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Fan P, Miranda O, Qi X, Kofler J, Sweet RA, Wang L. Unveiling the Enigma: Exploring Risk Factors and Mechanisms for Psychotic Symptoms in Alzheimer's Disease through Electronic Medical Records with Deep Learning Models. Pharmaceuticals (Basel) 2023; 16:911. [PMID: 37513822 PMCID: PMC10385983 DOI: 10.3390/ph16070911] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/14/2023] [Accepted: 06/16/2023] [Indexed: 07/30/2023] Open
Abstract
Around 50% of patients with Alzheimer's disease (AD) may experience psychotic symptoms after onset, resulting in a subtype of AD known as psychosis in AD (AD + P). This subtype is characterized by more rapid cognitive decline compared to AD patients without psychosis. Therefore, there is a great need to identify risk factors for the development of AD + P and explore potential treatment options. In this study, we enhanced our deep learning model, DeepBiomarker, to predict the onset of psychosis in AD utilizing data from electronic medical records (EMRs). The model demonstrated superior predictive capacity with an AUC (area under curve) of 0.907, significantly surpassing conventional risk prediction models. Utilizing a perturbation-based method, we identified key features from multiple medications, comorbidities, and abnormal laboratory tests, which notably influenced the prediction outcomes. Our findings demonstrated substantial agreement with existing studies, underscoring the vital role of metabolic syndrome, inflammation, and liver function pathways in AD + P. Importantly, the DeepBiomarker model not only offers a precise prediction of AD + P onset but also provides mechanistic understanding, potentially informing the development of innovative treatments. With additional validation, this approach could significantly contribute to early detection and prevention strategies for AD + P, thereby improving patient outcomes and quality of life.
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Affiliation(s)
- Peihao Fan
- Computational Chemical Genomics Screening Center, Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Oshin Miranda
- Computational Chemical Genomics Screening Center, Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Xiguang Qi
- Computational Chemical Genomics Screening Center, Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Julia Kofler
- Department of Pathology, Division of Neuropathology, UPMC Presbyterian Hospital, Pittsburgh, PA 15213, USA
| | - Robert A Sweet
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Lirong Wang
- Computational Chemical Genomics Screening Center, Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA 15213, USA
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Fan P, Kofler J, Ding Y, Marks M, Sweet RA, Wang L. Efficacy difference of antipsychotics in Alzheimer's disease and schizophrenia: explained with network efficiency and pathway analysis methods. Brief Bioinform 2022; 23:bbac394. [PMID: 36151774 PMCID: PMC9677501 DOI: 10.1093/bib/bbac394] [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] [Received: 05/10/2022] [Revised: 08/11/2022] [Accepted: 08/12/2022] [Indexed: 12/14/2022] Open
Abstract
Approximately 50% of Alzheimer's disease (AD) patients will develop psychotic symptoms and these patients will experience severe rapid cognitive decline compared with those without psychosis (AD-P). Currently, no medication has been approved by the Food and Drug Administration for AD with psychosis (AD+P) specifically, although atypical antipsychotics are widely used in clinical practice. These drugs have demonstrated modest efficacy in managing psychosis in individuals with AD, with an increased frequency of adverse events, including excess mortality. We compared the differences between the genetic variations/genes associated with AD+P and schizophrenia from existing Genome-Wide Association Study and differentially expressed genes (DEGs). We also constructed disease-specific protein-protein interaction networks for AD+P and schizophrenia. Network efficiency was then calculated to characterize the topological structures of these two networks. The efficiency of antipsychotics in these two networks was calculated. A weight adjustment based on binding affinity to drug targets was later applied to refine our results, and 2013 and 2123 genes were identified as related to AD+P and schizophrenia, respectively, with only 115 genes shared. Antipsychotics showed a significantly lower efficiency in the AD+P network than in the schizophrenia network (P < 0.001) indicating that antipsychotics may have less impact in AD+P than in schizophrenia. AD+P may be caused by mechanisms distinct from those in schizophrenia which result in a decreased efficacy of antipsychotics in AD+P. In addition, the network analysis methods provided quantitative explanations of the lower efficacy of antipsychotics in AD+P.
