Benzodiazepines and Related Drugs as a Risk Factor in Alzheimer's Disease Dementia

Neurexan Prescription Is Associated with Lower Risk of Sleep Disorder Recurrence and Depression Prevalence as Compared to Z-Drugs and Benzodiazepines: A Retrospective Database Analysis in Germany

Real-world evidence on the association between natural medicinal products and the recurrence of sleep disorders is currently limited, particularly when compared to the evidence reported for prescription hypnotics. In a retrospective cohort analysis, we investigated patients with sleep disorders prescribed either the natural medicinal product Neurexan (Nx4), benzodiazepines, or nonbenzodiazepines (Z-drugs) using the IQVIA Disease Analyzer database, which encompasses electronic medical records nationwide in Germany. A 1:1 matching procedure based on age, sex, prevalent depression, anxiety or adjustment disorder, and the number of medical consultations in the past 12 months resulted in four cohorts: patients prescribed Nx4 were matched with those prescribed Z-drugs (two cohorts with 8594 matched patients each), and another cohort of patients prescribed Nx4 were matched with those prescribed benzodiazepines (7779 matched pairs). Results from multivariable-adjusted Cox regression models demonstrated that Nx4 was associated with a significantly lower risk of recurrent sleep disorder diagnosis within 30-365 days after prescription compared to both Z-drugs (HR = 0.65, 95%CI = 0.60-0.70, p < 0.001) and benzodiazepines (HR = 0.85, 95%CI = 0.79-0.93, p < 0.001). Additionally, Nx4 was associated with a lower prevalence of depression compared to Z-drugs (HR = 0.90, 95%CI = 0.83-0.98, p = 0.020) and benzodiazepines (HR = 0.89, 95%CI = 0.82-0.97, p = 0.009). These findings suggest an association between Nx4 and improved sleep and mental health outcomes. However, due to inherent limitations in the study design, the causality of this relationship cannot be stated.

Delirious Mania in a 77-Year-Old Female

Delirium is associated with acute episodes of disturbances in attention and awareness along with changes to cognition, including memory deficits and disorientation. Delirious mania (DM) is an unusual phenomenon where symptoms of delirium co-exist with symptoms of mania such as elevated or irritable mood, grandiosity, agitation, and cognitive disorganization. There is no formal agreement upon clinical symptoms for DM, but it generally includes acute onset of confusion, poor orientation, excitation, restlessness, and delusions. DM was first identified in the mid-1800s by Dr. Luther Bell and has only been identified by case reports since. We investigated a 77-year-old woman who was found at a gas station in an altered mental state. Upon observation, she has symptoms consistent with DM, including inappropriate laughter, distraction and confusion. She was diagnosed with acute metabolic encephalopathy, but the presentation of DM was considered in the differential and remains a unique finding.

Isolation of a new flavonoid from Prasium majus L. with evaluation of its potential biological activities

In line with the importance of Prasium majus L. (Lamiaciatae) in traditional medicine as a calming and sedative remedy, the present study was designed to reveal its chemical constituents and bioactivity potentials. Thus, after extraction and fractionation of the plant material, the obtained butanol fraction (BPm) was subjected to conventional chromatographic separation of its constituents in addition to LC-MS/MS evaluation versus some authentic standards. The study resulted in the isolation and characterisation of 8 compounds, including one new chrysoeriol derivative, majusiode (1). Structural elucidation of all isolated compounds was based on detailed investigation of their spectral data (NMR (1 & 2D), ESI-MS, IR and UV-Vis). HPLC-MS/MS analysis versus authentic samples lead to the detection of 31 constituents, including all 8 isolated compounds. The new compound (1) showed moderate AChE inhibition power (IC50: 163.3 ± 3.4 µg/mL) as compared to the positive control galanthamine (91.4 ± 5.2 µg/mL) and moderate DPPH•/ABTS•+ scavenging power.

Association Between Hypnotics and Dementia: A Mini Narrative Review

OBJECTIVE

This narrative review aims to provide a comprehensive assessment of the existing literature on the relationship between hypnotics and dementia, considering both potential link and inconclusive or lack of association.

METHODS

Data from studies that investigate the association between hypnotic medications and dementia were reviewed. Studies included both cohort studies and systematic reviews, participants with various type of dementia and hypnotics including benzodiazepines (BZDs) and Z-drugs (ZDs).

RESULTS

The existing literatures presents conflicting evidence regarding the association between hypnotics, including BZDs and ZDs, and the risk of dementia. Some studies suggest a potential link between prolonged use of hypnotics and an increased risk of dementia. However, other studies indicate inconclusive or lacking evidence regarding this association. Factors such as study design, sample characteristics, and control of confounding variables contribute to the variability in findings.

CONCLUSION

The relationship between hypnotics and dementia remains complex and controversial. While some studies suggest a potential association, others find inconclusive or conflicting evidence. Future research should focus on addressing methodological limitations, considering classifying dementia subtypes, and try to adjust medication lag time.

Pharmacists' contribution to benzodiazepine deprescribing in older outpatients: a systematic review and meta-analysis

BACKGROUND

Consolidated and reliable evidence regarding the effectiveness of pharmacist interventions for deprescribing benzodiazepines in older outpatients is lacking.

AIM

This study evaluated and summarized the impact of pharmacist interventions on benzodiazepine deprescribing among older outpatients.

