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Carpi M, Palagini L, Fernandes M, Calvello C, Geoffroy PA, Miniati M, Pini S, Gemignani A, Mercuri NB, Liguori C. Clinical usefulness of dual orexin receptor antagonism beyond insomnia: Neurological and psychiatric comorbidities. Neuropharmacology 2024; 245:109815. [PMID: 38114045 DOI: 10.1016/j.neuropharm.2023.109815] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 12/11/2023] [Accepted: 12/12/2023] [Indexed: 12/21/2023]
Abstract
Orexin is a neurotransmitter produced by a small group of hypothalamic neurons. Besides its well-known role in the regulation of the sleep-wake cycle, the orexin system was shown to be relevant in several physiological functions including cognition, mood and emotion modulation, and energy homeostasis. Indeed, the implication of orexin neurotransmission in neurological and psychiatric diseases has been hypothesized via a direct effect exerted by the projections of orexin neurons to several brain areas, and via an indirect effect through orexin-mediated modulation of sleep and wake. Along with the growing evidence concerning the use of dual orexin receptor antagonists (DORAs) in the treatment of insomnia, studies assessing their efficacy in insomnia comorbid with psychiatric and neurological diseases have been set in order to investigate the potential impact of DORAs on both sleep-related symptoms and disease-specific manifestations. This narrative review aimed at summarizing the current evidence on the use of DORAs in neurological and psychiatric conditions comorbid with insomnia, also discussing the possible implication of modulating the orexin system for improving the burden of symptoms and the pathological mechanisms of these disorders. Target searches were performed on PubMed/MEDLINE and Scopus databases and ongoing studies registered on Clinicaltrials.gov were reviewed. Despite some contradictory findings, preclinical studies seemingly support the possible beneficial role of orexin antagonism in the management of the most common neurological and psychiatric diseases with sleep-related comorbidities. However, clinical research is still limited and further studies are needed for corroborating these promising preliminary results.
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Affiliation(s)
- Matteo Carpi
- Sleep and Epilepsy Centre, Neurology Unit, University Hospital Tor Vergata, Rome, Italy.
| | - Laura Palagini
- Department of Clinical and Experimental Medicine, Unit of Psychiatry, Azienda Ospedaliero Universitaria Pisana AUOP, Pisa, Italy.
| | - Mariana Fernandes
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy.
| | - Carmen Calvello
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy.
| | - Pierre Alexis Geoffroy
- Département de Psychiatrie et D'addictologie, AP-HP, GHU Paris Nord, DMU Neurosciences, Hopital Bichat - Claude Bernard, F-75018, Paris, France; GHU Paris - Psychiatry & Neurosciences, Paris, France; Université de Paris, NeuroDiderot, Inserm, FHU I2-D2, F-75019, Paris, France.
| | - Mario Miniati
- Department of Clinical and Experimental Medicine, Unit of Psychiatry, Azienda Ospedaliero Universitaria Pisana AUOP, Pisa, Italy.
| | - Stefano Pini
- Department of Clinical and Experimental Medicine, Unit of Psychiatry, Azienda Ospedaliero Universitaria Pisana AUOP, Pisa, Italy.
| | - Angelo Gemignani
- Unit of Psychology, Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Azienda Ospedaliero Universitaria Pisana AUOP, Pisa, Italy.
| | | | - Claudio Liguori
- Sleep and Epilepsy Centre, Neurology Unit, University Hospital Tor Vergata, Rome, Italy; Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy.
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Pless A, Ware D, Saggu S, Rehman H, Morgan J, Wang Q. Understanding neuropsychiatric symptoms in Alzheimer's disease: challenges and advances in diagnosis and treatment. Front Neurosci 2023; 17:1263771. [PMID: 37732300 PMCID: PMC10508352 DOI: 10.3389/fnins.2023.1263771] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 08/21/2023] [Indexed: 09/22/2023] Open
Abstract
Neuropsychiatric symptoms (NPS) in Alzheimer's disease (AD) affect up to 97% of AD patients, with an estimated 80% of current AD patients experiencing these symptoms. Common AD-associated NPS include depression, anxiety, agitation, aggression, and apathy. The severity of NPS in AD is typically linked to the disease's progression and the extent of cognitive decline. Additionally, these symptoms are responsible for a significant increase in morbidity, mortality, caregiver burden, earlier nursing home placement, and greater healthcare expenditure. Despite their high prevalence and significant impact, there is a notable lack of clinical research on NPS in AD. In this article, we explore and analyze the prevalence, symptom manifestations, challenges in diagnosis, and treatment options of NPS associated with AD. Our literature review reveals that distinguishing and accurately diagnosing the NPS associated with AD remains a challenging task in clinical settings. It is often difficult to discern whether NPS are secondary to pathophysiological changes from AD or are comorbid psychiatric conditions. Furthermore, the availability of effective pharmaceutical interventions, as well as non-pharmacotherapies for NPS in AD, remains limited. By highlighting the advance and challenges in diagnosis and treatment of AD-associated NPS, we aspire to offer new insights into the complexity of identifying and treating these symptoms within the context of AD, and contribute to a deeper understanding of the multifaceted nature of NPS in AD.
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Affiliation(s)
- Andrew Pless
- Department of Neuroscience and Regenerative Medicine, Medical College of Georgia at Augusta University, Augusta, GA, United States
| | - Destany Ware
- Department of Neuroscience and Regenerative Medicine, Medical College of Georgia at Augusta University, Augusta, GA, United States
| | - Shalini Saggu
- Department of Neuroscience and Regenerative Medicine, Medical College of Georgia at Augusta University, Augusta, GA, United States
| | - Hasibur Rehman
- Department of Neuroscience and Regenerative Medicine, Medical College of Georgia at Augusta University, Augusta, GA, United States
| | - John Morgan
- Department of Neurology, Medical College of Georgia at Augusta University, Augusta, GA, United States
| | - Qin Wang
- Department of Neuroscience and Regenerative Medicine, Medical College of Georgia at Augusta University, Augusta, GA, United States
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Owen NE, Barker RA, Voysey ZJ. Sleep Dysfunction in Huntington's Disease: Impacts of Current Medications and Prospects for Treatment. J Huntingtons Dis 2023; 12:149-161. [PMID: 37248911 PMCID: PMC10473096 DOI: 10.3233/jhd-230567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2023] [Indexed: 05/31/2023]
Abstract
Sleep dysfunction is highly prevalent in Huntington's disease (HD). Increasing evidence suggests that such dysfunction not only impairs quality of life and exacerbates symptoms but may even accelerate the underlying disease process. Despite this, current HD treatment approaches neither consider the impact of commonly used medications on sleep, nor directly tackle sleep dysfunction. In this review, we discuss approaches to these two areas, evaluating not only literature from clinical studies in HD, but also that from parallel neurodegenerative conditions and preclinical models of HD. We conclude by summarizing a hierarchical framework of current medications with regard to their impact on sleep, and by outlining key emerging sleep therapies.
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Affiliation(s)
- Natalia E. Owen
- Department of Clinical Neurosciences, John van Geest Centre for Brain Repair, University of Cambridge, Cambridge, UK
| | - Roger A. Barker
- Department of Clinical Neurosciences, John van Geest Centre for Brain Repair, University of Cambridge, Cambridge, UK
- Wellcome Trust-MRC Cambridge Stem Cell Institute, University of Cambridge, Cambridge, UK
| | - Zanna J. Voysey
- Department of Clinical Neurosciences, John van Geest Centre for Brain Repair, University of Cambridge, Cambridge, UK
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4
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Ghalayini J, Boulianne GL. Deciphering mechanisms of action of ACE inhibitors in neurodegeneration using Drosophila models of Alzheimer's disease. Front Neurosci 2023; 17:1166973. [PMID: 37113150 PMCID: PMC10126366 DOI: 10.3389/fnins.2023.1166973] [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: 02/15/2023] [Accepted: 03/17/2023] [Indexed: 04/29/2023] Open
Abstract
Alzheimer's disease (AD) is a devastating neurodegenerative disorder for which there is no cure. Recently, several studies have reported a significant reduction in the incidence and progression of dementia among some patients receiving antihypertensive medications such as angiotensin-converting enzyme inhibitors (ACE-Is) and angiotensin receptor blockers (ARBs). Why these drugs are beneficial in some AD patients and not others is unclear although it has been shown to be independent of their role in regulating blood pressure. Given the enormous and immediate potential of ACE-Is and ARBs for AD therapeutics it is imperative that we understand how they function. Recently, studies have shown that ACE-Is and ARBs, which target the renin angiotensin system in mammals, are also effective in suppressing neuronal cell death and memory defects in Drosophila models of AD despite the fact that this pathway is not conserved in flies. This suggests that the beneficial effects of these drugs may be mediated by distinct and as yet, identified mechanisms. Here, we discuss how the short lifespan and ease of genetic manipulations available in Drosophila provide us with a unique and unparalleled opportunity to rapidly identify the targets of ACE-Is and ARBs and evaluate their therapeutic effectiveness in robust models of AD.
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Affiliation(s)
- Judy Ghalayini
- Program in Developmental and Stem Cell Biology, Peter Gilgin Center for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Molecular Genetics, University of Toronto, Toronto, ON, Canada
| | - Gabrielle L. Boulianne
- Program in Developmental and Stem Cell Biology, Peter Gilgin Center for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Molecular Genetics, University of Toronto, Toronto, ON, Canada
- *Correspondence: Gabrielle L. Boulianne,
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Ansart M, Epelbaum S, Houot M, Nedelec T, Lekens B, Gantzer L, Dormont D, Durrleman S. Changes in the use of psychotropic drugs during the course of Alzheimer's disease: A large-scale longitudinal study of French medical records. ALZHEIMER'S & DEMENTIA (NEW YORK, N. Y.) 2021; 7:e12210. [PMID: 34541292 PMCID: PMC8439142 DOI: 10.1002/trc2.12210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 04/30/2021] [Accepted: 07/28/2021] [Indexed: 11/23/2022]
Abstract
INTRODUCTION We aim to understand how patients with Alzheimer's disease (AD) are treated by identifying in a longitudinal fashion the late-life changes in patients' medical history that precede and follow AD diagnosis. METHODS We use prescription history of 34,782 patients followed between 1996 and 2019 by French general practitioners. We compare patients with an AD diagnosis, patients with mild cognitive impairment (MCI), and patients free of mental disorders. We use a generalized mixed-effects model to study the longitudinal changes in the prescription of eight drug types for a period 15 years before diagnosis and 10 years after. RESULTS In the decades preceding diagnosis, we find that future AD patients are treated significantly more than MCI patients with most psychotropic drugs and that most studied drugs are increasingly prescribed with age. At the time of diagnosis, all psychotropic drugs except benzodiazepines show a significant increase in prescription, while other drugs are significantly less prescribed. In the 10 years after diagnosis, nearly all categories of drugs are less and less prescribed including antidementia drugs. DISCUSSION Pre-diagnosis differences between future AD patients and MCI patients may indicate that subtle cognitive changes are recognized and treated as psychiatric symptoms. The disclosure of AD diagnosis drastically changes patients' care, priority being given to the management of psychiatric symptoms. The decrease of all prescriptions in the late stages may reflect treatment discontinuation and simplification of therapeutic procedures. This study therefore provides new insights into the medical practices for management of AD.
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Affiliation(s)
- Manon Ansart
- Sorbonne UniversitésUPMC Univ Paris 06InsermCNRSInstitut du cerveau et la moelle épinière (ICM) ‐ Hôpital de la Pitié‐SalpêtrièreParisFrance
- Inria ParisAramis project‐teamParisFrance
| | - Stéphane Epelbaum
- Sorbonne UniversitésUPMC Univ Paris 06InsermCNRSInstitut du cerveau et la moelle épinière (ICM) ‐ Hôpital de la Pitié‐SalpêtrièreParisFrance
- Inria ParisAramis project‐teamParisFrance
- Department of NeurologyAP‐HPHôpital de la Pitié‐SalpêtrièreInstitut de la Mémoire et de la Maladie d'Alzheimer (IM2A)Reference Center for Rare or Early Dementias and Center of Excellence of Neurodegenerative Disease (CoEN)ParisFrance
| | - Marion Houot
- Sorbonne UniversitésUPMC Univ Paris 06InsermCNRSInstitut du cerveau et la moelle épinière (ICM) ‐ Hôpital de la Pitié‐SalpêtrièreParisFrance
- Sorbonne UniversityAlzheimer Precision Medicine (APM)AP‐HPHôpital de la Pitié‐SalpêtrièreParisFrance
| | - Thomas Nedelec
- Sorbonne UniversitésUPMC Univ Paris 06InsermCNRSInstitut du cerveau et la moelle épinière (ICM) ‐ Hôpital de la Pitié‐SalpêtrièreParisFrance
- Inria ParisAramis project‐teamParisFrance
| | | | | | - Didier Dormont
- Sorbonne UniversitésUPMC Univ Paris 06InsermCNRSInstitut du cerveau et la moelle épinière (ICM) ‐ Hôpital de la Pitié‐SalpêtrièreParisFrance
- Inria ParisAramis project‐teamParisFrance
- Department of NeuroradiologyAP‐HPHôpital de la Pitié‐SalpêtrièreParisFrance
| | - Stanley Durrleman
- Sorbonne UniversitésUPMC Univ Paris 06InsermCNRSInstitut du cerveau et la moelle épinière (ICM) ‐ Hôpital de la Pitié‐SalpêtrièreParisFrance
- Inria ParisAramis project‐teamParisFrance
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Voysey ZJ, Barker RA, Lazar AS. The Treatment of Sleep Dysfunction in Neurodegenerative Disorders. Neurotherapeutics 2021; 18:202-216. [PMID: 33179197 PMCID: PMC8116411 DOI: 10.1007/s13311-020-00959-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2020] [Indexed: 12/13/2022] Open
Abstract
Sleep dysfunction is highly prevalent across the spectrum of neurodegenerative conditions and is a key determinant of quality of life for both patients and their families. Mounting recent evidence also suggests that such dysfunction exacerbates cognitive and affective clinical features of neurodegeneration, as well as disease progression through acceleration of pathogenic processes. Effective assessment and treatment of sleep dysfunction in neurodegeneration is therefore of paramount importance; yet robust therapeutic guidelines are lacking, owing in part to a historical paucity of effective treatments and trials. Here, we review the common sleep abnormalities evident in neurodegenerative disease states and evaluate the latest evidence for traditional and emerging interventions, both pharmacological and nonpharmacological. Interventions considered include conservative measures, targeted treatments of specific clinical sleep pathologies, established sedating and alerting agents, melatonin, and orexin antagonists, as well as bright light therapy, behavioral measures, and slow-wave sleep augmentation techniques. We conclude by providing a suggested framework for treatment based on contemporary evidence and highlight areas that may emerge as major therapeutic advances in the near future.
