Relations between symptomatology and brain function in dementias: double-blind, placebo-controlled, clinical and EEG/ERP mapping studies with nicergoline

[Efficacy of Sermion in the treatment of tinnitus noise in patients with chronic cerebrovascular pathology]

Noise in the ears or tinnitus is one of the earliest and most frequent non-cognitive manifestations of chronic cerebral ischemia (CCI) and is the most difficult clinical phenomenon for therapeutic intervention.

OBJECTIVE

Of an open observational noncomparative clinical study was to study in patients with CCI and tinnitus and/or head the efficacy and tolerability of Sermion in a daily dose of 30 mg for 6 months.

MATERIAL AND METHODS

56 patients (51.1±8.7 years) were clinically and neurologically examined using standard questionnaires to analyze the severity of tinnitus and its impact on daily life and the level of patient distress associated with noise, and to study the quality of life using the SF-36 questionnaire. All patients independently assessed the therapy satisfaction index.

RESULTS AND CONCLUSION

The safety, good tolerance and obvious clinical effect were shown when using the drug Sermion. The best results were obtained with the use of Sermion for 6 months in relation to the severity of tinnitus, the degree of its influence on daily activity, the level of distress and an increase in the quality of life of patients, as well as a significant improvement in well-being and cognitive functions in almost all subjects. It has been shown that after an adequate course of therapy and after 3 months, the therapeutic efficacy of Sermion is preserved, and the patients themselves were more satisfied with this remedy after 6 months of treatment. The data obtained suggest a wider use of Sermion in patients with cerebrovascular diseases and tinnitus and/or head, the use of which allows a safe, effective and pathogenetically reasonable effect on the existing disorders in these patients.

EEG measures for clinical research in major vascular cognitive impairment: recommendations by an expert panel

Vascular contribution to cognitive impairment (VCI) and dementia is related to etiologies that may affect the neurophysiological mechanisms regulating brain arousal and generating electroencephalographic (EEG) activity. A multidisciplinary expert panel reviewed the clinical literature and reached consensus about the EEG measures consistently found as abnormal in VCI patients with dementia. As compared to cognitively unimpaired individuals, those VCI patients showed (1) smaller amplitude of resting state alpha (8-12 Hz) rhythms dominant in posterior regions; (2) widespread increases in amplitude of delta (< 4 Hz) and theta (4-8 Hz) rhythms; and (3) delayed N200/P300 peak latencies in averaged event-related potentials, especially during the detection of auditory rare target stimuli requiring participants' responses in "oddball" paradigms. The expert panel formulated the following recommendations: (1) the above EEG measures are not specific for VCI and should not be used for its diagnosis; (2) they may be considered as "neural synchronization" biomarkers to enlighten the relationships between features of the VCI-related cerebrovascular lesions and abnormalities in neurophysiological brain mechanisms; and (3) they may be tested in future clinical trials as prognostic biomarkers and endpoints of interventions aimed at normalizing background brain excitability and vigilance in wakefulness.

Does EEG montage influence Alzheimer's disease electroclinic diagnosis?

There is not a specific Alzheimer's disease (AD) diagnostic test. AD diagnosis relies on clinical history, neuropsychological, and laboratory tests, neuroimaging and electroencephalography. Therefore, new approaches are necessary to enable earlier and more accurate diagnosis and to measure treatment results. Quantitative EEG (qEEG) can be used as a diagnostic tool in selected cases. The aim of this study was to answer if distinct electrode montages have different sensitivity when differentiating controls from AD patients. We analyzed EEG spectral peaks (delta, theta, alpha, beta, and gamma bands), and we compared references (Biauricular, Longitudinal bipolar, Crossed bipolar, Counterpart bipolar, and Cz reference). Support Vector Machines and Logistic Regression classifiers showed Counterpart bipolar montage as the most sensitive electrode combination. Our results suggest that Counterpart bipolar montage is the best choice to study EEG spectral peaks of controls versus AD.