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Affiliation(s)
- Peihao Fan
- School of Pharmacy, University of Pittsburgh
| | | | - Ying Ding
- Department of Biostatistics at the University of Pittsburgh
| | - Michael Marks
- Center for Neuroscience at the University of Pittsburgh and the Department of Neurobiology
| | - Robert A Sweet
- UPMC Endowed Professor of Psychiatric Neuroscience and Professor of Neurology at the University of Pittsburgh
| | - Lirong Wang
- department of pharmaceutical sciences, school of pharmacy at University of Pittsburgh, USA
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Álvarez-Fernández B, Bernal-López MR, Gómez-Huelgas R. Role of aripiprazole in the management of behavioural and psychological symptoms of dementia: a narrative review. Psychogeriatrics 2022; 22:137-144. [PMID: 34761857 DOI: 10.1111/psyg.12787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 10/13/2021] [Accepted: 10/26/2021] [Indexed: 11/26/2022]
Abstract
Behavioural and psychological symptoms of dementia affect in a great way quality of life of both patients and their caregivers, which increases the risk of patient institutionalisation when such symptoms are poorly controlled. One of the drugs that are used for controlling behavioural and psychological symptoms of dementia (BPSD) is aripiprazole. This narrative review aims to solve three basic questions. Is aripiprazole useful for the management of these symptoms? Does aripiprazole play a substantial role regarding safety and efficacy, compared with the other pharmacological options available for the same purpose? Has aripiprazole gained importance in treatment regimens of these symptoms, in current clinical practice? We conclude that aripiprazole is effective to manage BPSD. Moreover, it has shown a good safety profile compared with other antipsychotics in advanced disease and frail patients. Thus, aripiprazole has gained importance in current management algorithms for dementia patients mainly due to its efficacy regarding rapid control of agitation and aggressiveness.
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Affiliation(s)
- Baldomero Álvarez-Fernández
- Geriatrics Unit, Department of Internal Medicine, Regional University Hospital of Malaga, Instituto de Investigación Biomédica de Malaga (IBIMA), University of Malaga, Malaga, Spain
| | - M Rosa Bernal-López
- Geriatrics Unit, Department of Internal Medicine, Regional University Hospital of Malaga, Instituto de Investigación Biomédica de Malaga (IBIMA), University of Malaga, Malaga, Spain.,CIBER Fisiopatología de la Obesidad y la Nutrición, Instituto de Salud Carlos III, Madrid, Spain
| | - Ricardo Gómez-Huelgas
- Geriatrics Unit, Department of Internal Medicine, Regional University Hospital of Malaga, Instituto de Investigación Biomédica de Malaga (IBIMA), University of Malaga, Malaga, Spain.,CIBER Fisiopatología de la Obesidad y la Nutrición, Instituto de Salud Carlos III, Madrid, Spain
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Atypical antipsychotics in the treatment of psychotic symptoms in Alzheimer's disease: a systematic review. Int Clin Psychopharmacol 2021; 36:169-180. [PMID: 33902085 DOI: 10.1097/yic.0000000000000358] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
With the advancement of Alzheimer's disease as well as other types of dementia, in addition to the cognitive decline, psychiatric symptoms have been outlined, including psychotic symptoms. The aim of the study is to review the available results on the antipsychotic treatment of Alzheimer's disease associated psychotic symptoms. The main objective of the study is to evaluate the efficacy of the treatment. The second objective is to assess the tolerability of this treatment. Double-blind, randomized, placebo-controlled trials, which took place over the course of at least 4 weeks, have been searched. Studies that compared one atypical antipsychotic to placebo, as well as more atypical antipsychotics, compared one to another, have been taken into account. In total 17 studies have been selected. The efficacy of the atypical antipsychotics has proven to be significant in most studies. Moreover, antipsychotic medication, such as risperidone, aripiprazole, olanzapine, quetiapine and pimavanserin, has been well tolerated. Atypical antipsychotics are the treatment of choice for psychotic symptoms in dementia. Despite the consistent results present in the literature up to this point, various antipsychotics remain insufficiently studied and would need more generous sample sizes for their outcomes to be substantiated.
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Kok JS, Oude Voshaar RC, Scherder EJA. Psychotropic drug use in residents with dementia living in small-scaled special care facilities; a longitudinal study. Aging Ment Health 2020; 24:689-696. [PMID: 30835505 DOI: 10.1080/13607863.2019.1584784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objectives: Over the past decade, a trend has been noticed in the Netherlands to replace large-scaled special care units (SCUs) caring for 20-30 residents with dementia by small-scaled SCUs caring for up to 8 residents. Systematic evaluations, however, have yielded a differentiated picture of the effects. As the impact on psychotropic drug use has hardly been addressed thus far, we examined the (potential) impact of psychotropic drug use when moving residents with dementia from large-scaled to small-scaled SCUs.Methods: We conducted a non-randomized, controlled study with a six-month follow-up. Among 145 residents with dementia living a large-scaled SCUs for dementia caring for 20-30 residents per unit, a total of 77 residents were moved to small-scaled SCUs caring for up to 8 residents per unit. Psychotropic drug use, classified according to the Anatomical Therapeutic Chemical Classification (ATC) system was monitored at 2 months before replacement, as well as at 3 and 6 months thereafter. Repeated measures ANOVAs were conducted for the mean Defined Daily Doses (DDDs) of both groups.Results: No significant differences between both groups in psychotropic medication use were found over a period of 8 months.Conclusion: Prescription of psychotropic drugs does not change after a transfer from a large-scaled SCU to a small-scaled SCU of patients with moderate to severe dementia.Current Controlled Trials: ISRCTN11151241.