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Affiliation(s)
- Zanna J Voysey
- Department of Clinical Neurosciences, John van Geest Centre for Brain Repair, University of Cambridge, Cambridge, CB2 0PY, UK
| | - Roger A Barker
- Department of Clinical Neurosciences, John van Geest Centre for Brain Repair and WT-MRC Cambridge Stem Cell Institute, University of Cambridge, Cambridge, CB2 0PY, UK
| | - Alpar S Lazar
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, NR4 7TJ, UK.
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Oh ES, Rosenberg PB, Rattinger GB, Stuart EA, Lyketsos CG, Leoutsakos JMS. Psychotropic Medication and Cognitive, Functional, and Neuropsychiatric Outcomes in Alzheimer's Disease (AD). J Am Geriatr Soc 2020; 69:955-963. [PMID: 33382921 DOI: 10.1111/jgs.16970] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 11/05/2020] [Accepted: 11/06/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND/OBJECTIVES There are growing concerns about the safety and efficacy of psychotropic medications in Alzheimer's disease (AD). We sought to examine associations between psychotropic medication exposure and longitudinal change in cognitive, functional, and neuropsychiatric outcomes in a large clinical AD cohort. DESIGN Longitudinal observational study. SETTING National Alzheimer's Disease Coordinating Center combining data from 39 Alzheimer's disease centers. PARTICIPANTS 8,034 participants with AD dementia. MEASUREMENTS Mini-Mental State Exam (MMSE), Clinical Dementia Rating Scale-Sum of Boxes (CDR-SB), and Neuropsychiatric Inventory Questionnaire (NPI-Q) Total. Probability of exposure to medication (the propensity score, PS) calculated via logistic regression. Medication classes included all antipsychotics (atypical vs conventional), antidepressants (Selective Serotonin Reuptake Inhibitor [SSRI] vs non-SSRI), and benzodiazepines. Participants treated with a medication class were matched with participants not treated with that class with the closest-matched PS. The effect of medication treatment was assessed using linear mixed-effects models. RESULTS Participants had a mean (SD) age of 75.5 (9.8) years, and mean (SD) scores of MMSE 21.3 (5.7), CDR-SB 5.5 (3.4), and NPI-Q Total 4.5 (4.4). Mean duration of follow-up was 2.9-3.3 years depending on medication class. Non-SSRI antidepressant use was associated with better CDR-SB (2-year difference in change-DIC: -0.38 [-0.61, -0.15], P = .001). Atypical antipsychotic use was associated with greater decline on MMSE (DIC: -0.91 [-1.54, -0.28] P = .005) and CDR-SB scores (DIC: 0.50 [0.14, 0.86], P = .006). Notably, no drug class was associated with better NPI-Q scores. CONCLUSIONS Use of atypical antipsychotics was associated with poorer cognition and function, and no drug class was associated with improvement in neuropsychiatric symptoms.
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Affiliation(s)
- Esther S Oh
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
| | - Paul B Rosenberg
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Gail B Rattinger
- Binghamton University School of Pharmacy and Pharmaceutical Sciences, Binghamton, New York, USA
| | - Elizabeth A Stuart
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Constantine G Lyketsos
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jeannie-Marie S Leoutsakos
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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8
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Voysey Z, Fazal SV, Lazar AS, Barker RA. The sleep and circadian problems of Huntington's disease: when, why and their importance. J Neurol 2020; 268:2275-2283. [PMID: 33355880 PMCID: PMC8179890 DOI: 10.1007/s00415-020-10334-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 11/15/2020] [Accepted: 11/19/2020] [Indexed: 11/30/2022]
Abstract
Introduction Mounting evidence supports the existence of an important feedforward cycle between sleep and neurodegeneration, wherein neurodegenerative diseases cause sleep and circadian abnormalities, which in turn exacerbate and accelerate neurodegeneration. If so, sleep therapies bear important potential to slow progression in these diseases. Findings This cycle is challenging to study, as its bidirectional nature renders cause difficult to disentangle from effect. Likewise, well-controlled intervention studies are often impractical in the setting of established neurodegenerative disease. It is this that makes understanding sleep and circadian abnormalities in Huntington’s disease (HD) important: as a monogenic fully penetrant neurodegenerative condition presenting in midlife, it provides a rare opportunity to study sleep and circadian abnormalities longitudinally, prior to and throughout disease manifestation, and in the absence of confounds rendered by age and comorbidities. It also provides potential to trial sleep therapies at a preclinical or early disease stage. Moreover, its monogenic nature facilitates the development of transgenic animal models through which to run parallel pre-clinical studies. HD, therefore, provides a key model condition through which to gain new insights into the sleep-neurodegeneration interface. Conclusions Here, we begin by summarising contemporary knowledge of sleep abnormalities in HD, and consider how well these parallel those of Alzheimer’s and Parkinson’s as more common neurodegenerative conditions. We then discuss what is currently known of the sleep-neurodegeneration cyclical relationship in HD. We conclude by outlining key directions of current and future investigation by which to advance the sleep-neurodegeneration field via studies in HD.
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Affiliation(s)
- Z Voysey
- Department of Clinical Neurosciences, John Van Geest Centre for Brain Repair, University of Cambridge, Cambridge, UK.
| | - S V Fazal
- Department of Clinical Neurosciences, John Van Geest Centre for Brain Repair, University of Cambridge, Cambridge, UK
| | - A S Lazar
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - R A Barker
- Department of Clinical Neurosciences, John Van Geest Centre for Brain Repair, WT-MRC Cambridge Stem Cell Institute, University of Cambridge, Cambridge, UK
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Moloney ME, Oh GY, Moga DC. Determinants of Sleep Medication Use among Participants in the National Alzheimer's Coordinating Center Uniform Data Set. J Appl Gerontol 2020; 39:1340-1349. [PMID: 31747852 PMCID: PMC7237298 DOI: 10.1177/0733464819888447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Sufficient sleep is critical for health in older adults, but prescription sleep aids are associated with numerous health risks (e.g., cognitive impairment and falls). We examine usage prevalence of two medication categories-sedative hypnotics (SH) and medications commonly used for insomnia (MCUFI)-among adults aged 45+ in the National Alzheimer's Coordinating Center data set. Analyzing the visits conducted between September 2005 and June 2018, we determine the factors associated with SH and MCUFI use, including sociodemographic, health, independence, and cognitive statuses. Usage rates were 9% for MCUFI (N = 3,279) and 4% for SH (N = 1,382). Multivariable logistic regression identified White race, higher education, younger age, depression, and sedative polypharmacy as factors associated with prescription sleep aid use. We conclude that sleep medication usage rates among older adults, higher likelihood of sedative medication polypharmacy, and higher likelihood of MCUFI use among adults with cognitive impairment are findings of concern and may warrant clinical intervention.
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Affiliation(s)
- Mairead Eastin Moloney
- Department of Sociology, College of Arts and Sciences, University of Kentucky, Lexington, KY
| | - GYeon Oh
- Department of Epidemiology, College of Public Health, University of Kentucky, Lexington, KY
| | - Daniela C. Moga
- Department of Pharmacy Practice and Science, College of Pharmacy Department of Epidemiology, College of Public Health, Sanders-Brown Center on Aging, University of Kentucky, Lexington, KY
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Möllers T, Perna L, Stocker H, Ihle P, Schubert I, Schöttker B, Frölich L, Brenner H. New use of psychotropic medication after hospitalization among people with dementia. Int J Geriatr Psychiatry 2020; 35:640-649. [PMID: 32100308 DOI: 10.1002/gps.5282] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 01/14/2020] [Accepted: 02/13/2020] [Indexed: 01/24/2023]
Abstract
OBJECTIVES Psychotropic medication is commonly used among people with dementia (PWD), but it shows modest efficacy and it has been associated with severe adverse events. Hospitalizations are an opportunity for medication management as well as treatment recommendations for outpatient physicians. The aim of this study was to asses factors associated with new use of psychotropic medication after hospitalization among PWD. METHODS We conducted a retrospective dynamic cohort study from 2004 to 2015 using claims data from a German health insurance company. PWD were identified by an algorithm that included ICD-10 diagnosis and diagnostic measures. The medication classes included were antidepressants, antipsychotics, anxiolytics or hypnotics/sedatives, and Alzheimer's medication. The assessment period was up to 30 days after discharge from the hospital across four hospitalizations. RESULTS The main predictors for new use of psychotropic medication were similar across medication classes. Neuropsychiatric symptoms (NPS) and the need of care were associated with higher odds of new use of antidepressants, antipsychotics, and anxiolytics or hypnotics/sedatives. A hospital stay due to dementia was an independent predictor for new use across medication classes as well. Delirium increased the odds for new use of antipsychotics and anxiolytics or hypnotics/sedatives. CONCLUSIONS Factors associated with new use of psychotropic medication included delirium, NPS, and the need of care in PWD. The findings highlight the need for preventive interventions and non-medical treatment options in regards to delirium and NPS as well as for a more intensive use of screening tools for inappropriate medication use among PWD. Key points The percentage of new users was 1.8%, 7.1%, 2.1%, and 2.5% across hospitalizations for antidepressants, antipsychotics, anxiolytics or hypnotics/sedatives, and Alzheimer's medication, respectively. 83.0%, 61.9%, 56.9%, and 88.1% of new users received antidepressants, antipsychotics, anxiolytics or hypnotics/sedatives, and Alzheimer's medication for more than 6 weeks. Delirium and neuropsychiatric symptoms were associated with significantly increased odds of new psychotropic medication use. Hospital stays due to dementia and the need of care were predictors for new use of psychotropic medication.
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Affiliation(s)
- Tobias Möllers
- Network Aging Research, Heidelberg University, Heidelberg, Germany.,Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany.,Medical Faculty, Heidelberg University, Heidelberg, Germany
| | - Laura Perna
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany.,Department of Translational Research in Psychiatry, Max Planck Institute for Psychiatry, Munich, Germany
| | - Hannah Stocker
- Network Aging Research, Heidelberg University, Heidelberg, Germany.,Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany.,Medical Faculty, Heidelberg University, Heidelberg, Germany
| | - Peter Ihle
- PMV Research Group, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Ingrid Schubert
- PMV Research Group, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Ben Schöttker
- Network Aging Research, Heidelberg University, Heidelberg, Germany.,Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany
| | - Lutz Frölich
- Department of Gerontopsychiatry, Central Institute of Mental Health, Heidelberg University, Mannheim, Germany
| | - Hermann Brenner
- Network Aging Research, Heidelberg University, Heidelberg, Germany.,Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany
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Wright JW, Harding JW. Contributions by the Brain Renin-Angiotensin System to Memory, Cognition, and Alzheimer's Disease. J Alzheimers Dis 2020; 67:469-480. [PMID: 30664507 DOI: 10.3233/jad-181035] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Alzheimer's disease (AD) is a neurodegenerative disease characterized by progressive neuron losses in memory-associated brain structures that rob patients of their dignity and quality of life. Five drugs have been approved by the FDA to treat AD but none modify or significantly slow disease progression. New therapies are needed to delay the course of this disease with the ultimate goal of preventing neuron losses and preserving memory functioning. In this review we describe the renin-angiotensin II (AngII) system (RAS) with specific regard to its deleterious contributions to hypertension, facilitation of neuroinflammation and oxidative stress, reduced cerebral blood flow, tissue remodeling, and disruption of memory consolidation and retrieval. There is evidence that components of the RAS, AngIV and Ang(1-7), are positioned to counter such damaging influences and these systems are detailed with the goal of drawing attention to their importance as drug development targets. Ang(1-7) binds at the Mas receptor, while AngIV binds at the AT4 receptor subtype, and these receptor numbers are significantly decreased in AD patients, accompanied by declines in brain aminopeptidases A and N, enzymes essential for the synthesis of AngIV. Potent analogs may be useful to counter these changes and facilitate neuronal functioning and reduce apoptosis in memory associated brain structures of AD patients.
