Pharmacotherapy of Alzheimer disease

The effect of electroacupuncture combined with donepezil on cognitive function in Alzheimer's disease patients: study protocol for a randomized controlled trial

Background

Alzheimer’s disease is a progressive neurodegenerative disease. Although some of the current treatments offer some symptomatic relief, this disease cannot be cured at present. Electroacupuncture may be effective for Alzheimer’s disease for cognitive function, but the evidence for its effectiveness is still limited. The aim of this study is to evaluate the add-on effect of electroacupuncture to donepezil for improving the cognitive function of Alzheimer’s disease.

Methods/design

A total of 334 participants with Alzheimer’s disease will be randomly assigned to either an electroacupuncture combined with donepezil group or a donepezil group with a ratio of 1:1. Participants in the electroacupuncture combined with donepezil group will receive electroacupuncture in addition to donepezil for 12 weeks and will keep taking donepezil for the following 24 weeks. Participants in the control group will take donepezil only. The primary outcome is the change from baseline in the total score of the Alzheimer’s Disease Assessment Scale-cognition at week 12. A follow-up will be conducted 24 weeks after the treatment.

Discussion

We expect to verify the hypothesis that acupuncture in addition to donepezil is better than donepezil in improving the cognitive function of patients with Alzheimer’s disease. This trial has a limitation that participant blinding is impossible.

Trial registration

Clinical Trials.gov: ID: NCT02305836. Registered on 13 November 2014.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2052-y) contains supplementary material, which is available to authorized users.

Chronic pre-treatment with memantine prevents amyloid-beta protein-mediated long-term potentiation disruption

Previous studies indicate that memantine, a low-affinity N-methyl-D-aspartate receptor antagonist, exerted acute protective effects against amyloid-β protein-induced neurotoxicity. In the present study, the chronic effects and mechanisms of memantine were investigated further using electrophysiological methods. The results showed that 7-day intraperitoneal application of memantine, at doses of 5 mg/kg or 20 mg/kg, did not alter hippocampal long-term potentiation induction in rats, while 40 mg/kg memantine presented potent long-term potentiation inhibition. Then further in vitro studys were carried out in 5 mg/kg and 20 mg/kg memantine treated rats. We found that 20 mg/kg memantine attenuated the potent long-term potentiation inhibition caused by exposure to amyloid-β protein in the dentate gyrus in vitro. These findings are the first to demonstrate the antagonizing effect of long-term systematic treatment of memantine against amyloid-β protein triggered long-term potentiation inhibition to improve synaptic plasticity.

[Virtual reality for clinical assessment of elderly people: early screening for dementia]

Today, there are 24.3 million people suffering from dementia worldwide, that is a new case every 7 seconds (Ferri et al., 2005) and more than 80 million cases expected in 2040. Aging-related morbidity is a real social problem making screening a major challenge. Currently, screening and diagnostic tools for dementia remain independent from each other, screening tools being non-specific and diagnostic tools non-naturalistic. With the technological possibilities offered by virtual reality, it is becoming easier to investigate cognition and behavior in elderly people. Virtual reality allows a better understanding and assessment, and perhaps could stimulate cognitive functioning of elderly people. Combining measurements of cognitive impairment and disability might help close the gap between structural and naturalistic validity.

Atividade física e sintomas neuropsiquiátricos em pacientes com demência de Alzheimer