METHOD

A literature search was conducted until August 2022 in PubMed, PsycINFO, and the Cochrane Central Register of Controlled Trials databases. The review included randomized controlled trials that assessed the impact of pharmacist interventions on deprescribing benzodiazepine in older outpatients. Two independent investigators conducted the study selection, data extraction, and risk of bias assessment. Meta-analyses were conducted using random-effect models in the RStudio software.

RESULTS

A total of 893 records were identified. Five studies, including 3,879 patients, met the inclusion criteria and were included in the systematic review. All five studies used health education as an intervention strategy, and three also conducted medication reviews. There was no evidence of the pharmacist's authority to modify prescriptions during benzodiazepine deprescribing. One study was classified as having a low risk of bias, whereas the other had some concerns or a high risk of bias. Three studies were included in the meta-analysis and a significant impact of pharmacist interventions on benzodiazepines deprescribing rates in older outpatients was observed (RR = 2.75 [95%CI 1.29; 5.89]; p = 0.04; I2 = 69%; low certainty of evidence).

CONCLUSION

Pharmacists may contribute to deprescribing benzodiazepines in older outpatients. Further studies are needed to increase the reliability of these findings. PROSPERO registration number: CRD42022358563.

[The exposome in the context of preventive measures for Alzheimer's and Parkinson's diseases]

BACKGROUND

Preventive measures addressing the exposome can counteract neurodegenerative diseases.

OBJECTIVE

This article gives an overview on the influence of general and individual exogenous factors (environmental influences and lifestyle changes) as well as endogenous factors (e.g. metabolic alterations) on the development and progression of Alzheimer's disease (AD) and Parkinson's disease (PD).

METHODS

Summary and evaluation of current scientific studies and evidence regarding the exposome and prevention of AD and PD.

RESULTS

Numerous studies could demonstrate a potential influence of environmental influences associated with industrialization (general exogenous factors), such as pesticides, solvents or air pollution on the development of AD and PD. Additionally, individually addressable changes of lifestyle (individual exogenous factors, e.g. physical activity, cognitive stimulation, nutrition and sleep) contribute to disease protection and modification and are becoming increasingly more important in light of still limited therapeutic interventions. Moreover, other exogenous factors (medication, noise pollution, head trauma and heavy metals) are discussed as risk factors for AD and/or PD. Endogenous factors (e.g., changes of the enteral microbiome, systemic inflammation and neuroinflammation, metabolic changes) can contribute to disease development by a higher potential for interacting with exogenous factors.

CONCLUSION

Despite the comprehensive scientific evidence confirming the significance of the exposome for the pathogenesis of AD and PD, the great potential of preventive measures has not yet been exploited. A clarification of the high potential of lifestyle changes should be a therapeutic standard not only for individuals with manifest PD/AD but also for individuals with a risk profile or with suspected prodromal disease. Further investigations on the influence of environmental factors and the implementation of preventive strategies to avoid exposure should be the focus of international efforts.

Clinically significant anxiety as a risk factor for Alzheimer's disease: Results from a 10-year follow-up community study

OBJECTIVE

There is growing evidence for an association between anxiety and an increased risk of dementia, but it is not clear whether anxiety is a risk factor or a prodromic symptom. In this study, we investigated if clinically significant anxiety increases the risk of developing Alzheimer's disease (AD) up to 10 years later.

METHODS

We used data from the longitudinal Zaragoza Dementia and Depression (ZARADEMP) Project. Excluding subjects with dementia at baseline left us with 3044 individuals aged >65 years. The Geriatric Mental State-Automated Geriatric Examination for Computer Assisted Taxonomy (GMS-AGECAT) package was used to identify cases and subcases of anxiety. AD was diagnosed by a panel of research psychiatrists according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria. Multivariate survival analysis with a competing risk regression model was performed.

RESULTS

We observed a significant association between clinically significant anxiety at baseline and AD risk within a 10-year follow-up (SHR 2.82 [95% CI 1.21-6.58]), after controlling for confounders including depression. In contrast, isolated symptoms of anxiety were not significantly associated with an increased incidence of AD.

CONCLUSION

Our results support the hypothesis that clinically significant anxiety is an independent risk factor for AD and not just a prodromic symptom. Future studies should clarify if treating anxiety reduces the incidence of AD.

Baseline Profiles of Drug Prescriptions Prior to Diagnosis of Mild Cognitive Impairment (MCI) Obtained by Latent Class Analysis (LCA), and Assessment of Their Association with Conversion to Dementia

Polypharmacy has been linked to cognitive decline. However, interventions targeting modifiable risk factors, some of which are targets of the most commonly used drugs, could reduce the prevalence of dementia. Our aim was to determine the drug prescription regimen at baseline, prior to the diagnosis of mild cognitive impairment (MCI), and its possible association with progression to dementia. Data were collected from the electronic medical records of 342 MCI outpatients diagnosed during 2006-2017 at their first neurology consultation. We followed the classical three-step method of statistical analysis, starting with a Latent Class Analysis (LCA) to discover subgroups of drug prescription probability. Half of the patients were under polypharmacy (≥5 drugs), 17.5% had no recorded medication, 33.3% progressed to dementia (94.7% in ≤5 years), and 84.1% of them to Alzheimer's disease (AD). According to the LCA and based on 20 therapeutic indicators obtained from 240 substances and regrouped according the Anatomical Therapeutic Chemical Classification, we identified a four-profile model: (1) low (35.7% of patients); (2) mixed (28.7%); (3) cardio-metabolic (19.3%); and (4) psychotropic (16.4%). The binomial regression logistic model showed that profiles 2 and 3 (and 4 for AD), with a higher drug prescription conditioned probability against classic risk factors, were protective than profile 1 (OR = 0.421, p = 0.004; OR = 0.278, p = 0.000; OR = 0.457, p = 0.040, respectively), despite polypharmacy being significant in profiles 2 and 3 (mean > 7 drugs) vs. profile 1 (1.4 ± 1.6) (p = 0.000). Patients in the latter group were not significantly older, although being aged 65-79 years old quadrupled (OR = 4.217, p = 000) and being >79 tripled (OR = 2.945, p = 0.010) the conversion risk compared to patients <65 years old. According to the proposed analytical model, profiling the heterogeneous association of risk factors, which were taken prior to diagnosis, could be explored as an indicator of prior care and a predictor of conversion to dementia.