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Affiliation(s)
- John W Wright
- Department of Psychology, Washington State University, Pullman, WA, USA.,Department of Integrative Physiology and Neuroscience, and Program in Biotechnology, Washington State University, Pullman, WA, USA.,M3 Biotechnology, Inc., Seattle, WA, USA
| | - Joseph W Harding
- Department of Psychology, Washington State University, Pullman, WA, USA.,Department of Integrative Physiology and Neuroscience, and Program in Biotechnology, Washington State University, Pullman, WA, USA.,M3 Biotechnology, Inc., Seattle, WA, USA
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12
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Herring WJ, Ceesay P, Snyder E, Bliwise D, Budd K, Hutzelmann J, Stevens J, Lines C, Michelson D. Polysomnographic assessment of suvorexant in patients with probable Alzheimer's disease dementia and insomnia: a randomized trial. Alzheimers Dement 2020; 16:541-551. [PMID: 31944580 PMCID: PMC7984350 DOI: 10.1002/alz.12035] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 10/08/2019] [Accepted: 01/04/2019] [Indexed: 02/06/2023]
Abstract
Introduction We evaluated the clinical profile of the orexin receptor antagonist suvorexant for treating insomnia in patients with mild‐to‐moderate probable Alzheimer's disease (AD) dementia. Methods Randomized, double‐blind, 4‐week trial of suvorexant 10 mg (could be increased to 20 mg based on clinical response) or placebo in patients who met clinical diagnostic criteria for both probable AD dementia and insomnia. Sleep was assessed by overnight polysomnography in a sleep laboratory. The primary endpoint was change‐from‐baseline in polysomnography‐derived total sleep time (TST) at week 4. Results Of 285 participants randomized (suvorexant, N = 142; placebo, N = 143), 277 (97%) completed the trial (suvorexant, N = 136; placebo, N = 141). At week 4, the model‐based least squares mean improvement‐from‐baseline in TST was 73 minutes for suvorexant and 45 minutes for placebo; (difference = 28 minutes [95% confidence interval 11‐45], p < 0.01). Somnolence was reported in 4.2% of suvorexant‐treated patients and 1.4% of placebo‐treated patients. Discussion Suvorexant improved TST in patients with probable AD dementia and insomnia.
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Affiliation(s)
| | | | | | - Donald Bliwise
- Sleep Center, Emory University School of Medicine, Atlanta, Georgia
| | - Kerry Budd
- Merck & Co., Inc., Kenilworth, New Jersey
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Ettcheto M, Olloquequi J, Sánchez-López E, Busquets O, Cano A, Manzine PR, Beas-Zarate C, Castro-Torres RD, García ML, Bulló M, Auladell C, Folch J, Camins A. Benzodiazepines and Related Drugs as a Risk Factor in Alzheimer's Disease Dementia. Front Aging Neurosci 2020; 11:344. [PMID: 31969812 PMCID: PMC6960222 DOI: 10.3389/fnagi.2019.00344] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 11/26/2019] [Indexed: 12/21/2022] Open
Abstract
Benzodiazepines (BZDs) and Z-drugs are compounds widely prescribed in medical practice due to their anxiolytic, hypnotic, and muscle relaxant properties. Yet, their chronic use is associated with cases of abuse, dependence, and relapse in many patients. Furthermore, elderly people are susceptible to alterations in pharmacodynamics, pharmacokinetics as well as to drug interaction due to polypharmacy. These situations increase the risk for the appearance of cognitive affectations and the development of pathologies like Alzheimer's disease (AD). In the present work, there is a summary of some clinical studies that have evaluated the effect of BZDs and Z-drugs in the adult population with and without AD, focusing on the relationship between their use and the loss of cognitive function. Additionally, there is an assessment of preclinical studies focused on finding molecular proof on the pathways by which these drugs could be involved in AD pathogenesis. Moreover, available data (1990-2019) on BZD and Z-drug use among elderly patients, with and without AD, was compiled in this work. Finally, the relationship between the use of BZD and Z-drugs for the treatment of insomnia and the appearance of AD biomarkers was analyzed. Results pointed to a vicious circle that would worsen the condition of patients over time. Likewise, it put into relevance the need for close monitoring of those patients using BZDs that also suffer from AD. Consequently, future studies should focus on optimizing strategies for insomnia treatment in the elderly by using other substances like melatonin agonists, which is described to have a much more significant safety profile.
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Affiliation(s)
- Miren Ettcheto
- Departament de Farmacologia, Toxicologia i Química Terapèutica, Facultat de Farmàcia i Ciències de l'Alimentació, Universitat de Barcelona, Barcelona, Spain
- Departament de Bioquímica i Biotecnologia, Facultat de Medicina i Ciències de la Salut, Universitat Rovira i Virgili, Reus, Spain
- Institut de Neurociències, Universitat de Barcelona, Barcelona, Spain
- Biomedical Research Networking Centre in Neurodegenerative Diseases (CIBERNED), Madrid, Spain
| | - Jordi Olloquequi
- Laboratory of Cellular and Molecular Pathology, Facultad de Ciencias de la Salud, Instituto de Ciencias Biomédicas, Universidad Autónoma de Chile, Talca, Chile
| | - Elena Sánchez-López
- Biomedical Research Networking Centre in Neurodegenerative Diseases (CIBERNED), Madrid, Spain
- Unitat de Farmàcia, Tecnologia Farmacèutica i Fisico-química, Facultat de Farmàcia i Ciències de l'Alimentació, Universitat de Barcelona, Barcelona, Spain
- Institute of Nanoscience and Nanotechnology (IN2UB), Universitat de Barcelona, Barcelona, Spain
| | - Oriol Busquets
- Departament de Farmacologia, Toxicologia i Química Terapèutica, Facultat de Farmàcia i Ciències de l'Alimentació, Universitat de Barcelona, Barcelona, Spain
- Departament de Bioquímica i Biotecnologia, Facultat de Medicina i Ciències de la Salut, Universitat Rovira i Virgili, Reus, Spain
- Institut de Neurociències, Universitat de Barcelona, Barcelona, Spain
- Biomedical Research Networking Centre in Neurodegenerative Diseases (CIBERNED), Madrid, Spain
| | - Amanda Cano
- Biomedical Research Networking Centre in Neurodegenerative Diseases (CIBERNED), Madrid, Spain
- Unitat de Farmàcia, Tecnologia Farmacèutica i Fisico-química, Facultat de Farmàcia i Ciències de l'Alimentació, Universitat de Barcelona, Barcelona, Spain
- Institute of Nanoscience and Nanotechnology (IN2UB), Universitat de Barcelona, Barcelona, Spain
| | | | - Carlos Beas-Zarate
- Laboratorio de Regeneración y Desarrollo Neural, Departamento de Biología Celular y Molecular, Instituto de Neurobiología, CUCBA, Guadalajara, Mexico
| | - Rubén D. Castro-Torres
- Laboratorio de Regeneración y Desarrollo Neural, Departamento de Biología Celular y Molecular, Instituto de Neurobiología, CUCBA, Guadalajara, Mexico
| | - Maria Luisa García
- Biomedical Research Networking Centre in Neurodegenerative Diseases (CIBERNED), Madrid, Spain
- Unitat de Farmàcia, Tecnologia Farmacèutica i Fisico-química, Facultat de Farmàcia i Ciències de l'Alimentació, Universitat de Barcelona, Barcelona, Spain
- Institute of Nanoscience and Nanotechnology (IN2UB), Universitat de Barcelona, Barcelona, Spain
| | - Mónica Bulló
- Departament de Bioquímica i Biotecnologia, Facultat de Medicina i Ciències de la Salut, Universitat Rovira i Virgili, Reus, Spain
- Institut d'Investigació Sanitària Pere Virgili (IISPV), Reus, Spain
- Centro de Investigación Biomédica en Red Fisiopatologia de la Obesidad y la Nutrición (CIBEROBN), Institut de Salud Carlos III, Madrid, Spain
| | - Carme Auladell
- Institut de Neurociències, Universitat de Barcelona, Barcelona, Spain
- Biomedical Research Networking Centre in Neurodegenerative Diseases (CIBERNED), Madrid, Spain
- Departament de Biologia Cellular, Fisiologia i Immunologia, Facultat de Biologia, Universitat de Barcelona, Barcelona, Spain
| | - Jaume Folch
- Departament de Bioquímica i Biotecnologia, Facultat de Medicina i Ciències de la Salut, Universitat Rovira i Virgili, Reus, Spain
- Biomedical Research Networking Centre in Neurodegenerative Diseases (CIBERNED), Madrid, Spain
| | - Antonio Camins
- Departament de Farmacologia, Toxicologia i Química Terapèutica, Facultat de Farmàcia i Ciències de l'Alimentació, Universitat de Barcelona, Barcelona, Spain
- Institut de Neurociències, Universitat de Barcelona, Barcelona, Spain
- Biomedical Research Networking Centre in Neurodegenerative Diseases (CIBERNED), Madrid, Spain
- Laboratory of Cellular and Molecular Pathology, Facultad de Ciencias de la Salud, Instituto de Ciencias Biomédicas, Universidad Autónoma de Chile, Talca, Chile
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Sepassi A, Watanabe JH. Emergency Department Visits for Psychotropic-Related Adverse Drug Events in Older Adults With Alzheimer Disease, 2013-2014. Ann Pharmacother 2019; 53:1173-1183. [PMID: 31342766 DOI: 10.1177/1060028019866927] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: More than 1.3 million emergency department visits have been associated with adverse drug events (ADEs) in older adults. Increasing Alzheimer's disease (AD) prevalence in the geriatric population poses an additive risk of ADEs because of the array of psychotropic medications prescribed for AD patients. Scant research has been conducted at a nationwide level on psychotropic-related ADEs in this population. Objective: This study aimed to determine the incidence and economic burden of psychotropic ADEs in the geriatric AD population compared with the non-AD geriatric population. Methods: A retrospective analysis was conducted of geriatric AD patients who visited the ED in 2013 with a psychotropic-related ADE to determine the incidence and resource utilization of these events. The relationship between presence of AD and an ADE was analyzed using multiple logistic regression. Results: There were 427 969 Alzheimer's ED visits compared with 20 492 554 ED visits without. Of the AD cases, 1.04% were associated with at least 1 adverse event. AD cases more frequently were admitted as inpatients (64.90% vs 34.92%, P < 0.01). Common drug classes associated with AD-related ADEs were benzodiazepines, antipsychotics, and autonomic nervous system-affecting agents (adrenergic agonists, antimuscarinic agents, anticholinergic agents). There was a significantly higher likelihood for Alzheimer's cases to experience any psychotropic-related adverse event (OR = 1.66; 95% CI = 1.20, 1.82). Conclusion and Relevance: Alzheimer's patients more frequently experienced psychotropic-related adverse events and related adverse outcomes than older adults without Alzheimer's. Application of these findings should be implemented in protocol development to reduce future psychotropic-related adverse outcomes for this population.
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Kehoe PG. The Coming of Age of the Angiotensin Hypothesis in Alzheimer's Disease: Progress Toward Disease Prevention and Treatment? J Alzheimers Dis 2019; 62:1443-1466. [PMID: 29562545 PMCID: PMC5870007 DOI: 10.3233/jad-171119] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
There is wide recognition of a complex association between midlife hypertension and cardiovascular disease and later development of Alzheimer’s disease (AD) and cognitive impairment. While significant progress has been made in reducing rates of mortality and morbidity due to cardiovascular disease over the last thirty years, progress towards effective treatments for AD has been slower. Despite the known association between hypertension and dementia, research into each disease has largely been undertaken in parallel and independently. Yet over the last decade and a half, the emergence of converging findings from pre-clinical and clinical research has shown how the renin angiotensin system (RAS), which is very important in blood pressure regulation and cardiovascular disease, warrants careful consideration in the pathogenesis of AD. Numerous components of the RAS have now been found to be altered in AD such that the multifunctional and potent vasoconstrictor angiotensin II, and similarly acting angiotensin III, are greatly altered at the expense of other RAS signaling peptides considered to contribute to neuronal and cognitive function. Collectively these changes may contribute to many of the neuropathological hallmarks of AD, as well as observed progressive deficiencies in cognitive function, while also linking elements of a number of the proposed hypotheses for the cause of AD. This review discusses the emergence of the RAS and its likely importance in AD, not only because of the multiple facets of its involvement, but also perhaps fortuitously because of the ready availability of numerous RAS-acting drugs, that could be repurposed as interventions in AD.