Na demência de Alzheimer (DA) é comum a presença de sintomas neuropsiquiátricos resultantes de mudanças anatômicas e bioquímicas no cérebro. O objetivo deste estudo foi realizar uma revisão sistemática dos estudos que investigaram a relação entre atividade física e sintomas neuropsiquiátricos na DA. Efetuou-se uma pesquisa nas bases de dados: Academic Search Premier, Biological Abstracts, Medline, PsycINFO, Pubmed, Scielo, Science Direct, Sport Discus e Web of Science, utilizando-se as seguintes palavras - chave e operadores boleanos: (Neuropsychiatric disturbances OR Neuropsychiatric symptoms OR Neuropsychological disturbances OR Aberrant behavior OR Aberrant behaviour OR Behavior disturbances OR Behaviour disturbances OR Behavior management OR Behaviour management OR Disruptive behavior OR Disruptive behaviour) AND (Alzheimer) AND (Exercise OR Motor intervention OR training OR Physical activity OR fitness), além de referências cruzadas dos artigos selecionados. Foram encontrados oito estudos que preencheram os critérios de inclusão. Concluiu-se que bons resultados têm sido evidenciados para os distúrbios de agitação e sono de pacientes com DA. Entretanto então há um consenso de qual o melhor tipo de atividade para estes pacientes.

Efficacy and safety of Cerebrolysin in moderate to moderately severe Alzheimer's disease: results of a randomized, double-blind, controlled trial investigating three dosages of Cerebrolysin

BACKGROUND

cerebrolysin is a neuropeptide preparation mimicking the effects of neurotrophic factors. This subgroup analysis assessed safety and efficacy of Cerebrolysin in patients with moderate to moderately severe Alzheimer's disease (AD) (ITT data set: N = 133; MMSE: 14-20) included in a dose-finding study (ITT data set: N = 51; MMSE: 14-25). Results of the mild AD subgroup (ITT data set: N = 118; MMSE: 21-25) are also presented.

METHODS

patients with AD received 100 ml IV infusions of Cerebrolysin (10, 30 or 60 ml diluted in saline; N = 32, 34 and 35, respectively) or placebo (saline; N = 32) over twelve weeks (5 days per week for 4 weeks and 2 days per week for another 8 weeks). Primary efficacy criteria ADAS-cog+ (Alzheimer's Disease Assessment Scale Cognitive Subpart Modified) and CIBIC+ (Clinical Interview-based Impression of Change with Caregiver Input) were assessed 24 weeks after baseline.

RESULTS

at week 24, Cerebrolysin improved the global clinical function significantly with all three dosages and induced significant improvements in cognition, initiation of activities of daily living (ADL) and neuropsychiatric symptoms at 10-, 30- and 60-ml doses, respectively. Treatment effects on total ADL and other secondary parameters (MMSE, Trail-making test) were not significant. Cerebrolysin was safe and well tolerated.

CONCLUSIONS

these results demonstrate the efficacy of Cerebrolysin in moderate to moderately severe AD, showing dose-specific effects similar to those reported for patients with mild to moderate AD. The benefits of Cerebrolysin in advanced AD need to be confirmed in larger trials.

Enhanced dendritic spine number of neurons of the prefrontal cortex, hippocampus, and nucleus accumbens in old rats after chronic donepezil administration

In Alzheimer's disease brains, morphological changes in the dendrites of pyramidal neurons of the prefrontal cortex (PFC) and hippocampus have been observed. These changes are particularly reflected in the decrement of both the dendritic tree and spine number. Donepezil is a potent and selective acetylcholinesterase inhibitor used in the treatment of Alzheimer's disease. We have studied the effect of oral administration of this drug on the morphology of neuronal cells from the brain of aged rats. We examined dendrites of pyramidal neurons of the PFC, dorsal or ventral hippocampus (VH), and medium spiny neurons of the nucleus accumbens (NAcc). Donepezil (1 mg/kg, vo) was administrated every day for 60 days to rats aged 10 and 18 months. Dendritic morphology was studied by the Golgi-Cox stain procedure followed by Sholl analysis at 12 and 20 months ages, respectively. In all Donepezil-treated rats, a significant increment of the dendritic spines number in pyramidal neurons of the PFC and dorsal hippocampus was observed. However, pyramidal neurons of the VH and medium spiny cells of the NAcc only showed an increase in the number of their spines in 12-month-old rats. Our results suggest that Donepezil prevents the alterations of the neuronal dendrite morphology caused by aging.