Associations of Late-Life Sleep Medication Use With Incident Dementia in the Atherosclerosis Risk in Communities Study

BACKGROUND

Sleep medications may contribute to dementia development or indicate sleep disturbances that are markers of or contributors to neurologic disease. The objective of this study was to examine the use of sleep medications and incident dementia in a community-based cohort of older adults. We hypothesize late-life sleep medication use is associated with a greater risk of dementia.

METHODS

The Atherosclerosis Risk in Communities (ARIC) study is an ongoing community-based cohort study. ARIC participants taking barbiturates, benzodiazepines, antidepressants, non-benzodiazepine receptor agonists (Z-drugs), or other hypnotics in 2011-2013 were categorized as sleep medication users. Participants were followed through 2019 for incident dementia. Logistic regression propensity scores were used to match sleep medication users with nonusers (1:2). Cox proportional hazards regression models were used to estimate hazard ratios (HR) for time to dementia diagnosis with adjustment for demographics, lifestyle characteristics, and cardiovascular risk factors.

RESULTS

One-quarter of the eligible ARIC participants used sleep medications. In the matched sample (N = 4 197; 69% female; mean age 75.3 + 5.0 years), 632 dementia cases were ascertained over a median follow-up of 6.5 years. In the fully adjusted model, sleep medication use compared to nonuse was associated with a 48% greater risk of dementia (HR: 1.48; 95% confidence interval (CI): 1.26-1.74).

CONCLUSION

To expand on these findings, studies with longer follow-up and earlier assessment of sleep medication use are needed. Furthermore investigation of the potential dose-response association of multiple sleep medications and the potential causal role of sleep medications in the development of dementia may be clinically meaningful.

Insights on benzodiazepines' potential in Alzheimer's disease

Alzheimer's disease (AD) is the most frequent type of dementia characterized by the deposition of amyloid beta (Aβ) plaque and tau-neurofibrillary tangles (TNTs) in the brain. AD is associated with the disturbances of various neurotransmitters including gamma-aminobutyric acid (GABA). Of note, GABA is reduced in AD, and restoration of GABA effect by benzodiazepines (BDZs) may improve AD outcomes. However, BDZs may adversely affect cognitive functions chiefly in elderly AD patients with sleep disorders. Besides, there is a controversy regarding the use of BDZs in AD. Consequently, the objective of the present review was to disclose the possible role of BDZs on the pathogenesis of AD that might be beneficial, neutral, or detrimental effects on AD. Prolonged use of intermediate-acting BDZ lorazepam exerts amnesic effects due to attenuation of synaptic plasticity and impairment of recognition memory. However, BDZs may have a protective effect against the development of AD by reducing tau phosphorylation, neuroinflammation, and progression of AD neuropathology. On the other side, other findings highlighted that extended use of BDZs was not associated with the development of AD. In conclusion, there are controversial points concerning the use of BDZs and the risk for the progression of AD. Thus, preclinical, and clinical studies are essential in this regard.

Benzodiazepine-Receptor Agonist Utilization in Outpatients with Anxiety Disorder: A Retrospective Study Based on Electronic Healthcare Data from a Large General Tertiary Hospital

Benzodiazepine-receptor agonists (BZRAs), including benzodiazepines (BZDs) and drugs related to BZDs (Z-drugs), are commonly used for anxiety, but often have side effects. We retrospectively investigated the utilization and prescription characteristics of BZRAs for patients with anxiety disorders in a large tertiary care general hospital between 2018 and 2021, based on electronic healthcare records. We also examined the pattern of simultaneous consumption of multiple BZRA drugs, and the diseases coexisting with anxiety that are associated with this. The numbers of patients and BZRA prescriptions increased over the 4 years. Moreover, 7195 prescriptions from 694 patients contained two or more BZRAs, of which 78.08% contained both BZDs and Z-drugs, 19.78% contained multiple BZDs, and 2.14% contained multiple Z-drugs. For anxiety patients with concomitant Alzheimer's disease or Parkinson's disease, and dyslipidemia, they were more likely to consume multiple BZRAs simultaneously, whereas patients with concomitant insomnia, depression, hypertension, diabetes, or tumors were less likely to consume multiple BZRAs (all p < 0.05). Furthermore, older patients who consume multiple BZRAs simultaneously may have higher probabilities of long-term drug use. Better interventions supporting standardized BZD utilization may be needed to minimize the side effects of inappropriate BZRA administration.