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Affiliation(s)
- Patrick Gavin Kehoe
- Dementia Research Group, Translational Health Sciences, Bristol Medical School, University of Bristol, Southmead Hospital, Bristol, UK
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16
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Gebre AK, Altaye BM, Atey TM, Tuem KB, Berhe DF. Targeting Renin-Angiotensin System Against Alzheimer's Disease. Front Pharmacol 2018; 9:440. [PMID: 29760662 PMCID: PMC5937164 DOI: 10.3389/fphar.2018.00440] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 04/13/2018] [Indexed: 01/01/2023] Open
Abstract
Renin Angiotensin System (RAS) is a hormonal system that regulates blood pressure and fluid balance through a coordinated action of renal, cardiovascular, and central nervous systems. In addition to its hemodynamic regulatory role, RAS involves in many brain activities, including memory acquisition and consolidation. This review has summarized the involvement of RAS in the pathology of Alzheimer’s disease (AD), and the outcomes of treatment with RAS inhibitors. We have discussed the effect of brain RAS in the amyloid plaque (Aβ) deposition, oxidative stress, neuroinflammation, and vascular pathology which are directly and indirectly associated with AD. Angiotensin II (AngII) via AT1 receptor is reported to increase brain Aβ level via different mechanisms including increasing amyloid precursor protein (APP) mRNA, β-secretase activity, and presenilin expression. Similarly, it was associated with tau phosphorylation, and reactive oxygen species generation. However, these effects are counterbalanced by Ang II mediated AT2 signaling. The protective effect observed with angiotensin receptor blockers (ARBs) and angiotensin converting enzyme inhibitors (ACEIs) could be as the result of inhibition of Ang II signaling. ARBs also offer additional benefit by shifting the effect of Ang II toward AT2 receptor. To conclude, targeting RAS in the brain may benefit patients with AD though it still requires further in depth understanding.
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Affiliation(s)
- Abadi Kahsu Gebre
- Department of Pharmacology and Toxicology, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Birhanetensay Masresha Altaye
- Department of Pharmacology and Toxicology, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Tesfay Mehari Atey
- Clinical Pharmacy Unit, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Kald Beshir Tuem
- Department of Pharmacology and Toxicology, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Derbew Fikadu Berhe
- Department of Pharmacology and Toxicology, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
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Saarelainen L, Tolppanen AM, Koponen M, Tanskanen A, Tiihonen J, Hartikainen S, Taipale H. Risk of death associated with new benzodiazepine use among persons with Alzheimer disease: A matched cohort study. Int J Geriatr Psychiatry 2018; 33:583-590. [PMID: 29143367 DOI: 10.1002/gps.4821] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 09/27/2017] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To investigate the risk of death associated with new benzodiazepine and related drug (BZDR) use in a nationwide cohort of persons with Alzheimer disease (AD). METHODS The register-based MEDALZ cohort, including all community-dwelling Finns diagnosed with AD during 2005 to 2011 (n = 70 718), was used. Clinically verified AD diagnoses were obtained from the Special Reimbursement Register. Drug use periods were modeled from BZDR purchases, derived from the Prescription Register. To study new users, persons who had any BZDR use during the year preceding the AD diagnosis were excluded. For each person initiating BZDR use (n = 10 380), 2 nonusers (n = 20 760) were matched on age, gender, and time since AD diagnosis. The outcome was 180-day mortality, and BZDR use was compared with nonuse with Cox regression. Multivariable analyses were adjusted for Charlson comorbidity index, socioeconomic position, hip fractures, psychiatric disorders, substance abuse, stroke, and other psychotropic drug use. RESULTS During the follow-up, 5 excess deaths per 100 person-years occurred during BZDR use in comparison to nonuse, and mortality rates were 13.4 (95% confidence interval [CI], 12.2-14.5) and 8.5 (95% CI, 7.9-9.1), respectively. Benzodiazepine and related drug use was associated with an increased risk of death (adjusted hazard ratio = 1.4 [95% CI, 1.2-1.6]), and the association was significant from the initiation of use. Benzodiazepine use was associated with an increased risk of death, whereas benzodiazepine-related drug use was not. CONCLUSIONS Benzodiazepine and related drug use was associated with an increased risk of death in persons with AD. Our results support treatment guidelines stating that nonpharmacological approaches should be the first-line option for symptomatic treatment of AD.
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Affiliation(s)
- Laura Saarelainen
- Kuopio Research Centre for Geriatric Care, University of Eastern Finland, Kuopio, Finland.,School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Anna-Maija Tolppanen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland.,Research Centre for Comparative Effectiveness and Patient Safety, University of Eastern Finland, Kuopio, Finland
| | - Marjaana Koponen
- Kuopio Research Centre for Geriatric Care, University of Eastern Finland, Kuopio, Finland.,School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Antti Tanskanen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Impact Assessment Unit, National Institute for Health and Welfare, Helsinki, Finland.,Department of Forensic Psychiatry, Niuvanniemi Hospital, Kuopio, Finland
| | - Jari Tiihonen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Forensic Psychiatry, Niuvanniemi Hospital, Kuopio, Finland.,Stockholm County Council, Stockholm, Sweden
| | - Sirpa Hartikainen
- Kuopio Research Centre for Geriatric Care, University of Eastern Finland, Kuopio, Finland.,School of Pharmacy, University of Eastern Finland, Kuopio, Finland.,Department of Psychiatry, Kuopio University Hospital, Kuopio, Finland
| | - Heidi Taipale
- Kuopio Research Centre for Geriatric Care, University of Eastern Finland, Kuopio, Finland.,School of Pharmacy, University of Eastern Finland, Kuopio, Finland.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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18
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Use of psychotropic medications in relation to neuropsychiatric symptoms, cognition and functional performance in Alzheimer's disease over a three-year period: Kuopio ALSOVA study. Int Psychogeriatr 2017. [PMID: 28625207 DOI: 10.1017/s1041610217001090] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Psychotropic medications are widely prescribed to manage neuropsychiatric symptoms (NPS) of Alzheimer's disease (AD). Our objective was to investigate the longitudinal associations between psychotropic medication use and NPS, cognition, and functional performance in persons with very mild or mild AD at baseline. METHODS Data were collected as part of the prospective three-year study of home-dwelling persons with AD and their caregivers (n = 236 dyads). The associations between psychotropic medication use and clinical measures were analyzed using repeated measures Generalized Estimating Equation (GEE) models. NPS, cognition, daily functioning, and disease severity were assessed with NPI, CERAD-NB, or MMSE, ADCS-ADL, and CDR-SOB, respectively. All analyses were adjusted for age, gender, education, and co-morbidities. RESULTS The prevalence of benzodiazepines and related medications increased from 16% to 24% (p = 0.031), antidepressants from 11% to 18% (p = 0.057), and antipsychotics from 4% to 16% (p = 0.011) in the three years following AD diagnosis. In adjusted multivariable analyses, a one-point increase in NPI increased the odds of using any psychotropic medication class by 4% (odds ratio (OR) 1.04, 95% confidence interval (CI) 1.01-1.07). ADCS-ADL (1/OR 1.04, 95% CI 1.02-1.06) and CDR-SOB (OR 1.27, 95% CI 1.13-1.42) were associated with use of antipsychotics. CERAD-NB and MMSE were not associated with any psychotropic medication class use in the models. CONCLUSIONS Psychotropic medication use increased significantly in relation to increasing dependency in AD, especially with NPS. Furthermore, the use of antipsychotics increased with disease severity, and with decline in daily functioning. Cognitive performance was not associated with psychotropic medication use.
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Breining A, Bonnet-Zamponi D, Zerah L, Micheneau C, Riolacci-Dhoyen N, Chan-Chee C, Deligne J, Harlin JM, Boddaert J, Verny M, Leperre-Desplanques A. Exposure to psychotropics in the French older population living with dementia: a nationwide population-based study. Int J Geriatr Psychiatry 2017; 32:750-760. [PMID: 27237864 DOI: 10.1002/gps.4517] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 02/24/2016] [Accepted: 05/05/2016] [Indexed: 11/08/2022]
Abstract
BACKGROUND Little is known about the level of psychotropic chronic exposure in all patients living with dementia. The aim of the study was to quantify chronic psychotropic exposure in older adults with dementia compared with the general population of the same age. METHODS This prospective cohort study was conducted in France between 2009 and 2011. Aged at least 65 years, 10,781,812 individuals (440,215 of them with dementia) either community based or nursing home residents were included. The numbers of single or combined prescriptions, per year for antipsychotics, antidepressants, anxiolytics, or hypnotics were measured. RESULTS Of patients with dementia, 15.5% are exposed to antipsychotics compared with 2.2% of the age-matched population (relative risk [RR] = 6.44, 95% confidence interval [CI] [6.39-6.48]), 39.5% to antidepressants compared with 12.6% (RR = 4.10, 95% CI [.4.07-4.12]), and 39.6% to anxiolytics or hypnotics compared with 26.9% (RR = 1.74, 95% CI [1.72-1.75]). Among older adults with dementia, 13.8% simultaneously consumed at least three psychotropics. All class age of older patients with dementia is more exposed to all psychotropics except for long-acting benzodiazepines. During the study period, chronic anxiolytic/hypnotic and antipsychotic exposure slightly decreased in population with dementia while chronic exposure to antidepressant drugs tended to increase. CONCLUSION This nationwide, population-based, drug-used study showed for the first time that older patients with dementia are chronically overexposed not only to antipsychotics but also to psychotropics.
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Affiliation(s)
- Alice Breining
- APHP, DHU FAST, Groupe Hospitalier Pitié Salpêtrière - Charles Foix, Centre de Gériatrie, Paris, France
| | - Dominique Bonnet-Zamponi
- OMEDIT Ile de France, Paris, France.,Université Paris Diderot, Sorbonne Paris Cité, UMR 1123 INSERM, Paris, France
| | - Lorène Zerah
- APHP, DHU FAST, Groupe Hospitalier Pitié Salpêtrière - Charles Foix, Centre de Gériatrie, Paris, France.,Sorbonne Universités, UPMC Univ Paris 06 and CNRS, UMR 8256 B2A, Paris, France
| | | | | | | | - Jean Deligne
- Régime Social des Indépendants, Saint Denis la Plaine, France
| | - Jean-Marc Harlin
- Caisse Centrale de la Mutualité Sociale Agricole, Bagnolet, France
| | - Jacques Boddaert
- APHP, DHU FAST, Groupe Hospitalier Pitié Salpêtrière - Charles Foix, Centre de Gériatrie, Paris, France.,Sorbonne Universités, UPMC Univ Paris 06 and CNRS, UMR 8256 B2A, Paris, France
| | - Marc Verny
- APHP, DHU FAST, Groupe Hospitalier Pitié Salpêtrière - Charles Foix, Centre de Gériatrie, Paris, France.,Sorbonne Universités, UPMC Univ Paris 06 and CNRS, UMR 8256 B2A, Paris, France
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20
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Saarelainen L, Taipale H, Koponen M, Tanskanen A, Tolppanen AM, Tiihonen J, Hartikainen S. The Incidence of Benzodiazepine and Related Drug Use in Persons with and without Alzheimer's Disease. J Alzheimers Dis 2016; 49:809-18. [PMID: 26484930 DOI: 10.3233/jad-150630] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Benzodiazepines and related drugs (BZDR) are occasionally used to treat certain symptoms of Alzheimer's disease (AD). However, the risks related to BZDR use are high in older persons. Although frequent BZDR use has been reported in persons with AD, no previous study has focused specifically on the incidence of BZDR use in this population. OBJECTIVE We investigated the incidence of BZDR use in persons with and without AD during a five-year follow-up. METHODS The Finnish nationwide, register-based MEDALZ cohort includes all AD cases who received a clinically verified AD diagnosis in 2005-2011 (n = 70,718) and their matched comparison persons. Incidence of BZDR, including benzodiazepines (lorazepam, oxazepam, temazepam, alprazolam, chlordiazepoxide, diazepam, and nitrazepam) and Z-drugs (zolpidem and zopiclone), use was investigated in the cohort from two years before to three years after the diagnosis of AD. Further, initial BZDRs were investigated. RESULTS The incidence of BZDR use was higher in persons with AD starting from 12 months before the diagnosis and peaked at six months after the diagnosis of AD (incidence rate ratio [IRR] = 2.6, 95% confidence interval [CI] = 2.5-2.8). Benzodiazepines were more frequently initiated by persons with AD, with the incidence peaking at six months after the diagnosis (IRR = 4.5, 95% CI = 4.1-4.9) and remaining over three times higher than in comparison persons until three years after the diagnosis. CONCLUSION Early symptomatic treatment with BZDRs is contrary to AD treatment guidelines. As BZDRs impair cognition, the observed early treatment with BZDRs may complicate the monitoring of AD treatment effectiveness.
