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Abstract
Alzheimer disease (AD) and dementia are becoming increasingly prevalent due to the aging of the global populations. Currently available treatment options, including acetylcholinesterase inhibitors and memantine, only have symptomatic effects and no drugs with disease-modifying properties are available. Research on the amyloid cascade indicates that amyloid-β (Aβ) clearance from the brain may be the main pathophysiological change in late-onset AD and the key driver of neurodegeneration, which ultimately results in progressive cognitive deterioration and dementia. Most new AD drug candidates target different aspects of Aβ clearance, eg, using passive anti-Aβ immunization, but so far, all efforts to develop more effective drugs have failed. In parallel, nonpharmacological prevention trials are being conducted to modify dementia risk associated with known epidemiological risk factors. Some initial results are promising, but replication across independent cohorts remains a challenge.
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Affiliation(s)
- Robert Perneczky
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany; German Center for Neurodegenerative Diseases (DZNE) Munich, Munich, Germany; Neuroepidemiology and Ageing Research Unit, School of Public Health, Imperial College London, London, UK
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2
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Moreta MPG, Burgos-Alonso N, Torrecilla M, Marco-Contelles J, Bruzos-Cidón C. Efficacy of Acetylcholinesterase Inhibitors on Cognitive Function in Alzheimer's Disease. Review of Reviews. Biomedicines 2021; 9:biomedicines9111689. [PMID: 34829917 PMCID: PMC8615650 DOI: 10.3390/biomedicines9111689] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 11/08/2021] [Accepted: 11/09/2021] [Indexed: 12/03/2022] Open
Abstract
Alzheimer’s disease (AD) is the most common form of dementia over the age of 65. It is estimated that 115.4 million people will be affected by AD by 2050. Acetylcholinesterase inhibitors (AChEI) are the only available and approved treatment for AD. The aim of the present study was to analyse the evidence on the efficacy of the AChEI in the treatment of cognitive symptoms of Alzheimer’s disease. For that purpose, a review of review of the systematic reviews (SRs) on this topic was carried out by Web of Science, PubMed, and The Cochrane Library, among others, were searched until 24 September 2021. Thirteen of the 1773 articles evaluated the efficacy of AChEI on cognitive function and/or general condition and/or behavioural disturbances of patients with mild to moderate AD. Methodological quality and risk of bias were rated using the ROBIS scale. The quality of the identified studies was high for nine of them, unclear for two, and finally only in two of the 13 studies did we detect low quality. Overall, AChEI showed very low efficacy in improving cognition in patients with mild to moderate AD. Better results were obtained in improving global state, with donepezil being the most effective treatment. No improvements in behavioural disturbances were found. Few high-quality reviews provide clear evidence of the effects of AChEI on cognition, global change, behaviour, and mortality. The data suggest that AChEI stabilize or slow cognitive deterioration, improving global status. In addition, data indicate that the use of AChEI decreases mortality in patients with mild to moderate AD. However, there is no evidence that they improve patient behaviour. Donepezil is the best therapeutic alternative at a dose of 10 mg/day.
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Affiliation(s)
- Marta Pérez-Gómez Moreta
- Preventive Medicine and Public Health Department, Faculty of Medicine and Nursing, University of the Basque Country UPV/EHU, 48940 Leioa, Spain;
- Correspondence: or ; Tel.: +34-607-304-793
| | - Natalia Burgos-Alonso
- Preventive Medicine and Public Health Department, Faculty of Medicine and Nursing, University of the Basque Country UPV/EHU, 48940 Leioa, Spain;
| | - María Torrecilla
- Pharmacology Department, Faculty of Medicine and Nursing, University of the Basque Country UPV/EHU, 48940 Leioa, Spain;
| | - José Marco-Contelles
- Laboratory of Medicinal Chemistry, Institute of Organic Chemistry (CSIC), Juan de la Cierva, 3, 28006 Madrid, Spain;
| | - Cristina Bruzos-Cidón
- Nursing I Department, Faculty of Medicine and Nursing, University of the Basque Country UPV/EHU, 48940 Leioa, Spain;
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Avedisova AS, Guekht AB, Zakharova KV, Akzhigitov RG. [The efficacy of pharmacological approaches to therapy of the apathy syndrome in dementia disorders (the review)]. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 118:126-133. [PMID: 29863706 DOI: 10.17116/jnevro201811841126-133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The article presents a literature review of psychopharmacological methods of treatment of the apathy syndrome, which is common in neurocognitive disorders. The review provides recommendations for the management of such patients, taking into account evidence-based medicine.