Polypharmacy and Potentially Inappropriate Medication Use in Older Adults With Systemic Lupus Erythematosus

OBJECTIVE

To assess the prevalence and potential risk factors for polypharmacy and prescribing of the potentially inappropriate medications, opioids and benzodiazepines/Z-drugs, in older adults with systemic lupus erythematosus (SLE).

METHODS

The study population comprised adults age ≥50 years meeting American College of Rheumatology or Systemic Lupus International Collaborating Clinics classification criteria followed at a tertiary care rheumatology clinic. Information on prescriptions filled in the 4 months preceding chart review was obtained from the Manitoba Drug Program Information Network. Clinical data, including age, sex, Charlson Comorbidity Index (CCI) score, Systemic Lupus Erythematosus Disease Activity Index 2000 score, prednisone use, SLE duration, and rural residence were abstracted from electronic medical records. Logistic regression analyses were performed to assess any association between polypharmacy (using 2 definitions: ≥5 and ≥10 medications), potentially inappropriate medication use, and clinical features.

RESULTS

A total of 206 patients (mean age 62 years, 91% female, 36% rural) were included: 148 (72%) filled ≥5 medications, 71 (35%) filled ≥10 medications, 63 (31%) used benzodiazepines/Z-drugs, and 50 (24%) used opioids. Among the 77 patients age ≥65 years, 57 (74%) filled ≥5 medications, and 26 (34%) filled ≥10 medications, compared to 30% and 4%, respectively, of Manitobans age ≥65 years (National Prescription Drug Utilization Information System, 2016). The odds of polypharmacy were greater with prednisone use (adjusted odds ratio [OR] 3.70 [95% confidence interval (95% CI) 1.40-9.79] for ≥5 medications), CCI score (adjusted OR 1.62 [95% CI 1.20-2.17]), and rural residence (adjusted OR 2.05 [95% CI 1.01-4.18]). Odds of benzodiazepine/Z-drug use were increased with polypharmacy (adjusted OR 4.35 [95% CI 1.69-11.22]), and odds of opioid use were increased with polypharmacy (adjusted OR 6.75 [95% CI 1.93-23.69]) and CCI score (adjusted OR 1.29 [95% CI 1.08-1.54]).

CONCLUSION

The prevalence of polypharmacy in this SLE cohort was higher than in the general Manitoban population. Polypharmacy is a strong marker for use of prescription benzodiazepines/Z-drugs and opioids.

Benzodiazepines in Alzheimer's disease: beneficial or detrimental effects

Dementia is considered a clinical syndrome characterized by cognitive dysfunction and memory loss. Alzheimer's disease (AD) is the most common type of dementia. AD is linked with the turbulence of diverse neurotransmitters including gamma-aminobutyric acid (GABA). Notably, GABA in the brain and cerebrospinal fluid was reduced in AD. Thus, allosteric modulation of the GABA effect by benzodiazepines (BDZs) may improve the clinical outcomes of AD patients. Therefore, the objective of the present review was to reveal the possible role of BDZs on the pathogenesis and clinical outcomes in AD patients. Though BDZs may adversely affect cognitive functions mainly in elderly patients, herein it was postulated that BDZs may have beneficial, neutral, or detrimental effects in AD. Taken together, there is strong controversy regarding the use of BDZs and the risk for the development of AD. Therefore, experimental, preclinical and clinical studies are critical to determine the potential protective or detrimental effects of BDZs on AD neuropathology.

Rationale for a Multi-Factorial Approach for the Reversal of Cognitive Decline in Alzheimer's Disease and MCI: A Review

Alzheimer's disease (AD) is a multifactorial, progressive, neurodegenerative disease typically characterized by memory loss, personality changes, and a decline in overall cognitive function. Usually manifesting in individuals over the age of 60, this is the most prevalent type of dementia and remains the fifth leading cause of death among Americans aged 65 and older. While the development of effective treatment and prevention for AD is a major healthcare goal, unfortunately, therapeutic approaches to date have yet to find a treatment plan that produces long-term cognitive improvement. Drugs that may be able to slow down the progression rate of AD are being introduced to the market; however, there has been no previous solution for preventing or reversing the disease-associated cognitive decline. Recent studies have identified several factors that contribute to the progression and severity of the disease: diet, lifestyle, stress, sleep, nutrient deficiencies, mental health, socialization, and toxins. Thus, increasing evidence supports dietary and other lifestyle changes as potentially effective ways to prevent, slow, or reverse AD progression. Studies also have demonstrated that a personalized, multi-therapeutic approach is needed to improve metabolic abnormalities and AD-associated cognitive decline. These studies suggest the effects of abnormalities, such as insulin resistance, chronic inflammation, hypovitaminosis D, hormonal deficiencies, and hyperhomocysteinemia, in the AD process. Therefore a personalized, multi-therapeutic program based on an individual's genetics and biochemistry may be preferable over a single-drug/mono-therapeutic approach. This article reviews these multi-therapeutic strategies that identify and attenuate all the risk factors specific to each affected individual. This article systematically reviews studies that have incorporated multiple strategies that target numerous factors simultaneously to reverse or treat cognitive decline. We included high-quality clinical trials and observational studies that focused on the cognitive effects of programs comprising lifestyle, physical, and mental activity, as well as nutritional aspects. Articles from PubMed Central, Scopus, and Google Scholar databases were collected, and abstracts were reviewed for relevance to the subject matter. Epidemiological, pathological, toxicological, genetic, and biochemical studies have all concluded that AD represents a complex network insufficiency. The research studies explored in this manuscript confirm the need for a multifactorial approach to target the various risk factors of AD. A single-drug approach may delay the progression of memory loss but, to date, has not prevented or reversed it. Diet, physical activity, sleep, stress, and environment all contribute to the progression of the disease, and, therefore, a multi-factorial optimization of network support and function offers a rational therapeutic strategy. Thus, a multi-therapeutic program that simultaneously targets multiple factors underlying the AD network may be more effective than a mono-therapeutic approach.