Characterization of micropatterned nanofibrous scaffolds for neural network activity readout for high-throughput screening

Micropatterns were fabricated in nanofibrous poly-L-lactic acid (PLLA) films by laser micromachining and the resulting scaffolds were characterized with respect to architecture, thermal, mechanical, and mass transport properties. Also, human neural stem cells were successfully cultured in these micropatterned nanofibrous scaffolds (MNFSs). The scaffolds were incorporated in high-density well plates (e.g., 96-well plates), creating a platform for high-throughput screening of drugs with physiologically more relevant networked neural cultures. Through mathematical modeling of the transport of model stimulants, the feasibility of stimulating neural networks cultured in MNFSs was demonstrated. More work is needed to establish biological network activity-MNFS architecture relationships.

Apple juice improved behavioral but not cognitive symptoms in moderate-to-late stage Alzheimer's disease in an open-label pilot study

Preclinical studies demonstrate that apple juice exerts multiple beneficial effects including reduction of central nervous system oxidative damage, suppression of Alzheimer's disease (AD) hallmarks, improved cognitive performance, and organized synaptic signaling. Herein, we initiated an open-label clinical trial in which 21 institutionalized individuals with moderate-to-severe AD consumed 2 4-oz glasses of apple juice daily for 1 month. Participants demonstrated no change in the Dementia Rating Scale, and institutional caregivers reported no change in Alzheimer's Disease Cooperative Study (ADCS)-Activities of Daily Living (ADL) in this brief study. However, caregivers reported an approximate 27% (P < .01) improvement in behavioral and psychotic symptoms associated with dementia as quantified by the Neuropsychiatric Inventory, with the largest changes in anxiety, agitation, and delusion. This pilot study suggests that apple juice may be a useful supplement, perhaps to augment pharmacological approaches, for attenuating the decline in mood that accompanies progression of AD, which may also reduce caregiver burden.

Cerebrolysin: a review of its use in dementia

Cerebrolysin is a parenterally administered, porcine brain-derived peptide preparation that has pharmacodynamic properties similar to those of endogenous neurotrophic factors. In several randomized, double-blind trials of up to 28 weeks' duration in patients with Alzheimer's disease, Cerebrolysin was superior to placebo in improving global outcome measures and cognitive ability. A large, randomized comparison of Cerebrolysin, donepezil or combination therapy showed beneficial effects on global measures and cognition for all three treatment groups compared with baseline. Although not as extensively studied in patients with vascular dementia, Cerebrolysin has also shown beneficial effects on global measures and cognition in this patient population. Cerebrolysin was generally well tolerated in clinical trials, with dizziness (or vertigo) being the most frequently reported adverse event. Although further studies with Cerebrolysin, including longer term trials and further exploration of its use in combination with cholinesterase inhibitors, are needed to more clearly determine its place in the management of Alzheimer's disease and vascular dementia, available data suggest that Cerebrolysin is a useful addition to the treatment options available for dementia.

Treatment effects of Memantine on language in moderate to severe Alzheimer's disease patients

BACKGROUND

Language impairment is one of the most troublesome manifestations of Alzheimer's disease (AD). The objective of this post hoc analysis was to assess the treatment effects of Memantine on language in patients with moderate to severe AD, using the recently developed Severe Impairment Battery-Language (SIB-L) scale.

METHODS

From a combined database including four Memantine clinical trials in moderate-to-severe AD, we analyzed 801 patients with SIB-L scores of <38 and Mini-Mental State Examination scores of <15. Patients were treated with either 20 mg Memantine per day or placebo. Mean changes in SIB-L scores from baseline were calculated. For responder analyses, a change in SIB-L score greater than or equal to the SIB-L measurement error of 3.7 points was considered a clinically relevant response.

