Neuropsychiatric symptoms and survival in amyotrophic lateral sclerosis: a missing link?

Prevalence and associated factors of apathy in Chinese ALS patients

Objectivve

This study aimed to explore the prevalence and clinical correlates of apathy in amyotrophic lateral sclerosis (ALS) in a cohort of Chinese patients.

Methods

A total of 1,013 ALS patients were enrolled in this study. Apathy was recorded during face-to-face interviews using Frontal Behavioral Inventory, and other patient characteristics, including depression, anxiety, and cognitive function, were collected using Hamilton Depression Rating Scale (HDRS), Hamilton Anxiety Rating Scale (HARS), and Chinese version of Addenbrooke’s Cognitive Examination-revised. Health-related quality of life of ALS patients and their caregivers was also evaluated, and the potential factors associated with apathy were explored using forward binary regression analysis. Survival was analyzed using the Cox proportional hazards model.

Results

The prevalence of apathy in all patients was 28.9%. Patients in the late disease stage had a higher prevalence of apathy than those in the early disease stage. Furthermore, patients with apathy had a lower ALS Functional Rating Scale revised (ALSFRS-R) score, higher HDRS score, HARS score and higher proportion of reported problems in the anxiety/depression. Additionally, their caregivers had higher score of depression and higher Zarit-Burden Interview scores. Multivariate regression analysis revealed that apathy in ALS was associated with the onset region (p = 0.027), ALSFRS-R score (p = 0.007), depression (p = 0.001) and anxiety (p < 0.001). Apathy had a significant negative effect on survival in ALS patients (p = 0.032).

Conclusion

Apathy is relatively common (28.9%) in Chinese patients with ALS. Apathy is related to both the severity of the disease, and the presentation of non-motor symptoms in ALS, such as depression and anxiety disorders. Apathy is an independent prognostic factor for survival and requires early intervention and management.

A systematic review of neuropsychiatric and cognitive assessments used in clinical trials for amyotrophic lateral sclerosis

Background

Up to 50% of people with amyotrophic lateral sclerosis (ALS) experience cognitive dysfunction, whilst depression and anxiety are reported in up to 44% and 33%, respectively. These symptoms impact on quality of life, and are associated with a poorer prognosis. Historically, outcomes in clinical trials have focused on the effect of candidate drugs on physical functioning.

Methods

We reviewed the past 25 years of clinical trials of investigative medicinal products in people with ALS, since the licensing of riluzole, and extracted data on frequency and type of assessment for neuropsychiatric symptoms and cognitive impairment. Trial registry databases, including WHO International Trials Registry, European Clinical Trials Register, clinicaltrials.gov, and PubMed, were systematically searched for Phase II, III or IV trials registered, completed or published between 01/01/1994 and 31/10/2019. No language restrictions were applied. Outcome measures, exclusion criteria and assessment tool used were extracted.

Results

216 trials, investigating 26,326 people with ALS, were reviewed. 35% assessed neuropsychiatric symptoms, and 22% assessed cognition, as Exclusion Criteria or Outcome Measures. 3% (n = 6) of trials assessed neuropsychiatric symptoms as a Secondary Outcome Measure, and 4% (n = 8) assessed cognition as Outcome Measures; only one trial included assessments for both cognition and neuropsychiatric symptoms as Outcome Measures. Three ALS-specific assessments were used in six trials.

Conclusions

Trials for people with ALS have neglected the importance of neuropsychiatric symptoms and cognitive impairment. Evaluation of these extra-motor features is essential to understanding the impact of candidate drugs on all symptoms of ALS.

PROPSERO registration

CRD42020175612.

Electronic supplementary material

The online version of this article (10.1007/s00415-020-10203-z) contains supplementary material, which is available to authorized users.

Associations between neuropsychiatric symptoms and cognition in Chinese patients with amyotrophic lateral sclerosis

Our objective was to explore features of the neuropsychiatric symptoms in Chinese patients with amyotrophic lateral sclerosis (ALS) and the associations between these neuropsychiatric symptoms and cognition. A total of 91 ALS patients were evaluated using three recommended scales including the Neuropsychiatric Inventory (NPI), Addenbrooke's Cognitive Examination Revised (ACE-R), and Frontal Assessment Battery (FAB) tests. The mean age of onset was 52.5 ± 10.8 years. The median NPI score of all patients was 2.0. The most common neuropsychiatric symptom was dysphoria/depression (59.3%), followed by anxiety (41.8%) and irritability/lability (26.4%). There were no significant differences in the frequency of neuropsychiatric symptoms in terms of gender, age of onset, onset form and disease duration. There were no significant differences in NPI total score, ACE-R total score and FAB total score in terms of gender, age of onset, onset form and disease duration, except for a higher ACE-R score observed in patients with a shorter disease duration. The NPI score had a strong correlation with the ACE-R score but not with the FAB score. In conclusion, neuropsychiatric symptoms appear to be quite common in Chinese ALS patients, who were likely to present with the emotional states of depression or anxiety. The neuropsychiatric symptoms in ALS are closely related to global cognition dysfunction.