Recognition and treatment of Alzheimer's disease: a case-based review

Medication compliance in Singaporean patients with Alzheimer's disease

INTRODUCTION

Singapore has a rapidly ageing population and an increasing prevalence of Alzheimer's disease (AD). Compliance to AD medications is associated with treatment effectiveness. We investigated compliance to acetylcholinesterase inhibitors (AChEIs) and N-methyl-D-aspartate (NMDA) receptor antagonist and treatment persistence among patients seen at the General Memory Clinic of National University Hospital, Singapore. We also identified the reasons for non-compliance.

METHODS

Patients seen at the General Memory Clinic between 1 January 2013 and 31 December 2014, who were prescribed AChEIs and NMDA receptor antagonist, were included in this retrospective cohort study. Non-compliance to medications was indirectly measured by failure to renew prescription within 60 days of the last day of medication supplied by the previous prescription. The reasons for non-compliance were identified.

RESULTS

A total of 144 patients were included. At one year, 107 patients were compliant to AD medications, while 37 patients were non-compliant. Around 60% of the non-compliant patients discontinued the use of AD medications within the first six months, and the mean persistent treatment period among this group of patients was 10.3 ± 3.5 months. The main reason for non-compliance was patients' and caregivers' perception that memory loss was of lower priority than other coexisting illnesses. Other reasons for non-compliance included side effects of medications (18.9%), perceived ineffectiveness of treatment (16.2%), inability to attend clinic (5.4%) and high cost of medications (2.7%).

CONCLUSION

Our findings suggest that the reasons for medication non-compliance can be identified early. Better compliance may be achieved through a multidisciplinary approach to patient education.

Effects of polyprenols from pine needles of Pinus massoniana on ameliorating cognitive impairment in a D-galactose-induced mouse model

Cognitive deficiency and oxidative stress have been well documented in aging and in neurodegenerative disorders such as Alzheimer's disease. In this study, we assessed the therapeutic effect of polyprenols on D-galactose-induced cognitive impairment in mice by testing on of behavioral and cognitive performance. In order to explore the possible role of polyprenols against D-galactose-induced oxidative damages, we assessed various biochemical indicators. Chronic administration of D-galactose (150 mg/kg·d, s.c.) for 7 weeks significantly impaired cognitive performance (both in step-through passive and active avoidance tests) and locomotor activity (in open-field test) and the ability of spatial learning and memory (in Morris water maze test) compared with the control group. The results revealed that polyprenols treatment for 2 weeks significantly ameliorated model mice's cognitive performance and oxidative defense. All groups of polyprenols enhanced the learning and memory ability in step-through passive and active avoidance tests, locomotor activity in open-field test, and the ability of spatial learning and memory in Morris water maze test. Furthermore, high and middle level of polyprenols significantly increased total antioxidative capacity (T-AOC), glutathione peroxidase (GSH-Px), super oxide dismutase (SOD) activity, neprilysin (NEP), and β-site AβPP cleaving enzyme 1 (BACE1) expression, while nitric oxide (NO), nitric oxide synthase (NOS) activity, malondialdehyde (MDA) concentration, and the level of Aβ1-42 and presenilin 1 (PS1) were decreased. Polyprenols have a significant relieving effect on learning, memory, and spontaneous activities in a D-galactose-induced mouse model and ameliorates cognitive impairment and biochemical dysfunction in mice. In summary, we have demonstrated that polyprenols may ameliorate memory and cognitive impairment via enhancing oxidative defense and affecting generation and dissimilation of Aβ-related enzymes, suggesting that polyprenols represent a novel drug for treating Alzheimer's disease.

[Cholinesterase inhibitors and depression in the elderly]

BACKGROUND

Depression in the elderly is characterized by an atypical expression with delusion, major anxiety, behaviour disorders, somatic complains or cognitive impairment. These clinical aspects are suspected to be at the origin of the poor response to antidepressants observed in these cases. It is currently indicated to add sedative medicines to antidepressants, when a major anxiety is associated with depression, or an antipsychotic in the delusional forms of the depression. However, it is not consensually established that cholinesterase inhibitors can be helpful in depression with cognitive impairment. Cholinesterase inhibitors are efficient among patients with Alzheimer disease. They improve cognitive performances and slow down the degenerative process during the first years of treatment. Today, new findings on neurobiological mechanisms of depression involve a located degenerative process, with some similar anomalies in the brain in both depression and pre-Alzheimer states. New therapeutic trials have shown that cholinesterase inhibitors can be also efficient on depressed symptoms among patients with Alzheimer disease. These evidences support the hypothesis that the association of cholinesterase inhibitors to antidepressants can bring more benefits to depressed elderly patients.

AIM

Through a review of the literature and a case report, we tried to specify whether cholinesterase inhibitors can be useful in the treatment of depression among the elderly.

CASE REPORT

We report the case of a 68-year-old man who had presented, four years ago, a second episode of major depression with a cognitive impairment. Treated with an antidepressant (venlafaxine), the improvement was poor with major anxiety, slow thoughts, and an evidence of a persistent cognitive impairment. Despite normal cerebral scanning images, we decided to add a cholinesterase inhibitor (donepezil) to the same antidepressant. With this association, we rapidly obtained a total remission from depression with restitution of cognitive performances. This state is still maintained until today (four years after the last depressive episode) with no new mood relapses. Recent cerebral scanning images did not show any degenerative process.

CONCLUSION

The association of cholinesterase inhibitors and an antidepressant seems a good alternative, when the response to antidepressant is partial in depression with cognitive impairment in the elderly. However, further therapeutic trials are still needed, to prove the usefulness of cholinesterase inhibitors among depressed elderly patients.

Dilemmas in the (un)veiling of the diagnosis of Alzheimer's disease: walking an ethical and professional tight rope

OBJECTIVE

To enhance the understanding and effect of physician's difficulties, attitudes and communication styles on the disclosure of the diagnosis of AD in practice.

METHODS

Qualitative, phenomenological study, combining pre-encounter interviews with physicians, observations of actual encounters of diagnosis disclosure of AD, and post-encounter interviews.

RESULTS

There were various ways or tactics to (un)veil the bad news that may be perceived as different ways of dulling the impact and avoiding full and therefore problematic statements. In the actual encounters this was accomplished by keeping encounters short, avoiding elaboration, confirmation of comprehension and explicit terminology and using fractured sentences.

CONCLUSION

The present study's findings highlight the difficulties encountered in breaking the news about AD, in the way it is actually done, and the problems that may arise from this way of un/veiling the news. The main problem is that the reluctance to make a candid disclosure of the diagnosis as was demonstrated in this study may violate basic moral and legal rights and may also deprive patients and caregivers of some of the benefits of early disclosure of diagnosis.

PRACTICE IMPLICATIONS

There is a need for assisting physicians to cope with their personal difficulties, problems and pitfalls in breaking the news.