Therapeutic use of nicergoline

The ergot alkaloid derivative nicergoline became clinically available about 35 years ago in the 1970s. Nicergoline has a broad spectrum of action: (i) as an alpha(1)-adrenoceptor antagonist, it induces vasodilation and increases arterial blood flow; (ii) it enhances cholinergic and catecholaminergic neurotransmitter function; (iii) it inhibits platelet aggregation; (iv) it promotes metabolic activity, resulting in increased utilization of oxygen and glucose; and (v) it has neurotrophic and antioxidant properties. Acting on several basic pathophysiological mechanisms, nicergoline has therapeutic potential in a number of disorders. This article provides an overview of the published clinical evidence relating to the efficacy and safety of nicergoline (30 mg twice daily) in the treatment of dementia (including Alzheimer's disease and vascular dementia) and vascular and balance disorders. For dementia of different aetiologies, the therapeutic benefit of nicergoline has been established, with up to 89% of patients showing improvements in cognition and behaviour. After as little as 2 months of treatment, symptom improvement is apparent compared with placebo, and most patients are still improved or stable after 12 months. Concomitant neurophysiological changes in the brain indicate (after only 4-8 weeks' treatment) improved vigilance and information processing. In patients with balance disorders, mean improvements of 44-78% in symptom severity and quality of life have been observed with nicergoline. Although clinical experience with nicergoline in vascular disorders is limited to relatively short-term, small-scale studies, it has been successfully used in rehabilitation therapy of patients with chronic ischaemic stroke. Open-label evaluations suggest that nicergoline may also be valuable in glaucoma, depression and peripheral arterio-pathy. Adverse events of nicergoline, if any, are related to the central nervous system, the metabolic system and the overall body. Most are considered typical symptoms of ergot derivatives. Because of their generally mild and transient nature, treatment discontinuations occur relatively infrequently. The efficacy of nicergoline combined with a favourable safety and tolerability profile at commonly applied doses (60 mg/day) make this agent a valuable therapy in patients with mild to moderate dementia, vascular diseases and balance disorders.

Age-related cognitive decline in the menopause: effects of hormone replacement therapy on cognitive event-related potentials

OBJECTIVE

Although epidemiological and clinical studies suggest that hormone replacement therapy (HRT) may protect against cognitive disorders and neurodegenerative diseases, the relation between estrogen and cognition in postmenopausal women remains controversial.

METHODS

In a double-blind placebo-controlled, parallel group design study the effects of HRT with the estrogen-progestogen combination Presomen 1.25 compositum((R)) (1.25mg equine conjugated estrogens administered for 21 days plus the progestogen 5mg medrogeston given for 11 days) on event-related potentials (ERPs) in postmenopausal patients with age-related cognitive decline (DSM-IV code 780.9, ICD-10 code R 41.8) were investigated. After a pre-drug comparison with age-matched normal postmenopausal controls, 48 psychotropic drug-free patients aged 60 +/- 6 years were randomized to receive either placebo or verum for 4 months. ERPs were recorded before as well as on the 91-92 days of the study, which thus fell into the estrogen phase of the treatment during the fourth cycle.

RESULTS

At baseline, patients showed a lengthening of P300 latency and an attenuation of P300 amplitudes as compared with normal controls. After HRT with Presomen, a significant shortening of P300 latency as compared with placebo was observed.

CONCLUSIONS

The baseline P300 differences suggest that in the patient group the aging process was advanced, while after HRT with Presomen a significant improvement and normalization of information processing as indexed by P300 was observed.

Effects of hormone replacement therapy on perceptual and cognitive event-related potentials in menopausal insomnia

