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Holmgren S, Andersson T, Berglund A, Aarsland D, Cummings J, Freund-Levi Y. Neuropsychiatric Symptoms in Dementia: Considering a Clinical Role for Electroencephalography. J Neuropsychiatry Clin Neurosci 2022; 34:214-223. [PMID: 35306829 PMCID: PMC9357098 DOI: 10.1176/appi.neuropsych.21050135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Degenerative dementia is characterized by progressive cognitive decline and neuropsychiatric symptoms. People with Alzheimer's disease (AD), the most common cause of dementia, show synaptic loss and disruption of functional brain networks along with neuritic plaques and neurofibrillary tangles. Electroencephalography (EEG) directly reflects synaptic activity, and among patients with AD it is associated with slowing of background activity. The purpose of this study was to identify associations between neuropsychiatric symptoms and EEG in patients with dementia and to determine whether EEG parameters could be used for clinical assessment of pharmacological treatment of neuropsychiatric symptoms in dementia (NPSD) with galantamine or risperidone. METHODS Seventy-two patients with EEG recordings and a score ≥10 on the Neuropsychiatric Inventory (NPI) were included. Clinical assessments included administration of the NPI, the Mini-Mental State Examination (MMSE), and the Cohen-Mansfield Agitation Inventory (CMAI). Patients underwent EEG examinations at baseline and after 12 weeks of treatment with galantamine or risperidone. EEG frequency analysis was performed. Correlations between EEG and assessment scale scores were statistically examined, as were EEG changes from baseline to the week 12 visit and the relationship with NPI, CMAI, and MMSE scores. RESULTS Significant correlations were found between NPI agitation and delta EEG frequencies at baseline and week 12. No other consistent and significant relationships were observed between NPSD and EEG at baseline, after NPSD treatment, or in the change in EEG from baseline to follow-up. CONCLUSIONS The limited informative findings in this study suggest that there exists a complex relationship between NPSD and EEG; hence, it is difficult to evaluate and use EEG for clinical assessment of pharmacological NPSD treatment.
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Affiliation(s)
- Simon Holmgren
- Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Clinical Geriatrics, Karolinska Institutet, Stockholm (Holmgren, Aarsland, Freund-Levi); Department of Neurophysiology, Karolinska University Hospital, Huddinge, Sweden (Andersson); Department of Clinical Neuroscience, Karolinska Institutet, Stockholm (Berglund); Institute of Psychiatry, Psychology and Neuroscience, Division of Old Age Psychiatry, Kings College London (Aarsland, Freund-Levi); Centre for Age-Related Medicine, Stavanger University Hospital, Stavanger, Norway (Aarsland); Chambers-Grundy Center for Transformative Neuroscience, Department of Brain Health, School of Integrated Health Science, University of Nevada, Las Vegas (Cummings); Department of Psychiatry and Geriatrics, University Hospital Örebro, Sweden (Freund-Levi); and School of Medical Sciences, Örebro University, Sweden (Freund-Levi)
| | - Thomas Andersson
- Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Clinical Geriatrics, Karolinska Institutet, Stockholm (Holmgren, Aarsland, Freund-Levi); Department of Neurophysiology, Karolinska University Hospital, Huddinge, Sweden (Andersson); Department of Clinical Neuroscience, Karolinska Institutet, Stockholm (Berglund); Institute of Psychiatry, Psychology and Neuroscience, Division of Old Age Psychiatry, Kings College London (Aarsland, Freund-Levi); Centre for Age-Related Medicine, Stavanger University Hospital, Stavanger, Norway (Aarsland); Chambers-Grundy Center for Transformative Neuroscience, Department of Brain Health, School of Integrated Health Science, University of Nevada, Las Vegas (Cummings); Department of Psychiatry and Geriatrics, University Hospital Örebro, Sweden (Freund-Levi); and School of Medical Sciences, Örebro University, Sweden (Freund-Levi)
| | - Anders Berglund
- Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Clinical Geriatrics, Karolinska Institutet, Stockholm (Holmgren, Aarsland, Freund-Levi); Department of Neurophysiology, Karolinska University Hospital, Huddinge, Sweden (Andersson); Department of Clinical Neuroscience, Karolinska Institutet, Stockholm (Berglund); Institute of Psychiatry, Psychology and Neuroscience, Division of Old Age Psychiatry, Kings College London (Aarsland, Freund-Levi); Centre for Age-Related Medicine, Stavanger University Hospital, Stavanger, Norway (Aarsland); Chambers-Grundy Center for Transformative Neuroscience, Department of Brain Health, School of Integrated Health Science, University of Nevada, Las Vegas (Cummings); Department of Psychiatry and Geriatrics, University Hospital Örebro, Sweden (Freund-Levi); and School of Medical Sciences, Örebro University, Sweden (Freund-Levi)
| | - Dag Aarsland
- Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Clinical Geriatrics, Karolinska Institutet, Stockholm (Holmgren, Aarsland, Freund-Levi); Department of Neurophysiology, Karolinska University Hospital, Huddinge, Sweden (Andersson); Department of Clinical Neuroscience, Karolinska Institutet, Stockholm (Berglund); Institute of Psychiatry, Psychology and Neuroscience, Division of Old Age Psychiatry, Kings College London (Aarsland, Freund-Levi); Centre for Age-Related Medicine, Stavanger University Hospital, Stavanger, Norway (Aarsland); Chambers-Grundy Center for Transformative Neuroscience, Department of Brain Health, School of Integrated Health Science, University of Nevada, Las Vegas (Cummings); Department of Psychiatry and Geriatrics, University Hospital Örebro, Sweden (Freund-Levi); and School of Medical Sciences, Örebro University, Sweden (Freund-Levi)
| | - Jeffrey Cummings
- Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Clinical Geriatrics, Karolinska Institutet, Stockholm (Holmgren, Aarsland, Freund-Levi); Department of Neurophysiology, Karolinska University Hospital, Huddinge, Sweden (Andersson); Department of Clinical Neuroscience, Karolinska Institutet, Stockholm (Berglund); Institute of Psychiatry, Psychology and Neuroscience, Division of Old Age Psychiatry, Kings College London (Aarsland, Freund-Levi); Centre for Age-Related Medicine, Stavanger University Hospital, Stavanger, Norway (Aarsland); Chambers-Grundy Center for Transformative Neuroscience, Department of Brain Health, School of Integrated Health Science, University of Nevada, Las Vegas (Cummings); Department of Psychiatry and Geriatrics, University Hospital Örebro, Sweden (Freund-Levi); and School of Medical Sciences, Örebro University, Sweden (Freund-Levi)
| | - Yvonne Freund-Levi
- Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Clinical Geriatrics, Karolinska Institutet, Stockholm (Holmgren, Aarsland, Freund-Levi); Department of Neurophysiology, Karolinska University Hospital, Huddinge, Sweden (Andersson); Department of Clinical Neuroscience, Karolinska Institutet, Stockholm (Berglund); Institute of Psychiatry, Psychology and Neuroscience, Division of Old Age Psychiatry, Kings College London (Aarsland, Freund-Levi); Centre for Age-Related Medicine, Stavanger University Hospital, Stavanger, Norway (Aarsland); Chambers-Grundy Center for Transformative Neuroscience, Department of Brain Health, School of Integrated Health Science, University of Nevada, Las Vegas (Cummings); Department of Psychiatry and Geriatrics, University Hospital Örebro, Sweden (Freund-Levi); and School of Medical Sciences, Örebro University, Sweden (Freund-Levi)
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Bloniecki V, Zetterberg H, Aarsland D, Vannini P, Kvartsberg H, Winblad B, Blennow K, Freund-Levi Y. Are neuropsychiatric symptoms in dementia linked to CSF biomarkers of synaptic and axonal degeneration? ALZHEIMERS RESEARCH & THERAPY 2020; 12:153. [PMID: 33203439 PMCID: PMC7670701 DOI: 10.1186/s13195-020-00718-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 10/29/2020] [Indexed: 01/12/2023]
Abstract
Background The underlying disease mechanism of neuropsychiatric symptoms (NPS) in dementia remains unclear. Cerebrospinal fluid (CSF) biomarkers for synaptic and axonal degeneration may provide novel neuropathological information for their occurrence. The aim was to investigate the relationship between NPS and CSF biomarkers for synaptic (neurogranin [Ng], growth-associated protein 43 [GAP-43]) and axonal (neurofilament light [NFL]) injury in patients with dementia. Methods A total of 151 patients (mean age ± SD, 73.5 ± 11.0, females n = 92 [61%]) were included, of which 64 had Alzheimer’s disease (AD) (34 with high NPS, i.e., Neuropsychiatric Inventory (NPI) score > 10 and 30 with low levels of NPS) and 18 were diagnosed with vascular dementia (VaD), 27 with mixed dementia (MIX), 12 with mild cognitive impairment (MCI), and 30 with subjective cognitive