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Affiliation(s)
- Jeroen S Kok
- Lentis
- Dignis, Mental Health Care Institute, Zuidlaren, The Netherlands
| | - Richard C Oude Voshaar
- Department of Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Erik J A Scherder
- Department of Clinical Neuropsychology, VU University Amsterdam, Amsterdam, The Netherlands
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SUVN-502, a novel, potent, pure, and orally active 5-HT6 receptor antagonist: pharmacological, behavioral, and neurochemical characterization. Behav Pharmacol 2019; 30:16-35. [DOI: 10.1097/fbp.0000000000000414] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Abstract
Aripiprazole was the first antipsychotic developed to possess agonist properties at dopamine D2 autoreceptors, a groundbreaking strategy that presented a new vista for schizophrenia drug discovery. The dopamine D2 receptor is the crucial target of all extant antipsychotics, and all developed prior to aripiprazole were D2 receptor antagonists. Extensive blockade of these receptors, however, typically produces extrapyramidal (movement) side effects, which plagued first-generation antipsychotics, such as haloperidol. Second-generation antipsychotics, such as clozapine, with unique polypharmacology and D2 receptor binding kinetics, have significantly lower risk of movement side effects but can cause myriad additional ones, such as severe weight gain and metabolic dysfunction. Aripiprazole's polypharmacology, characterized by its unique agonist activity at dopamine D2 and D3 and serotonin 5-HT1A receptors, as well as antagonist activity at serotonin 5-HT2A receptors, translates to successful reduction of positive, negative, and cognitive symptoms of schizophrenia, while also mitigating risk of weight gain and movement side effects. New observations, however, link aripiprazole to compulsive behaviors in a small group of patients, an unusual side effect for antipsychotics. In this review, we discuss the chemical synthesis, pharmacology, pharmacogenomics, drug metabolism, and adverse events of aripiprazole, and we present a current understanding of aripiprazole's neurotherapeutic mechanisms, as well as the history and importance of aripiprazole to neuroscience.
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Affiliation(s)
- Austen B. Casey
- Department of Pharmaceutical Sciences, Center for Drug Discovery, Northeastern University, Boston, Massachusetts 02115, United States
| | - Clinton E. Canal
- Department of Pharmaceutical Sciences, Center for Drug Discovery, Northeastern University, Boston, Massachusetts 02115, United States
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Woodis CB, Fuentes D, Sease L. De-escalation of antipsychotic medications in an elderly patient with Alzheimer's dementia residing in an assisted living facility. Ment Health Clin 2012. [DOI: 10.9740/mhc.n127370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Clinicians frequently encounter the use of antipsychotic medications in elderly patients with Alzheimer's dementia (AD). The use of these agents may be a concern since they are not approved by the Food and Drug Administration (FDA) for the treatment of AD and have been shown to increase mortality in the elderly population. This case report focuses on the gradual de-escalation of antipsychotic medications in an 80 year-old female with AD residing in an assisted living facility who was prescribed three antipsychotic medications to help manage behavioral and psychotic symptoms consistent with progressing AD. Following a request by the assisted living facility, a local family medicine practice assessed the resident's treatment regimen. A collaborative consultation between the family medicine practice's clinical pharmacist, the family medicine physician, and the health care providers at the assisted living facility resulted in the decision to gradually discontinue each antipsychotic agent at subsequent facility visits by the family medicine team.