The influence of a combined estrogen-progestin regimen (Climodien, Lafamme) on auditory event-related potentials (ERPs) was investigated in a double-blind, placebo-controlled, comparative, randomized 3-arm trial phase (Climodien 2/3=estradiol valerate 2 mg+the progestin dienogest 3 mg, EV=estradiol valerate 2 mg, and placebo), followed by an open-label phase in which all patients received Climodien 2/2 (estradiol valerate 2 mg+dienogest 2 mg). Both the double-blind and the open-label phase lasted 2 months. ERPs were recorded from 19 EEG leads in a two-tone odd-ball paradigm in 49 patients aged between 46 and 67 yr with the diagnosis of insomnia (G 47.0) related to postmenopausal syndrome (N 95.1). Climodien reduced standard N1 and target P300 latencies as compared to placebo, while EV did not affect N1 latency but similarly reduced P300 latency. Climodien increased N1, P2 and P300 amplitudes dose-dependently, predominantly at frontal leads. Estrogen alone had only minor effects on ERP amplitudes. The shortening of standard N1 latency and enhancement of N1 and P2 amplitudes indicates a positive effect of Climodien on perceptual processing, most likely due to vigilance improvements also observed in EEG mapping. Concerning target P300, it seems that estradiol is responsible for the improvement in stimulus evaluation time, as reflected by the shortening of the peak latency, while dienogest seems to account for the improvement in cognitive information processing capacity, whereby 3 mg induced a more pronounced augmentation of P300 amplitudes than 2 mg. Based on the spatial distribution of this increase, it can be speculated that Climodien mainly affects the more frontally distributed P3a subcomponent, which is associated with attention and orientation. Furthermore, the observed changes in ERP-components are consistent with recent studies showing significant positive effects of hormone replacement therapy on cholinergic functions. Thus, Climodien seems to be of interest in preventing cognitive decline and treating cognitive disorders in postmenopausal women. Indeed, there is increasing evidence of beneficial effects of estrogen in dementia. Our present findings suggest that the estrogen effects may be augmented by dienogest.

Upregulation of the secretory-type Na(+)/K(+)/2Cl(-)-cotransporter in the kidney by metabolic acidosis and dehydration in rats

The functional role and mechanisms of regulation of the Na(+)/K(+)/2Cl(-)-cotransporter NKCC1 in the kidney have not yet been clarified. NKCC1 mRNA and protein expression in control rats, rats with dehydration (2 d), and rats with metabolic acidosis (NH(4)Cl in the food for 6 to 7 d) was examined using reverse transcription-PCR and Western blotting. In contrast to the abundant NKCC1 mRNA expression in the terminal inner medullary collecting ducts in mice, expression was found to be most abundant in the outer medullary collecting ducts (OMCD) in rats. Dehydration and metabolic acidosis increased NKCC1 mRNA expression three- to fivefold not only in the OMCD but also in the cortical collecting ducts and inner medullary collecting ducts. Dehydration and metabolic acidosis increased NKCC1 protein expression twofold in the membrane fraction from the outer medulla. NKCC1 protein expression was observed not in the microdissected medullary thick ascending limbs but in the OMCD, and it was stimulated twofold by dehydration and metabolic acidosis. Incubation of OMCD in low-pH medium increased NKCC1 mRNA expression. In summary, NKCC1 mRNA and protein expression is upregulated with dehydration and metabolic acidosis. NKCC1 may play an important role in adaptation to these physiologic conditions. Low pH and possibly hypertonicity stimulate NKCC1 mRNA expression in OMCD.

Efficacy of nicergoline in dementia and other age associated forms of cognitive impairment

BACKGROUND

Nicergoline is an ergot derivative currently in use in over fifty countries for more than three decades, for the treatment of cognitive, affective, and behavioral disorders of older people. It was initially considered as a vasoactive drug and mainly prescribed for cerebrovascular disorders. Recent findings suggest other actions which has provided a rationale for the use of nicergoline for the treatment of various forms of dementia, including Alzheimer's Disease.

OBJECTIVES

To determine whether there is evidence of efficacy of nicergoline in the treatment of dementia and other age-associated forms of cognitive decline,and to assess the safety and tolerability of the drug.

SEARCH STRATEGY

1. Electronic databases search. The Cochrane Controlled Trials Register (which contains citations from the MEDLINE, EMBASE, Psych LIT, and hand searches of geriatric, dementia, psychogeriatric journals, and conference abstracts) was searched using the following terms: 'Nicergoline', 'Sermion'. 2. Reference search. The reference lists of all obtained studies was checked. 3. Pharmaceutical company Pharmacia & Upjohn, owners of the rights to produce and market nicergoline in various different countries, was asked to provide data and reports of clinical trials. In case of unavailability of numerical data in published studies, the authors of each paper, were asked for any published or unpublished data.