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Affiliation(s)
- A S Avedisova
- Serbsky Federal Medical Research Centre for Psychiatry and Narcology, Moscow, Russia, Soloviev Scientific and Practical Center of Psychoneurology, Moscow, Russia
| | - A B Guekht
- Serbsky Federal Medical Research Centre for Psychiatry and Narcology, Moscow, Russia, Soloviev Scientific and Practical Center of Psychoneurology, Moscow, Russia
| | - K V Zakharova
- Serbsky Federal Medical Research Centre for Psychiatry and Narcology, Moscow, Russia, Soloviev Scientific and Practical Center of Psychoneurology, Moscow, Russia
| | - R G Akzhigitov
- Serbsky Federal Medical Research Centre for Psychiatry and Narcology, Moscow, Russia, Soloviev Scientific and Practical Center of Psychoneurology, Moscow, Russia
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Liang J, Li J, Jia R, Wang Y, Wu R, Zhang H, Hang L, Xu Y. Identification of the optimal cognitive drugs among Alzheimer's disease: a Bayesian meta-analytic review. Clin Interv Aging 2018; 13:2061-2073. [PMID: 30425461 PMCID: PMC6201988 DOI: 10.2147/cia.s184968] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
PURPOSE The increasing prevalence of Alzheimer's disease (AD) demands more effective drugs, which are still unclear. The aim of this study is to compare the effectiveness of six drugs, such as donepezil, rivastigmine, galantamine, memantine, huperzine-A, and tacrine, in senior AD patients and identify the most effective one to improve patients' cognitive function. METHODS A system of search strategies was used to identify relevant studies including randomized controlled trials and clinical controlled trials evaluating the efficacy of six drugs in patients with AD. We updated relevant studies that were published before March 2018 as full-text articles. Using Bayesian network meta-analysis (NMA), we ranked cognitive ability objectively based on Mini-Mental State Examination (MMSE). Pairwise and NMAs were sequentially performed for the efficacy of drugs compared to each drug or control group through the trials included. RESULTS Among the 35 trials included, no obvious heterogeneity (I 2=0.0%, P=0.583) was revealed according to the pooled data for cognition in NMA and the mean difference (MD) of memantine (MD=1.7, 95% CI: 0.73, 2.8) showed that the memantine was significantly efficacious in the treatment group in terms of MMSE. Followed by galantamine, huperzine-A, rivastigmine, tacrine, and donepezil. CONCLUSION As the first NMA comparing the major drugs in market for AD, our study suggests that memantine might have a more significant benefit on cognition than other five drugs available.