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Affiliation(s)
- Laura Saarelainen
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland.,School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Heidi Taipale
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland.,School of Pharmacy, University of Eastern Finland, Kuopio, Finland.,Research Centre for Comparative Effectiveness and Patient Safety, University of Eastern Finland, Kuopio, Finland
| | - Marjaana Koponen
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland.,School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Antti Tanskanen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Impact Assessment Unit, National Institute for Health and Welfare, Helsinki, Finland.,Department of Forensic Psychiatry, Niuvanniemi Hospital, Kuopio, Finland
| | - Anna-Maija Tolppanen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland.,Research Centre for Comparative Effectiveness and Patient Safety, University of Eastern Finland, Kuopio, Finland
| | - Jari Tiihonen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Forensic Psychiatry, Niuvanniemi Hospital, Kuopio, Finland
| | - Sirpa Hartikainen
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland.,School of Pharmacy, University of Eastern Finland, Kuopio, Finland
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Alanen HM, Pitkänen A, Suontaka-Jamalainen K, Kampman O, Leinonen E. Acute Psychogeriatric Inpatient Treatment Improves Neuropsychiatric Symptoms but Impairs the Level of Functioning in Patients with Dementia. Dement Geriatr Cogn Disord 2016; 40:290-6. [PMID: 26334962 DOI: 10.1159/000431087] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/30/2015] [Indexed: 11/19/2022] Open
Abstract
AIMS To explore the impact of hospitalization on neuropsychiatric symptoms (NPS) and the level of functioning in patients with dementia. Our aim was also to study the influence of psychotropic medications. METHODS Behavioral disturbances, cognition and functional status of 89 patients were assessed using the Neuropsychiatric Inventory (NPI), Mini-Mental State Examination, Barthel Index, and Alzheimer's Disease Cooperative Study-Activities of Daily Living (ADCSADL). RESULTS The total NPI score decreased from 34.6 to 19.5 (p < 0.001), and ADL decreased from 32.2 to 21.7 (p < 0.001) during the hospital stay (mean of 44 days). For a change in ADL, only the effect of anxiolytics was significant (p = 0.045). For a change in NPI with antipsychotic and anxiolytic doses and Mini-Mental State Examination as covariates, no significant relationship was found. CONCLUSION NPS improved significantly during hospitalization, but neither antipsychotic nor anxiolytic medication use explained this improvement. In patients using anxiolytics, the functional decline was substantial. These results do not support anxiolytic use in demented patients with NPS.
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Affiliation(s)
- Hanna-Mari Alanen
- Neuropsychiatry and Geriatric Psychiatry, Tampere University Hospital, Tampere, Finland
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Libertini G, Ferrara N. Aging of perennial cells and organ parts according to the programmed aging paradigm. AGE (DORDRECHT, NETHERLANDS) 2016; 38:35. [PMID: 26957493 PMCID: PMC5005898 DOI: 10.1007/s11357-016-9895-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Accepted: 02/22/2016] [Indexed: 06/05/2023]
Abstract
If aging is a physiological phenomenon-as maintained by the programmed aging paradigm-it must be caused by specific genetically determined and regulated mechanisms, which must be confirmed by evidence. Within the programmed aging paradigm, a complete proposal starts from the observation that cells, tissues, and organs show continuous turnover: As telomere shortening determines both limits to cell replication and a progressive impairment of cellular functions, a progressive decline in age-related fitness decline (i.e., aging) is a clear consequence. Against this hypothesis, a critic might argue that there are cells (most types of neurons) and organ parts (crystalline core and tooth enamel) that have no turnover and are subject to wear or manifest alterations similar to those of cells with turnover. In this review, it is shown how cell types without turnover appear to be strictly dependent on cells subjected to turnover. The loss or weakening of the functions fulfilled by these cells with turnover, due to telomere shortening and turnover slowing, compromises the vitality of the served cells without turnover. This determines well-known clinical manifestations, which in their early forms are described as distinct diseases (e.g., Alzheimer's disease, Parkinson's disease, age-related macular degeneration, etc.). Moreover, for the two organ parts (crystalline core and tooth enamel) without viable cells or any cell turnover, it is discussed how this is entirely compatible with the programmed aging paradigm.
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Affiliation(s)
- Giacinto Libertini
- Department of Translational Medical Sciences, Federico II University, Naples, Italy.
| | - Nicola Ferrara
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
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Magierski R, Sobow T. Serotonergic drugs for the treatment of neuropsychiatric symptoms in dementia. Expert Rev Neurother 2016; 16:375-87. [PMID: 26886148 DOI: 10.1586/14737175.2016.1155453] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Behavioral and psychological symptoms of dementia (known also as neuropsychiatric symptoms) are essential features of Alzheimer's disease and related dementias. The near universal presence of neuropsychiatric symptoms in dementia (up to 90% of cases) has brought significant attention of clinicians and experts to the field. Non-pharmacological and pharmacological interventions are recommended for various types of neuropsychiatric symptoms. However, most pharmacological interventions for the treatment of behavioral and psychological symptoms of dementia are used off-label in many countries. Cognitive decline and neuropsychiatric symptoms can be linked to alterations in multiple neurotransmitter systems, so modification of abnormalities in specific systems may improve clinical status of patients with neuropsychiatric symptoms. Use of serotonergic compounds (novel particles acting on specific receptors and widely acting drugs) in the treatment of neuropsychiatric symptoms is reviewed.
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Affiliation(s)
- Radoslaw Magierski
- a Department of Old Age Psychiatry and Psychotic Disorders , Medical University of Lodz , Lodz , Poland
| | - Tomasz Sobow
- b Department of Medical Psychology , Medical University of Lodz , Lodz , Poland
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24
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Xiao H, Tang GX, Wu R. Site-Specific Quantification of Surface N-Glycoproteins in Statin-Treated Liver Cells. Anal Chem 2016; 88:3324-32. [PMID: 26894747 DOI: 10.1021/acs.analchem.5b04871] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The frequent modification of cell-surface proteins by N-linked glycans is known to be correlated with many biological processes. Aberrant glycosylation on surface proteins is associated with different cellular statuses and disease progression. However, it is extraordinarily challenging to comprehensively and site-specifically analyze glycoproteins located only on the cell surface. Currently mass spectrometry (MS)-based proteomics provides the possibility to analyze the N-glycoproteome, but effective separation and enrichment methods are required for the analysis of surface glycoproteins prior to MS measurement. The introduction of bio-orthogonal groups into proteins accelerates research in the robust visualization, identification, and quantification of proteins. Here we have comprehensively evaluated different sugar analogs in the analysis of cell-surface N-glycoproteins by combining copper-free click chemistry and MS-based proteomics. Comparison of three sugar analogs, N-azidoacetylgalactosamine (GalNAz), N-azidoacetylglucosamine (GlcNAz), and N-azidoacetylmannosamine (ManNAz), showed that metabolic labeling with GalNAz resulted in the greatest number of glycoproteins and glycosylation sites in biological duplicate experiments. GalNAz was then employed for the quantification experiment in statin-treated HepG2 liver cells, and 280 unique N-glycosylated sites were quantified from 168 surface proteins. The quantification results demonstrated that many glycosylation sites on surface proteins were down-regulated in statin-treated cells compared to untreated cells because statin prevents the synthesis of dolichol, which is essential for the formation of dolichol-linked precursor oligosaccharides. Several glycosylation sites in proteins that participate in the Alzheimer's disease pathway were down-regulated. This method can be extensively applied for the global analysis of the cell-surface N-glycoproteome.
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Affiliation(s)
- Haopeng Xiao
- School of Chemistry and Biochemistry and the Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology , Atlanta, Georgia 30332, United States
| | - George X Tang
- School of Chemistry and Biochemistry and the Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology , Atlanta, Georgia 30332, United States
| | - Ronghu Wu
- School of Chemistry and Biochemistry and the Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology , Atlanta, Georgia 30332, United States
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Dziedzic T, Pera J, Klimkowicz-Mrowiec A, Mroczko B, Slowik A. Biochemical and Radiological Markers of Alzheimer's Disease Progression. J Alzheimers Dis 2016; 50:623-44. [PMID: 26757184 DOI: 10.3233/ifs-150578] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Alzheimer's disease (AD) is a neurodegenerative, inevitably progressive disease with a rate of cognitive, functional, and behavioral decline that varies highly from patient to patient. Although several clinical predictors of AD progression have been identified, to our mind in clinical practice there is a lack of a reliable biomarker that enables one to stratify the risk of deterioration. Identification of biomarkers that allow the monitoring of AD progression could change the way physicians and caregivers make treatment decisions. This review summarizes the results of studies on potential biochemical and radiological markers related to AD progression.
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Affiliation(s)
- Tomasz Dziedzic
- Department of Neurology, Jagiellonian University, Krakow, Poland
| | - Joanna Pera
- Department of Neurology, Jagiellonian University, Krakow, Poland
| | | | - Barbara Mroczko
- Department of Neurodegeneration Diagnostics, Medical University of Białystok, Poland.,Department of Biochemical Diagnostics, University Hospital, Białystok, Poland
| | - Agnieszka Slowik
- Department of Neurology, Jagiellonian University, Krakow, Poland
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Abstract
Ischemic heart disease remains the leading cause of death in the USA. Statins have substantially contributed to the decline in mortality due to heart disease. Historically, statins are hypothesized to be neuroprotective and beneficial in dementia, but recent reports have suggested an association with transient cognitive decline. We have critically appraised the relationship between statins and cognitive function in this review. Most of the data are observational and reported a protective effect of statins on dementia and Alzheimer's disease in patients with normal cognition at baseline. Few studies, including two randomized control trials, were unable to find a statistically significant decrease in the risk or improvement in patients with established dementia or decline in cognitive function with statin use. As more randomized control trials are required to definitively settle this, cardiovascular benefits of statins must be weighed against the risks of cognitive decline on an individual basis.
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Defrancesco M, Marksteiner J, Fleischhacker WW, Blasko I. Use of Benzodiazepines in Alzheimer's Disease: A Systematic Review of Literature. Int J Neuropsychopharmacol 2015; 18:pyv055. [PMID: 25991652 PMCID: PMC4648159 DOI: 10.1093/ijnp/pyv055] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 05/12/2015] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Benzodiazepines are frequently prescribed in patients with Alzheimer's disease. Unfortunately, studies evaluating their benefits and risks in these patients are limited. METHODS Clinical trials focusing on the effect of benzodiazepines on cognitive functions, disease progression, behavioral symptoms, sleep disturbances, and the general frequency of benzodiazepine use were included in this review. Published articles from January 1983 to January 2015 were identified using specific search terms in MEDLINE and PubMed Library according to the recommendations of The Strengthening the Reporting of Observational Studies in Epidemiology initiative. RESULTS Of the 657 articles found, 18 articles met predefined selection criteria and were included in this review (8 on frequency, 5 on cognitive functions, 5 on behavioral and sleep disturbances). The frequency of benzodiazepine use ranged from 8.5% to 20%. Five studies reported accelerated cognitive deterioration in association with benzodiazepine use. Two studies reported clinical efficacy for lorazepam and alprazolam to reduce agitation in Alzheimer's disease patients. No evidence was found for an improvement of sleep quality using benzodiazepines. CONCLUSION This systematic review shows a relatively high prevalence of benzodiazepine use but limited evidence for clinical efficacy in Alzheimer's disease patients. However, there is a paucity of methodologically high quality controlled clinical trials. Our results underscore a need for randomized controlled trials in this area.
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Affiliation(s)
- Michaela Defrancesco
- Memory Clinic (Dr Defrancesco), and Division of General and Social Psychiatry (Drs Fleischhacker and Blasko), Department of Psychiatry and Psychotherapy, Innsbruck Medical University, Innsbruck, Austria; Department of Psychiatry and Psychotherapy A, Landeskrankenhaus Hall, Hall, Austria (Dr Marksteiner); Division of Biological Psychiatry, Department of Psychiatry and Psychotherapy, Innsbruck Medical University, Innsbruck, Austria (Dr Fleischhacker)
| | - Josef Marksteiner
- Memory Clinic (Dr Defrancesco), and Division of General and Social Psychiatry (Drs Fleischhacker and Blasko), Department of Psychiatry and Psychotherapy, Innsbruck Medical University, Innsbruck, Austria; Department of Psychiatry and Psychotherapy A, Landeskrankenhaus Hall, Hall, Austria (Dr Marksteiner); Division of Biological Psychiatry, Department of Psychiatry and Psychotherapy, Innsbruck Medical University, Innsbruck, Austria (Dr Fleischhacker)
| | - W Wolfgang Fleischhacker
- Memory Clinic (Dr Defrancesco), and Division of General and Social Psychiatry (Drs Fleischhacker and Blasko), Department of Psychiatry and Psychotherapy, Innsbruck Medical University, Innsbruck, Austria; Department of Psychiatry and Psychotherapy A, Landeskrankenhaus Hall, Hall, Austria (Dr Marksteiner); Division of Biological Psychiatry, Department of Psychiatry and Psychotherapy, Innsbruck Medical University, Innsbruck, Austria (Dr Fleischhacker)
| | - Imrich Blasko
- Memory Clinic (Dr Defrancesco), and Division of General and Social Psychiatry (Drs Fleischhacker and Blasko), Department of Psychiatry and Psychotherapy, Innsbruck Medical University, Innsbruck, Austria; Department of Psychiatry and Psychotherapy A, Landeskrankenhaus Hall, Hall, Austria (Dr Marksteiner); Division of Biological Psychiatry, Department of Psychiatry and Psychotherapy, Innsbruck Medical University, Innsbruck, Austria (Dr Fleischhacker)
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Kalra J, Prakash A, Kumar P, Majeed ABA. Cerebroprotective effects of RAS inhibitors: Beyond their cardio-renal actions. J Renin Angiotensin Aldosterone Syst 2015; 16:459-68. [PMID: 25944853 DOI: 10.1177/1470320315583582] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 03/22/2015] [Indexed: 01/25/2023] Open
Abstract
Work on the brain renin-angiotensin system has been explored by various researchers and has led to elucidation of its basic physiologies and behavior, including its role in reabsorption and uptake of body fluid, blood pressure maintenance with angiotensin II being its prominent effector. Currently, this system has been implicated for its newly established effects, which are far beyond its cardio-renal effects accounting for maintenance of cerebral blood flow and cerebroprotection, seizure, in the etiology of Alzheimer's disease, Parkinson's disease, multiple sclerosis, and bipolar disorder. In this review, we have discussed the distribution of angiotensin receptor subtypes in the central nervous system (CNS) together with enzymatic pathways leading to active angiotensin ligands and its interaction with angiotensin receptor 2 (AT2) and Mas receptors. Secondly, the use of angiotensin analogues (angiotensin converting enzyme inhibitors and AT1 and/or AT2 receptor blockers) in the treatment and management of the CNS disorders mentioned above has been discussed.
