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Budak M, Bayraktaroglu Z, Hanoglu L. The effects of repetitive transcranial magnetic stimulation and aerobic exercise on cognition, balance and functional brain networks in patients with Alzheimer's disease. Cogn Neurodyn 2023; 17:39-61. [PMID: 36704634 PMCID: PMC9871139 DOI: 10.1007/s11571-022-09818-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 04/20/2022] [Accepted: 05/02/2022] [Indexed: 01/29/2023] Open
Abstract
The purpose of this study was to investigate the effects of high-frequency repetitive Transcranial Magnetic Stimulation (rTMS) and aerobic exercises (AE) in addition to the pharmacological therapy (PT) in Alzheimer's Disease (AD). Twenty-seven patients with AD aged ≥ 60 years were included in the study and divided into 3 groups (rTMS, AE and control). All groups received PT. rTMS group (n = 10) received 20 Hz rTMS over dorsolateral prefrontal cortex (dlPFC) bilaterally and AE group (n = 9) received the structured moderate-intensity AE for 5 consecutive days/week over 2 weeks. Control group (n = 8) only received PT. Cognition, balance, mobility, quality of life (QoL), and resting state functional brain activity were evaluated one week before and one week after the interventions. (ClinicalTrials.gov ID:NCT05102045). Significant improvements were found in executive functions, behavior, and QoL in the rTMS group, in balance and mobility in the AE group, and in the visual memory and behavior in the control group (p < 0.05). Significant differences were found in the behavior in favor of the rTMS group, and balance in favor of the AE group (p < 0.05). There was a significant increase in activation on middle temporal gyrus, intra calcarine, central opercular cortex, superior parietal lobule, and paracingulate cortex in Default Mode Network (DMN) in the rTMS group (p < 0.05). High-frequency rTMS over bilateral dlPFC may improve executive functions and behavior and lead to increased activation in DMN, structured moderate-intensity AE may improve balance and mobility, and PT may improve memory and behaviour compared to pretreatment in AD.
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Affiliation(s)
- Miray Budak
- Functional Imaging and Cognitive-Affective Neuroscience Lab (fINCAN), Research Institute for Health Sciences and Technologies (SABITA), Istanbul Medipol University, Istanbul, Turkey
- Department of Physical Therapy and Rehabilitation, Institute of Health Sciences, Istanbul Medipol University, Istanbul, Turkey
- Department of Ergotherapy, School of Health Sciences, Istanbul Medipol University, Istanbul, Turkey
| | - Zubeyir Bayraktaroglu
- Functional Imaging and Cognitive-Affective Neuroscience Lab (fINCAN), Research Institute for Health Sciences and Technologies (SABITA), Istanbul Medipol University, Istanbul, Turkey
- Department of Physiology, International School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Lutfu Hanoglu
- Functional Imaging and Cognitive-Affective Neuroscience Lab (fINCAN), Research Institute for Health Sciences and Technologies (SABITA), Istanbul Medipol University, Istanbul, Turkey
- Department of Neurology, School of Medicine, Istanbul Medipol University, Istanbul, Turkey
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Sadeghi S, Mohammadian F, Tehrani-Doost M, Gholami K, Mohebbi N. Evaluating the Effects of Rivastigmine on Decision-Making in Patients with Mild Cognitive Impairment by Cambridge Neuropsychological Test Automated Battery (CANTAB); A Randomized, Double-Blind, Placebo-Controlled Trial. IRANIAN JOURNAL OF PHARMACEUTICAL RESEARCH : IJPR 2023; 22:e138943. [PMID: 38444714 PMCID: PMC10912857 DOI: 10.5812/ijpr-138943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 09/04/2023] [Accepted: 09/09/2023] [Indexed: 03/07/2024]
Abstract
Background Decision-making is a complex process, and most studies showed that patients with mild cognitive impairment (MCI) make worse decisions than healthy people. Objectives This study aims to evaluate the effect of rivastigmine on the decision-making of MCI patients using the Cambridge Neuropsychological Test Automated Battery (CANTAB) tests. Methods The study was conducted at the Roozbeh Hospital neurology clinic, and 30 patients with mild cognitive impairment over 40 years old were randomly recruited to receive rivastigmine or placebo twice daily for 12 weeks. The initial dose of rivastigmine or placebo was 1.5 mg twice daily and was increased to 3 mg twice daily per patient compliance. A CANTAB test was conducted before and following the intervention. Results The mean age of patients in the rivastigmine group was 58.93 ± 10.88, and in the placebo group was 59.33 ± 10.34. The median MMSE (Mini-Mental State Examination) was 26 (IQR = 25 - 26) in both groups. Patients in the rivastigmine group showed significant differences in all subgroup tests of CGT, IST, and SST except in risk adjustment in the CGT test, discrimination in the IST test, and median correct RT on the go trial and SSRT in the SST test. The most commonly reported adverse effects were gastrointestinal complications. Conclusions According to the results, rivastigmine significantly improved the primary decision-making outcomes in comparison with placebo.