impairment (SCI). NPS were primarily assessed using the NPI. CSF samples were analyzed using enzyme-linked immunosorbent assays (ELISAs) for T-tau, P-tau, Aβ1–42, Ng, NFL, and GAP-43. Results No significant differences were seen in the CSF levels of Ng, GAP-43, and NFL between AD patients with high vs low levels of NPS (but almost significantly decreased for Ng in AD patients < 70 years with high NPS, p = 0.06). No significant associations between NPS and CSF biomarkers were seen in AD patients. In VaD (n = 17), negative correlations were found between GAP-43, Ng, NFL, and NPS. Conclusion Our results could suggest that low levels of Ng may be associated with higher severity of NPS early in the AD continuum (age < 70). Furthermore, our data may indicate a potential relationship between the presence of NPS and synaptic as well as axonal degeneration in the setting of VaD pathology.
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Affiliation(s)
- Victor Bloniecki
- Department of Neurobiology, Caring Sciences and Society (NVS), Division of Clinical Geriatrics, Karolinska Institutet, Stockholm, Sweden. .,Department of Dermatology, Karolinska University Hospital, Solna, Sweden.
| | - Henrik Zetterberg
- Institute of Neuroscience and Physiology, Department of Psychiatry and Neurochemistry, Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,UK Dementia Research Institute at UCL, London, UK.,Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK
| | - Dag Aarsland
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,Center for Age-Related Diseases, Stavanger University Hospital, Stavanger, Norway
| | - Patrizia Vannini
- Center for Alzheimer Research and Treatment, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Hlin Kvartsberg
- Institute of Neuroscience and Physiology, Department of Psychiatry and Neurochemistry, Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Bengt Winblad
- Department of Neurobiology, Caring Sciences and Society (NVS), Division of Neurogeriatrics, Karolinska Institutet, Stockholm, Sweden.,Theme Aging, Karolinska University Hospital, Huddinge, Sweden
| | - Kaj Blennow
- Institute of Neuroscience and Physiology, Department of Psychiatry and Neurochemistry, Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Yvonne Freund-Levi
- Department of Neurobiology, Caring Sciences and Society (NVS), Division of Clinical Geriatrics, Karolinska Institutet, Stockholm, Sweden.,Department of Psychiatry in Region Örebro County and School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.,Department of Old Age Psychiatry, Psychology & Neuroscience, King's College London, London, UK
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Phan SV, Osae S, Morgan JC, Inyang M, Fagan SC. Neuropsychiatric Symptoms in Dementia: Considerations for Pharmacotherapy in the USA. Drugs R D 2019; 19:93-115. [PMID: 31098864 PMCID: PMC6544588 DOI: 10.1007/s40268-019-0272-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Dementia affects all domains of cognition. The relentless progression of the disease after diagnosis is associated with a 98% incidence of neuropsychiatric symptoms (NPS) at some point in the disease, including depression, psychosis, agitation, aggression, apathy, sleep disturbances, and disinhibition. These symptoms can be severe and lead to excess morbidity and mortality. The purpose of this article was to describe current literature on the medication management of NPS of dementia and highlight approaches to and concerns about the pharmacological treatment of NPS in the USA. Guidelines and expert opinion favor nonpharmacologic management of NPS as first-line management. Unfortunately, lack of adequate caregiver training and a high failure rate eventually result in the use of psychotropic agents in patients with dementia. Various psychotropic medications have been studied, although how they should be used in the management of NPS remains unclear. A systematic approach to evaluation, treatment, and monitoring, along with careful documentation and evidenced-based agent and dose selection, is likely to reduce risk and improve patient outcomes. Considerations should be given to the NPS presentation, including type, frequency, and severity, when weighing the risks and benefits of initiating, continuing, or discontinuing psychotropic management. Use of antidepressants, sedative/hypnotics, antipsychotics, and antiepileptic agents should include a clear and documented analysis of risk and benefit in a given patient with dementia.
