, Glasgow, UK
| | - Edo Richard
- Department of Neurology, Donders
Institute for Brain, Behaviour and Cognition, Radboud University Medical
Centre, Nijmegen, The Netherlands
| | - Yvonne Teuschl
- Department for Clinical
Neurosciences and Preventive Medicine, Danube University Krems, der Donau, Austria
| | - Thomas Gattringer
- Department of Neurology and
Division of Neuroradiology, Vascular and Interventional Radiology, Department of
Radiology, Medical University of
Graz, Graz, Austria
| | - Melanie Hafdi
- Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - John T O’Brien
- Department of Psychiatry, University of Cambridge School of
Clinical Medicine, Cambridge, UK
| | - Niamh Merriman
- Deptartment of Health Psychology,
Division of Population Health Sciences, Royal College of Surgeons in
Ireland, Dublin, Ireland
| | - Celine Gillebert
- Department Brain & Cognition, Leuven Brain Institute, KU Leuven, Leuven, Belgium
- TRACE, Centre for Translational
Psychological Research (TRACE), KU Leuven – Hospital
East-Limbourgh, Genk, Belgium
| | - Hanne Huyglier
- Department Brain & Cognition, Leuven Brain Institute, KU Leuven, Leuven, Belgium
- TRACE, Centre for Translational
Psychological Research (TRACE), KU Leuven – Hospital
East-Limbourgh, Genk, Belgium
| | - Ana Verdelho
- Department of Neurosciences and
Mental Health, Hospital de Santa Maria, Lisbon, Portugal
| | - Reinhold Schmidt
- Department of Neurology, Medical University of
Graz, Graz, Austria
| | - Emma Ghaziani
- Department of Physical and
Occupational Therapy, Bispebjerg and Frederiksberg
Hospital, Copenhagen, Denmark
| | | | - Sarah T Pendlebury
- Departments of Medicine and
Geratology and NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford University Hospitals NHS
Foundation Trust, Oxford, UK
| | - Rose Bruffaerts
- Biomedical Research Institute, Hasselt University, Hasselt, Belgium
| | - Milija Mijajlovic
- Neurosonology Unit, Neurology
Clinic, University Clinical Center of Serbia
and Faculty of Medicine University of Belgrade, Belgrade, Serbia
| | - Bogna A Drozdowska
- Institute of Cardiovascular and
Medical Sciences, University of Glasgow, Glasgow, UK
| | - Emily Ball
- Centre for Clinical Brain
Sciences, University of Edinburgh, Edinburgh, Scotland
| | - Hugh S Markus
- Stroke Research Group, Department
of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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20
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Lee KP, Chang AYW, Sung PS. Association between Blood Pressure, Blood Pressure Variability, and Post-Stroke Cognitive Impairment. Biomedicines 2021; 9:773. [PMID: 34356837 PMCID: PMC8301473 DOI: 10.3390/biomedicines9070773] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 06/23/2021] [Accepted: 06/29/2021] [Indexed: 12/18/2022] Open
Abstract
After stroke, dynamic changes take place from necrotic-apoptotic continuum, inflammatory response to poststroke neurogenesis, and remodeling of the network. These changes and baseline brain pathology such as small vessel disease (SVD) and amyloid burden may be associated with the occurrence of early or late poststroke cognitive impairment (PSCI) or dementia (PSD), which affect not only stroke victims but also their families and even society. We reviewed the current concepts and understanding of the pathophysiology for PSCI/PSD and identified useful tools for the diagnosis and the prediction of PSCI in serological, CSF, and image characteristics. Then, we untangled their relationships with blood pressure (BP) and blood pressure variability (BPV), important but often overlooked risk factors for PSCI/PSD. Finally, we provided evidence for the modifying effects of BP and BPV on PSCI as well as pharmacological and non-pharmacological interventions and life style modification for PSCI/PSD prevention and treatment.
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Affiliation(s)
- Kang-Po Lee
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan;
- Department of Neurology, E-DA Hospital, Kaohsiung 824, Taiwan
| | - Alice Y. W. Chang
- Department of Physiology, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan;
- Institute of Basic Medical Sciences, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
| | - Pi-Shan Sung
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan;
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
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21
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Efficacy and Safety of the Association of Nimodipine and Choline Alphoscerate in the Treatment of Cognitive Impairment in Patients with Cerebral Small Vessel Disease. The CONIVaD Trial. Drugs Aging 2021; 38:481-491. [PMID: 33855653 PMCID: PMC8211589 DOI: 10.1007/s40266-021-00852-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2021] [Indexed: 11/25/2022]
Abstract
Background No approved treatment is available for patients with vascular cognitive impairment (VCI) due to cerebral small vessel disease (SVD). Objective The CONIVaD (Choline Alphoscerate and Nimodipine in Vascular Dementia) study aimed to investigate the feasibility, efficacy, and safety of a combined treatment with choline alphoscerate and nimodipine in patients with SVD and mild-to-moderate cognitive impairment. Methods Within this pilot, single-center (university hospital), double-blinded, randomized clinical trial, patients were randomized to two arms: 1-year treatment with nimodipine 30 mg three times a day (TID) plus choline alphoscerate 600 mg twice a day (BID) (arm 1) or nimodipine 30 mg TID plus placebo BID (arm 2). Patients underwent an evaluation at baseline and after 12 months. Cognitive decline, defined as a ≥ 2-point loss on the Montreal Cognitive Assessment, was the primary endpoint. Functional, quality of life, other cognitive measures, and safety were secondary endpoints. Treatment adherence was measured by the count of medicine bottles returned by patients. Results Sixty-two patients were randomized (31 each arm). Fourteen patients (22%) dropped out for reasons including consent withdrawal (n = 9), adverse reactions (n = 4), and stroke (n = 1). Forty-eight patients (mean ± SD age 75.1 ± 6.8 years), well balanced between arms, completed the study. Regarding adherence, of the prescribed total drug dose, > 75% was taken by 96% of patients for choline alphoscerate, 87.5% for placebo, and 15% for nimodipine. No statistically significant differences were found between the treatment groups for the primary cognitive outcome, nor for the secondary outcomes. Eight patients had non-serious adverse reactions; five presented adverse events. Conclusion Patients’ adherence to treatment was low. With this limitation, the combined choline alphoscerate–nimodipine treatment showed no significant effect in our cohort of VCI patients with SVD. The safety profile was good overall. Trial Registration Clinical Trial NCT03228498. Registered 25 July 2017.
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22
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Chen CLH, Nguyen TH, Marasigan S, Lee CF, Lu Q, Kandiah N, de Silva D, Chong E, Venketasubramanian N. NEURoaid II (MLC901) in cognitively Impaired not demenTEd patientS (NEURITES): A pilot double blind, placebo-controlled randomized trial. ALZHEIMER'S & DEMENTIA (NEW YORK, N. Y.) 2021; 7:e12161. [PMID: 33816765 PMCID: PMC8010368 DOI: 10.1002/trc2.12161] [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] [Received: 06/02/2020] [Revised: 12/05/2020] [Accepted: 01/06/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To investigate the efficacy and safety of MLC901 in vascular cognitive impairment no dementia (VCIND) patients. DESIGN This was a multi-center, double-blind, randomized, placebo-controlled pilot study. SETTING AND PARTICIPANT VCIND patients from hospitals in Singapore (67), Vietnam (19), and the Philippines (17) were recruited and followed-up from March 2013 to April 2018. METHODS The primary outcome was executive function as measured by the Verbal Fluency (VF) and 2-part Color Trails Test (CTT). The mean difference in the scores between baseline and week 12, and baseline and week 24, was compared between MLC901 and placebo using a two-sample t-test. RESULTS The trial randomized 103 subjects: MLC901 (n = 57) and placebo (n = 46). The mean age of participants was 68.3 ± 8.4 years and 38.8% were female. Improvement in executive function with MLC901 was not significantly better than placebo at week 12 (CTT1 mean difference [md] 3.8 seconds, 95% confidence interval [CI]: -9.0 to 16.5, CTT2 md 10.9 seconds, 95% CI: -0.2 to 22.0), and at week 24 (CTT1 md 2.8 seconds, 95% CI: -8.4 to 14.0, CTT2 md = 4.4 seconds, 95% CI: -8.2 to 16.9). Improvement in VF from baseline was not significantly different between MLC901 and placebo at weeks 12 and 24. There were no significant differences in adverse events (43.5% vs. 56.1%) or serious adverse events (13% vs. 22.8%) in placebo versus MLC901 groups. In post hoc exploratory analysis, the treatment effect of MLC901 on cognitive function appears more apparent in subjects with existing impairment in executive function: CTT2 (md 14.4 seconds [P = .05] and 9.9 seconds [P = .3] at week 12 and week 24, respectively). CONCLUSIONS Whilst MLC901 appears to be safe, there was no significant cognitive benefit from MLC901 in the study population. Post hoc hypotheses generating analyses suggest that VCIND patients with existing impairment in executive function may show benefit.