Dementia, Substance Misuse, and Social Determinants of Health: American Indian and Alaska Native Peoples' Prevention, Service, and Care

Background

American Indian and Alaska Native (AI/AN) peoples are disproportionately impacted by substance use disorders (SUDs) and health consequences in contrast to all racial/ethnic groups in the United States. This is alarming that AI/AN peoples experience significant health disparities and disease burden that are exacerbated by settler-colonial traumas expressed through prejudice, stigma, discrimination, and systemic and structural inequities. One such compounding disease for AI/AN peoples that is expected to increase but little is known is Alzheimer's disease and related dementias (ADRD). AI/AN approaches for understanding and treating disease have long been rooted in culture, context, and worldview. Thus, culturally based prevention, service, and caregiving are critical to optimal outcomes, and investigating cultural beliefs regarding ADRD can provide insights into linkages of chronic stressors, disease, prevention and treatment, and the role of substance misuse.

Method

To understand the cultural practices and values that compose AI/AN Elder beliefs and perceptions of ADRD, a grounded theory, qualitative study was conducted. Twelve semistructured interviews with AI/AN Elders (M age = 73; female = 8, male = 4) assessed the etiology, course, treatment, caregiving, and the culturally derived meanings of ADRD, which provides a frame of understanding social determinants of health (SDH; eg, healthcare equity, community context) and impacts (eg, historical trauma, substance misuse) across the lifespan.

Results

Qualitative analyses specific to disease etiology, barriers to treatment, and SDH revealed 6 interrelated and nested subthemes elucidating both the resilience and the chronic stressors and barriers faced by AI/AN peoples that directly impact prevention, disease progression, and related services: (1) postcolonial distress; (2) substance misuse; (3) distrust of Western medicine; (4) structural inequities; (5) walking in two worlds; and (6) decolonizing and indigenizing medicine.

Conclusion

Barriers to optimal wellbeing and SDH for AI/AN peoples are understood through SUDs, ADRD, and compounding symptoms upheld by colonial traumas and postcolonial distress. En masse historical and contemporary discrimination and stress, particularly within Western medicine, both contextualizes the present and points to the ways in which the strengths, wisdom, and balance inherent in AI/AN culture are imperative to the holistic health and healing of AI/AN peoples, families, and communities.

Melatonin for Insomnia in Medical Inpatients: A Narrative Review

In this narrative review, we describe what is known about non-pharmacological and pharmacological treatments for insomnia in medical inpatients, with a focus on melatonin. Hospital-acquired insomnia is common, resulting in shortened total sleep time and more nighttime awakenings. Sleep disturbance has been shown to increase systemic inflammation, pain, and the likelihood of developing delirium in hospital. Treatment for insomnia includes both non-pharmacological and pharmacological interventions, the latter of which requires careful consideration of risks and benefits given the known adverse effects. Though benzodiazepines and non-benzodiazepine benzodiazepine receptor agonists are commonly prescribed (i.e., sedative-hypnotics), they are relatively contraindicated for patients over the age of 65 due to the risk of increased falls, cognitive decline, and potential for withdrawal symptoms after long-term use. Exogenous melatonin has a comparatively low likelihood of adverse effects and drug-drug interactions and is at least as effective as other sedative-hypnotics. Though more research is needed on both its effectiveness and relative safety for inpatients, small doses of melatonin before bedtime may be an appropriate choice for inpatients when insomnia persists despite non-pharmacological interventions.

CBD Oil as a Miracle Drug: A Thematic Analysis of Caregivers’ Attitudes and Practices Towards Cannabidiol in Dementia Treatment

The aim of this study was to understand caregivers of individuals with dementia attitudes toward CBD oil. Thematic analysis was conducted with 67 posts (570 comments) about CBD oil selected from a Polish online support forum for caregivers. We identified caregivers’ expectations, motivations, and practices of using CBD oil. Caregivers expected CBD to improve the behavior, cognition, communication, and daily activities of their loved ones. They motivated each other by sharing experiences about the positive effects of CBD oil and claimed to be administering CBD oil without medical advice, which led to dangerous practices such as an overnight withdrawal of all drugs or experimenting with CBD oil dosage. Caregivers perceive CBD oil as a safer and more effective treatment for those with dementia than the conventional methods. We recommend healthcare professionals inquire about possible CBD oil usage during follow-up visits and thoroughly explain what to expect from prescribed medications.