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Affiliation(s)
- Setayesh Sadeghi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Mohammadian
- Department of Psychiatry, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehdi Tehrani-Doost
- Research Center for Cognitive and Behavioral Sciences, Tehran University of Medial Sciences, Tehran, Iran
| | - Kheirollah Gholami
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
- Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran
| | - Niayesh Mohebbi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
- Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran
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Chaudhary S, Zhornitsky S, Chao HH, van Dyck CH, Li CSR. Emotion Processing Dysfunction in Alzheimer's Disease: An Overview of Behavioral Findings, Systems Neural Correlates, and Underlying Neural Biology. Am J Alzheimers Dis Other Demen 2022; 37:15333175221082834. [PMID: 35357236 PMCID: PMC9212074 DOI: 10.1177/15333175221082834] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
We described behavioral studies to highlight emotional processing deficits in Alzheimer's disease (AD). The findings suggest prominent deficit in recognizing negative emotions, pronounced effect of positive emotion on enhancing memory, and a critical role of cognitive deficits in manifesting emotional processing dysfunction in AD. We reviewed imaging studies to highlight morphometric and functional markers of hippocampal circuit dysfunction in emotional processing deficits. Despite amygdala reactivity to emotional stimuli, hippocampal dysfunction conduces to deficits in emotional memory. Finally, the reviewed studies implicating major neurotransmitter systems in anxiety and depression in AD supported altered cholinergic and noradrenergic signaling in AD emotional disorders. Overall, the studies showed altered emotions early in the course of illness and suggest the need of multimodal imaging for further investigations. Particularly, longitudinal studies with multiple behavioral paradigms translatable between preclinical and clinical models would provide data to elucidate the time course and underlying neurobiology of emotion processing dysfunction in AD.
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Affiliation(s)
- Shefali Chaudhary
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Simon Zhornitsky
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Herta H. Chao
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA,VA Connecticut Healthcare System, West Haven, CT, USA
| | - Christopher H. van Dyck
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA,Department of Neuroscience, Yale University School of Medicine, New Haven, CT, USA,Interdepartmental Neuroscience Program, Yale University School of Medicine, New Haven, CT, USA
| | - Chiang-Shan R. Li
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA,Department of Neuroscience, Yale University School of Medicine, New Haven, CT, USA,Interdepartmental Neuroscience Program, Yale University School of Medicine, New Haven, CT, USA,Wu Tsai Institute, Yale University, New Haven, CT, USA
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Hsieh SW, Chen JC, Chen NC, Jhang KM, Wang W, Yang YH. Real-world Evaluation of Tolerability, Safety and Efficacy of Rivastigmine Oral Solution in Patients with Mild to Moderate Alzheimer's Disease Dementia. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE : THE OFFICIAL SCIENTIFIC JOURNAL OF THE KOREAN COLLEGE OF NEUROPSYCHOPHARMACOLOGY 2021; 19:459-469. [PMID: 34294615 PMCID: PMC8316665 DOI: 10.9758/cpn.2021.19.3.459] [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: 06/30/2020] [Revised: 09/03/2020] [Accepted: 10/16/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study is to investigate the safety, tolerability and efficacy of titrating dose of rivastigmine oral solution in patients with mild to moderate Alzheimer's disease (AD) in Taiwan. METHODS We recruited 108 mild to moderate AD patients with RivastⓇ (rivastigmine oral solution 2 mg/ml) treatment for 52 weeks. We recorded the demographic characteristics, initial cognition by mini-mental state examination (MMSE), initial global status by clinical dementia rating (CDR) with CDR-Sum of Boxes (CDR-SB), initial dose, and titrating dose at each visit. We investigated the adherence, proportion of possible side effects, optimal dose, and time to optimal dose. We demonstrated the proportion of cognitive decline and its possible risk factors. RESULTS During the course, 9 patients discontinued the rivastigmine oral solution due to poor compliance or preference. Twelve out of 99 patients (12.1%) reported possible side effects. Among 87 patients, the mean age was 77.2 ± 9.0 years ago with female predominant (65.2%). The optimal dose was 3.6 ± 1.4 ml in average and 4 ml (n = 31, 35.6%) in mode. The duration to optimal dose was 12.5 ± 10.2 weeks and 24 weeks (n = 35, 40.2%) in mode. It presented 25% with cognitive decline in MMSE, 27% with global function decline in CDR and 63% with global function decline in CDR-SB. CONCLUSION We demonstrated the clinical experience of rivastigmine oral solution in mild to moderate AD patients. It suggested rivastigmine oral solution 4ml is the optimal dose with 24 weeks to the optimal dose for at least one third of patients.