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Affiliation(s)
- Jaspreet Kalra
- Department of Pharmacology, Indo Soviet Friendship (ISF) College of Pharmacy, Moga, India
| | - Atish Prakash
- Department of Pharmacology, Indo Soviet Friendship (ISF) College of Pharmacy, Moga, India Faculty of Pharmacy, Universiti Teknologi MARA (UiTM), Bandar Puncak Alam, Malaysia Brain Degeneration and Therapeutics Group, Universiti Teknologi MARA (UiTM), Shah Alam, Malaysia
| | - Puneet Kumar
- Department of Pharmacology, Indo Soviet Friendship (ISF) College of Pharmacy, Moga, India
| | - Abu Bakar Abdul Majeed
- Faculty of Pharmacy, Universiti Teknologi MARA (UiTM), Bandar Puncak Alam, Malaysia Brain Degeneration and Therapeutics Group, Universiti Teknologi MARA (UiTM), Shah Alam, Malaysia
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Wright JW, Kawas LH, Harding JW. The development of small molecule angiotensin IV analogs to treat Alzheimer's and Parkinson's diseases. Prog Neurobiol 2014; 125:26-46. [PMID: 25455861 DOI: 10.1016/j.pneurobio.2014.11.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Revised: 11/17/2014] [Accepted: 11/19/2014] [Indexed: 02/07/2023]
Abstract
Alzheimer's (AD) and Parkinson's (PD) diseases are neurodegenerative diseases presently without effective drug treatments. AD is characterized by general cognitive impairment, difficulties with memory consolidation and retrieval, and with advanced stages episodes of agitation and anger. AD is increasing in frequency as life expectancy increases. Present FDA approved medications do little to slow disease progression and none address the underlying progressive loss of synaptic connections and neurons. New drug design approaches are needed beyond cholinesterase inhibitors and N-methyl-d-aspartate receptor antagonists. Patients with PD experience the symptomatic triad of bradykinesis, tremor-at-rest, and rigidity with the possibility of additional non-motor symptoms including sleep disturbances, depression, dementia, and autonomic nervous system failure. This review summarizes available information regarding the role of the brain renin-angiotensin system (RAS) in learning and memory and motor functions, with particular emphasis on research results suggesting a link between angiotensin IV (AngIV) interacting with the AT4 receptor subtype. Currently there is controversy over the identity of this AT4 receptor protein. Albiston and colleagues have offered convincing evidence that it is the insulin-regulated aminopeptidase (IRAP). Recently members of our laboratory have presented evidence that the brain AngIV/AT4 receptor system coincides with the brain hepatocyte growth factor/c-Met receptor system. In an effort to resolve this issue we have synthesized a number of small molecule AngIV-based compounds that are metabolically stable, penetrate the blood-brain barrier, and facilitate compromised memory and motor systems. These research efforts are described along with details concerning a recently synthesized molecule, Dihexa that shows promise in overcoming memory and motor dysfunctions by augmenting synaptic connectivity via the formation of new functional synapses.
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Affiliation(s)
- John W Wright
- Departments of Psychology, Integrative Physiology and Neuroscience and Program in Biotechnology, Washington State University, Pullman, WA 99164-4820, USA; M3 Biotechnology, Inc., 4000 Mason Rd Suite 300, Box 352141, Seattle, WA 98195-2141, USA.
| | - Leen H Kawas
- Departments of Psychology, Integrative Physiology and Neuroscience and Program in Biotechnology, Washington State University, Pullman, WA 99164-4820, USA; M3 Biotechnology, Inc., 4000 Mason Rd Suite 300, Box 352141, Seattle, WA 98195-2141, USA
| | - Joseph W Harding
- Departments of Psychology, Integrative Physiology and Neuroscience and Program in Biotechnology, Washington State University, Pullman, WA 99164-4820, USA; M3 Biotechnology, Inc., 4000 Mason Rd Suite 300, Box 352141, Seattle, WA 98195-2141, USA
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Valenti R, Pantoni L, Markus HS. Treatment of vascular risk factors in patients with a diagnosis of Alzheimer's disease: a systematic review. BMC Med 2014; 12:160. [PMID: 25385407 PMCID: PMC4226862 DOI: 10.1186/s12916-014-0160-z] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Accepted: 08/20/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Increasing evidence suggests vascular risk factors (VRF) play a role in the pathogenesis of Alzheimer's disease (AD). Epidemiological studies have found associations between VRF and risk of AD. Treating VRF in patients with AD offers a potential treatment option but ineffective treatments should be avoided in this group who are frequently on multiple medications and in whom compliance may be challenging. METHODS Studies containing information on the treatment of VRF in patients with a diagnosis of AD were identified using a defined search strategy. Randomised controlled trials and observational studies were included. RESULTS The pre-specified search strategy retrieved 11,992 abstract articles, and 25 papers including those identified on review of reference lists and reviews met the inclusion criteria. Of these, 11 were randomised controlled trials (RCTs) and 14 observational studies. Observational studies suggested that a VRF package and treatment of hypertension and statin therapy may be associated with improved outcome but these studies suffered from potential bias. The few RCTs performed were mostly small with short duration follow-up, and do not provide clear evidence either way. CONCLUSIONS Observational data raises the possibility that treating VRF could alter the rate of decline in AD. However RCT data are not yet available to support this hypothesis and to alter clinical practice. RCTs in larger numbers of individuals with longer follow-up, ideally in the early stages of AD, are required to address this potentially important treatment question.
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Affiliation(s)
| | | | - Hugh S Markus
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.
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31
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Solomon A, Kivipelto M. Cholesterol-modifying strategies for Alzheimer’s disease. Expert Rev Neurother 2014; 9:695-709. [DOI: 10.1586/ern.09.25] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Abstract
Angiotensin II represents a key molecule in hypertension and cerebrovascular pathology. By promoting inflammation and oxidative stress, enhanced Ang II levels accelerate the onset and progression of cell senescence. Sustained activation of RAS promotes end-stage organ injury associated with aging and results in cognitive impairment and dementia. The discovery of the angiotensin-converting enzyme ACE2-angiotensin (1–7)-Mas receptor axis that exerts vasodilator, antiproliferative, and antifibrotic actions opposed to those of the ACE-Ang II-AT1 receptor axis has led to the hypothesis that a decrease in the expression or activity of angiotensin (1–7) renders the systems more susceptible to the pathological actions of Ang II. Given the successful demonstration of beneficial effects of increased expression of ACE2/formation of Ang1–7/Mas receptor binding and modulation of Mas expression in animal models in containing cerebrovascular pathology in hypertensive conditions and aging, one could reasonably hope for analogous effects regarding the prevention of cognitive decline by protecting against hypertension and cerebral microvascular damage. Upregulation of ACE2 and increased balance of Ang 1–7/Ang II, along with positive modulation of Ang II signaling through AT2 receptors and Ang 1–7 signaling through Mas receptors, may be an appropriate strategy for improving cognitive function and treating dementia.
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Soto ME, van Kan GA, Nourhashemi F, Gillette-Guyonnet S, Cesari M, Cantet C, Rolland Y, Vellas B. Angiotensin-converting enzyme inhibitors and Alzheimer's disease progression in older adults: results from the Réseau sur la Maladie d'Alzheimer Français cohort. J Am Geriatr Soc 2013; 61:1482-8. [PMID: 24000874 DOI: 10.1111/jgs.12415] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To assess whether angiotensin-converting enzyme inhibitor (ACE-I) treatment is associated with less cognitive decline in older adults with Alzheimer's disease (AD) than in those using other hypertensive or no drugs. DESIGN Four-year prospective multicenter cohort study with a biannual assessment. SETTING Memory clinics from 16 university hospitals in France. PARTICIPANTS Community-dwelling older adults with mild to moderate AD (N = 616). MEASUREMENTS Participants were stratified into four groups according to type and duration of antihypertensive drug treatment. Cognitive decline was assessed using the Mini-Mental State Examination (MMSE). Linear mixed-effects models were used to assess differences in decline in MMSE score between the four groups. Hypertension at each visit was included in the model. RESULTS Sixty-one participants had used ACE-Is continuously, 57 had used them intermittently, 189 had used other antihypertensive drugs, and 309 never used any antihypertensive drugs. Continuous ACE-Is users had a 4-year decline in MMSE of 6.4 ± 1.6 points (P < .001), intermittent ACE-Is users of 7.9 ± 1.1 points (P < .001), continuous or intermittent users of other antihypertensive drugs of 8.8 ± 0.7 points (P < .001), and never-users of 10.2 ± 0.6 points (P < .001). MMSE decline between the four groups was significantly different (adjusted P = .02). In subgroup analysis, the 118 (19.2%) participants who had continuously or intermittently used ACE-Is had a significant difference in 4-year MMSE decline from the 498 (80.8%) who had never used ACE-Is (7.5 ± 0.9 vs 9.7 ± 0.4; P = .03). CONCLUSION The use of ACE-Is in older adults with AD is associated with a slower rate of cognitive decline independent of hypertension. Future research is needed to explore the role of ACE-Is in long-term AD progression.
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Affiliation(s)
- Maria E Soto
- Department of Geriatric Medicine, Gérontopôle, CHU Toulouse University Hospital, Toulouse, France; Inserm, UMR1027, Toulouse, France
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Plasma renin-angiotensin system-regulating aminopeptidase activities are modified in early stage Alzheimer's disease and show gender differences but are not related to apolipoprotein E genotype. Exp Gerontol 2013; 48:557-64. [PMID: 23500679 DOI: 10.1016/j.exger.2013.03.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Revised: 03/05/2013] [Accepted: 03/07/2013] [Indexed: 12/25/2022]
Abstract
Alterations in blood pressure and components of the renin-angiotensin system (RAS) contribute to the development and progression of Alzheimer's disease (AD), resulting in changes that can lead or contribute to cognitive decline. Aspartyl aminopeptidase (ASAP), aminopeptidase A (APA), aminopeptidase N (APN) and aminopeptidase B (APB) catabolise circulating angiotensins, whereas insulin-regulated aminopeptidase (IRAP) has been described as the AT4 receptor. We have found in AD patients a significant decrease of APA activity in men but not in women, and of APN, APB and IRAP in both genders, when compared with control subjects. No changes were found in ASAP activity. Also, APN, APB and IRAP but not APA correlated with the Mini-Mental test, but no relationship with APOE genotype was found. We conclude that several components of the RAS are modified in AD patients, with gender differences. Furthermore, ROC analysis indicates that APN, APB and IRAP activities could be useful non-invasive biomarkers of AD from the earliest stages.
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Rosenberg PB, Mielke MM, Han D, Leoutsakos JS, Lyketsos CG, Rabins PV, Zandi PP, Breitner JCS, Norton MC, Welsh-Bohmer KA, Zuckerman IH, Rattinger GB, Green RC, Corcoran C, Tschanz JT. The association of psychotropic medication use with the cognitive, functional, and neuropsychiatric trajectory of Alzheimer's disease. Int J Geriatr Psychiatry 2012; 27:1248-57. [PMID: 22374884 PMCID: PMC3448859 DOI: 10.1002/gps.3769] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2011] [Revised: 12/06/2011] [Accepted: 12/09/2011] [Indexed: 11/07/2022]
Abstract
OBJECTIVE The use of psychotropic medications in Alzheimer's disease (AD) has been associated with both deleterious and potentially beneficial outcomes. We examined the longitudinal association of psychotropic medication use with cognitive, functional, and neuropsychiatric symptom (NPS) trajectories among community-ascertained incident AD cases from the Cache County Dementia Progression Study. METHODS A total of 230 participants were followed for a mean of 3.7 years. Persistency index (PI) was calculated for all antidepressants, selective serotonin reuptake inhibitors (SSRIs), antipsychotics (atypical and typical), and benzodiazepines as the proportion of observed time of medication exposure. Mixed-effects models were used to examine the association between PI for each medication class and Mini-Mental State Exam (MMSE), Clinical Dementia Rating Sum of Boxes (CDR-Sum), and Neuropsychiatric Inventory - Total (NPI-Total) trajectories, controlling for appropriate demographic and clinical covariates. RESULTS At baseline, psychotropic medication use was associated with greater severity of dementia and poorer medical status. Higher PI for all medication classes was associated with a more rapid decline in MMSE. For antidepressant, SSRI, benzodiazepine, and typical antipsychotic use, a higher PI was associated with a more rapid increase in CDR-Sum. For SSRIs, antipsychotics, and typical antipsychotics, a higher PI was associated with more rapid increase in NPI-Total. CONCLUSIONS Psychotropic medication use was associated with more rapid cognitive and functional decline in AD, and not with improved NPS. Clinicians may tend to prescribe psychotropic medications to AD patients at risk of poorer outcomes, but one cannot rule out the possibility of poorer outcomes being caused by psychotropic medications.