Importance of Bmal1 in Alzheimer's disease and associated aging-related diseases: Mechanisms and interventions

With the aging world population, the prevalence of aging-related disorders is on the rise. Diseases such as Alzheimer's, type 2 diabetes mellitus (T2DM), Parkinson's, atherosclerosis, hypertension, and osteoarthritis are age-related, and most of these diseases are comorbidities or risk factors for AD; however, our understandings of molecular events that regulate the occurrence of these diseases are still not fully understood. Brain and muscle Arnt-like protein-1 (Bmal1) is an irreplaceable clock gene that governs multiple important physiological processes. Continuous research of Bmal1 in AD and associated aging-related diseases is ongoing, and this review picks relevant studies on a detailed account of its role and mechanisms in these diseases. Oxidative stress and inflammation turned out to be common mechanisms by which Bmal1 deficiency promotes AD and associated aging-related diseases, and other Bmal1-dependent mechanisms remain to be identified. Promising therapeutic strategies involved in the regulation of Bmal1 are provided, including melatonin, natural compounds, metformin, d-Ser2-oxyntomodulin, and other interventions, such as exercise, time-restricted feeding, and adiponectin. The establishment of the signaling pathway network for Bmal1 in aging-related diseases will lead to advances in the comprehension of the molecular and cellular mechanisms, shedding light on novel treatments for aging-related diseases and promoting aging-associated brain health.

Pinus halepensis Essential Oil Ameliorates Aβ1-42-Induced Brain Injury by Diminishing Anxiety, Oxidative Stress, and Neuroinflammation in Rats

The Pinus L. genus comprises around 250 species, being popular worldwide for their medicinal and aromatic properties. The present study aimed to evaluate the P. halepensis Mill. essential oil (PNO) in an Alzheimer’s disease (AD) environment as an anxiolytic and antidepressant agent. The AD-like symptoms were induced in Wistar male rats by intracerebroventricular administration of amyloid beta1-42 (Aβ1-42), and PNO (1% and 3%) was delivered to Aβ1-42 pre-treated rats via inhalation route for 21 consecutive days, 30 min before behavioral assessments. The obtained results indicate PNO’s potential to relieve anxious–depressive features and to restore redox imbalance in the rats exhibiting AD-like neuropsychiatric impairments. Moreover, PNO presented beneficial effects against neuroinflammation and neuroapoptosis in the Aβ1-42 rat AD model.

Neurovascular Dysfunction in Diverse Communities With Health Disparities-Contributions to Dementia and Alzheimer's Disease

Alzheimer's disease and related dementias (ADRD) are an expanding worldwide crisis. In the absence of scientific breakthroughs, the global prevalence of ADRD will continue to increase as more people are living longer. Racial or ethnic minority groups have an increased risk and incidence of ADRD and have often been neglected by the scientific research community. There is mounting evidence that vascular insults in the brain can initiate a series of biological events leading to neurodegeneration, cognitive impairment, and ADRD. We are a group of researchers interested in developing and expanding ADRD research, with an emphasis on vascular contributions to dementia, to serve our local diverse community. Toward this goal, the primary objective of this review was to investigate and better understand health disparities in Alabama and the contributions of the social determinants of health to those disparities, particularly in the context of vascular dysfunction in ADRD. Here, we explain the neurovascular dysfunction associated with Alzheimer's disease (AD) as well as the intrinsic and extrinsic risk factors contributing to dysfunction of the neurovascular unit (NVU). Next, we ascertain ethnoregional health disparities of individuals living in Alabama, as well as relevant vascular risk factors linked to AD. We also discuss current pharmaceutical and non-pharmaceutical treatment options for neurovascular dysfunction, mild cognitive impairment (MCI) and AD, including relevant studies and ongoing clinical trials. Overall, individuals in Alabama are adversely affected by social and structural determinants of health leading to health disparities, driven by rurality, ethnic minority status, and lower socioeconomic status (SES). In general, these communities have limited access to healthcare and healthy food and other amenities resulting in decreased opportunities for early diagnosis of and pharmaceutical treatments for ADRD. Although this review is focused on the current state of health disparities of ADRD patients in Alabama, future studies must include diversity of race, ethnicity, and region to best be able to treat all individuals affected by ADRD.

Prevalence and characteristics of psychiatric morbidity treated in specialized health care in a nationwide cohort of people with newly diagnosed Alzheimer's disease

OBJECTIVE

Psychiatric disorders have been implied as both risk factors and prodromal symptoms of Alzheimer's disease (AD). A better understanding of the history of psychiatric morbidity in people with AD may aid with understanding this relationship and highlight challenges in diagnosing AD in people with concomitant psychiatric disorders.

METHODS

Medication use and Alzheimer's disease (MEDALZ) study is a nationwide register-based cohort of people (n = 70,718) who received a clinically verified AD diagnosis in Finland in 2005-2011 and were community-dwelling at the time of diagnosis. The study population was divided into four groups based on psychiatric morbidity treated in specialized health care. We characterized the groups using data of psychiatric and somatic illnesses, psychotropic drug use, and socioeconomic factors and investigated factors associated with prodromal AD.

RESULTS

Altogether, 4.3% of cohort members had a psychiatric diagnosis at least five years before AD diagnosis, 3.1% had a psychiatric diagnosis only up to five years before AD diagnosis, and 1.1% had a psychiatric diagnosis both less and more than 5 years before AD. Belonging to the Prodromal group (psychiatric diagnosis within 5 years before AD diagnosis) was most strongly associated with substance abuse (RR 65.06, 95%CI 55.54-76.22). Other associated factors with the Prodromal group were female gender, use of psychotropics, stroke, and asthma/COPD.

CONCLUSION

Substance abuse and psychotropic drug use are common five years before AD diagnosis. These can be potential markers of possible prodromal symptoms of AD and should be acknowledged in clinical work.