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Affiliation(s)
- Sun-Wung Hsieh
- Department of Neurology, Kaohsiung Municipal Siao-Gang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Neuroscience Research Center, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jui-Cheng Chen
- Department of Neurology, China Medical University Hsinchu Hospital, Taichung, Taiwan
- Department of Neurology, China Medical University Hospital, Taichung, Taiwan
- School of Medicine, China Medical University, Taichung, Taiwan
| | - Nai-Ching Chen
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- Department of Neurology, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Kai-Ming Jhang
- Department of Neurology, Changhua Christian Hospital, Changhua, Taiwan
| | - Wenfu Wang
- Department of Neurology, Changhua Christian Hospital, Changhua, Taiwan
- Department of Holistic Wellness, Ming Dao University, Changhua, Taiwan
| | - Yuan-Han Yang
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Neuroscience Research Center, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Neurology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University Hospital, Taiwan
- Department of and Master’s Program in Neurology, Faculty of Medicine, Kaohsiung Medical University, Taiwan
- Chinese Mentality Protection Association, Kaohsiung, Taiwan
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Abstract
Current treatment paradigm in Alzheimer’s disease (AD) involves multiple approaches combining pharmacological and nonpharmacological intervention to mitigate the clinical symptoms, slow the progressive loss of cognitive and functional abilities, or modify the disease course. So far, beyond anti-cholinesterase inhibitors (AChEIs), donepezil, rivastigmine, galantamine, and antagonist of N-methyl-D-aspartic acid (NMDA) receptor, there are no newly approved medicines to treat AD. Under pharmacological treatment, the personal characteristic and the intra-individual therapeutic evaluations to examine various cognitive domains, behavioral and psychological problems, and global function should be considered when choosing any of AChEIs. The use of optimal dosage referring to the expected clinical outcomes and currently reported deficits from patient with AD has become an important issue in clinical treatment. Establishing and maintaining a strong therapeutic alliance to physician, patient, and caregiver is crucial and central to the comprehensive care in AD.
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Affiliation(s)
- Yuan-Han Yang
- Department of Neurology, Kaohsiung Municipal Ta-Tung Hospital, Taiwan, China
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, China
- Neuroscience Research Center, Kaohsiung Medical University, Kaohsiung City, Taiwan, China
| | - Rajka Liscic
- Department of Neurology, Johannes Kepler University Linz, Austria
| | - Jacqueline Dominguez
- Institute for Neurosciences, St. Luke’s Medical Center, Quezon City, Philippines
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Theleritis CG, Siarkos KT, Politis AM. Unmet Needs in Pharmacological Treatment of Apathy in Alzheimer's Disease: A Systematic Review. Front Pharmacol 2019; 10:1108. [PMID: 31680942 PMCID: PMC6797825 DOI: 10.3389/fphar.2019.01108] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 08/29/2019] [Indexed: 01/15/2023] Open
Abstract
Background: Apathy is one of the most prevalent neuropsychiatric symptoms encountered in Alzheimer’s disease (AD) and may be an early sign in the development of dementia persisting over the disease course. It has been associated with poor disease outcome, impaired daily functioning, and significant caregiver distress. Early diagnosis and timely treatment of apathy in AD are of great importance. However, approved agents for apathy are still missing. Methods: Within this context, we conducted an extensive electronic search in the databases included in the National Library of Medicine, PsychInfo, and Google Scholar for studies that have investigated the effect of pharmacological treatments in apathy in AD. There were no limitations regarding study design and all care settings were considered for inclusion. Structured measures for level of evidence and study quality were employed to evaluate the results. Results: A total of 1,607 records were identified; 1,483 records remained after the removal of duplicates and were screened; 166 full-text articles were selected and assessed for eligibility and a remaining 90 unique studies and relevant reviews were included in the qualitative synthesis. Acetylcholinesterase inhibitors, gingko biloba, and methylphenidate were found to be successful in reducing apathy in patients with AD. Methodological heterogeneity in the studies and the small amount of studies where apathy was the primary outcome are limiting factors to assess for group effects. Conclusions: Pharmacological treatment of apathy in AD is an underexplored field. Standardized and systematic efforts are needed to establish a possible treatment benefit. Elucidating the pathophysiology of apathy and its components or subtypes will inform disease models and mechanistic drug studies that can quantify a benefit from specific agents for specific AD groups.