RESULTS

The mean change from baseline in SIB-L score at week 12 and weeks 24/28 (study end) significantly favored Memantine over placebo treatment (P < .0001 and P = .0182, respectively). Overall, more Memantine-treated patients than placebo-treated patients benefited from treatment. The effect was especially pronounced in patients with substantial language impairment on the SIB-L (baseline score, <or=20). At weeks 24/28, significantly more Memantine-treated patients experienced a clinically relevant improvement (25.4% vs. 10.8%, P = .0414), and significantly fewer patients experienced clinically relevant worsening (32.8% vs. 60.0%, P = .0029).

CONCLUSIONS

Memantine treatment of AD patients results in significant benefits for language function. Our results suggest that it is worth considering this therapeutic option, even for AD patients with marked language impairment.

Donepezil in the treatment of patients with Alzheimer's disease

Alzheimer's disease (AD) is the most common cause of dementia and is characterized by an insidious onset and slow deterioration in cognition, activities of daily living (ADL), mood stability and social functioning. The cholinesterase inhibitors (ChEIs), developed based on the cholinergic hypothesis, are currently considered to be the best established treatment for AD, although the significant advances in the symptomatic pharmacotherapy of AD may be followed by disease-modification treatments. Donepezil is a mixed competitive and noncompetitive acetylcholinesterase inhibitor that shows a relative selectivity for acetylcholinesterase inhibitor compared with butyrylcholinesterase. In many clinical trials of donepezil, beneficial effects on standard measures of cognitive function, ADL and behavior have been shown in patients with mild, moderate or severe AD. Although the pharmacological and phamacokinetic profiles of the currently available ChEIs have notable differences that may affect efficacy, the clinical significance of these differences remains hypothetical in the absence of large, randomized trials that compare the ChEIs with each other.

Alzheimer's disease: from pathology to therapeutic approaches

Mind how you go: The current strategies for the development of therapies for Alzheimer's disease are very diverse. Particular attention is given to the search for inhibitors (see picture for two examples) of the proteolytic enzyme beta- and gamma-secretase, which inhibits the cleavage of the amyloid precursor proteins into amyloid beta peptides, from which the disease-defining deposits of plaque in the brains of Alzheimer's patients originates.Research on senile dementia and Alzheimer's disease covers an extremely broad range of scientific activities. At the recent international meeting of the Alzheimer's Association (ICAD 2008, Chicago) more than 2200 individual scientific contributions were presented. The aim of this Review is to give an overview of the field and to outline its main areas, starting from behavioral abnormalities and visible pathological findings and then focusing on the molecular details of the pathology. The "amyloid hypothesis" of Alzheimer's disease is given particular attention, since the majority of the ongoing therapeutic approaches are based on its theoretical framework.

Atividade física sistematizada e desempenho cognitivo em idosos com demência de Alzheimer: uma revisão sistemática

OBJETIVO : Apesar da crescente evidência dos benefícios do exercício físico para a cognição, existem controvérsias a respeito da prática de atividade física sistematizada em pacientes com doença de Alzheimer. Desta forma, o objetivo deste trabalho foi o de realizar uma revisão sistemática dos estudos que analisaram o efeito da atividade física sistematizada no desempenho cognitivo em idosos com doença de Alzheimer. MÉTODO : Efetuou-se uma pesquisa na PsycINFO, Biological Abstracts, Medline, Web of Science, Physical Education Index e SPORTDiscus, no período de 1990 a 2008, utilizando-se as seguintes palavras-chave: "physical activity", "physical therapy", "exercise", "fitness", "aerobic", "strength", "intervention", "cognition", "cognitive performance", "Alzheimer's disease", "Alzheimer's dementia", "Alzheimer", além de referências cruzadas dos artigos selecionados. RESULTADOS: Foram encontrados oito estudos que preencheram os critérios de inclusão adotados para o presente trabalho. Estes estudos mostraram que a atividade física sistematizada contribuiu para melhorar pelo menos temporariamente as funções cognitivas em paciente com doença de Alzheimer, particularmente, atenção, funções executivas e linguagem. CONCLUSÃO: Não foi possível estabelecer um protocolo de recomendações a respeito do tipo e intensidade da atividade física sistematizada necessária para produzir benefícios no funcionamento cognitivo. No entanto, a prática regular de atividade física sistematizada parece contribuir para a preservação ou mesmo melhora das funções cognitivas em pacientes com doença de Alzheimer.