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Affiliation(s)
- Jinghong Liang
- Department of Child Health, Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, School of Public Health, Soochow University, Suzhou, China,
| | - Jiayu Li
- Department of Child Health, Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, School of Public Health, Soochow University, Suzhou, China,
| | - Ruixia Jia
- Department of Child Health, Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, School of Public Health, Soochow University, Suzhou, China,
| | - Yingquan Wang
- Department of Child Health, Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, School of Public Health, Soochow University, Suzhou, China,
| | - Rongkun Wu
- Department of Child Health, Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, School of Public Health, Soochow University, Suzhou, China,
| | - Hongbo Zhang
- Department of Child Health, Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, School of Public Health, Soochow University, Suzhou, China,
| | - Lei Hang
- Department of Child Health, Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, School of Public Health, Soochow University, Suzhou, China,
| | - Yong Xu
- Department of Child Health, Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, School of Public Health, Soochow University, Suzhou, China,
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Carotenuto A, Rea R, Traini E, Fasanaro AM, Ricci G, Manzo V, Amenta F. The Effect of the Association between Donepezil and Choline Alphoscerate on Behavioral Disturbances in Alzheimer's Disease: Interim Results of the ASCOMALVA Trial. J Alzheimers Dis 2018; 56:805-815. [PMID: 28035924 DOI: 10.3233/jad-160675] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Behavioral and psychological symptoms of dementia (BPSD) are a group of psychological reactions, psychiatric symptoms, and behaviors commonly found in Alzheimer's disease (AD). Four clusters of BPSD have been described: mood disorders (depression, anxiety, and apathy), psychotic symptoms (delusions and hallucinations), aberrant motor behaviors (pacing, wandering, and other purposeless behaviors), and inappropriate behaviors (agitation, disinhibition, and euphoria). Most of them are attributed to acetylcholine deficiency. OBJECTIVE To evaluate if a higher amount of acetylcholine obtained by associating donepezil and choline alphoscerate might have a favorable effect on BPSD. METHODS BPSD were measured at baseline and after 24 months in 113 mild/moderate AD patients, included in the double-blind randomized trial ASCOMALVA, by the Neuropsychiatric Inventory (NPI). Two matched groups were compared: group A treated with donepezil (10 mg/day) plus choline alphoscerate (1200 mg/day), and group B treated with donepezil (10 mg/day) plus placebo. RESULTS Data of NPI revealed a significant decrease of BPSD severity and distress of the caregiver in patients of group A compared with group B. Mood disorders (depression, anxiety and apathy) were significantly decreased in subjects treated with donepezil and choline alphoscerate, while their severity and frequency was increased in the other group. CONCLUSIONS Patients treated with donepezil plus choline alphoscerate showed a lower level of behavioral disturbances than subjects treated with donepezil only, suggesting that the association can have beneficial effects.
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Affiliation(s)
- Anna Carotenuto
- Clinical Research, Telemedicine and Telepharmacy Center, University of Camerino, Camerino, Italy.,Neurology Unit, National Hospital, "A. Cardarelli", Naples, Italy
| | - Raffaele Rea
- Clinical Research, Telemedicine and Telepharmacy Center, University of Camerino, Camerino, Italy.,Neurology Unit, National Hospital, "A. Cardarelli", Naples, Italy
| | - Enea Traini
- Clinical Research, Telemedicine and Telepharmacy Center, University of Camerino, Camerino, Italy
| | | | - Giovanna Ricci
- Bioethics and Legal Medicine Center, School of Law, University of Camerino, Camerino, Italy
| | - Valentino Manzo
- Neurology Unit, National Hospital, "A. Cardarelli", Naples, Italy
| | - Francesco Amenta
- Clinical Research, Telemedicine and Telepharmacy Center, University of Camerino, Camerino, Italy
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Messerer R, Dallanoce C, Matera C, Wehle S, Flammini L, Chirinda B, Bock A, Irmen M, Tränkle C, Barocelli E, Decker M, Sotriffer C, De Amici M, Holzgrabe U. Novel bipharmacophoric inhibitors of the cholinesterases with affinity to the muscarinic receptors M 1 and M 2. MEDCHEMCOMM 2017; 8:1346-1359. [PMID: 30108847 DOI: 10.1039/c7md00149e] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 04/21/2017] [Indexed: 01/25/2023]
Abstract
A set of hybrid compounds composed of the fragment of allosteric modulators of the muscarinic receptor, i.e. W84 and naphmethonium, and the well-known AChE inhibitor tacrine on the one hand, and the skeletons of the orthosteric muscarinic agonists, iperoxo and isox, on the other hand, were synthesized. The two molecular moieties were connected via a polymethylene linker of varying length. These bipharmacophoric compounds were investigated for inhibition of AChE (from electric eel) and BChE (from equine serum) as well as human ChEs in vitro and compared to previously synthesized dimeric inhibitors. Among the studied hybrids, compound 10-C10, characterized by a 10 carbon alkylene linker connecting tacrine and iperoxo, proved to be the most potent inhibitor with the highest pIC50 values of 9.81 (AChE from electric eel) and 8.75 (BChE from equine serum). Docking experiments with compounds 10-C10, 7b-C10, and 7a-C10 helped to interpret the experimental inhibitory power against AChE, which is affected by the nature of the allosteric molecular moiety, with the tacrine-containing hybrid being much more active than the naphthalimido- and phthalimido-containing analogs. Furthermore, the most active AChE inhibitors were found to have affinity to M1 and M2 muscarinic receptors. Since 10-C10 showed almost no cytotoxicity, it emerged as a promising lead structure for the development of an anti-Alzheimer drug.