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Affiliation(s)
- Christopher L. H. Chen
- Memory and Aging CenterDepartments of Pharmacology and Psychological MedicineNational University of SingaporeSingapore
| | | | - Simeon Marasigan
- Neurology and PsychiatryUniversity of Santo Tomas HospitalManilaPhilippines
| | - Chun Fan Lee
- Duke‐NUSCentre for Quantitative MedicineSingaporeRepublic of Singapore
| | - Qingshu Lu
- Singapore Clinical Research InstituteSingaporeRepublic of Singapore
| | | | - Deidre de Silva
- NeurologySingapore General HospitalSingaporeRepublic of Singapore
| | - Eddie Chong
- Memory Aging and Cognition CenterNational University of SingaporeSingaporeRepublic of Singapore
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Battle CE, Abdul-Rahim AH, Shenkin SD, Hewitt J, Quinn TJ. Cholinesterase inhibitors for vascular dementia and other vascular cognitive impairments: a network meta-analysis. Cochrane Database Syst Rev 2021; 2:CD013306. [PMID: 33704781 PMCID: PMC8407366 DOI: 10.1002/14651858.cd013306.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Vascular cognitive impairment (VCI) describes a broad spectrum of cognitive impairments caused by cerebrovascular disease, ranging from mild cognitive impairment to dementia. There are currently no pharmacological treatments recommended for improving either cognition or function in people with VCI. Three cholinesterase inhibitors (donepezil, galantamine, and rivastigmine) are licenced for the treatment of dementia due to Alzheimer's disease. They are thought to work by compensating for reduced cholinergic neurotransmission, which is also a feature of VCI. Through pairwise comparisons with placebo and a network meta-analysis, we sought to determine whether these medications are effective in VCI and whether there are differences between them with regard to efficacy or adverse events. OBJECTIVES (1) To assess the efficacy and safety of cholinesterase inhibitors in the treatment of adults with vascular dementia and other VCI. (2) To compare the effects of different cholinesterase inhibitors on cognition and adverse events, using network meta-analysis. SEARCH METHODS We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's register, MEDLINE (OvidSP), Embase (OvidSP), PsycINFO (OvidSP), CINAHL (EBSCOhost), Web of Science Core Collection (ISI Web of Science), LILACS (BIREME), ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform on 19 August 2020. SELECTION CRITERIA We included randomised controlled trials in which donepezil, galantamine, or rivastigmine was compared with placebo or in which the drugs were compared with each other in adults with vascular dementia or other VCI (excluding cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL)). We included all drug doses and routes of administration. DATA COLLECTION AND ANALYSIS Two review authors independently identified eligible trials, extracted data, assessed risk of bias, and applied the GRADE approach to assess the certainty of the evidence. The primary outcomes were cognition, clinical global impression, function (performance of activities of daily living), and adverse events. Secondary outcomes were serious adverse events, incidence of development of new dementia, behavioural disturbance, carer burden, institutionalisation, quality of life and death. For the pairwise analyses, we pooled outcome data at similar time points using random-effects methods. We also performed a network meta-analysis using Bayesian methods. MAIN RESULTS We included eight trials (4373 participants) in the review. Three trials studied donepezil 5 mg or 10 mg daily (n= 2193); three trials studied rivastigmine at a maximum daily dose of 3 to 12 mg (n= 800); and two trials studied galantamine at a maximum daily dose of 16 to 24 mg (n= 1380). The trials included participants with possible or probable vascular dementia or cognitive impairment following stroke. Mean ages were between 72.2 and 73.9 years. All of the trials were at low or unclear risk of bias in all domains, and the evidence ranged from very low to high level of certainty. For cognition, the results showed that donepezil 5 mg improves cognition slightly, although the size of the effect is unlikely to be clinically important (mean difference (MD) -0.92 Alzheimer's Disease Assessment Scale-Cognitive Subscale (ADAS-Cog) points (range 0 to 70), 95% confidence interval (CI) -1.44 to -0.40; high-certainty evidence). Donepezil 10 mg (MD -2.21 ADAS-Cog points, 95% CI -3.07 to -1.35; moderate-certainty evidence) and galantamine 16 to 24 mg (MD -2.01 ADAS-Cog point, 95%CI -3.18 to -0.85; moderate-certainty evidence) probably also improve cognition, although the larger effect estimates still may not be clinically important. With low certainty, there may be little to no effect of rivastigmine 3 to 12 mg daily on cognition (MD 0.03 ADAS-Cog points, 95% CI -3.04 to 3.10; low-certainty evidence). Adverse events reported in the studies included nausea and/or vomiting, diarrhoea, dizziness, headache, and hypertension. The results showed that there was probably little to no difference between donepezil 5 mg and placebo in the number of adverse events (odds ratio (OR) 1.22, 95% CI 0.94 to 1.58; moderate-certainty evidence), but there were slightly more adverse events with donepezil 10 mg than with placebo (OR 1.95, 95% CI 1.20 to 3.15; high-certainty evidence). The effect of rivastigmine 3 to 12 mg on adverse events was very uncertain (OR 3.21, 95% CI 0.36 to 28.88; very low-certainty evidence). Galantamine 16 to 24 mg is probably associated with a slight excess of adverse events over placebo (OR 1.57, 95% CI 1.02 to 2.43; moderate-certainty evidence). In the network meta-analysis (NMA), we included cognition to represent benefit, and adverse events to represent harm. All drugs ranked above placebo for cognition and below placebo for adverse events. We found donepezil 10 mg to rank first in terms of benefit, but third in terms of harms, when considering the network estimates and quality of evidence. Galantamine was ranked second in terms of both benefit and harm. Rivastigmine had the lowest ranking of the cholinesterase inhibitors in both benefit and harm NMA estimates, but this may reflect possibly inadequate doses received by some trial participants and small trial sample sizes. AUTHORS' CONCLUSIONS We found moderate- to high-certainty evidence that donepezil 5 mg, donepezil 10 mg, and galantamine have a slight beneficial effect on cognition in people with VCI, although the size of the change is unlikely to be clinically important. Donepezil 10 mg and galantamine 16 to 24 mg are probably associated with more adverse events than placebo. The evidence for rivastigmine was less certain. The data suggest that donepezil 10 mg has the greatest effect on cognition, but at the cost of adverse effects. The effect is modest, but in the absence of any other treatments, people living with VCI may still wish to consider the use of these agents. Further research into rivastigmine is needed, including the use of transdermal patches.