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Affiliation(s)
- Christos G Theleritis
- Division of Geriatric Psychiatry, First Department of Psychiatry, National and Kapodistrian University of Athens, Athens, Greece
| | - Kostas T Siarkos
- Division of Geriatric Psychiatry, First Department of Psychiatry, National and Kapodistrian University of Athens, Athens, Greece
| | - Antonios M Politis
- Division of Geriatric Psychiatry, First Department of Psychiatry, National and Kapodistrian University of Athens, Athens, Greece.,Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MD, United States
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8
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Avedisova AS, Guekht AB, Zakharova KV, Akzhigitov RG. [The efficacy of pharmacological approaches to therapy of the apathy syndrome in dementia disorders (the review)]. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 118:126-133. [PMID: 29863706 DOI: 10.17116/jnevro201811841126-133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The article presents a literature review of psychopharmacological methods of treatment of the apathy syndrome, which is common in neurocognitive disorders. The review provides recommendations for the management of such patients, taking into account evidence-based medicine.
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Affiliation(s)
- A S Avedisova
- Serbsky Federal Medical Research Centre for Psychiatry and Narcology, Moscow, Russia, Soloviev Scientific and Practical Center of Psychoneurology, Moscow, Russia
| | - A B Guekht
- Serbsky Federal Medical Research Centre for Psychiatry and Narcology, Moscow, Russia, Soloviev Scientific and Practical Center of Psychoneurology, Moscow, Russia
| | - K V Zakharova
- Serbsky Federal Medical Research Centre for Psychiatry and Narcology, Moscow, Russia, Soloviev Scientific and Practical Center of Psychoneurology, Moscow, Russia
| | - R G Akzhigitov
- Serbsky Federal Medical Research Centre for Psychiatry and Narcology, Moscow, Russia, Soloviev Scientific and Practical Center of Psychoneurology, Moscow, Russia
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9
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Theleritis C, Siarkos K, Katirtzoglou E, Politis A. Pharmacological and Nonpharmacological Treatment for Apathy in Alzheimer Disease : A systematic review across modalities. J Geriatr Psychiatry Neurol 2017; 30:26-49. [PMID: 28248559 DOI: 10.1177/0891988716678684] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Apathy is one of the most frequent neuropsychiatric symptoms encountered in Alzheimer disease (AD). Early diagnosis and timely treatment of apathy in AD seem to be of great importance, since apathy has been associated with poor disease outcome, reduced daily functioning, and caregiver distress. DESIGN Within this context, we conducted an extensive electronic search from the databases included in the National Library of Medicine as well as PsychInfo and Google Scholar for studies that have investigated the effect of pharmacological and nonpharmacological treatments of apathy in AD. RESULTS Acetylcholinesterase inhibitors, gingko biloba, methylphenidate, and a variety of nonpharmacological interventions were found to be successful in reducing apathy in patients with AD. Methodological heterogeneity of the studies and the small amount of studies where apathy was a primary outcome measure are limiting factors to evaluate for group effects. CONCLUSION Treatment of apathy in AD is a complicated and an underexplored field. Standardized and systematic efforts primarily focused on the study of apathy in AD may establish a benefit from individualized treatment for specific disease groups that would stem from a combination of both pharmacological and nonpharmacological interventions.