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Affiliation(s)
- Regina Messerer
- Pharmaceutical and Medicinal Chemistry , Institute of Pharmacy and Food Chemistry , University of Würzburg , Am Hubland , 97074 Würzburg , Germany . ; ; Tel: +49 931 31 85460
| | - Clelia Dallanoce
- Dipartimento di Scienze Farmaceutiche , Sezione di Chimica Farmaceutica "Pietro Pratesi" , Università degli Studi di Milano , Via Mangiagalli 25 , 20133 Milano , Italy
| | - Carlo Matera
- Dipartimento di Scienze Farmaceutiche , Sezione di Chimica Farmaceutica "Pietro Pratesi" , Università degli Studi di Milano , Via Mangiagalli 25 , 20133 Milano , Italy
| | - Sarah Wehle
- Pharmaceutical and Medicinal Chemistry , Institute of Pharmacy and Food Chemistry , University of Würzburg , Am Hubland , 97074 Würzburg , Germany . ; ; Tel: +49 931 31 85460
| | - Lisa Flammini
- Dipartimento di Farmacia , Università degli Studi di Parma , Parco Area delle Scienze, 27/A , 43124 Parma , Italy
| | - Brian Chirinda
- Pharmacology and Toxicology , Institute of Pharmacy , University of Bonn , Gerhard-Domagk-Straße 3 , 53121 Bonn , Germany
| | - Andreas Bock
- Institute of Pharmacology and Toxicology , University of Würzburg , Versbacher Strasse 9 , 97078 Würzburg , Germany
| | - Matthias Irmen
- Pharmacology and Toxicology , Institute of Pharmacy , University of Bonn , Gerhard-Domagk-Straße 3 , 53121 Bonn , Germany
| | - Christian Tränkle
- Pharmacology and Toxicology , Institute of Pharmacy , University of Bonn , Gerhard-Domagk-Straße 3 , 53121 Bonn , Germany
| | - Elisabetta Barocelli
- Dipartimento di Farmacia , Università degli Studi di Parma , Parco Area delle Scienze, 27/A , 43124 Parma , Italy
| | - Michael Decker
- Pharmaceutical and Medicinal Chemistry , Institute of Pharmacy and Food Chemistry , University of Würzburg , Am Hubland , 97074 Würzburg , Germany . ; ; Tel: +49 931 31 85460
| | - Christoph Sotriffer
- Pharmaceutical and Medicinal Chemistry , Institute of Pharmacy and Food Chemistry , University of Würzburg , Am Hubland , 97074 Würzburg , Germany . ; ; Tel: +49 931 31 85460
| | - Marco De Amici
- Dipartimento di Scienze Farmaceutiche , Sezione di Chimica Farmaceutica "Pietro Pratesi" , Università degli Studi di Milano , Via Mangiagalli 25 , 20133 Milano , Italy
| | - Ulrike Holzgrabe
- Pharmaceutical and Medicinal Chemistry , Institute of Pharmacy and Food Chemistry , University of Würzburg , Am Hubland , 97074 Würzburg , Germany . ; ; Tel: +49 931 31 85460
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Bohlken J, Schulz M, Rapp MA, Bätzing-Feigenbaum J. Pharmacotherapy of dementia in Germany: Results from a nationwide claims database. Eur Neuropsychopharmacol 2015; 25:2333-8. [PMID: 26476703 DOI: 10.1016/j.euroneuro.2015.09.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Revised: 09/10/2015] [Accepted: 09/24/2015] [Indexed: 11/30/2022]
Abstract
In 2011, about 1.1-1.4 million patients with dementia were living in Germany, a number expected to rise to three million by 2050. Dementia poses a major challenge to the healthcare system and neuropharmacological service provision. The aim of this study was to determine prescription rates for anti-dementia drugs as well as for neuroleptics, sedative-hypnotics and antidepressants in dementia using the complete nationwide outpatient claims data pertaining to the services of statutory health insurance. We controlled for gender, age, dementia diagnosis, physician specialty (general practitioner GP versus neuropsychiatry specialist physician NPSP), and rural and urban living area. In about one million prevalent dementia patients (N=1,014,710) in 2011, the prescription prevalence rate of anti-dementia