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Affiliation(s)
- Ceri E Battle
- Welsh Centre for Emergency Medicine Research, ABM University Health Board, Swansea, UK
| | - Azmil H Abdul-Rahim
- Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, UK
| | - Susan D Shenkin
- Geriatric Medicine, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Jonathan Hewitt
- 3rd Floor, Academic Building, Llandough Hospital., Cardiff University and Aneurin Bevan Health Board, Cardiff, UK
| | - Terry J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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Matsunaga S, Fujishiro H, Takechi H. Efficacy and Safety of Cholinesterase Inhibitors for Mild Cognitive Impairment:A Systematic Review and Meta-Analysis. J Alzheimers Dis 2020; 71:513-523. [PMID: 31424411 DOI: 10.3233/jad-190546] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The clinical benefit of cholinesterase inhibitors (ChEIs) for mild cognitive impairment (MCI) remains inconclusive. OBJECTIVE We performed a systematic review and meta-analysis of the efficacy/safety of ChEIs on subjects with MCI. METHODS We included randomized controlled trials (RCTs) of ChEIs in subjects with MCI, using cognitive function scores as a primary outcome measure. RESULTS Fourteen RCTs (six using donepezil, four using galantamine, and four using rivastigmine) with 5,278 subjects were included. We found no significant difference in cognitive function scores between the ChEIs and placebo groups [standardized mean difference (SMD) = -0.06, p = 0.38, I2 = 76% ]. However, in the secondary outcomes, ChEIs were associated with a lower incidence of progression to dementia compared with placebo (risk ratio = 0.76, the number needed to treat = 20). For safety outcomes, ChEIs were associated with a lower prevalence of fall than placebo. On the other hand, compared with placebo, ChEIs were associated with a higher incidence of discontinuation due to all causes, discontinuation due to adverse events, at least one adverse event, abnormal dreams, diarrhea, dizziness, headache, insomnia, loose stools, muscle cramps, nausea, vomiting, and weight loss. CONCLUSIONS Although ChEIs have a slight efficacy in the treatment of MCI, there are many safety issues. Therefore, ChEIs are difficult to recommend for MCI. However, the efficacy and safety of ChEIs on MCI with a biomarker-based diagnosis is unclear. Further RCTs are needed to confirm the efficacy and safety of ChEIs when used for individual neuropathological classifications of MCI.
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Affiliation(s)
- Shinji Matsunaga
- Department of Geriatrics and Cognitive Disorders, Fujita Health University School of Medicine, Kutsukake, Toyoake, Aichi, Japan
| | - Hiroshige Fujishiro
- Department of Psychiatry, Kawasaki Memorial Hospital, Miyamae, Kawasaki, Kanagawa, Japan
| | - Hajime Takechi
- Department of Geriatrics and Cognitive Disorders, Fujita Health University School of Medicine, Kutsukake, Toyoake, Aichi, Japan
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Salvadori E, Poggesi A, Donnini I, Rinnoci V, Chiti G, Squitieri M, Tudisco L, Fierini F, Melone A, Pescini F, Pantoni L. Association of nimodipine and choline alphoscerate in the treatment of cognitive impairment in patients with cerebral small vessel disease: study protocol for a randomized placebo-controlled trial-the CONIVaD trial. Aging Clin Exp Res 2020; 32:449-457. [PMID: 31148099 DOI: 10.1007/s40520-019-01229-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 05/18/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Vascular cognitive impairment (VCI) is an extremely disabling condition that includes post-stroke dementia and VCI caused by cerebral small vessel disease (SVD). Currently, there is no approved treatment for this condition. Drugs active on the cholinergic pathway have been tested in VCI patients showing positive but limited efficacy. The calcium-antagonist nimodipine also showed some moderate positive effects in VCI patients. AIMS CONIVaD (choline alphoscerate and nimodipine in vascular dementia) is a pilot, single-center, double-blinded, randomized trial aimed to assess whether the association of choline alphoscerate and nimodipine is more effective than nimodipine alone in reducing cognitive decline in patients with SVD and mild-to-moderate cognitive impairment. METHODS All patients are evaluated at baseline and after 12 months with: (1) clinical, daily functions, quality of life, and mood assessment and (2) extensive neuropsychological evaluation. After the baseline evaluation, patients are randomly assigned to one of the two arms of treatment: (1) nimodipine 90 mg/die t.i.d plus placebo b.i.d and (2) nimodipine 90 mg t.i.d plus choline alphoscerate 1200 mg/die b.i.d. for a total of 12 months. The primary endpoint is cognitive decline, expressed as the loss of at least two points on the Montreal Cognitive Assessment at 12 months. Secondary endpoints include safety and tolerability, functional, quality of life, and neuropsychological measures. DISCUSSION CONIVaD study is the first randomized controlled trial to examine the cognitive efficacy of combined choline alphoscerate-nimodipine treatment in VCI patients. Results of this pilot study will serve as a methodological basis for other clinical controlled, multicentric, double-blinded, and randomized trials. TRIAL REGISTRATION Clinical Trial NCT03228498. Registered 25 July 2017.
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Affiliation(s)
| | - Anna Poggesi
- NEUROFARBA Department, University of Florence, Florence, Italy
| | - Ida Donnini
- NEUROFARBA Department, University of Florence, Florence, Italy
| | | | - Guido Chiti
- NEUROFARBA Department, University of Florence, Florence, Italy
| | | | - Laura Tudisco
- NEUROFARBA Department, University of Florence, Florence, Italy
| | - Fabio Fierini
- Psychiatry Unit, Department of Health Sciences, University of Florence, Florence, Italy
| | - Anna Melone
- NEUROFARBA Department, University of Florence, Florence, Italy
| | - Francesca Pescini
- Stroke Unit, Emergency Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Leonardo Pantoni
- Department of Biomedical and Clinical Sciences, 'L. Sacco' Hospital, University of Milan, Via Giovanni Battista Grassi 74, 20157, Milan, Italy.
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Effect of acetylcholinesterase inhibitors on post-stroke cognitive impairment and vascular dementia: A meta-analysis. PLoS One 2020; 15:e0227820. [PMID: 32032361 PMCID: PMC7006920 DOI: 10.1371/journal.pone.0227820] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 12/30/2019] [Indexed: 12/17/2022] Open
Abstract
Cognitive impairment is a common complication observed after a stroke. Currently there are no definitively proven pharmacologic therapies for recovery from post-stroke cognitive impairment and vascular dementia. In this meta-analysis, we evaluated the efficacy and safety of cholinesterase inhibitors in their improvement of cognition in patients with post-stroke cognitive impairment and vascular dementia. We conducted a meta-analysis using seven eligible studies from 305 published articles. We investigated the differences in Mini-Mental State Examination (MMSE) and Alzheimer's Disease Assessment Scale-Cognitive subscale (ADAS-Cog) scores, before and after cholinergic augmentation in patients with post-stroke cognitive impairment and vascular dementia. MMSE and ADAS-cog scores were also compared during the subsequent follow-up periods. MMSE score of patients with post-stroke cognitive impairment was increased after cholinergic augmentation throughout the 24 weeks with mean differences [MD] of 3.000, 1.732, 1.578 1.516, and 1.222, at 4, 4-8, 8-12, 12-18, and 18-24 weeks, respectively. In addition, ADAS-cog scores decreased at 6, 12, 18, and 24 weeks by pharmaceutical augmentation, but not with placebo with mean differences [MD] of -2.333, -2.913, -2.767, -2.416, and -1.859, respectively. This meta-analysis shows that acetylcholinesterase inhibitors maintain a stable pattern of improved cognitive function in patients with post stroke cognitive impairment and vascular dementia without the increased risk of side effects.