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Affiliation(s)
- Christos Theleritis
- 1 First Department of Psychiatry, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece.,2 Department of Psychosis Studies, Institute of Psychiatry, King's College, London, United Kingdom
| | - Kostas Siarkos
- 1 First Department of Psychiatry, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Everina Katirtzoglou
- 1 First Department of Psychiatry, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Antonios Politis
- 1 First Department of Psychiatry, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece.,3 Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University, Baltimore, MD, USA
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Hvoslef-Eide M, Nilsson SRO, Saksida LM, Bussey TJ. Cognitive Translation Using the Rodent Touchscreen Testing Approach. Curr Top Behav Neurosci 2016; 28:423-447. [PMID: 27305921 DOI: 10.1007/7854_2015_5007] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The development of novel therapeutic avenues for the treatment of cognitive deficits in psychiatric and neurodegenerative disease is of high importance, yet progress in this field has been slow. One reason for this lack of success may lie in discrepancies between how cognitive functions are assessed in experimental animals and humans. In an attempt to bridge this translational gap, the rodent touchscreen testing platform is suggested as a translational tool. Specific examples of successful cross-species translation are discussed focusing on paired associate learning (PAL), the 5-choice serial reaction time task (5-CSRTT), the rodent continuous performance task (rCPT) and reversal learning. With ongoing research assessing the neurocognitive validity of tasks, the touchscreen approach is likely to become increasingly prevalent in translational cognitive research.
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Affiliation(s)
- M Hvoslef-Eide
- Department of Psychology, University of Cambridge, Cambridge, CB2 3EB, UK.
| | - S R O Nilsson
- Department of Psychology, University of Cambridge, Cambridge, CB2 3EB, UK
| | - L M Saksida
- Department of Psychology, University of Cambridge, Cambridge, CB2 3EB, UK
| | - T J Bussey
- Department of Psychology, University of Cambridge, Cambridge, CB2 3EB, UK
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Apathy in Alzheimer's disease: any effective treatment? ScientificWorldJournal 2014; 2014:421385. [PMID: 24672318 PMCID: PMC3929376 DOI: 10.1155/2014/421385] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 11/06/2013] [Indexed: 11/18/2022] Open
Abstract
Objective. This review has evaluated the effectiveness of pharmacological treatment of apathy in patients with Alzheimer's disease (AD). Methods. A systematic literature search was conducted on published clinical trials assessing the effects of pharmacological treatment on apathy in AD over the last 10 years. Results. Fourteen studies considered of good quality were included in the analysis (4 randomized controlled trials, 9 open-label studies, and 1 retrospective analysis). Cholinesterase inhibitors were investigated in 9 studies, monoaminergic compounds such as methylphenidate and modafinil in two trials and one trial, respectively, and Ginkgo biloba (EGb 761 extract) and citalopram in one study each. Cholinesterase inhibitors did not show statistical significant effect in 1 RCT study but were associated to improvement in 3 open-label studies. Methylphenidate elicited a small but significant activity accompanied by relevant side effects such as high blood pressure, cough, and osteoarticular pain. EGb 761 was well tolerated and countered apathy. Other treatments induced modest improvements or were ineffective. Conclusions. Apathy treatment remains a challenge and there is no evident advantage of any specific pharmacotherapy tested so far. The development of controlled studies according to updated guidelines for the diagnosis of apathy in patients with AD is desirable.
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Gauthier S, Robillard A, Cohen S, Black S, Sampalis J, Colizza D, de Takacsy F, Schecter R. Real-life effectiveness and tolerability of the rivastigmine transdermal patch in patients with mild-to-moderate Alzheimer's disease: the EMBRACE study. Curr Med Res Opin 2013; 29:989-1000. [PMID: 23647369 DOI: 10.1185/03007995.2013.802230] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To assess the real-life effectiveness and tolerability of the rivastigmine transdermal patch in patients with mild-to-moderate Alzheimer's disease (AD) in Canada. RESEARCH DESIGN AND METHODS Eighteen-month observational, prospective, multi-center, open-label study conducted on AD patients with Standardized Mini-Mental State Examination (SMMSE) score of 10-26 and Global Deterioration Scale (GDS) score of 4-6. Patients were treated with the rivastigmine transdermal patch (Exelon patch*) 5 cm² (4.6 mg/24 hours) or 10 cm² (9.5 mg/24 hours), once daily. MAIN OUTCOME MEASURES Primary outcome was change in SMMSE from baseline to 18 months. Secondary outcomes included change in SMMSE at 6 and 12 months and change in GDS, Assessment of Patient Ability (APA-C), Overall Patient Assessment Rating (OPAR), caregiver-reported compliance and treatment satisfaction at 6, 12, and 18 months. RESULTS Among the 1204 patients enrolled, 969 were included in the ITT analysis. Mean (SD) age was 80.2 (8.00) years, disease duration was 0.6 (1.26) years, 62.0% of patients were women, 80.4% were living in the community, and 69.3% were treatment naïve. Mean (SD) baseline SMMSE and GDS scores were 21.8 (3.98) and 4.2 (0.61), respectively. Over 18 months of treatment there were no clinically significant changes in SMMSE and GDS. The majority of patients showed improvement or no change in GDS, APA-C and OPAR over 18 months. The proportion with reported improvement in GDS, APA-C and OPAR was higher than the proportion that deteriorated. Compliance improved from baseline to 18 months and for 88.2% of patients caregivers preferred the transdermal patch to oral medications. CONCLUSIONS The rivastigmine transdermal patch is effective in maintaining cognitive function over 18 months of treatment in patients with mild-to-moderate AD. The safety profile was comparable to the data in the Canadian product monograph. Lack of a comparator group is a potential limitation of the study.