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Affiliation(s)
- P. B. Rosenberg
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA,Division of Geriatric Psychiatry and Neuropsychiatry, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - M. M. Mielke
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA,Division of Geriatric Psychiatry and Neuropsychiatry, Johns Hopkins School of Medicine, Baltimore, MD, USA,Section of Epidemiology, Department of Health Sciences Research, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - D. Han
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA,Division of Geriatric Psychiatry and Neuropsychiatry, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - J. S. Leoutsakos
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA,Division of Geriatric Psychiatry and Neuropsychiatry, Johns Hopkins School of Medicine, Baltimore, MD, USA,Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - C. G. Lyketsos
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA,Division of Geriatric Psychiatry and Neuropsychiatry, Johns Hopkins School of Medicine, Baltimore, MD, USA,Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - P. V. Rabins
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA,Division of Geriatric Psychiatry and Neuropsychiatry, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - P. P. Zandi
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - J. C. S. Breitner
- Department of Psychiatry, Douglas Mental Health University Institute Research Center, Montreal, Quebec, Canada,Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - M. C. Norton
- Department of Psychology, Utah State University, Logan, UT, USA,Department of Family Consumer and Human Development, Utah State University, Logan, UT, USA
| | - K. A. Welsh-Bohmer
- Department of Psychiatry, Duke University, Durham, NC, USA,Division Medical Psychology, Duke University, Durham, NC, USA
| | - I. H. Zuckerman
- Pharmaceutical Health Services Research Department, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - G. B. Rattinger
- Pharmaceutical Health Services Research Department, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - R. C. Green
- Division of Genetics, Brigham and Women’s Hospital, Boston, MA, USA,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - C. Corcoran
- Department of Psychology, Utah State University, Logan, UT, USA
| | - J. T. Tschanz
- Department of Psychology, Utah State University, Logan, UT, USA
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Chen PL, Lee WJ, Sun WZ, Oyang YJ, Fuh JL. Risk of dementia in patients with insomnia and long-term use of hypnotics: a population-based retrospective cohort study. PLoS One 2012; 7:e49113. [PMID: 23145088 PMCID: PMC3492301 DOI: 10.1371/journal.pone.0049113] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2012] [Accepted: 10/04/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Hypnotics have been reported to be associated with dementia. However, the relationship between insomnia, hypnotics and dementia is still controversial. We sought to examine the risk of dementia in patients with long-term insomnia and the contribution of hypnotics. METHODS Data was collected from Taiwan's Longitudinal Health Insurance Database. The study cohort comprised all patients aged 50 years or older with a first diagnosis of insomnia from 2002 to 2007. The comparison cohort consisted of randomly selected patients matched by age and gender. Each patient was individually tracked for 3 years from their insomnia index date to identify whether the patient had a first diagnosis of dementia. Cox regression was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). RESULTS We identified 5693 subjects with long-term insomnia and 28,465 individuals without. After adjusting for hypertension, diabetes mellitus, hyperlipidemia, and stroke, those with long-term insomnia had significantly higher risks of dementia (HR, 2.34; 95% CI, 1.92-2.85). Patients with long-term insomnia and aged 50 to 65 years had a higher increased risk of dementia (HR, 5.22; 95% CI, 2.62-10.41) than those older than 65 years (HR, 2.33; 95% CI, 1.90-2.88). The use of hypnotics with a longer half-life and at a higher prescribed dose predicted a greater increased risk of dementia. CONCLUSIONS Patients with long-term use of hypnotics have more than a 2-fold increased risk of dementia, especially those aged 50 to 65 years. In addition, the dosage and half-lives of the hypnotics used should be considered, because greater exposure to these medications leads to a higher risk of developing dementia.
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Affiliation(s)
- Pin-Liang Chen
- Department of Computer Science and Information Engineering, National Taiwan University, Taipei, Taiwan
| | - Wei-Ju Lee
- Department of Neurology, Taichung Veterans General Hospital, Taichung, Taiwan
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wei-Zen Sun
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yen-Jen Oyang
- Department of Computer Science and Information Engineering, National Taiwan University, Taipei, Taiwan
- Graduate Institutes of Biomedical Electronics and Bioinformatics, National Taiwan University, Taipei, Taiwan
| | - Jong-Ling Fuh
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- * E-mail:
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Wright JW, Harding JW. The brain renin–angiotensin system: a diversity of functions and implications for CNS diseases. Pflugers Arch 2012; 465:133-51. [DOI: 10.1007/s00424-012-1102-2] [Citation(s) in RCA: 154] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Revised: 03/20/2012] [Accepted: 03/30/2012] [Indexed: 12/14/2022]
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Puustinen J, Nurminen J, Vahlberg T, Lyles A, Isoaho R, Räihä I, Kivelä SL. CNS medications as predictors of precipitous cognitive decline in the cognitively disabled aged: a longitudinal population-based study. Dement Geriatr Cogn Dis Extra 2012; 2:57-68. [PMID: 22619661 PMCID: PMC3350354 DOI: 10.1159/000336710] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND/AIMS Psychotropics and antiepileptics (AE) are medications commonly used among the aged with cognitive decline or dementia, although they may precipitate further cognitive decline. Our aim was to analyze the relationships between the use of (i) psychotropics (i.e. benzodiazepines or related drugs, BZD, antipsychotics, AP, or antidepressants, AD), opioids (Op), anticholinergics (ACh) or AEs or the concomitant use of two of these drugs, and (ii) the risk of precipitous cognitive decline in an older (≥65 years) cognitively disabled population. METHODS A longitudinal population-based study of general aged community-dwelling patients was executed in two phases (1990-1991 and 1998-1999) in Lieto, Finland. Fifty-two individuals cognitively disabled (MMSE score 0-23) at the 1990-1991 baseline form this study's sample. Cognitive abilities were assessed in each phase with the Mini-Mental State Examination (MMSE) and medication utilization data were collected in both phases. The mean follow-up time was 7.6 years. Multivariate models were used to analyze the change in MMSE total score between medication users and non-users. RESULTS BZD or any psychotropic use was associated with greater cognitive decline in elders aged ≥75 years compared to non-users (change in MMSE sum score: -8.6 ± 7.0 vs. -3.3 ± 5.6 and -5.9 ± 7.0 vs. -2.7 ± 6.4, respectively). A greater decline was also associated specifically with the concomitant use of BZD and AP (-16 vs. -1.4 ± 7.8); as were BZD and any drug with CNS effects (-9.6 ± 9.9 vs. -1.3 ± 7.2) compared to non-users. The concomitant use of BZD and AD (-10.7 ± 4.7 vs. -3.2 ± 5.6) or ACh (-15.0 ± 8.5 vs. -3.3 ± 5.6) or any drug with CNS effects (-13.3 ± 6.5 vs. -3.3 ± 5.6) was associated with cognitive decline in patients ≥75 years compared to non-users of any drug with CNS effects. CONCLUSION The use of a BZD or any psychotropic medication may be an independent risk factor for cognitive decline in the cognitively disabled aged, and patients co-prescribed psychotropic medications had greater cognitive decline. Studies with larger sample sizes and studies on possible pathophysiologic mechanisms are needed.
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Affiliation(s)
- Juha Puustinen
- Department of Family Medicine, University of Turku, Turku and Pori, Pori
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Kolanowski AM, Hill N, Clare L, Marx P. Practical Protocol for Implementing Cognitive Stimulation in Persons with Delirium Superimposed on Dementia. NON-PHARMACOLOGICAL THERAPIES IN DEMENTIA 2012; 2:101-110. [PMID: 23828731 PMCID: PMC3698984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Delirium is common in persons with dementia and often accompanies acute medical or surgical conditions. These individuals are at risk for an accelerated decline in their cognitive and physical function. For this reason, interventions that help resolve delirium are critically needed. We have developed a non-pharmacological intervention for delirium in persons with dementia based on our prior interdisciplinary work on delirium, dementia and cognitive stimulation. The intervention uses recreational activities that are alerting, capture attention, and provide cognitive stimulation that encourages cognitive processing in support of cognitive function. In this paper we describe the practical protocol we have developed for implementing these activities, and present a video that will enhance treatment fidelity for studies that replicate the approach.
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Affiliation(s)
- Ann M. Kolanowski
- School of Nursing, Pennsylvania State University, University Park, PA., US
| | - Nikki Hill
- School of Nursing, Pennsylvania State University, University Park, PA., US
| | - Linda Clare
- Department of Psychology, Bangor University, Wales, UK
| | - Patricia Marx
- School of Nursing, Pennsylvania State University, University Park, PA., US
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Lau DT, Mercaldo ND, Shega JW, Rademaker A, Weintraub S. Functional decline associated with polypharmacy and potentially inappropriate medications in community-dwelling older adults with dementia. Am J Alzheimers Dis Other Demen 2011; 26:606-15. [PMID: 22207646 PMCID: PMC3298080 DOI: 10.1177/1533317511432734] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study provides empirical evidence on whether polypharmacy and potentially inappropriate prescription medications (PIRx, as defined by the 2003 Beers criteria) increase the likelihood of functional decline among community-dwelling older adults with dementia. Data were from the National Alzheimer's Coordinating Center, Uniform Data Set (9/2005-9/2009). Study sample included 1994 community-dwelling participants aged ≥65 with dementia at baseline. Results showed that participants having ≥5 medications were more likely to have functional decline than participants having <5 medications. However, the increased likelihood was only apparent in participants who did not have PIRx. Instead of magnifying the associated risk as hypothesized, PIRx appeared to have a protective effect albeit marginally statistically significant. Therefore, increased medication burden may be associated with functional decline in community-dwelling older adults with dementia who are not prescribed with PIRx. More research is needed to understand which classes of medications have the most deleterious effect on this population.
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Affiliation(s)
- Denys T Lau
- Department of Pharmacy Administration, University of Illinois at Chicago, College of Pharmacy, 60612, USA.
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Yamada K, Horita T, Takayama M, Takahashi S, Takaba K, Nagata Y, Suzuki N, Kanda T. Effect of a centrally active angiotensin converting enzyme inhibitor, perindopril, on cognitive performance in chronic cerebral hypo-perfusion rats. Brain Res 2011; 1421:110-20. [PMID: 21981801 DOI: 10.1016/j.brainres.2011.09.016] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Revised: 08/31/2011] [Accepted: 09/09/2011] [Indexed: 11/25/2022]
Abstract
We have previously demonstrated that perindopril, an angiotensin-converting enzyme (ACE) inhibitor, ameliorated the cognitive deficits in Alzheimer's disease model animals, independently of its anti-hypertensive effect. In this study, we again investigated the effects of perindopril on cognitive function in a vascular dementia model animal, comparing it with other ACE inhibitors. We also determined ACE activity in the brain and extracellular acetylcholine (ACh) concentration in the perirhinal cortex in order to elucidate the mechanism(s) responsible for the effects of these ACE inhibitors on cognitive function. Perindopril was suggested to be more centrally active than imidapril and enalapril, in consideration of the relative distribution of their active metabolites in the brain. This property was at least partially attributed to the lipophilicity of the compound. While the 3 day treatment with perindopril, imidapril or enalapril lowered blood pressure to the same level in spontaneous hypertensive rats, only perindopril reversed the decline in the recognition index in chronic cerebral hypo-perfusion rats, regarded as an animal model of vascular dementia, during an object recognition task. Using the same dosing regimen, perindopril inhibited the brain ACE activities of rats more than imidapril or enalapril. Moreover, a single treatment with perindopril enhanced the extracellular level of ACh in the perirhinal cortex of normal rats. Therefore, we confirmed that only centrally active ACE inhibitors, such as perindopril, can inhibit the ACE in the brain, augmenting cholinergic neurotransmission and thereby ameliorating cognitive impairment in the animal model of vascular dementia.
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Affiliation(s)
- Koji Yamada
- Pharmacological Research Laboratories, Research Division, Kyowa Hakko Kirin Co., Ltd., 1188 Shimotogari, Nagaizumi-cho, Sunto-gun, Shizuoka 411-8731, Japan.