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Affiliation(s)
- Stephanie V Phan
- Clinical and Administrative Pharmacy, College of Pharmacy, University of Georgia, Southwest Georgia Clinical Campus, Albany, GA, USA.
| | - Sharmon Osae
- Clinical and Administrative Pharmacy, College of Pharmacy, University of Georgia, Southwest Georgia Clinical Campus, Albany, GA, USA
| | - John C Morgan
- Memory Disorders Program, Department of Neurology, Augusta University, Augusta, GA, USA
| | - Mfon Inyang
- Phoebe Putney Memorial Hospital, Albany, GA, USA
| | - Susan C Fagan
- Memory Disorders Program, Department of Neurology, Augusta University, Augusta, GA, USA.,Clinical and Administrative Pharmacy, College of Pharmacy, University of Georgia, Augusta, GA, USA.,Program in Clinical and Experimental Therapeutics, College of Pharmacy, University of Georgia, Augusta, GA, USA
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Kongpakwattana K, Sawangjit R, Tawankanjanachot I, Bell JS, Hilmer SN, Chaiyakunapruk N. Pharmacological treatments for alleviating agitation in dementia: a systematic review and network meta-analysis. Br J Clin Pharmacol 2018; 84:1445-1456. [PMID: 29637593 PMCID: PMC6005613 DOI: 10.1111/bcp.13604] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 03/28/2018] [Accepted: 03/28/2018] [Indexed: 12/18/2022] Open
Abstract
AIMS To determine the most efficacious and acceptable treatments of agitation in dementia. METHODS MEDLINE, EMBASE, PsycINFO, CENTRAL and clinicaltrials.gov were searched up to 7 February 2017. Two independent reviewers selected randomized controlled trials (RCTs) of treatments to alleviate agitation in people with all-types dementia. Data were extracted using standardized forms and study quality was assessed using the revised Cochrane Risk of Bias Tool for RCTs. Data were pooled using meta-analysis. The primary outcome, efficacy, was 8-week response rates defined as a 50% reduction in baseline agitation score. The secondary outcome was treatment acceptability defined as treatment continuation for 8 weeks. RESULTS Thirty-six RCTs comprising 5585 participants (30.9% male; mean ± standard deviation age, 81.8 ± 4.9 years) were included. Dextromethorphan/quinidine [odds ratio (OR) 3.04; 95% confidence interval (CI), 1.63-5.66], risperidone (OR 1.96; 95% CI, 1.49-2.59) and selective serotonin reuptake inhibitors as a class (OR 1.61; 95% CI, 1.02-2.53) were found to be significantly more efficacious than placebo. Haloperidol appeared less efficacious than nearly all comparators. Most treatments had noninferior treatment continuation compared to placebo, except oxcarbazepine, which was inferior. Findings were supported by subgroup and sensitivity analyses. CONCLUSIONS Risperidone, serotonin reuptake inhibitors as a class and dextromethorphan/quinidine demonstrated evidence of efficacy for agitation in dementia, although findings for dextromethorphan/quinidine were based on a single RCT. Our findings do not support prescribing haloperidol due to lack of efficacy, or oxcarbazepine due to lack of acceptability. The decision to prescribe should be based on comprehensive consideration of the benefits and risks, including those not evaluated in this meta-analysis.