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Affiliation(s)
- Serge Gauthier
- McGill Centre for Studies of Aging, Douglas Hospital, Montreal, Quebec, Canada.
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Huang YJ, Lin CH, Lane HY, Tsai GE. NMDA Neurotransmission Dysfunction in Behavioral and Psychological Symptoms of Alzheimer's Disease. Curr Neuropharmacol 2013; 10:272-85. [PMID: 23450042 PMCID: PMC3468881 DOI: 10.2174/157015912803217288] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Revised: 06/04/2012] [Accepted: 07/09/2012] [Indexed: 01/06/2023] Open
Abstract
Dementia has become an all-important disease because the population is aging rapidly and the cost of health care associated with dementia is ever increasing. In addition to cognitive function impairment, associated behavioral and psychological symptoms of dementia (BPSD) worsen patient’s quality of life and increase caregiver’s burden. Alzheimer’s disease is the most common type of dementia and both behavioral disturbance and cognitive impairment of Alzheimer’s disease are thought to be associated with the N-methyl-D-aspartate (NMDA) dysfunction as increasing evidence of dysfunctional glutamatergic neurotransmission had been reported in behavioral changes and cognitive decline in Alzheimer’s disease. We review the literature regarding dementia (especially Alzheimer’s disease), BPSD and relevant findings on glutamatergic and NMDA neurotransmission, including the effects of memantine, a NMDA receptor antagonist, and NMDA-enhancing agents, such as D-serine and D-cycloserine. Literatures suggest that behavioral disturbance and cognitive impairment of Alzheimer’s disease may be associated with excitatory neurotoxic effects which result in impairment of neuronal plasticity and degenerative processes. Memantine shows benefits in improving cognition, function, agitation/aggression and delusion in Alzheimer’s disease. On the other hand, some NMDA modulators which enhance NMDA function through the co-agonist binding site can also improve cognitive function and psychotic symptoms. We propose that modulating NMDA neurotransmission is effective in treating behavioral and psychological symptoms of Alzheimer’s disease. Prospective study using NMDA enhancers in patients with Alzheimer’s disease and associated behavioral disturbance is needed to verify this hypothesis.
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Affiliation(s)
- Yu-Jhen Huang
- Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan ; Department of Psychiatry, China Medical University Hospital, Taichung, Taiwan
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López-Pousa S, Arranz FJ. Characteristics of patients with Alzheimer's disease who switch to rivastigmine transdermal patches in routine clinical practice. Patient Prefer Adherence 2013; 7:47-54. [PMID: 23341737 PMCID: PMC3546803 DOI: 10.2147/ppa.s38719] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The aim of this study was to assess the sociodemographic and clinical characteristics of patients with Alzheimer's disease who switched from any oral cholinesterase inhibitor to rivastigmine patches. METHODS An observational, retrospective, multicenter study was conducted in patients with a diagnosis of Alzheimer's disease who had switched to rivastigmine patches within the previous year in the routine clinical practice of 150 neurologists. Sociodemographic, clinical, and therapeutic data were collected in one office visit. Stepwise logistic regression models were used to find associations. RESULTS Data were obtained from a total of 1022 patients and their caregivers, and showed a mean age of 78.4 ± 6.62 years, 62.61% being women, and mostly having a family caregiver. The switch to rivastigmine patches was mainly instigated on the initiative of the physician (82.39%) or on request of the caregiver (21.23%) or patient (10.37%). Reasons for the switch included improving ease of administration (56.65%), tolerability (36.79%), efficacy (31.60%), and adherence (18.59%). Prior treatment with oral rivastigmine versus donepezil or galantamine increased the probability of switching in order to improve ease of administration (odds ratio, oral rivastigmine versus donepezil 4.20, P < 0.0001; odds ratio, oral rivastigmine versus galantamine 3.55, P < 0.0001). Conversely, previous treatment with donepezil or galantamine produced an approximate four-fold increase in the odds of switching due to lack of efficacy. A higher level of education as well as more concomitant diseases increased the probability of switching because of intolerance. CONCLUSION Improved ease of administration was the main reason for switching to transdermal rivastigmine. Other reasons involved in the decision to switch to rivastigmine patches included sociodemographic and clinical characteristics, including the educational level of patients and caregivers, number of concomitant diseases, and previous treatment for Alzheimer's disease.