Personalized Management and Treatment of Alzheimer's Disease

Alzheimer’s disease (AD) is a priority health problem with a high cost to society and a large consumption of medical and social resources. The management of AD patients is complex and multidisciplinary. Over 90% of patients suffer from concomitant diseases and require personalized therapeutic regimens to reduce adverse drug reactions (ADRs), drug−drug interactions (DDIs), and unnecessary costs. Men and women show substantial differences in their AD-related phenotypes. Genomic, epigenetic, neuroimaging, and biochemical biomarkers are useful for predictive and differential diagnosis. The most frequent concomitant diseases include hypertension (>25%), obesity (>70%), diabetes mellitus type 2 (>25%), hypercholesterolemia (40%), hypertriglyceridemia (20%), metabolic syndrome (20%), hepatobiliary disorder (15%), endocrine/metabolic disorders (>20%), cardiovascular disorder (40%), cerebrovascular disorder (60−90%), neuropsychiatric disorders (60−90%), and cancer (10%). Over 90% of AD patients require multifactorial treatments with risk of ADRs and DDIs. The implementation of pharmacogenetics in clinical practice can help optimize the limited therapeutic resources available to treat AD and personalize the use of anti-dementia drugs, in combination with other medications, for the treatment of concomitant disorders.

Efficacy and safety of Z-substances in the management of insomnia in older adults: a systematic review for the development of recommendations to reduce potentially inappropriate prescribing

BACKGROUND

Z-drugs are usually prescribed as first line pharmacological therapy for insomnia. However, the benefits and risks of Z-drugs may differ for older adults. This systematic review investigated the available evidence on the efficacy and safety of Z-drugs in the management of insomnia in older adults.

METHODS

The Cochrane database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed/MEDLINE and EMBASE were searched for systematic reviews, meta-analyses, controlled interventional and observational studies using a pre-formulated search term. The target population was older adults (≥65 years old) with insomnia. Studies were included if they reported efficacy and/or safety outcomes of the use of Z-drugs for the management of insomnia compared to placebo, usual or no treatment, or other pharmacological agents.

RESULTS

Eighteen studies were included (8 interventional and 10 observational studies). In short-term interventional studies, Z-drugs were similarly or better efficacious in improving both sleep and daytime parameters than placebo or other pharmacological treatments, while showing good results on measures of safety. However, in longer-term observational studies, Z-drugs significantly increased the risk for falls and fractures in comparison to no treatment or melatonin agonists.

CONCLUSIONS

Analyzing the evidence from short-term interventional studies, Z-drugs appear effective and safe for treatment of insomnia in older adults, but they may have unfavorable side effects when used for longer periods of time. We, therefore, recommend discontinuing Z-drugs, principally because of the high risk for falls and fractures. Nonetheless, quality and quantity of evidence are low. Due to the scarcity of data, especially concerning drug dependence after longer periods of treatment and due to the significantly increased risk for falls and fractures, further studies are needed to evaluate the benefit-risk profile of Z-drugs use in older patients, particularly for long-term use.

Pharmacogenomics of Alzheimer's Disease: Novel Strategies for Drug Utilization and Development

Alzheimer's disease (AD) is a priority health problem in developed countries with a high cost to society. Approximately 20% of direct costs are associated with pharmacological treatment. Over 90% of patients require multifactorial treatments, with risk of adverse drug reactions (ADRs) and drug-drug interactions (DDIs) for the treatment of concomitant diseases such as hypertension (>25%), obesity (>70%), diabetes mellitus type 2 (>25%), hypercholesterolemia (40%), hypertriglyceridemia (20%), metabolic syndrome (20%), hepatobiliary disorder (15%), endocrine/metabolic disorders (>20%), cardiovascular disorder (40%), cerebrovascular disorder (60-90%), neuropsychiatric disorders (60-90%), and cancer (10%).For the past decades, pharmacological studies in search of potential treatments for AD focused on the following categories: neurotransmitter enhancers (11.38%), multitarget drugs (2.45%), anti-amyloid agents (13.30%), anti-tau agents (2.03%), natural products and derivatives (25.58%), novel synthetic drugs (8.13%), novel targets (5.66%), repository drugs (11.77%), anti-inflammatory drugs (1.20%), neuroprotective peptides (1.25%), stem cell therapy (1.85%), nanocarriers/nanotherapeutics (1.52%), and other compounds (<1%).Pharmacogenetic studies have shown that the therapeutic response to drugs in AD is genotype-specific in close association with the gene clusters that constitute the pharmacogenetic machinery (pathogenic, mechanistic, metabolic, transporter, pleiotropic genes) under the regulatory control of epigenetic mechanisms (DNA methylation, histone/chromatin remodeling, microRNA regulation). Most AD patients (>60%) are carriers of over ten pathogenic genes. The genes that most frequently (>50%) accumulate pathogenic variants in the same AD case are A2M (54.38%), ACE (78.94%), BIN1 (57.89%), CLU (63.15%), CPZ (63.15%), LHFPL6 (52.63%), MS4A4E (50.87%), MS4A6A (63.15%), PICALM (54.38%), PRNP (80.7059), and PSEN1 (77.19%). There is also an accumulation of 15 to 26 defective pharmagenes in approximately 85% of AD patients. About 50% of AD patients are carriers of at least 20 mutant pharmagenes, and over 80% are deficient metabolizers for the most common drugs, which are metabolized via the CYP2D6, CYP2C9, CYP2C19, and CYP3A4/5 enzymes.The implementation of pharmacogenetics can help optimize drug development and the limited therapeutic resources available to treat AD, and personalize the use of anti-dementia drugs in combination with other medications for the treatment of concomitant disorders.