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Jin BR, Liu HY. Comparative efficacy and safety of cognitive enhancers for treating vascular cognitive impairment: systematic review and Bayesian network meta-analysis. Neural Regen Res 2019; 14:805-816. [PMID: 30688266 PMCID: PMC6375033 DOI: 10.4103/1673-5374.249228] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 08/21/2018] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVE To assess and compare the clinical efficacy and safety of cognitive enhancers (donepezil, galantamine, rivastigmine, and memantine) on cognition, behavior, function, and global status in patients with vascular cognitive impairment. DATA SOURCES The initial literature search was performed with PubMed, EMBASE, the Cochrane Methodology Register, the Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing & Allied Health (CINAHL) from inception to January 2018 for studies regarding donepezil, galantamine, rivastigmine, and memantine for treatment of vascular cognitive impairment. DATA SELECTION Randomized controlled trials on donepezil, galantamine, rivastigmine, and memantine as monotherapy in the treatment of vascular cognitive impairment were included. A Bayesian network meta-analysis was conducted. OUTCOME MEASURES Efficacy was assessed by changes in scores of the Alzheimer's Disease Assessment Scale, cognitive subscale, Mini-Mental State Examination, Neuropsychiatric Inventory scores and Clinician's Interview-Based Impression of Change Scale Plus Caregiver's Input, Activities of Daily Living, the Clinical Dementia Rating scale. Safety was evaluated by mortality, total adverse events (TAEs), serious adverse events (SAEs), nausea, vomiting. diarrhea, or cerebrovascular accidents (CVAs). RESULTS After screening 1717 citations, 12 randomized controlled trials were included. Donepezil and rivastigmine (mean difference (e) = -0.77, 95% confidence interval (CI): 0.25-1.32; MD = 1.05, 95% CI: 0.18-1.79) were significantly more effective than placebo in reducing Mini-Mental State Examination scores. Donepezil, galantamine, and memantine (MD = -1.30, 95% CI: -2.27 to -0.42; MD = -1.67, 95% CI: -3.36 to -0.06; MD = -2.27, 95% CI: -3.91 to -0.53) showed superior benefits on the Alzheimer's Disease Assessment Scale-cognitive scores compared with placebo. Memantine (MD = 2.71, 95% CI: 1.05-7.29) improved global status (Clinician's Interview-Based Impression of Change Scale Plus Caregiver's Input) more than the placebo. Safety results revealed that donepezil 10 mg (odds ratio (OR) = 3.04, 95% CI: 1.86-5.41) contributed to higer risk of adverse events than placebo. Galantamine (OR = 5.64, 95% CI: 1.31-26.71) increased the risk of nausea. Rivastigmine (OR = 16.80, 95% CI: 1.78-319.26) increased the risk of vomiting. No agents displayed a significant risk of serious adverse events, mortality, cerebrovascular accidents, or diarrhea. CONCLUSION We found significant efficacy of donepezil, galantamine, and memantine on cognition. Memantine can provide significant efficacy in global status. They are all safe and well tolerated.
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Affiliation(s)
- Bo-Ru Jin
- Department of Neurology, First Affiliated Hospital, China Medical University, Shenyang, Liaoning Province, China
| | - Hua-Yan Liu
- Department of Neurology, First Affiliated Hospital, China Medical University, Shenyang, Liaoning Province, China
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Yeo SH, Lim ZJI, Mao J, Yau WP. Effects of Central Nervous System Drugs on Recovery After Stroke: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Clin Drug Investig 2018; 37:901-928. [PMID: 28756557 DOI: 10.1007/s40261-017-0558-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVE Pilot trials have suggested that pharmacotherapy may aid stroke recovery. The aim of this study was to systematically review the effects of antidepressants, anti-Alzheimer drugs, anti-Parkinson drugs, central nervous system (CNS) stimulants and piracetam on gross motor function, cognition, disability, dependency and quality of life (QOL) after stroke. METHODS PubMed, EMBASE and the Cochrane Central Register of Controlled Trials databases were searched, and 44 randomized controlled trials that compared outcomes of interest between drug treatment and placebo or no treatment were included. For each study, standardized mean difference (SMD) or mean difference (MD) with 95% confidence interval (CI) were calculated. Meta-analyses were conducted to pool results using either the fixed-effects or random-effects model. RESULTS Selective serotonin reuptake inhibitors (SSRIs) improved gross motor function (SMD 0.54, 95% CI 0.22-0.85; three studies), disability (SMD 0.49, 95% CI 0.32-0.66; 14 studies) and QOL (MD 6.46, 95% CI 4.71-8.22; two studies), but there was insufficient evidence for their use in enhancing global cognition (SMD 0.23, 95% CI -0.01 to 0.46; five studies) and dependency (risk ratio 0.81, 95% CI 0.68-0.97; one fluoxetine study). In particular, gross motor function was improved by fluoxetine (SMD 0.64, 95% CI 0.31-0.98; two studies), while disability was improved by paroxetine (SMD 1.05, 95% CI 0.63-1.46; two studies), citalopram (SMD 0.51, 95% CI 0.08-0.93; two studies) and fluoxetine (SMD 0.41, 95% CI 0.22-0.60; nine studies). There is insufficient evidence for the use of anti-Alzheimer drugs, anti-Parkinson drugs, CNS stimulants and piracetam to promote stroke recovery. CONCLUSIONS Administration of SSRIs may improve gross motor function, reduce disability and enhance QOL for patients recovering from stroke.
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Affiliation(s)
- See-Hwee Yeo
- Department of Pharmacy, Faculty of Science, National University of Singapore, 18 Science Drive 4, Singapore, 117543, Singapore
| | - Zheng-Jie Ian Lim
- Department of Pharmacy, Faculty of Science, National University of Singapore, 18 Science Drive 4, Singapore, 117543, Singapore
| | - Jia Mao
- Department of Pharmacy, Faculty of Science, National University of Singapore, 18 Science Drive 4, Singapore, 117543, Singapore
| | - Wai-Ping Yau
- Department of Pharmacy, Faculty of Science, National University of Singapore, 18 Science Drive 4, Singapore, 117543, Singapore.
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Abstract
Vascular cognitive impairment (VCI) is the second most common type of dementia after Alzheimer's disease (AD). Stroke and cardiovascular risk factors have been linked to both AD and VCI and potentially can affect cognitive function in mid and later life. Various pharmacological agents, including donepezil, galantamine, and memantine, approved for the treatment of AD have shown modest cognitive benefits in patients with vascular dementia (VaD). However, their functional and global benefits have been inconsistent. Donepezil has shown some cognitive benefit in patients with VaD only, and galantamine has shown some benefit in mixed dementia (AD/VaD). The benefits of other drugs such as rivastigmine, memantine, nimodipine, and piracetam are not clear. Some other supplements and herbal therapies, such as citicoline, actovegin, huperzine A, and vinpocetine, have also been studied in patients with VaD, but their beneficial effects are not well established. Non-drug therapies and lifestyle modifications such as diet, exercise, and vascular risk factor control are important in the management of VCI and should not be ignored. However, there is a need for more robust clinical trials focusing on executive function and other cognitive measures and incorporation of newer imaging modalities to provide additional evidence about the utility of these strategies in patients with VCI.