drugs was 24.6%; it varied with gender, age, and diagnosis (highest in Alzheimer's disease; 42%), and was higher in patients treated by NPSPs (48% vs. 25% in GPs). At the same time, we found an alarmingly high rate of treatment with neuroleptics in dementia patients (35%), with an only slightly decreased risk in patients treated exclusively by NPSPs (OR=0.86). We found marginal differences between rural and urban areas. Our results show that the majority of anti-dementia drug prescriptions appear guideline-oriented, yet prescription rates are overall comparatively low. On the other hand, neuroleptic drugs, which are associated with excess morbidity and mortality in dementia, were prescribed very frequently, suggesting excess use given current guidelines. We therefore suggest that guideline implementation measures and increasing quality control procedures are needed with respect to the pharmacotherapy of this vulnerable population.
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Affiliation(s)
| | - Mandy Schulz
- Central Research Institute of Ambulatory Health Care in Germany (Zi), Berlin, Germany
| | - Michael A Rapp
- Social and Preventive Medicine, University of Potsdam, Am Neuen Palais 10, D-14469 Potsdam, Germany.
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Reducing Aβ load and tau phosphorylation: Emerging perspective for treating Alzheimer's disease. Eur J Pharmacol 2015. [DOI: 10.1016/j.ejphar.2015.07.043] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Zhu CW, Livote EE, Scarmeas N, Albert M, Brandt J, Blacker D, Sano M, Stern Y. Long-term associations between cholinesterase inhibitors and memantine use and health outcomes among patients with Alzheimer's disease. Alzheimers Dement 2013; 9:733-40. [PMID: 23332671 PMCID: PMC3633652 DOI: 10.1016/j.jalz.2012.09.015] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Revised: 08/18/2012] [Accepted: 09/19/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVES To examine in an observational study (1) relationships between cholinesterase inhibitors (ChEI) and memantine use, and functional and cognitive end points and mortality in patients with Alzheimer's disease (AD); (2) relationships between other patient characteristics and these clinical end points; and (3) whether effects of the predictors change across time. METHODS The authors conducted a multicenter, natural history study that included three university-based AD centers in the United States. A total of 201 patients diagnosed with probable AD with modified Mini-Mental State Examination (MMSE) scores ≥ 30 at study entry were monitored annually for 6 years. Discrete-time hazard analyses were used to examine relationships between ChEI and memantine use during the previous 6 months reported at each assessment, and time to cognitive (MMSE score ≤ 10) and functional (Blessed Dementia Rating Scale score ≥ 10) end points and mortality. Analyses controlled for clinical characteristics, including baseline cognition, function, and comorbid conditions, and presence of extrapyramidal signs and psychiatric symptoms at each assessment interval. Demographic characteristics included baseline age, sex, education, and living arrangement at each assessment interval. RESULTS ChEI use was associated with delayed time in reaching the functional end point and death. Memantine use was associated with delayed time to death. Different patient characteristics were associated with different clinical end points. CONCLUSIONS Results suggest long-term beneficial effects of ChEI and memantine use on patient outcomes. As for all observational cohort studies, observed relationships should not be interpreted as causal effects.