The value of deprescribing in older adults with dementia: a narrative review

Introduction:Mitigating the burden of unnecessary polypharmacy or multiple medication use in people living with dementia has been recognized as a key priority internationally. One approach to reducing inappropriate polypharmacy is through medication withdrawal or deprescribing.Area covered:Non-systematic searches of key databases including PubMed, Embase, and Google Scholar were conducted from inception to 28 February 2021 for articles that assessed the safety and/or efficacy of deprescribing in older adults living with dementia. Personal reference libraries were also utilized. Information on current clinical trials was found in clinicaltrial.gov.Expert Opinion: There is limited direct evidence to inform deprescribing in older adults with dementia specifically. This review identified nineteen studies that have assessed the impact of deprescribing interventions to reduce inappropriate polypharmacy or direct deprescribing of specific medications. However, the current evidence is limited in scope as most studies focused on medication-related outcomes (e.g. discontinuation of high-risk medications) rather than patient-centered outcomes in individuals living with dementia. Furthermore, most studies focused on addressing inappropriate polypharmacy in older adults with dementia living in long-term care facilities, and interventions did not involve the person and their carer. Further evidence on the impact of deprescribing in this population across clinical settings is needed.

Is there a link between the use of benzodiazepines and related drugs and dementia? A systematic review of reviews

PURPOSE

Benzodiazepines (BZDs) and related drugs (BZRDs) are commonly used to treat diverse psychiatric disorders due to their anxiolytic, hypnotic and sedative properties, despite their known associated side effects, including acute consequences on cognition. Recently, some studies have also suggested that long-term cognitive effects may coexist, as the increased risk of cognitive decline and dementia. This review aims to appraise and summarise published synthesis studies on the risk of dementia development due to BZDs/BZRDs use.

METHODS

A comprehensive systematic search was carried out in PubMed, Web of Science, Cochrane Library and Epistemonikos databases. Grey literature and hand search of the studies' reference lists were undertaken. Meta-analysis, systematic and non-systematic reviews were included. Neither language nor date restrictions were applied. Search results other than synthesis studies were excluded. The methodological quality of the included reviews was analysed with AMSTAR-2 and SANRA tools.

RESULTS

Overall, 877 records were initially retrieved and 15 complied with the inclusion criteria. From these, five were systematic reviews with meta-analysis, two were systematic reviews and eight were non-systematic reviews. Most of the primary studies included in the analysed reviews found an association between BZDs/BZRDs use and subsequent dementia, with meta-analysis studies reporting an increased risk for users (ORs ranging from 1.38 to 1.78). However, the considerable clinical and methodological heterogeneity of the primary studies makes it difficult to establish a causal relationship.

CONCLUSION

Although hampered by the heterogeneity between the studies, the present findings suggest an association between BZDs/BZRDs use and increased risk of dementia in older adults.

ATS Core Curriculum 2020. Adult Sleep Medicine

The American Thoracic Society Core Curriculum updates clinicians annually in adult and pediatric pulmonary disease, medical critical care, and sleep medicine, in a 3–4-year recurring cycle of topics. These topics will be presented at the 2020 Virtual Conference. Below is the adult sleep medicine core that includes topics pertinent to sleep-disordered breathing and insomnia.

AAV delivery of shRNA against IRS1 in GABAergic neurons in rat hippocampus impairs spatial memory in females and male rats

Brain insulin resistance is a major factor leading to impaired cognitive function and it is considered as the onset of Alzheimer´s disease. Insulin resistance is intimately linked to inflammatory conditions, many studies have revealed how pro-inflammatory cytokines lead to insulin resistance, by inhibiting IRS1 function. Thus, the dysfunction of insulin signaling is concomitant with inflammatory biomarkers. However, the specific effect of IRS1 impaired function in otherwise healthy brain has not been dissected out. So, we decided in our study, to study the specific role of IRS1 in the hippocampus, in the absence of comorbidities. To that end, shRNA against rat and human IRS1 was designed and tested in cultured HEK cells to evaluate mRNA levels and specificity. The best candidate sequence was encapsulated in an AAV vector (strain DJ8) under the control of the cytomegalovirus promoter and together with the green fluorescent protein gene as a reporter. AAV-CMV-shIRS1-EGFP and control AAV-CMV-EGFP were inoculated into the dorsal hippocampus of female and male Wistar rats. One month later, animals undertook a battery of behavioral paradigms evaluating spatial and social memory and anxiety. Our results suggest that females displayed increased susceptibility to AAV-shIRS1 in the novel recognition object paradigm; whereas both females and males show impaired performance in the T maze when infected with AAV-shIRS1 compared to control. Anxiety parameters were not affected by AAV-shIRS1 infection. We observed specific fluorescence within the hilum of the dentate gyrus, in immuno-characterized parvalbumin and somatostatin neurons. AAV DJ8 did not enter astrocytes. Intense green fibers were found in the fornix, mammillary bodies, and in the medial septum indicating that hippocampal efferent had been efficiently targeted by the AAV DJ8 infection. We observed that AAV-shIRS1 reduced significantly synaptophysin labeling in hippocampal-septal projections compared to controls. These results support that, small alterations in the insulin/IGF1 pathway in specific hippocampal circuitries can underlie alterations in synaptic plasticity and affect behavior, in the absence of inflammatory conditions.