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Affiliation(s)
- Muhammad U Farooq
- Division of Stroke and Vascular Neurology, Mercy Health Hauenstein Neurosciences, 200 Jefferson Street SE, Grand Rapids, MI, 49503, USA.
| | - Jiangyong Min
- Division of Stroke and Vascular Neurology, Mercy Health Hauenstein Neurosciences, 200 Jefferson Street SE, Grand Rapids, MI, 49503, USA
| | - Christopher Goshgarian
- Division of Stroke and Vascular Neurology, Mercy Health Hauenstein Neurosciences, 200 Jefferson Street SE, Grand Rapids, MI, 49503, USA
| | - Philip B Gorelick
- Division of Stroke and Vascular Neurology, Mercy Health Hauenstein Neurosciences, 200 Jefferson Street SE, Grand Rapids, MI, 49503, USA.,Department Translational Science and Molecular Medicine, Michigan State University College of Human Medicine, 220 Cherry Street SE Room H 3037, Grand Rapids, MI, 49503, USA
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Pakdaman H, Amini Harandi A, Gharagozli K, Abbasi M, Ghaffarpour M, Ashrafi F, Delavar Kasmaei H, Amini Harandi A. MLC601 in vascular dementia: an efficacy and safety pilot study. Neuropsychiatr Dis Treat 2017; 13:2551-2557. [PMID: 29042785 PMCID: PMC5634376 DOI: 10.2147/ndt.s145047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND AND AIM Vascular dementia (VaD) is the second most common cause of dementia and currently there is scarcity of therapies for VaD. We aimed to investigate the efficacy and safety of MLC601 in the treatment of VaD. METHODS In this multicenter, pilot, randomized, double-blind trial, 82 patients with VaD according to DSM-5 criteria received MLC601 or placebo capsules three times a day for 2 years. The primary efficacy end-point was evaluated by comparing Mini-Mental State Examination (MMSE) and Alzheimer's Disease Assessment Scale-cognitive subscale (ADAS-cog) score between the two groups over 2 years of study. Safety was also assessed by recording adverse events and abnormal laboratory results. RESULTS Eighty-one patients completed the study and were included in the analysis. One patient was lost to follow-up in the placebo group. After 2 years, mean (±SD) changes in the MMSE score were -3.71 (±4.50) for MLC601 group and -9.33 (±4.80) for placebo group. ADAS-cog score showed (±SD) changes of 7.34 (±9.55) and 19.00 (±11.28) for MLC601 and placebo group, respectively. Repeated measures analyses showed that both MMSE and ADAS-cog scores were significantly better in the treatment group at 24 months (p<0.001). Ten (24.39%) patients reported predominantly transient gastrointestinal adverse events in MLC601 group. No patient left the study due to adverse events. There were no clinically significant abnormalities on laboratory tests. CONCLUSION Patients treated with MLC601 over the 2 years showed dramatically better cognitive outcome compared with those treated with placebo. MLC601 was devoid of any serious adverse events and was well-tolerated.
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Affiliation(s)
- Hossein Pakdaman
- Brain Mapping Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Amini Harandi
- Brain Mapping Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Koroush Gharagozli
- Brain Mapping Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehdi Abbasi
- Brain Mapping Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Majid Ghaffarpour
- Iranian Center of Neurological Research, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Farzad Ashrafi
- Brain Mapping Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hosein Delavar Kasmaei
- Brain Mapping Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Asghar Amini Harandi
- Department of Biochemistry, School of Medicine, Jiroft University of Medical Sciences, Jiroft, Iran
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31
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Winstein CJ, Stein J, Arena R, Bates B, Cherney LR, Cramer SC, Deruyter F, Eng JJ, Fisher B, Harvey RL, Lang CE, MacKay-Lyons M, Ottenbacher KJ, Pugh S, Reeves MJ, Richards LG, Stiers W, Zorowitz RD. Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2016; 47:e98-e169. [PMID: 27145936 DOI: 10.1161/str.0000000000000098] [Citation(s) in RCA: 1519] [Impact Index Per Article: 189.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke. METHODS Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee. RESULTS Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential. CONCLUSIONS As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.).
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Reijmer YD, van Veluw SJ, Greenberg SM. Ischemic brain injury in cerebral amyloid angiopathy. J Cereb Blood Flow Metab 2016; 36:40-54. [PMID: 25944592 PMCID: PMC4758563 DOI: 10.1038/jcbfm.2015.88] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 03/24/2015] [Accepted: 03/26/2015] [Indexed: 12/16/2022]
Abstract
Cerebral amyloid angiopathy (CAA) is a common form of cerebral small vessel disease and an important risk factor for intracerebral hemorrhage and cognitive impairment. While the majority of research has focused on the hemorrhagic manifestation of CAA, its ischemic manifestations appear to have substantial clinical relevance as well. Findings from imaging and pathologic studies indicate that ischemic lesions are common in CAA, including white-matter hyperintensities, microinfarcts, and microstructural tissue abnormalities as detected with diffusion tensor imaging. Furthermore, imaging markers of ischemic disease show a robust association with cognition, independent of age, hemorrhagic lesions, and traditional vascular risk factors. Widespread ischemic tissue injury may affect cognition by disrupting white-matter connectivity, thereby hampering communication between brain regions. Challenges are to identify imaging markers that are able to capture widespread microvascular lesion burden in vivo and to further unravel the etiology of ischemic tissue injury by linking structural magnetic resonance imaging (MRI) abnormalities to their underlying pathophysiology and histopathology. A better understanding of the underlying mechanisms of ischemic brain injury in CAA will be a key step toward new interventions to improve long-term cognitive outcomes for patients with CAA.
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Affiliation(s)
- Yael D Reijmer
- Department of Neurology, Hemorrhagic Stroke Research Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Susanne J van Veluw
- Department of Neurology, Hemorrhagic Stroke Research Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Steven M Greenberg
- Department of Neurology, Hemorrhagic Stroke Research Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Metzger FG, Ehlis AC, Haeussinger FB, Fallgatter AJ, Hagen K. Effects of cholinesterase inhibitor on brain activation in Alzheimer's patients measured with functional near-infrared spectroscopy. Psychopharmacology (Berl) 2015; 232:4383-91. [PMID: 26359227 DOI: 10.1007/s00213-015-4066-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 08/26/2015] [Indexed: 11/25/2022]
Abstract
RATIONALE Neurobiological effects of neuropsychiatric medication can contribute to the understanding of mechanisms of action and to the evaluation of target medication effects. Cholinesterase inhibitors (ChEI) have been used in patients with Alzheimer's disease (AD) for years with only small knowledge about the underlying neurobiological effects. The measurement of brain activation links neurobiological and functional aspects but is challenging in the group of demented patients; here, an alternative method, functional near-infrared spectroscopy (fNIRS), is introduced to measure those medication effects. OBJECTIVES The current study investigated the influence of ChEI on cortical activation of patients with AD measured using fNIRS during a verbal fluency task (VFT). METHODS In this study, 24 probable AD patients were investigated three times using fNIRS: before medication with rivastigmine was given (t0), when the medication was at the target dose after 4 weeks (t1), and after the target dose was kept constant for a further 8 weeks (t2). RESULTS The results show a concentration increase of oxygenated hemoglobin as measured with fNIRS from t0 to t2 in speech relevant areas and a general decrease in prefrontal areas. Behaviorally, an improvement was found for the VFT used to measure cortical activation during fNIRS. In the neuropsychological test battery, no significant changes were found, yet high effect sizes for the mini mental status examination, immediate and delayed word list recall were found. CONCLUSIONS The results indicate a positive effect of ChEI on cognitive function. The underlying cortical changes can be imaged using fNIRS.
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Affiliation(s)
- Florian G Metzger
- Psychophysiology and Optical Imaging; Department of Psychiatry and Psychotherapy, University Hospital of Tuebingen, Calwerstrasse 14, 72076, Tuebingen, Germany.