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42
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Wright JW, Harding JW. Brain renin-angiotensin—A new look at an old system. Prog Neurobiol 2011; 95:49-67. [DOI: 10.1016/j.pneurobio.2011.07.001] [Citation(s) in RCA: 147] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Revised: 06/27/2011] [Accepted: 07/03/2011] [Indexed: 12/15/2022]
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Kolanowski AM, Fick DM, Clare L, Steis M, Boustani M, Litaker M. Pilot Study of a Nonpharmacological Intervention for Delirium Superimposed on Dementia. Res Gerontol Nurs 2011; 4:161-7. [DOI: 10.3928/19404921-20101001-98] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2009] [Accepted: 05/06/2010] [Indexed: 12/21/2022]
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Kolanowski AM, Fick DM, Litaker MS, Clare L, Leslie D, Boustani M. Study protocol for the recreational stimulation for elders as a vehicle to resolve delirium superimposed on dementia (Reserve For DSD) trial. Trials 2011; 12:119. [PMID: 21569370 PMCID: PMC3113988 DOI: 10.1186/1745-6215-12-119] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Accepted: 05/11/2011] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Delirium is a state of confusion characterized by an acute and fluctuating decline in cognitive functioning. Delirium is common and deadly in older adults with dementia, and is often referred to as delirium superimposed on dementia, or DSD. Interventions that treat DSD are not well-developed because the mechanisms involved in its etiology are not completely understood. We have developed a theory-based intervention for DSD that is derived from the literature on cognitive reserve and based on our prior interdisciplinary work on delirium, recreational activities, and cognitive stimulation in people with dementia. Our preliminary work indicate that use of simple, cognitively stimulating activities may help resolve delirium by helping to focus inattention, the primary neuropsychological deficit in delirium. Our primary aim in this trial is to test the efficacy of Recreational Stimulation for Elders as a Vehicle to resolve DSD (RESERVE- DSD). METHODS/DESIGN This randomized repeated measures clinical trial will involve participants being recruited and enrolled at the time of admission to post acute care. We will randomize 256 subjects to intervention (RESERVE-DSD) or control (usual care). Intervention subjects will receive 30-minute sessions of tailored cognitively stimulating recreational activities for up to 30 days. We hypothesize that subjects who receive RESERVE-DSD will have: decreased severity and duration of delirium; greater gains in attention, orientation, memory, abstract thinking, and executive functioning; and greater gains in physical function compared to subjects with DSD who receive usual care. We will also evaluate potential moderators of intervention efficacy (lifetime of complex mental activities and APOE status). Our secondary aim is to describe the costs associated with RESERVE-DSD. DISCUSSION Our theory-based intervention, which uses simple, inexpensive recreational activities for delivering cognitive stimulation, is innovative because, to our knowledge it has not been tested as a treatment for DSD. This novel intervention for DSD builds on our prior delirium, recreational activity and cognitive stimulation research, and draws support from cognitive reserve theory. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01267682
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Affiliation(s)
- Ann M Kolanowski
- School of Nursing, Pennsylvania State University, University Park, PA, USA.
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Ghio L, Natta W, Fravega R, Gotelli S, Pannocchia F, Puppo S, Rasore E. Cognitive impairment and psychopharmacological treatment: a drug utilization study in the emergency department. Int J Geriatr Psychiatry 2011; 26:438-9. [PMID: 21412850 DOI: 10.1002/gps.2637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Belbin O, Brown K, Shi H, Medway C, Abrahams R, Passmore P, Mann D, Smith AD, Holmes C, McGuiness B, Craig D, Warden D, Heun R, Kölsch H, Love S, Kalsheker N, Williams J, Owen MJ, Carrasquillo M, Younkin S, Morgan K, Kehoe PG. A multi-center study of ACE and the risk of late-onset Alzheimer's disease. J Alzheimers Dis 2011; 24:587-97. [PMID: 21297258 PMCID: PMC3655234 DOI: 10.3233/jad-2011-101914] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A key pathological feature of late-onset Alzheimer's disease (LOAD) is the abnormal extracellular accumulation of the amyloid-β (Aβ) peptide. Thus, altered Aβ degradation could be a major contributor to the development of LOAD. Variants in the gene encoding the Aβ-degrading enzyme, angiotensin-1 converting enzyme (ACE) therefore represent plausible candidates for association with LOAD pathology and risk. Following Alzgene meta-analyses of all published case-control studies, the ACE variants rs4291 and rs1800764 showed significant association with LOAD risk. Furthermore ACE haplotypes are associated with both plasma ACE levels and LOAD risk. We tested three ACE variants (rs4291, rs4343, and rs1800764) for association with LOAD in ten Caucasian case-control populations (n = 8,212). No association was found using multiple logistic models (all p > 0.09). We found no population heterogeneity (all p > 0.38) or evidence for association with LOAD risk following meta-analysis of the ten populations for rs4343 (OR = 1.00), rs4291 (OR = 0.97), or rs1800764 (OR = 0.99). Although we found no haplotypic association in our complete dataset (p = 0.51), a significant global haplotypic p-value was observed in one population (p = 0.007) due to an association of the H3 haplotype (OR = 0.72, p = 0.02) and a trend towards an association of H4 (OR = 1.38, p = 0.09) and H7 (OR = 2.07, p = 0.08) although these did not survive Bonferroni correction. Previously reported associations of ACE variants with LOAD will be diminished following this study. At best, ACE variants have modest effect sizes, which are likely part of a complex interaction between genetic, phenotypic and pharmacological effects that would be undetected in traditional case-control studies.
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Affiliation(s)
- Olivia Belbin
- Department of Clinical Chemistry, Institute of Genetics, Queen’s Medical Centre, University of Nottingham, UK
- Department of Neuroscience, Mayo Clinic, Jacksonville, FL, USA
| | - Kristelle Brown
- Department of Clinical Chemistry, Institute of Genetics, Queen’s Medical Centre, University of Nottingham, UK
| | - Hui Shi
- Department of Clinical Chemistry, Institute of Genetics, Queen’s Medical Centre, University of Nottingham, UK
| | - Christopher Medway
- Department of Clinical Chemistry, Institute of Genetics, Queen’s Medical Centre, University of Nottingham, UK
| | - Richard Abrahams
- Medical Research Council Centre for Neuropsychiatric Genetics and Genomics, Department of Psychological Medicine and Neurology, School of Medicine, Cardiff University, Cardiff, UK
| | - Peter Passmore
- Department of Geriatric Medicine, The Queen’s University of Belfast, Belfast, UK
| | - David Mann
- Greater Manchester Neurosciences Centre, University of Manchester, UK
| | - A. David Smith
- Memory Assessment and Research Centre, University of Southampton, Southampton, UK
| | - Clive Holmes
- OPTIMA, University Department of Pharmacology, Oxford, UK
| | - B. McGuiness
- Department of Geriatric Medicine, The Queen’s University of Belfast, Belfast, UK
| | - David Craig
- Department of Geriatric Medicine, The Queen’s University of Belfast, Belfast, UK
| | - Donald Warden
- OPTIMA, University Department of Pharmacology, Oxford, UK
| | - Reinhard Heun
- Department of Old Age Psychiatry, Queen Elizabeth Psychiatric Hospital, Birmingham, UK
| | | | - Seth Love
- Institute of Clinical Neurosciences, School of Clinical Science, University of Bristol, Frenchay Hospital, UK
| | - Noor Kalsheker
- Department of Clinical Chemistry, Institute of Genetics, Queen’s Medical Centre, University of Nottingham, UK
| | - Julie Williams
- Medical Research Council Centre for Neuropsychiatric Genetics and Genomics, Department of Psychological Medicine and Neurology, School of Medicine, Cardiff University, Cardiff, UK
| | - Michael J Owen
- Medical Research Council Centre for Neuropsychiatric Genetics and Genomics, Department of Psychological Medicine and Neurology, School of Medicine, Cardiff University, Cardiff, UK
| | | | - Steven Younkin
- Department of Neuroscience, Mayo Clinic, Jacksonville, FL, USA
| | - Kevin Morgan
- Department of Clinical Chemistry, Institute of Genetics, Queen’s Medical Centre, University of Nottingham, UK
| | - Patrick G Kehoe
- Institute of Clinical Neurosciences, School of Clinical Science, University of Bristol, Frenchay Hospital, UK
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Serrano-Pozo A, Vega GL, Lütjohann D, Locascio JJ, Tennis MK, Deng A, Atri A, Hyman BT, Irizarry MC, Growdon JH. Effects of simvastatin on cholesterol metabolism and Alzheimer disease biomarkers. Alzheimer Dis Assoc Disord 2010; 24:220-6. [PMID: 20473136 PMCID: PMC3694274 DOI: 10.1097/wad.0b013e3181d61fea] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Preclinical and epidemiologic studies suggest a protective effect of statins on Alzheimer disease (AD). Experimental evidence indicates that some statins can cross the blood-brain barrier, alter brain cholesterol metabolism, and may ultimately decrease the production of amyloid-beta (Abeta) peptide. Despite these promising leads, clinical trials have yielded inconsistent results regarding the benefits of statin treatment in AD. Seeking to detect a biological signal of statins effect on AD, we conducted a 12-week open-label trial with simvastatin 40 mg/d and then 80 mg/d in 12 patients with AD or amnestic mild cognitive impairment and hypercholesterolemia. We quantified cholesterol precursors and metabolites and AD biomarkers of Abeta and tau in both plasma and cerebrospinal fluid at baseline and after the 12-week treatment period. We found a modest but significant inhibition of brain cholesterol biosynthesis after simvastatin treatment, as indexed by a decrease of cerebrospinal fluid lathosterol and plasma 24S-hydroxycholesterol. Despite this effect, there were no changes in AD biomarkers. Our findings indicate that simvastatin treatment can affect brain cholesterol metabolism within 12 weeks, but did not alter molecular indices of AD pathology during this short-term treatment.
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Affiliation(s)
- Alberto Serrano-Pozo
- Memory Disorders Unit, Department of Neurology and Massachusetts Alzheimer's Disease Research Center. Massachusetts General Hospital, Boston
- Harvard Medical School, Boston
- Servicio de Neurología, Instituto de Biomedicina de Sevilla (IBiS), Hospitales Universitarios Virgen del Rocío, Av. Manuel Siurot s/n, 41013 Seville, Spain
| | - Gloria L. Vega
- Department of Clinical Nutrition, Center for Human Nutrition, University of Texas Southwestern Medical Center, Dallas, TX
| | - Dieter Lütjohann
- Institute of Clinical Chemistry and Pharmacology. University of Bonn, Bonn, Germany
| | - Joseph J. Locascio
- Memory Disorders Unit, Department of Neurology and Massachusetts Alzheimer's Disease Research Center. Massachusetts General Hospital, Boston
- Harvard Medical School, Boston
| | - Marsha K. Tennis
- Memory Disorders Unit, Department of Neurology and Massachusetts Alzheimer's Disease Research Center. Massachusetts General Hospital, Boston
| | - Amy Deng
- Memory Disorders Unit, Department of Neurology and Massachusetts Alzheimer's Disease Research Center. Massachusetts General Hospital, Boston
| | - Alireza Atri
- Memory Disorders Unit, Department of Neurology and Massachusetts Alzheimer's Disease Research Center. Massachusetts General Hospital, Boston
- Harvard Medical School, Boston
- Center for Translational Cognitive Neuroscience, and Geriatric Research, Education and Clinical Center, Veterans Administration Bedford Medical Center, Bedford, MA
| | - Bradley T. Hyman
- Memory Disorders Unit, Department of Neurology and Massachusetts Alzheimer's Disease Research Center. Massachusetts General Hospital, Boston
- Harvard Medical School, Boston
| | - Michael C. Irizarry
- Memory Disorders Unit, Department of Neurology and Massachusetts Alzheimer's Disease Research Center. Massachusetts General Hospital, Boston
| | - John H. Growdon
- Memory Disorders Unit, Department of Neurology and Massachusetts Alzheimer's Disease Research Center. Massachusetts General Hospital, Boston
- Harvard Medical School, Boston
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Kolanowski A, Fick D, Frazer C, Penrod J. It's About Time: Use of Nonpharmacological Interventions in the Nursing Home. J Nurs Scholarsh 2010; 42:214-22. [DOI: 10.1111/j.1547-5069.2010.01338.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Oulhaj A, Refsum H, Beaumont H, Williams J, King E, Jacoby R, Smith AD. Homocysteine as a predictor of cognitive decline in Alzheimer's disease. Int J Geriatr Psychiatry 2010; 25:82-90. [PMID: 19484711 DOI: 10.1002/gps.2303] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Moderately elevated levels of plasma total homocysteine are associated with an increased risk of developing Alzheimer's disease. We have tested whether baseline concentrations of homocysteine relate to the subsequent rate of cognitive decline in patients with established Alzheimer's disease (AD). METHODS In 97 patients with AD, 73 pathologically-confirmed, we analysed the decline of global cognitive test scores (CAMCOG) over time from the first assessment for at least three 6-monthly visits up to a maximum of 9.5 years (in total 689 assessments). Non-linear mixed-effects statistical models were used. RESULTS Baseline homocysteine levels showed a concentration-response relationship with the subsequent rate of decline in CAMCOG scores: the higher the homocysteine, the faster the decline. The relationship was significant in patients aged < 75 years who had not suffered a prior stroke. For example, in patients aged 65 years with a baseline homocysteine of 14 micromol/L, the decline from a CAMCOG score of 88 to a score of 44 occurred 19.2 (95% CI 6.8, 31.6) months earlier than in patients with a baseline homocysteine of 10 micromol/L. CONCLUSIONS Raised homocysteine concentrations within the normal range among the elderly strongly relate to the rate of global cognitive decline in patients with Alzheimer disease. Plasma homocysteine can readily be lowered by B-vitamin treatment and trials should be carried out to see if such treatments can slow the rate of cognitive decline in relatively young patients with Alzheimer disease.
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Affiliation(s)
- Abderrahim Oulhaj
- Oxford Project to Investigate Memory and Ageing (OPTIMA), University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
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Wright JW, Harding JW. The brain angiotensin IV/AT4receptor system as a new target for the treatment of Alzheimer's disease. Drug Dev Res 2009. [DOI: 10.1002/ddr.20328] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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