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Affiliation(s)
- Carolyn W. Zhu
- This work is from The Department of Geriatrics & Palliative Medicine, Mount Sinai School of Medicine, New York, NY
| | - Elayne E. Livote
- This work is from The Department of Geriatrics & Palliative Medicine, Mount Sinai School of Medicine, New York, NY
| | - Nikolaos Scarmeas
- Cognitive Neuroscience Division of the Taub Institute for Research in Alzheimer’s Disease and the Aging Brain
- Gertrude H. Sergievsky Center and the Department of Neurology, Columbia University Medical Center, New York, NY
- Department of Neurology, Medical School of National and Kapodistrian University of Athens, Greece
| | - Marilyn Albert
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MD
| | - Jason Brandt
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MD
| | - Deborah Blacker
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Mary Sano
- Department of Psychiatry, Mount Sinai School of Medicine, New York, NY
| | - Yaakov Stern
- Cognitive Neuroscience Division of the Taub Institute for Research in Alzheimer’s Disease and the Aging Brain
- Gertrude H. Sergievsky Center and the Department of Neurology, Columbia University Medical Center, New York, NY
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Abstract
Apathy in patients with dementia is common, underrecognized, and undertreated. We sought to improve understanding of the pharmacologic treatment of apathy in dementia by performing a systematic literature review of studies that used apathy outcome scales to document results of pharmacologic treatments for apathy. There is limited evidence of efficiency of pharmacotherapy for treatment of apathy in dementia. The best results were found for acetylcholinesterase inhibitors. There was some evidence of efficacy for memantine, but less evidence of efficacy for stimulants, calcium antagonists, and antipsychotics. There was no evidence to support the use of antidepressants or anticonvulsants. The research quality of studies was modest. Recommendations for standardizing research and for holistic evaluation and treatment are provided.
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Revisiting the cholinergic hypothesis of behavioral and psychological symptoms in dementia of the Alzheimer's type. Ageing Res Rev 2011; 10:404-12. [PMID: 21292041 DOI: 10.1016/j.arr.2011.01.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2010] [Revised: 01/17/2011] [Accepted: 01/20/2011] [Indexed: 11/23/2022]
Abstract
Behavioral and psychological symptoms of dementia (BPSD) include agitation, aberrant motor behavior, anxiety, elation, irritability, depression, apathy, disinhibition, delusions, hallucinations, and sleep or appetite impairment. These symptoms have adverse consequences for patients and caregivers, such as greater impairment in activities of daily living, worsening quality of life and earlier institutionalization. While the etiology of BPSD has not been clearly delineated, studies assessing the benefits of acetylcholinesterase inhibitors on BPSD suggest that some of the neuropsychiatric symptoms of dementia such as agitation, apathy and psychosis may represent a specific central cholinergic deficiency syndrome. Biochemical and neuroimaging studies of BPSD in Alzheimer's patients support these pharmacological data. This review discusses the literature describing the association between cholinergic deficiency and manifestations of BPSD.
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Novel insights for the treatment of Alzheimer's disease. Prog Neuropsychopharmacol Biol Psychiatry 2011; 35:373-9. [PMID: 20655969 DOI: 10.1016/j.pnpbp.2010.07.018] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2010] [Revised: 07/02/2010] [Accepted: 07/15/2010] [Indexed: 12/12/2022]
Abstract
The development of treatments for Alzheimer's disease (AD) is currently shifting away from the correction of neurotransmitter abnormalities and from attempts to remove the pathognomonic protein deposits. Drug discovery is heading towards novel types of pharmacological interventions which are aimed at more central and upstream pathophysiological events. The large number of upcoming treatment targets can be grouped into two major categories. The first category consists of antecedents of beta amyloid peptide (Aβ) and TAU deposition including Aβ production, degradation and clearance, TAU hyperphosphorylation and aggregation. The second consists of protectors against neuronal dysfunction and premature death such as mitochondrial functioning, nerve growth and regeneration, and neuronal membrane integrity. It is hoped that some of these strategies will not only have larger symptomatic effects than the currently available drugs but also an impact on the underlying neurodegeneration. Since the novel treatments will be typically administered over years they must meet high standards of safety, drug-drug compatibility, and tolerability. Probably the most important target groups for novel treatments are carriers of mutations causing AD, and individuals with minor cognitive impairment representing a pre-dementia stage of the disease. To minimise incorrect case identifications, drug development must be paralleled by improved diagnostic techniques. Novel pharmacological strategies may be cost-effective if disability and need of full-time care can be postponed or prevented without prolonging time lived with dementia or extending survival. We are uncertain whether the advent of novel disease-retarding strategies will revolutionise the management of AD. Symptomatic treatments will continue to be needed, and psychosocial approaches will retain an essential role in supporting affected individuals and their families.