- Geriatric Center, University Hospital of Tuebingen, Calwerstrasse 14, Tuebingen, 72076, Germany.
| | - Ann-Christine Ehlis
- Psychophysiology and Optical Imaging; Department of Psychiatry and Psychotherapy, University Hospital of Tuebingen, Calwerstrasse 14, 72076, Tuebingen, Germany
| | - Florian B Haeussinger
- Psychophysiology and Optical Imaging; Department of Psychiatry and Psychotherapy, University Hospital of Tuebingen, Calwerstrasse 14, 72076, Tuebingen, Germany
- Graduate School of Neural Information Processing, University of Tuebingen, Oesterbergstr. 3, Tuebingen, 72074, Germany
| | - Andreas J Fallgatter
- Psychophysiology and Optical Imaging; Department of Psychiatry and Psychotherapy, University Hospital of Tuebingen, Calwerstrasse 14, 72076, Tuebingen, Germany
- Center of Integrative Neuroscience (CIN), Cluster of Excellence, University of Tuebingen, Otfried-Müller-Str. 25, Tuebingen, 72076, Germany
| | - Katja Hagen
- Psychophysiology and Optical Imaging; Department of Psychiatry and Psychotherapy, University Hospital of Tuebingen, Calwerstrasse 14, 72076, Tuebingen, Germany
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Jia J, Wei C, Liang J, Zhou A, Zuo X, Song H, Wu L, Chen X, Chen S, Zhang J, Wu J, Wang K, Chu L, Peng D, Lv P, Guo H, Niu X, Chen Y, Dong W, Han X, Fang B, Peng M, Li D, Jia Q, Huang L. The effects of DL-3-n-butylphthalide in patients with vascular cognitive impairment without dementia caused by subcortical ischemic small vessel disease: A multicentre, randomized, double-blind, placebo-controlled trial. Alzheimers Dement 2015; 12:89-99. [PMID: 26086183 DOI: 10.1016/j.jalz.2015.04.010] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Revised: 02/27/2015] [Accepted: 04/06/2015] [Indexed: 11/15/2022]
Affiliation(s)
- Jianping Jia
- Department of Neurology; Xuan Wu Hospital of the Capital Medical University; Beijing China
- Center of Alzheimer's Disease; Beijing Institute for Brain Disorders; Beijing China
| | - Cuibai Wei
- Department of Neurology; Xuan Wu Hospital of the Capital Medical University; Beijing China
| | - Junhua Liang
- Department of Neurology; Xuan Wu Hospital of the Capital Medical University; Beijing China
| | - Aihong Zhou
- Department of Neurology; Xuan Wu Hospital of the Capital Medical University; Beijing China
| | - Xiumei Zuo
- Department of Neurology; Xuan Wu Hospital of the Capital Medical University; Beijing China
| | - Haiqing Song
- Department of Neurology; Xuan Wu Hospital of the Capital Medical University; Beijing China
| | - Liyong Wu
- Department of Neurology; Xuan Wu Hospital of the Capital Medical University; Beijing China
| | - Xiaochun Chen
- Department of Neurology; The Affiliated Union Hospital of Fujian Medical University; Fuzhou Fujian China
| | - Shengdi Chen
- Department of Neurology; Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine; Shanghai China
| | - Junjian Zhang
- Department of Neurology; Zhongnan Hospital of Wuhan University; Wuhan Hubei China
| | - Jiang Wu
- Department of Neurology; The First Teaching Hospital of Jilin University; Changchun Jilin China
| | - Kai Wang
- Department of Neurology; The First Affiliated Hospital of Anhui Medical University; Hefei Anhui China
| | - Lan Chu
- Department of Neurology; The Affiliated Hospital of Guiyang Medical College; Guiyang Guizhou China
| | - Dantao Peng
- Department of Neurology; Beijing Hospital; Beijing China
| | - Peiyuan Lv
- Department of Neurology; Hebei General Hospital; Shijiazhuang Hebei China
| | - Hongzhi Guo
- Department of Neurology; Qilu Hospital of Shandong University; Jinan Shandong China
| | - Xiaoyuan Niu
- Department of Neurology; The First Hospital of Shanxi Medical University; Taiyuan Shanxi China
| | - Yingzhu Chen
- Department of Neurology; Northern Jiangsu People's Hospital of Yangzhou University; Yangzhou Jiangsu China
| | - Wanli Dong
- Department of Neurology; The First Affiliated Hospital of Soochow University; Suzhou Jiangsu China
| | - Xiujie Han
- Department of Neurology; Anshan Changda Hospital; Anshan Liaoning China
| | - Boyan Fang
- Department of Neurology; The First Affiliated Hospital of Liaoning Medical College; Jinzhou Liaoning China
| | - Mao Peng
- Department of Neurology; Xuan Wu Hospital of the Capital Medical University; Beijing China
| | - Dan Li
- Department of Neurology; Xuan Wu Hospital of the Capital Medical University; Beijing China
| | - Qian Jia
- Department of Neurology; Xuan Wu Hospital of the Capital Medical University; Beijing China
| | - Liyuan Huang
- Department of Neurology; Xuan Wu Hospital of the Capital Medical University; Beijing China
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Abstract
Dementia is a broad term used to describe several chronic progressive neurological disorders that adversely affect higher mental functions including memory, language, behaviour, abstract thinking, comprehension, calculation, learning capacity and judgement. Alzheimer's disease is the most common form of dementia but other neurological conditions such as Parkinson's disease, cerebrovascular disease and chronic infections such as syphilis can also lead to the clinical syndrome of dementia. Initial investigations should always focus on finding any treatable cause for dementia such as HIV, structural lesions such as subdural haematomas or specific nutritional deficiency states such as that due to vitamin B12 and treated appropriately. Where no treatable or reversible aetiology is found, a referral to a specialist should be considered who may initiate further investigations including magnetic resonance imaging or perfusion single-photon emission computerised tomography scans of the brain, and sometimes cerebrospinal fluid examination or an electroencephalogram.
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Affiliation(s)
- Naveed Malek
- Institute of Neurological Sciences, Southern General Hospital, Glasgow, UK
| | - John Greene
- Institute of Neurological Sciences, Southern General Hospital, Glasgow, UK
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Singh DP, Chopra K. Flavocoxid, dual inhibitor of cyclooxygenase-2 and 5-lipoxygenase, exhibits neuroprotection in rat model of ischaemic stroke. Pharmacol Biochem Behav 2014; 120:33-42. [DOI: 10.1016/j.pbb.2014.02.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2013] [Revised: 01/27/2014] [Accepted: 02/08/2014] [Indexed: 01/02/2023]
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Tricco AC, Soobiah C, Berliner S, Ho JM, Ng CH, Ashoor HM, Chen MH, Hemmelgarn B, Straus SE. Efficacy and safety of cognitive enhancers for patients with mild cognitive impairment: a systematic review and meta-analysis. CMAJ 2013; 185:1393-401. [PMID: 24043661 DOI: 10.1503/cmaj.130451] [Citation(s) in RCA: 127] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Cognitive enhancers, including cholinesterase inhibitors and memantine, are used to treat dementia, but their effectiveness for mild cognitive impairment is unclear. We conducted a systematic review to examine the efficacy and safety of cognitive enhancers for mild cognitive impairment. METHODS Our eligibility criteria were studies of the effects of donepezil, rivastigmine, galantamine or memantine on mild cognitive impairment reporting cognition, function, behaviour, global status, and mortality or harms. We identified relevant material by searching electronic databases (e.g., MEDLINE, Embase), the references of included studies, trial registries and conference proceedings, and by contacting experts. Two reviewers independently screened the results of the literature search, abstracted data and appraised risk of bias using the Cochrane risk-of-bias tool. RESULTS We screened 15,554 titles and abstracts and 1384 full-text articles. Eight randomized clinical trials and 3 companion reports met our inclusion criteria. We found no significant effects of cognitive enhancers on cognition (Mini-Mental State Examination: 3 randomized clinical trials [RCTs], mean difference [MD] 0.14, 95% confidence interval [CI] -0.22 to 0.50; Alzheimer's Disease Assessment Scale - cognition subscale: 3 RCTs, standardized MD -0.07, 95% CI-0.16 to 0.01]) or function (Alzheimer's Disease Cooperative Study activities of daily living inventory: 2 RCTs, MD 0.30, 95% CI -0.26 to 0.86). Cognitive enhancers were associated with higher risks of nausea, diarrhea and vomiting than placebo. INTERPRETATION Cognitive enhancers did not improve cognition or function among patients with mild cognitive impairment and were associated with a greater risk of gastrointestinal harms. Our findings do not support the use of cognitive enhancers for mild cognitive impairment.