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Affiliation(s)
| | - Ratree Sawangjit
- Clinical Trials and Evidence Base Syntheses Research Unit (CTEBs RU), Department of Clinical Pharmacy, Faculty of PharmacyMahasarakham UniversityMahasarakhamThailand
| | - Itthipol Tawankanjanachot
- Department of Psychiatry, King Chulalongkorn Memorial Hospital, Faculty of MedicineChulalongkorn UniversityBangkokThailand
| | - J. Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical SciencesMonash UniversityAustralia
| | - Sarah N. Hilmer
- Kolling Institute of Medical ResearchRoyal North Shore Hospital and University of SydneySt LeonardsNSWAustralia
| | - Nathorn Chaiyakunapruk
- School of PharmacyMonash University MalaysiaSelangorMalaysia
- Center of Pharmaceutical Outcomes Research (CPOR), Department of Pharmacy Practice, Faculty of Pharmaceutical SciencesNaresuan UniversityPhitsanulokThailand
- Asian Centre for Evidence Synthesis in Population, Implementation and Clinical Outcomes (PICO), Health and Well‐being Cluster, Global Asia in the 21st Century (GA21) PlatformMonash University MalaysiaBandar SunwaySelangorMalaysia
- School of PharmacyUniversity of WisconsinMadisonUSA
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Optimizing Care for Older Adults With Dementia-Associated Psychosis. J Nurse Pract 2018. [DOI: 10.1016/j.nurpra.2017.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Farlow MR, Shamliyan TA. Benefits and harms of atypical antipsychotics for agitation in adults with dementia. Eur Neuropsychopharmacol 2017; 27:217-231. [PMID: 28111239 DOI: 10.1016/j.euroneuro.2017.01.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 11/13/2016] [Accepted: 01/05/2017] [Indexed: 01/12/2023]
Abstract
We evaluated the most current evidence regarding the benefits and harms of atypical antipsychotics in adults with dementia. In June 2016, following a protocol developed a priori, we systematically searched several databases for published and unpublished data from randomized controlled trials (RCT), observational studies, and meta-analyses; conducted direct meta-analyses using a random effects model; and graded the quality of evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) working group. One high-quality meta-analysis and published and unpublished data from 8 RCTs and 12 large observational studies met inclusion criteria. When compared with placebo, aripiprazole, risperidone, and olanzapine but not quetiapine result in modest (standardized mean difference <0.5 standard deviations) improvement in neuropsychiatric symptoms. Aripiprazole, risperidone, quetiapine, and olanzapine are associated with increased odds of acute myocardial infraction, and risperidone and olanzapine are associated with increased odds of hip fracture. Observational studies suggest no differences in all-cause mortality between atypical antipsychotics. Observational studies suggest that atypical antipsychotics are associated with lower risk of all-cause mortality and extrapyramidal symptoms but higher risk of stroke when compared with conventional antipsychotics. To manage agitation in adults with progressive dementia, clinicians may recommend atypical antipsychotics with continuous monitoring of behavioral symptoms, informing patients and their families or caregivers of the significant risk of adverse effects and baseline risk of acute myocardial infraction and bone fractures.
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Affiliation(s)
- Martin R Farlow
- Department of Neurology, IU Alzheimer׳s Disease and Related Disorders, 355 W. 16th Street, Suite 4700, Indianapolis, IN 46202, USA.
| | - Tatyana A Shamliyan
- Evidence-Based Medicine Quality Assurance, Elsevier, 1600 JFK Blvd 20th floor, Philadelphia, PA 19103, USA.
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Abstract
PURPOSE OF REVIEW The present article addresses intriguing questions related to the clinical intervention in distinct neuropsychiatric syndromes of patients with dementia. RECENT FINDINGS We reviewed 154 articles published between 2015 and 2016 targeting psychopharmacological and nonpharmacological interventions, and safety-tolerability concerns. We selected 115 articles addressing the purpose of this study. Of these, 33 were chosen because they were dedicated to subtopics: agitation (42), depression (33), apathy (18), sleep disorders/anxiety (8), and psychosis (4). Clinical studies using both pharmacological (70) and nonpharmacological (37) interventions were considered; others were included for theoretical support. Regarding the methodological design, we found double-blind RCTs (17), single-blinded RCTs (4), open-label studies (18), case reports (5), cross-sectional or cohort studies (25), epidemiological papers (2), and expert reviews (44). This observation raises concerns about the overall methodological adequacy of a substantial proportion of studies in this field, which limits the potential of generalization of the findings. Finally, 18 studies were designed to determine safety-tolerability issues of psychotropic medications (6 were discussed). SUMMARY Effective and well tolerated treatment of neuropsychiatric syndromes in dementia remains a critically unsolved challenge. We understand that this is an extremely important area of research, and critically required to guide clinical decisions in geriatric neuropsychiatry.