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Recomendaciones en la prevención de reacciones adversas a medicamentos en personas mayores con demencia. Rev Esp Geriatr Gerontol 2010; 45:89-96. [PMID: 20189268 DOI: 10.1016/j.regg.2009.10.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2009] [Revised: 10/07/2009] [Accepted: 10/08/2009] [Indexed: 12/31/2022]
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Nourhashémi F, Olde Rikkert MG, Burns A, Winblad B, Frisoni GB, Fitten J, Vellas B. Follow-up for Alzheimer patients: European Alzheimer Disease Consortium position paper. J Nutr Health Aging 2010; 14:121-30. [PMID: 20126960 DOI: 10.1007/s12603-010-0023-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND AND PURPOSE Alzheimer disease (AD) is one of the leading causes of dependence in the elderly. Providing care for patients with AD is complex and the type of care required depends on the stage of the disease and varies over time. The aim of this article is to discuss available care strategies once the AD diagnosis has been made and to propose a follow-up plan as standard of care at a European level. METHODS The proposals developed in this article stem from the collaborative work of a panel of multidisciplinary experts involved in the care of AD patients (European Alzheimer Disease Consortium) based on the results of published scientific studies and on their experience from clinical practice. CONCLUSION Suggestions for follow-up frequency and easily administered and scored assessment tools are provided, thereby increasing efficiency and quality of care for patients with Alzheimer disease.
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Sinforiani E, Zucchella C, Pasotti C, Bartolo M, Nappi G. Report of ten years' activity in an Alzheimer's disease assessment unit. Aging Clin Exp Res 2009; 21:365-8. [PMID: 19959929 DOI: 10.1007/bf03324930] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIMS After ten years' treatment with cholinesterase inhibitors (AcheI) in Alzheimer's disease (AD), we report here the activity of the Alzheimer's Disease Assessment Unit of IRCCS C. Mondino, Pavia, Italy. METHODS From September 2000 to December 2007, 794 out-patients (of 2236 referred to our Assessment Unit for cognitive disturbances) with AD of mild to moderate degree were treated with cholinesterase inhibitors (M/F: 273/521, mean age 73.6+/- 8.4 yrs, range 52-85 yrs). Outcome measures were scores on Mini Mental State Examination (MMSE), ADL, IADL and Neuropsychiatric Inventory (NPI). RESULTS Mean treatment duration was 36.9+/-16.1 months. After three months' treatment, MMSE scores remained stable (responders) in 60% of cases and improved (increase of 3 or more points - good responders) in 15%, with good preservation of autonomy. After 15 months, the percentage of "good responders" decreased to 7%, while after 15, 27 and 39 months the percentage of responders progressively decreased to 40%, 30% and 8%, respectively; greater impairment in instrumental with respect to basic everyday activities was noted. No variables capable of predicting the response to treatment were detected. The onset of behavioral disturbances caused significant (p<0.02) worsening of both cognition and function and, in 12% of cases, suspension of treatment. CONCLUSIONS Our results therefore confirm the efficacy of AcheI in AD of mild to moderate degree even in a nonselected population; efficacy also seems to persist in long-term treatment. This report, although brief and mainly descriptive, can make a contribution to better knowledge of the usefulness of these drugs in AD of mild to moderate extent in everyday clinical practice.