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Alonso de Leciñana M, Gutiérrez-Fernández M, Romano M, Cantú-Brito C, Arauz A, Olmos LE, Ameriso SF, Díez-Tejedor E. Strategies to improve recovery in acute ischemic stroke patients: Iberoamerican Stroke Group Consensus. Int J Stroke 2013; 9:503-13. [PMID: 23802573 DOI: 10.1111/ijs.12070] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Accepted: 10/31/2012] [Indexed: 12/20/2022]
Abstract
Stroke is not only a leading cause of death worldwide but also a main cause of disability. In developing countries, its burden is increasing as a consequence of a higher life expectancy. Whereas stroke mortality has decreased in developed countries, in Latin America, stroke mortality rates continue to rise as well as its socioeconomic dramatic consequences. Therefore, it is necessary to implement stroke care and surveillance programs to better describe the epidemiology of stroke in these countries in order to improve therapeutic strategies. Advances in the understanding of the pathogenic processes of brain ischemia have resulted in development of effective therapies during the acute phase. These include reperfusion therapies (both intravenous thrombolysis and interventional endovascular approaches) and treatment in stroke units that, through application of management protocols directed to maintain homeostasis and avoid complications, helps to exert effective brain protection that decreases further cerebral damage. Some drugs may enhance protection, and besides, there is increasing knowledge about brain plasticity and repair mechanisms that take place for longer periods beyond the acute phase. These mechanisms are responsible for recovery in certain patients and are the focus of basic and clinical research at present. This paper discusses recovery strategies that have demonstrated clinical effect, or that are promising and need further study. This rapidly evolving field needs to be carefully and critically evaluated so that investment in patient care is grounded on well-proven strategies.
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Affiliation(s)
- M Alonso de Leciñana
- Stroke Unit, Deparment of Neurology, University Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
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Cumming TB, Marshall RS, Lazar RM. Stroke, cognitive deficits, and rehabilitation: still an incomplete picture. Int J Stroke 2013; 8:38-45. [PMID: 23280268 DOI: 10.1111/j.1747-4949.2012.00972.x] [Citation(s) in RCA: 223] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Cognitive impairment after stroke is common and can cause disability with major impacts on quality of life and independence. There are also indirect effects of cognitive impairment on functional recovery after stroke through reduced participation in rehabilitation and poor adherence to treatment guidelines. In this article, we attempt to establish the following: ● whether there is a distinct profile of cognitive impairment after stroke; ● whether the type of cognitive deficit can be associated with the features of stroke-related damage; and ● whether interventions can improve poststroke cognitive performance. There is not a consistent profile of cognitive deficits in stroke, though slowed information processing and executive dysfunction tend to predominate. Our understanding of structure-function relationships has been advanced using imaging techniques such as lesion mapping and will be further enhanced through better characterization of damage to functional networks and identification of subtle white matter abnormalities. Effective cognitive rehabilitation approaches have been reported for focal cortical deficits such as neglect and aphasia, but treatments for more diffusely represented cognitive impairment remain elusive. In the future, the hope is that different techniques that have been shown to promote neural plasticity (e.g., exercise, brain stimulation, and pharmacological agents) can be applied to improve the cognitive function of stroke survivors.
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Affiliation(s)
- Toby B Cumming
- Stroke Division, Florey Neuroscience Institutes, Melbourne, Vic., Australia.
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Abstract
BACKGROUND Vascular dementia represents the second most common type of dementia after Alzheimer's disease. In older patients, in particular, the combination of vascular dementia and Alzheimer's disease is common, and is referred to as mixed dementia. The classification of vascular dementia broadly follows three clinico-pathological processes: multi-infarct dementia, single strategic infarct dementia and subcortical dementia. Not all victims fulfil strict criteria for dementia and may be significantly cognitively impaired without memory loss, when the term vascular cognitive impairment (VCI) is more useful. Currently, no established standard treatment for VCI exists. Reductions in acetylcholine and acetyltransferase activity are common to both Alzheimer's disease and VCI, raising the possibility that cholinesterase inhibitors - such as rivastigmine - which are beneficial in Alzheimer's disease, may also be beneficial for VCI. OBJECTIVES To assess the efficacy of rivastigmine compared with placebo in the treatment of people with vascular cognitive impairment (VCI), vascular dementia or mixed dementia. SEARCH METHODS We searched ALOIS (the Cochrane Dementia and Cognitive Improvement Group's Specialized Register) on 12 February 2013 using the terms: rivastigmine, exelon, "SDZ ENA 713". ALOIS contains records of clinical trials identified from monthly searches of a number of major healthcare databases (The Cochrane Library, MEDLINE, EMBASE, CINAHL, PsycINFO, LILACS), numerous trial registries and grey literature sources. SELECTION CRITERIA All unconfounded randomized double-blind trials comparing rivastigmine with placebo in the treatment of people with VCI, vascular dementia or mixed dementia were eligible for inclusion. DATA COLLECTION AND ANALYSIS Two reviewers extracted and assessed data independently, and agreement was reached after discussion. They noted results concerning adverse effects. MAIN RESULTS Three trials, with a total of 800 participants, were identified for inclusion. The participants in one trial did not have dementia, while the other two studies included participants with dementia of different severities. The dose of rivastigmine was different in each study. No pooling of study results was attempted because of these differences between the studies.One trial included 40 participants with subcortical vascular dementia (age range 40 to 90 years) with a mean mini-mental state examination (MMSE) score of 13.0 and 13.4 in the rivastigmine and placebo arms, respectively. Treatment over 26 weeks was limited to 3 mg rivastigmine twice daily, or placebo. No significant difference was found on any outcome measure relevant to cognition, neuropsychiatric symptoms, function or global rating, or in the number of withdrawals before the end of treatment.Another trial included 710 participants with vascular dementia, including subcortical and cortical forms (age range 50 to 85 years). Over 24 weeks, a mean dose of rivastigmine of 9.4 mg/day was achieved versus placebo. Baseline MMSE was identical for both groups, at 19.1. Statistically significant advantage in cognitive response (but not with global impression of change or non-cognitive measures) was seen with rivastigmine treatment at 24 weeks (MMSE change from baseline MD 0.6, 95% CI 0.11 to 1.09, P value 0.02; Vascular Dementia Assessment Scale (VaDAS) change from baseline MD -1.3, 95% CI-2.62 to 0.02, P value 0.05 ). Significantly higher rates of vomiting, nausea, diarrhoea and anorexia and withdrawals from treatment were noted in the participants randomized to rivastigmine compared with placebo (withdrawals rivastigmine 90/365, placebo 48/345, OR 2.02, 95% CI 1.38 to 2.98) (withdrawals due to an adverse event rivastigmine 49/365, placebo 19/345, OR 2.66, 95% CI 1.53 to 4.62, P value 0.0005).The third study included 50 participants (age range 48 to 84 years) with mean MMSE scores of 23.7 and 23.9 in the rivastigmine and placebo arms, respectively. Over a 24-week period, participants labelled as having cognitive impairment but no dementia (CIND) following ischaemic stroke were given up to 4.5 mg rivastigmine twice daily, or placebo. Primary and secondary outcome measures showed no statistically significant difference when considering neurocognitive abilities, function, neuropsychiatric symptoms and global performance. One participant in the rivastigmine group and two in the placebo group discontinued their medication because of an adverse effect. AUTHORS' CONCLUSIONS There is some evidence of benefit of rivastigmine in VCI from trial data from three studies. However, this conclusion is based on one large study. Rivastigmine is capable of inducing side effects that lead to withdrawal in a significant proportion of patients.
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Affiliation(s)
- Jacqueline Birks
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK.