SELECTION CRITERIA

- All unconfounded, double-blind, randomized, placebo-controlled, published and unpublished trials were sought. Non-randomized trials were excluded. Open trials were considered for inclusion if patients were randomized to the different treatment groups. - All patients diagnosed as having dementia or other cognitive disorder defined according to classification criteria accepted at the time of each study. - Nicergoline given at any dose for more than one day with placebo control. Type of outcome variables: 1. Cognitive function (as measured by psychometric tests). 2. Clinical impression (such as CIBIC or other clinical global measures of change). 3. Functional performance including dependency. 4. Behavioural disturbance. 5. Safety and acceptability as measured by the incidence of adverse effects (including side-effects) leading to withdrawal. 6. Death 7. Effect on carer 8. Use of services 9. Quality of life.

DATA COLLECTION AND ANALYSIS

A comprehensive search of the international literature and the producing company archives has been performed to identify all possible sources of data for this review. Only those trials fulfilling the inclusion criteria of belonging to either category A or B of allocation concealment, as defined by the Cochrane Organisation, were examined for data extraction by one reviewer. If there was doubt then the other reviewer was consulted. Data availability restricted analyses to 'completers' analyses for the outcome measures. Outcomes able to be assessed included: Behaviour, Cognition, Clinical Judgment, Tolerability, EEG.

MAIN RESULTS

The Sandoz Clinical Assessment Geriatric Scale (SCAG) was the outcome used in the largest number of patients (814 patients). The results from these studies were homogeneous in nature despite including patients observed for periods of time ranging from 2 months to 12 months. There was a difference in favour of the active treatment in reducing the behavioural symptoms described by this scale, -5.18 points [-8.03, -2.33]. This scale has a maximum of 133 points. The therapeutic effects of nicergoline seem to be evident by 2 months of treatment and maintained for 6 months. In general other behavioural outcome measures which include the GRS, the IADL, and the MACC and were episodically used in few studies, failed to demonstrate statistically significant results although there was a trend favouring treatment. Cognitive assessment has been performed in a moderate number of patients with the MMSE (261 patients) and the ADAS-Cog (342 patients). No significant heterogeneity was found for these trials, despite the trials extending over periods of treatment of 3 to 12 months. There was a difference between treatment and control groups on the MMSE favouring nicergoline treatment. At 12 months the effect size was 2.86 [0.98, 4.74] The effect size for the ADAS-Cog, used exclusively with Alzheimer's disease patients, did not reveal a significant benefit. At 12 months the trend favoured treatment (-1.64 [-4.62, 1.34]). The other results from various cognitive measures tended to favour nicergoline but this was based on a small number of cases. The clinical impression of change obtained from a total of 921 patients was homogeneous across the studies, despite reflecting changes over periods of time ranging from 2 to 12 months. The Peto odd ratio for improvement in the subjects treated with nicergoline over these varying time periods was 3.33 [2.50, 4.43]. Tolerability assessed in 1427 patients was homogeneous across all studies and demonstrated a mildly increased risk of adverse events on treatment, OR 1.51[1.10, 2.07].

REVIEWER'S CONCLUSIONS

The clinical studies on nicergoline were carried out with diverse criteria and modalities of evaluation. Despite this, the 14 studies included in this review, have presented generally consistent results. Results of this meta-analysis provide some evidence of positive effects of nicergoline on cognition and behaviour and these effects are supported by an effect on clinical global impression. There was some evidence that there were increased risk of adverse effects associated with nicergoline. These results were obtained on older patients with mild to moderate cognitive and behavioural impairment of various clinical origins, including chronic cerebrovascular disorders and Alzheimer's dementia. The few studies specifically performed on patients with Alzheimer's disease were performed with too few people to give a definitive answer to the questions concerning the use of nicergoline for this form of dementia. This drug has not been evaluated using current diagnostic categories such as MCI or in association with therapeutic agents of different nature such as cholinesterase or antioxidant drugs.

Vascular dementia, a new beginning: shifting focus from clinical phenotype to ischemic brain injury

Dementia may result from complete or incomplete infarction of brain regions subserving memory and cognition. Several effective treatments reduce the risk of initial and recurrent stroke. Presumably, these interventions reduce the risk of vascular cognitive impairment. Incomplete infarction caused by recurrent, chronic, or subclinical ischemia appears to represent another important cause of ischemic brain injury, but has been relatively neglected. A shift in focus from the serendipitous clinical phenotype of vascular dementia to preventing and ameliorating the broad spectrum of ischemic brain injury is recommended.