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Greenblatt HK, Greenblatt DJ. Use of Antipsychotics for the Treatment of Behavioral Symptoms of Dementia. J Clin Pharmacol 2016; 56:1048-57. [PMID: 26953213 DOI: 10.1002/jcph.731] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 02/29/2016] [Indexed: 01/08/2023]
Abstract
Antipsychotic medications are widely used in the management of behavioral and psychological symptoms of dementia. While nonpharmacological interventions should be the first-line treatment for behavioral symptoms of dementia, these are often unfeasible and/or ineffective. Conventional and atypical antipsychotic agents appear to have modest to moderate clinical efficacy in the treatment of these symptoms, though it is unclear which individual agents are most effective. No conclusive evidence exists that any available alternative medications are safer and more effective than antipsychotics. A number of studies have shown an increased risk of mortality associated with antipsychotics in patients with behavioral symptoms of dementia, though the observed risk increase may be partially confounded by illness severity and/or preexisting health determinants. The mechanisms of increased mortality risk are not fully established, but are likely to involve cardiovascular events. It is probable, though not certain, that conventional antipsychotics are associated with a greater number of poor outcomes than atypical antipsychotics. In certain patients with refractory behavioral symptoms, antipsychotics are a viable treatment option. Key considerations for antipsychotic prescribing for this population are published in regulatory guidelines, and include minimization of dosage and duration of treatment, continuous reevaluation of symptoms, and involvement of caregivers.
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Affiliation(s)
- H Karl Greenblatt
- Program in Pharmacology and Experimental Therapeutics, Sackler School of Graduate Biomedical Sciences, Tufts University School of Medicine, Boston, MA, USA
| | - David J Greenblatt
- Program in Pharmacology and Experimental Therapeutics, Sackler School of Graduate Biomedical Sciences, Tufts University School of Medicine, Boston, MA, USA
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Panza F, Solfrizzi V, Seripa D, Imbimbo BP, Santamato A, Lozupone M, Prete C, Greco A, Pilotto A, Logroscino G. Progresses in treating agitation: a major clinical challenge in Alzheimer's disease. Expert Opin Pharmacother 2015; 16:2581-8. [PMID: 26389682 DOI: 10.1517/14656566.2015.1092520] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Treatment of neuropsychiatric symptoms (NPS) represents a major clinical challenge in Alzheimer's disease (AD). Agitation and aggression are frequently seen during institutionalization and increase patient morbidity and mortality and caregiver burden. Off-label use of atypical antipsychotics for treating agitation in AD showed only modest clinical benefits, with high side-effect burden and risk of mortality. Non-pharmacological treatment approaches have become the preferred first-line option. When such treatment fails, pharmacological options are often used. Therefore, there is an urgent need to identify effective and safe pharmacological treatments for efficiently treating agitation and aggression in AD and dementia. AREAS COVERED Emerging evidence on the neurobiological substrates of agitation in AD has led to several recent clinical trials of repositioned and novel therapeutics for these NPS in dementia as an alternative to antipsychotics. We operated a comprehensive literature search for published articles evaluating pharmacological interventions for agitation in AD, with a review of recent clinical trials on mibampator, dextromethorphan/quinidine, cannabinoids, and citalopram. EXPERT OPINION Notwithstanding the renewed interest for the pharmacological treatment of agitation in AD, progresses have been limited. A small number and, sometimes methodologically questionable, randomized controlled trials (RCTs) have produced disappointing results. However, recently completed RCTs on novel or repositioned drugs (mibampator, dextromethorphan/quinidine, cannabinoids, and citalopram) showed some promise in treating agitation in AD, but still with safety concerns. Further evidence will come from ongoing Phase II and III trials on promising novel drugs for treating these distressing symptoms in patients with AD and dementia.