Efficacy of a vitamin/nutriceutical formulation for moderate-stage to later-stage Alzheimer's disease: a placebo-controlled pilot study

Recent studies demonstrated efficacy of a vitamin/ nutriceutical formulation (folate, vitamin B12, alpha-tocopherol, S-adenosyl methionine, N-acetyl cysteine, and acetyl-L-carnitine) for mild to moderate Alzheimer's disease. Herein, we tested the efficacy of this formulation in a small cohort of 12 institutionalized patients diagnosed with moderate-stage to later-stage Alzheimer's disease. Participants were randomly separated into treatment of placebo groups. Participants receiving the formulation demonstrated a clinically significant delay in decline in the Dementia Rating Scale and clock-drawing test as compared to those receiving placebo. Institutional caregivers reported approximately 30% improvement in the Neuropyschiatric Inventory and maintenance of performance in the Alzheimer's Disease Cooperative Study-Activities of Daily Living for more than 9 months. This formulation holds promise for delaying the decline in cognition, mood, and daily function that accompanies the progression of Alzheimer's disease, and may be particularly useful as a supplement for pharmacological approaches during later stages of this disorder. A larger trial is warranted.

Efficacy of a vitamin/nutriceutical formulation for early-stage Alzheimer's disease: a 1-year, open-label pilot study with an 16-month caregiver extension

We examined the efficacy of a vitamin/nutriceutical formulation (folate, vitamin B6, alpha-tocopherol, S-adenosyl methionine, N-acetyl cysteine, and acetyl-L-carnitine) in a 12-month, open-label trial with 14 community-dwelling individuals with early-stage Alzheimer's disease. Participants improved in the Dementia Rating Scale and Clock-drawing tests (Clox 1 and 2). Family caregivers reported improvement in multiple domains of the Neuropsychiatric Inventory (NPI) and maintenance of performance in the Alzheimer's Disease Cooperative Study-Activities of Daily Living (ADL). Sustained performance was reported by caregivers for those participants who continued in an 16-month extension. Performance on the NPI was equivalent to published findings at 3 to 6 months for donepezil and exceeded that of galantamine and their historical placebos. Participants demonstrated superior performance for more than 12 months in NPI and ADL versus those receiving naproxen and rofecoxib or their placebo group. This formulation holds promise for treatment of early-stage Alzheimer's disease prior to and/or as a supplement for pharmacological approaches. A larger, placebo-controlled trial is warranted.

Trials and tribulations of evidence-based medicine: the case of Alzheimer disease therapeutics

The practice of EBM has evolved since it was first defined. Even the most ardent EBM proponents have recognized the need to modify the EBM approach and now include elements such as the patient's clinical state and circumstances, the patient's preferences and actions, and the physician's clinical expertise, as well as the research evidence. Part of the clinical expertise required in this model is the ability to interpret and apply the research evidence. This editorial has highlighted some of the challenges faced by clinicians who would treat AD with an EBM approach. It suggests that, without a sophisticated understanding of the primary research studies, it might be hazardous to rely on a single RCT, or even on a systematic review, for treatment recommendations. If expert assistance is required, one solution might be to rely on clinical practice guidelines developed through a consensus approach. Although clinical practice guidelines have also been criticized, they appear to provide the best blend of EBM and expert opinion. The results of the Third Canadian Consensus Conference on the Diagnosis and Treatment of Dementia will be published shortly. Hopefully, this will provide helpful guidance for Canadian clinicians and their AD patients.