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Affiliation(s)
- Secundino López-Pousa
- Unit for Assessment of Memory and Dementia, Institut d’Assistència Sanitària de Girona, Salt, Girona
| | - Francisco Javier Arranz
- CNS Area, Medical Department and Health Innovation, Esteve, Barcelona, Spain
- Correspondence: Francisco Javier Arranz, CNS Area, Medical Department and Health Innovation, Esteve, Avda Mare de Déu de Montserrat 221, E-08041 Barcelona, Spain, Tel +34 93 446 6000, Fax +34 93 446 6251, Email
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Abstract
Apathy in patients with dementia is common, underrecognized, and undertreated. We sought to improve understanding of the pharmacologic treatment of apathy in dementia by performing a systematic literature review of studies that used apathy outcome scales to document results of pharmacologic treatments for apathy. There is limited evidence of efficiency of pharmacotherapy for treatment of apathy in dementia. The best results were found for acetylcholinesterase inhibitors. There was some evidence of efficacy for memantine, but less evidence of efficacy for stimulants, calcium antagonists, and antipsychotics. There was no evidence to support the use of antidepressants or anticonvulsants. The research quality of studies was modest. Recommendations for standardizing research and for holistic evaluation and treatment are provided.
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Santos GAAD, Canineu PR, Gonçalves ID, Pardi PC. Influence of Rivastigmine transdermal on butyrylcholinesterase levels in patients with Alzheimer's disease. Dement Neuropsychol 2011; 5:332-336. [PMID: 29213761 PMCID: PMC5619047 DOI: 10.1590/s1980-57642011dn05040012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Cholinesterase inhibitors (ChE-Is) are among the main drugs approved for the
treatment of Alzheimer's disease (AD). Rivastigmine in the form of a transdermal
patch is an alternative delivery method, and can give greater treatment
compliance.
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Khachiyants N, Trinkle D, Son SJ, Kim KY. Sundown syndrome in persons with dementia: an update. Psychiatry Investig 2011; 8:275-87. [PMID: 22216036 PMCID: PMC3246134 DOI: 10.4306/pi.2011.8.4.275] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2010] [Revised: 03/29/2011] [Accepted: 04/12/2011] [Indexed: 01/27/2023] Open
Abstract
"Sundowning" in demented individuals, as distinct clinical phenomena, is still open to debate in terms of clear definition, etiology, operationalized parameters, validity of clinical construct, and interventions. In general, sundown syndrome is characterized by the emergence or increment of neuropsychiatric symptoms such as agitation, confusion, anxiety, and aggressiveness in late afternoon, in the evening, or at night. Sundowning is highly prevalent among individuals with dementia. It is thought to be associated with impaired circadian rhythmicity, environmental and social factors, and impaired cognition. Neurophysiologically, it appears to be mediated by degeneration of the suprachiasmatic nucleus of the hypothalamus and decreased production of melatonin. A variety of treatment options have been found to be helpful to ameliorate the neuropsychiatric symptoms associated with this phenomenon: bright light therapy, melatonin, acetylcholinesterase inhibitors, N-methyl-d-aspartate receptor antagonists, antipsychotics, and behavioral modifications. To decrease the morbidity from this specific condition, improve patient's well being, lessen caregiver burden, and delay institutionalization, further attention needs to be given to development of clinically operational definition of sundown syndrome and investigations on etiology, risk factors, and effective treatment options.