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Affiliation(s)
- C. Brock Woodis
- 1Assistant Professor of Pharmacy Practice, Campbell University College of Pharmacy & Health Sciences Assistant Professor and Clinical Pharmacist, Duke University Medical Center, Department of Community and Family Medicine, Durham, NC
| | - David Fuentes
- 2Department Chair of Pharmacy Practice, Associate Professor of Pharmacy Practice, Manchester University College of Pharmacy, Fort Wayne, IN
| | - Lorraine Sease
- 3Assistant Professor, CAQ in Geriatric Medicine and Palliative Medicine, Duke University Medical Center, Department of Community and Family Medicine, Durham, NC
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Maalouf M, Ringman JM, Shi J. An update on the diagnosis and management of dementing conditions. REVIEWS IN NEUROLOGICAL DISEASES 2011; 8:e68-e87. [PMID: 22249572 PMCID: PMC4096631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Worsening memory is a common complaint in the elderly and predictably causes affected individuals and their families to wonder whether the underlying cause is Alzheimer disease, the most common form of dementia. Alzheimer disease is a devastating illness that unavoidably leads to a complete loss of independence and, as a result, substantial emotional, physical, and financial distress for patients and their families. The causes and severity of memory impairment in the elderly are diverse, however, so any given case might not necessarily be secondary to a neurodegenerative disorder such as Alzheimer disease. Consequently, it is critical to rule out potentially reversible causes of dementia and to initiate treatment while cognitive and functional deficits are still mild and more likely to respond to treatment. Furthermore, identifying the etiology and defining a suitable treatment plan early in the course of dementia allows patients to be more actively involved in the management of their disease and is more likely to improve quality of life for both patients and caregivers. This review presents the etiology of dementia in the elderly, describes the diagnostic process, and discusses current therapeutic strategies, including pharmacological agents, nonpharmacological interventions, safety assessments, legal issues, and caregiver needs.
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Affiliation(s)
- Marwan Maalouf
- Department of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
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Lester P, Kohen I, Stefanacci RG, Feuerman M. Antipsychotic drug use since the FDA black box warning: survey of nursing home policies. J Am Med Dir Assoc 2010; 12:573-577. [PMID: 21450177 DOI: 10.1016/j.jamda.2010.04.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2010] [Accepted: 04/13/2010] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To use a nationwide survey to assess changes in antipsychotic utilization patterns and usage policies in nursing homes (NHs) in the United States since the introduction of the black box warning by the FDA. DESIGN/SETTING/PARTICIPANTS A survey was distributed online and was completed by 250 directors of nursing of NH. The directors of nursing answered questions concerning policies about and use of antipsychotic medications. MEASUREMENTS/RESULTS The most commonly reported intervention to manage symptoms in residents with dementia since the black box warning was to lower doses of antipsychotics. Over half of facilities report obtaining more frequent psychiatry/psychology consults. One-hundred seven facilities have a policy regarding informing family members of residents about the black box warning. Most facilities (63.6%) with a policy require family to sign consent. In the NH setting, the presence or absence of a policy did not correlate with the reported change in use of antipsychotics or types of alternative interventions. CONCLUSION Notably, a large number of NH facilities have policies regarding informed consent on the use of antipsychotics. However, in our study, the rate of use of antipsychotics did not change in many facilities since the black box warning. In addition, having a policy did not correlate with decreased antipsychotic use or with use of alternate agents or nonpharmacologic methods to address symptoms. The results of this survey suggest that NH administrators should worry less about the legal exposure of using antipsychotics and focus on actions that result in improved patient care.
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Affiliation(s)
| | - Izchak Kohen
- Department of Psychiatry, Division of Geriatric Psychiatry, NS-LIJ Health System, Manhasset, NY
| | - Richard G Stefanacci
- Institute for Geriatric Studies, Mayes College of Health Care Business & Policy, University of the Sciences, Philadelphia, PA
| | - Martin Feuerman
- Office of Academic Affairs, Winthrop University Hospital, Mineola, NY
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Kohen I, Lester PE, Lam S. Antipsychotic treatments for the elderly: efficacy and safety of aripiprazole. Neuropsychiatr Dis Treat 2010; 6:47-58. [PMID: 20361061 PMCID: PMC2846120 DOI: 10.2147/ndt.s6411] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2010] [Indexed: 12/21/2022] Open
Abstract
Delusions, hallucinations and other psychotic symptoms can accompany a number of conditions in late life. As such, elderly patients are commonly prescribed antipsychotic medications for the treatment of psychosis in both acute and chronic conditions. Those conditions include schizophrenia, bipolar disorder, depression and dementia. Elderly patients are at an increased risk of adverse events from antipsychotic medications because of age-related pharmacodynamic and pharmacokinetic changes as well as polypharmacy. Drug selection should be individualized to the patient's previous history of antipsychotic use, current medical conditions, potential drug interactions, and potential side effects of the antipsychotic. Specifically, metabolic side effects should be closely monitored in this population. This paper provides a review of aripiprazole, a newer second generation antipsychotic agent, for its use in a variety of psychiatric disorders in the elderly including schizophrenia, bipolar disorder, dementia, Parkinson's disease and depression. We will review the pharmacokinetics and pharmacodynamics of aripiprazole as well as dosing, diagnostic indications, efficacy studies, and tolerability including its metabolic profile. We will also detail patient focused perspectives including quality of life, patient satisfaction and adherence.
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Affiliation(s)
- Izchak Kohen
- Division of Geriatric Psychiatry, Ambulatory Care Pavilion, Zucker-Hillside Hospital, Glen Oaks, NY, USA.
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