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Affiliation(s)
- Elena Sinforiani
- Alzheimer's Disease Assessment Unit/Laboratory of Neuropsychology, IRCCS C. Mondino, Institute of Neurology, Via Mondino 2, 27100 Pavia, Italy.
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Hasnain M, Vieweg WVR, Baron MS, Beatty-Brooks M, Fernandez A, Pandurangi AK. Pharmacological management of psychosis in elderly patients with parkinsonism. Am J Med 2009; 122:614-22. [PMID: 19559160 DOI: 10.1016/j.amjmed.2009.01.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2008] [Revised: 11/26/2008] [Accepted: 01/29/2009] [Indexed: 11/30/2022]
Abstract
Parkinsonism is a characteristic feature of Parkinson's disease and dementia with Lewy bodies and is commonly seen in Alzheimer's disease. Psychosis commonly appears during the course of these illnesses. Treatment of parkinsonism with antiparkinsonian medications constitutes an additional risk factor for the appearance or worsening of psychosis. Conversely, treatment of psychosis with antipsychotic drugs in patients with parkinsonism might worsen the underlying movement disorder, especially in the elderly. In this article, we review parkinsonian conditions in the elderly and offer guidelines to assess and manage comorbid psychosis. We focus on the pharmacologic management of psychosis with atypical antipsychotic medications and briefly review the role of acetylcholinesterase inhibitors.
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Affiliation(s)
- Mehrul Hasnain
- Department of Psychiatry, Western Regional Integrated Health Authority, Sir Thomas Roddick Hospital, Stephenville, Newfoundland, Canada.
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Long-term course and effectiveness of combination therapy in Alzheimer disease. Alzheimer Dis Assoc Disord 2008; 22:209-21. [PMID: 18580597 DOI: 10.1097/wad.0b013e31816653bc] [Citation(s) in RCA: 146] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare the real-world clinical effectiveness and long-term clinical trajectory in patients with Alzheimer disease (AD) treated with combination (COMBO) therapy consisting of cholinesterase-inhibitor (CI) plus memantine (MEM) versus CI alone versus no treatment with either. METHODS Three hundred eighty-two subjects with probable AD underwent serial clinical evaluations at a memory disorders unit. Cognition was assessed by the Information-Memory-Concentration subscale of the Blessed Dementia Scale (BDS) and function was assessed by the Weintraub Activities of Daily Living Scale (ADL) at 6-month intervals. One hundred forty-four subjects received standard care without CI or MEM (NO-RX), 122 received CI monotherapy, and 116 received COMBO therapy with CI plus MEM. Mean follow-up was 30 months (4.1 visits) and mean cumulative medication treatment time was 22.5 months. Rates of decline were analyzed using mixed-effects regression models, and Cohen's d effect sizes were calculated annually for years 1 to 4. RESULTS Covarying for baseline scores, age, education, and duration of illness, the COMBO group had significantly lower mean annualized rates of deterioration in BDS and ADL scores compared with the CI (P<0.001; Cohen's dBDS=0.10-0.34 and dADL=0.23-0.46 at 1 to 2 y) and NO-RX groups (P<0.001; Cohen's dBDS=0.56-0.73 and dADL=0.32-0.48 at 1 to 2 y). For the COMBO group, Cohen's d effect sizes increased with treatment duration. Similar comparisons significantly favored the CI over the NO-RX group on the BDS. CONCLUSIONS COMBO therapy slows cognitive and functional decline in AD compared with CI monotherapy and no treatment. These benefits had small-to-medium effect sizes that increased with time on treatment and were sustained for years.
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&NA;. Atypical antipsychotics are an option for treating serious psychosis of Alzheimer??s disease, despite safety concerns and lack of evidence. DRUGS & THERAPY PERSPECTIVES 2007. [DOI: 10.2165/00042310-200723110-00004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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