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Affiliation(s)
- Nina Khachiyants
- Carilion-Virginia Tech School of Medicine Geriatric Psychiatry Fellowship Program Roanoke, VA, USA
| | - David Trinkle
- Carilion Clinic, Roanoke, VA, USA
- Department of Psychiatry and Behavioral Sciences Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - Sang Joon Son
- Gwangju Community Mental Health Center, Gwangju, Korea
- Department of Psychiatry, College of Medicine, Yonsei University, Seoul, Korea
| | - Kye Y. Kim
- Department of Psychiatry and Behavioral Sciences Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
- Salem Veterans Affairs Medical Center, Salem, VA, USA
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18
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Abstract
The treatment of moderate to severe Alzheimer's disease is reviewed with regard to mechanisms of action, pharmacokinetics, metabolism, safety/tolerability, and efficacy in reducing cognitive, behavioral/psychiatric, functional and global symptoms. The cholinesterase inhibitors donepezil, rivastigmine and galantamine and the N-methyl-d-aspartate receptor channel blocker memantine are moderately beneficial. Small improvements over a few months are followed by slowed mental decline. Concerning cognitive, functional and global functions, these drugs are similarly effective. Cholinesterase inhibitors also reduce apathy, memantine counteracts agitation and aggression. Serious adverse effects are rare with all four drugs. Cholinesterase inhibitors bear a risk for patients with cardiac diseases. Adverse emetic events are typical for oral formulations of these drugs, but less for rivastigmine transdermal patches. Other routes of administration and use of a galantamine prodrug are currently investigated. The superiority of combination therapies over monotherapies requires further support. Promising investigational drugs include the copper/zinc ionophore PBT2 and multifunctional hybrid molecules.
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Affiliation(s)
- Rüdiger Hardeland
- Johann Friedrich Blumenbach Institute of Zoology and Anthropology, University of Göttingen, Berliner Str. 28, D-37073 Göttingen, Germany
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19
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Apathy in Neuropsychiatric Disease: Diagnosis, Pathophysiology, and Treatment. Neurotox Res 2010; 19:266-78. [DOI: 10.1007/s12640-010-9196-9] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2009] [Revised: 04/28/2010] [Accepted: 04/28/2010] [Indexed: 10/19/2022]
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Gauthier S, Juby A, Dalziel W, Réhel B, Schecter R. Effects of rivastigmine on common symptomatology of Alzheimer's disease (EXPLORE). Curr Med Res Opin 2010; 26:1149-60. [PMID: 20230208 DOI: 10.1185/03007991003688888] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate, in a real-world clinical setting, the efficacy of rivastigmine in the management of six symptoms commonly associated with Alzheimer's disease (AD). METHODS This was a naturalistic, prospective, open-label, multi-centre, post-marketing, observational study. Data were collected by the participating study physicians at their practices across Canada. Subjects had a clinical diagnosis of mild-to-moderate AD and were prescribed rivastigmine by their treating physician. Efficacy was primarily evaluated by a physician-assessed, abbreviated Clinical Global Impression of Change (CGI-C) scale, focusing on six symptoms: attention, apathy, anxiety, agitation, irritability and sleep disturbance. Changes were assessed at months 3, 6 and 12. Several other patient-, physician- and caregiver-related assessments were also included. RESULTS A total of 4460 patients were recruited by 353 study physicians; 3800 were deemed evaluable, having taken at least one dose of rivastigmine and with at least one post-baseline assessment. At baseline, attention problems were present in 86.0% of evaluable patients, anxiety in 77.3%, apathy in 68.3%, irritability in 64.0%, agitation in 54.6% and sleep disturbance in 54.5%. At both month 6 and month 12, for each symptom, the percentage of patients experiencing an improvement was considerably larger than the percentage of patients who experienced symptom worsening. Among evaluable patients, the proportions improving vs. deteriorating at month 6 were 46.4 vs. 8.8% for attention; 42.8 vs. 7.2% for apathy; 41.1 vs. 9.4% for anxiety; 33.8 vs. 7.7% for agitation; 35.1 vs. 10.1% for irritability; and 30.8 vs. 5.4% for sleep disturbance. LIMITATIONS Open-label studies have an inherent potential for bias by both the caregiver and the physician. CONCLUSIONS This study demonstrates that a considerable proportion of rivastigmine-treated patients experience improvements on each of the six symptoms studied. These findings add further support to previous randomised, clinical studies showing benefit of rivastigmine in AD.
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Affiliation(s)
- Serge Gauthier
- McGill Centre for Studies of Aging, Montreal, Quebec, Canada.
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21
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Smith DA. Treatment of Alzheimer’s disease in the long-term-care setting. Am J Health Syst Pharm 2009; 66:899-907. [DOI: 10.2146/ajhp070622] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- David A. Smith
- David A. Smith, M.D., FAAFP, CMD, is Professor, Family Medicine, College of Medicine, Texas A&M University, College Station; and President, Geriatric Consultants of Central Texas, 901 North Fisk, #224, Brownwood, TX 76801
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