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Affiliation(s)
- Francesco Panza
- a 1 University of Bari Aldo Moro, Neurodegenerative Disease Unit, Department of Basic Medicine, Neuroscience, and Sense Organs , Bari, Italy , .,b 2 University of Bari Aldo Moro, Department of Clinical Research in Neurology, "Pia Fondazione Cardinale G. Panico" , Tricase, Lecce, Italy.,c 3 Geriatric Unit & Laboratory of Gerontology and Geriatrics, Department of Medical Sciences, IRCCS "Casa Sollievo della Sofferenza" , San Giovanni Rotondo, Foggia, Italy
| | - Vincenzo Solfrizzi
- d 4 University of Bari Aldo Moro, Geriatric Medicine-Memory Unit and Rare Disease Centre , Bari, Italy
| | - Davide Seripa
- c 3 Geriatric Unit & Laboratory of Gerontology and Geriatrics, Department of Medical Sciences, IRCCS "Casa Sollievo della Sofferenza" , San Giovanni Rotondo, Foggia, Italy
| | - Bruno P Imbimbo
- e 5 Research & Development Department, Chiesi Farmaceutici , Parma, Italy
| | - Andrea Santamato
- f 6 University of Foggia, Physical Medicine and Rehabilitation Section, "OORR" Hospital , Foggia, Italy
| | - Madia Lozupone
- a 1 University of Bari Aldo Moro, Neurodegenerative Disease Unit, Department of Basic Medicine, Neuroscience, and Sense Organs , Bari, Italy ,
| | - Camilla Prete
- g 7 Geriatrics Unit, Department of OrthoGeriatrics, Rehabilitation and Stabilization, Frailty Area, Galliera Hospital NR-HS , Genova, Italy
| | - Antonio Greco
- c 3 Geriatric Unit & Laboratory of Gerontology and Geriatrics, Department of Medical Sciences, IRCCS "Casa Sollievo della Sofferenza" , San Giovanni Rotondo, Foggia, Italy
| | - Alberto Pilotto
- g 7 Geriatrics Unit, Department of OrthoGeriatrics, Rehabilitation and Stabilization, Frailty Area, Galliera Hospital NR-HS , Genova, Italy
| | - Giancarlo Logroscino
- a 1 University of Bari Aldo Moro, Neurodegenerative Disease Unit, Department of Basic Medicine, Neuroscience, and Sense Organs , Bari, Italy , .,b 2 University of Bari Aldo Moro, Department of Clinical Research in Neurology, "Pia Fondazione Cardinale G. Panico" , Tricase, Lecce, Italy
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Holmgren S, Hjorth E, Schultzberg M, Lärksäter M, Frenkel D, Tysen-Bäckström AC, Aarsland D, Freund-Levi Y. Neuropsychiatric symptoms in dementia—A role for neuroinflammation? Brain Res Bull 2014; 108:88-93. [DOI: 10.1016/j.brainresbull.2014.09.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 09/02/2014] [Accepted: 09/04/2014] [Indexed: 10/24/2022]
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Bloniecki V, Aarsland D, Cummings J, Blennow K, Freund-Levi Y. Agitation in dementia: relation to core cerebrospinal fluid biomarker levels. Dement Geriatr Cogn Dis Extra 2014; 4:335-43. [PMID: 25298777 PMCID: PMC4176467 DOI: 10.1159/000363500] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background The objective of this study was to examine the associations of agitation with the cerebrospinal fluid dementia biomarkers total-tau (T-tau), phosphorylated-tau (P-tau) and Aβ1-42. Methods One hundred patients (mean age ± SD, 78.6 ± 7.5 years) with dementia and neuropsychiatric symptoms, of whom 67% were female, were included. Agitation was measured using the Cohen-Mansfield Agitation Inventory (CMAI; 46.5 ± 11.8 points). Results Total CMAI correlated with T-tau [rs (31) = 0.36, p = 0.04] and P-tau [rs (31) = 0.35, p = 0.05] in patients with Alzheimer's disease (AD; n = 33) but not in the total dementia population (n = 95). Conclusions Our results suggest that tau-mediated pathology including neurofibrillary tangles and the intensity of the disease process might be associated with agitation in AD.
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Affiliation(s)
- Victor Bloniecki
- Division of Clinical Geriatrics, Karolinska University Hospital Huddinge, Stockholm, Mölndal, Sweden
| | - Dag Aarsland
- Center for Alzheimer Research, Division for Neurogeriatrics, Department of Neurobiology, Caring Sciences and Society (NVS), Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Mölndal, Sweden ; Clinical Neurochemistry Laboratory, Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska University Hospital, The Sahlgrenska Academy at University of Gothenburg, Mölndal, Sweden
| | - Jeffrey Cummings
- Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, Nev., USA
| | - Kaj Blennow
- Clinical Neurochemistry Laboratory, Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska University Hospital, The Sahlgrenska Academy at University of Gothenburg, Mölndal, Sweden
| | - Yvonne Freund-Levi
- Division of Clinical Geriatrics, Karolinska University Hospital Huddinge, Stockholm, Mölndal, Sweden
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