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Chen CL, Ikram K, Anqi Q, Yin WT, Chen A, Venketasubramanian N. The NeuroAiD II (MLC901) in Vascular Cognitive Impairment Study (NEURITES). Cerebrovasc Dis 2013; 35 Suppl 1:23-9. [DOI: 10.1159/000346234] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Abstract
BACKGROUND Mild cognitive impairment is hypothesised to represent a pre-clinical stage of dementia but forms a heterogeneous group with variable prognosis. OBJECTIVES To assess the safety and efficacy of cholinesterase inhibitors in people with mild cognitive impairment. SEARCH METHODS Trials were identified from the Cochrane Dementia and Cognitive Improvement Group's Specialised Register, which is frequently updated from the major healthcare databases (MEDLINE, EMBASE, CINAHL, PsycINFO and Lilacs) as well as trial registers and grey literature. SELECTION CRITERIA Double-blind, placebo-controlled randomised trials of any cholinesterase inhibitor in people with mild cognitive impairment. DATA COLLECTION AND ANALYSIS Data were extracted from the published reports of the included studies, combined by meta-analysis where appropriate, and treatment efficacy and risk of adverse events were estimated. MAIN RESULTS Nine studies (from eight published reports) of 5149 individuals with mild cognitive impairment (however defined) were included in the review. Limited pooling of results was possible owing to different lengths of trials. Meta-analysis of the three studies reporting conversion to dementia gives no strong evidence of a beneficial effect of cholinesterase inhibitors on the progression to dementia at one, two or three years. The risk ratio (RR) for conversion at two years was significantly different from unity (0.67; 95% confidence interval (CI) 0.55 to 0.83), but this is based on only two studies reported in the same article. There was essentially no effect of cholinesterase inhibitors on cognitive test scores.Based on the results from 4207 individuals, there were significantly more adverse events in the cholinesterase inhibitor groups (RR 1.09; 95% CI 1.02 to 1.16), but no more serious adverse events or deaths. Gastrointestinal side effects were much more common (diarrhoea: RR 2.10; 95% CI 1.30 to 3.39; nausea: RR 2.97; 95% CI 2.57 to 3.42; vomiting: RR 4.42; 95% CI 3.23 to 6.05). Cardiac problems were no more likely in either group (RR 0.71; 95% CI 0.25 to 2.02). Other side effects reported significantly more often in the cholinesterase inhibitor group were muscle spasms/leg cramps (RR 7.52; 95% CI 4.34 to 13.02), headache (RR 1.34; 95% CI 1.05 to 1.71), syncope or dizziness (RR 1.62; 95% CI 1.36 to 1.93), insomnia (RR 1.66; 95% CI 1.36 to 2.02) and abnormal dreams (RR 4.25; 95% CI 2.57 to 7.04). AUTHORS' CONCLUSIONS There is very little evidence that cholinesterase inhibitors affect progression to dementia or cognitive test scores in mild cognitive impairment. This weak evidence is overwhelmed by the increased risk of adverse events, particularly gastrointestinal. Cholinesterase inhibitors should not be recommended for mild cognitive impairment.
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Affiliation(s)
- Tom C Russ
- Alzheimer Scotland Dementia Research Centre, Edinburgh, UK.
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Gorelick PB, Scuteri A, Black SE, Decarli C, Greenberg SM, Iadecola C, Launer LJ, Laurent S, Lopez OL, Nyenhuis D, Petersen RC, Schneider JA, Tzourio C, Arnett DK, Bennett DA, Chui HC, Higashida RT, Lindquist R, Nilsson PM, Roman GC, Sellke FW, Seshadri S. Vascular contributions to cognitive impairment and dementia: a statement for healthcare professionals from the american heart association/american stroke association. Stroke 2011; 42:2672-713. [PMID: 21778438 PMCID: PMC3778669 DOI: 10.1161/str.0b013e3182299496] [Citation(s) in RCA: 2507] [Impact Index Per Article: 192.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE This scientific statement provides an overview of the evidence on vascular contributions to cognitive impairment and dementia. Vascular contributions to cognitive impairment and dementia of later life are common. Definitions of vascular cognitive impairment (VCI), neuropathology, basic science and pathophysiological aspects, role of neuroimaging and vascular and other associated risk factors, and potential opportunities for prevention and treatment are reviewed. This statement serves as an overall guide for practitioners to gain a better understanding of VCI and dementia, prevention, and treatment. METHODS Writing group members were nominated by the writing group co-chairs on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council Scientific Statement Oversight Committee, the Council on Epidemiology and Prevention, and the Manuscript Oversight Committee. The writing group used systematic literature reviews (primarily covering publications from 1990 to May 1, 2010), previously published guidelines, personal files, and expert opinion to summarize existing evidence, indicate gaps in current knowledge, and, when appropriate, formulate recommendations using standard American Heart Association criteria. All members of the writing group had the opportunity to comment on the recommendations and approved the final version of this document. After peer review by the American Heart Association, as well as review by the Stroke Council leadership, Council on Epidemiology and Prevention Council, and Scientific Statements Oversight Committee, the statement was approved by the American Heart Association Science Advisory and Coordinating Committee. RESULTS The construct of VCI has been introduced to capture the entire spectrum of cognitive disorders associated with all forms of cerebral vascular brain injury-not solely stroke-ranging from mild cognitive impairment through fully developed dementia. Dysfunction of the neurovascular unit and mechanisms regulating cerebral blood flow are likely to be important components of the pathophysiological processes underlying VCI. Cerebral amyloid angiopathy is emerging as an important marker of risk for Alzheimer disease, microinfarction, microhemorrhage and macrohemorrhage of the brain, and VCI. The neuropathology of cognitive impairment in later life is often a mixture of Alzheimer disease and microvascular brain damage, which may overlap and synergize to heighten the risk of cognitive impairment. In this regard, magnetic resonance imaging and other neuroimaging techniques play an important role in the definition and detection of VCI and provide evidence that subcortical forms of VCI with white matter hyperintensities and small deep infarcts are common. In many cases, risk markers for VCI are the same as traditional risk factors for stroke. These risks may include but are not limited to atrial fibrillation, hypertension, diabetes mellitus, and hypercholesterolemia. Furthermore, these same vascular risk factors may be risk markers for Alzheimer disease. Carotid intimal-medial thickness and arterial stiffness are emerging as markers of arterial aging and may serve as risk markers for VCI. Currently, no specific treatments for VCI have been approved by the US Food and Drug Administration. However, detection and control of the traditional risk factors for stroke and cardiovascular disease may be effective in the prevention of VCI, even in older people. CONCLUSIONS Vascular contributions to cognitive impairment and dementia are important. Understanding of VCI has evolved substantially in recent years, based on preclinical, neuropathologic, neuroimaging, physiological, and epidemiological studies. Transdisciplinary, translational, and transactional approaches are recommended to further our understanding of this entity and to better characterize its neuropsychological profile. There is a need for prospective, quantitative, clinical-pathological-neuroimaging studies to improve knowledge of the pathological basis of neuroimaging change and the complex interplay between vascular and Alzheimer disease pathologies in the evolution of clinical VCI and Alzheimer disease. Long-term vascular risk marker interventional studies beginning as early as midlife may be required to prevent or postpone the onset of VCI and Alzheimer disease. Studies of intensive reduction of vascular risk factors in high-risk groups are another important avenue of research.
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Messinis L, Malegiannaki AC, Christodoulou T, Panagiotopoulos V, Papathanasopoulos P. Color Trails Test: Normative Data and Criterion Validity for the Greek Adult Population. Arch Clin Neuropsychol 2011; 26:322-30. [DOI: 10.1093/arclin/acr027] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Current World Literature. Curr Opin Neurol 2011; 24:89-93. [DOI: 10.1097/wco.0b013e3283433a91] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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