Anti-Amyloid Therapies for Alzheimer's Disease: An Alzheimer Europe Position Paper and Call to Action

The growing prevalence and burden of Alzheimer's disease has catalysed huge investments in research on its causes, diagnosis, treatment and care. After many high-profile failures, recent clinical trials of anti-amyloid drugs have marked a turning point for the field, leading to the approval of the first disease-modifying therapies for Alzheimer's disease by the FDA. It is now up to European regulators to determine whether there is sufficient evidence to approve these drugs for patients with mild cognitive impairment or mild dementia due to Alzheimer's disease. Here, we outline Alzheimer Europe's position on anti-amyloid therapies for Alzheimer's disease, which was adopted by the Board of Alzheimer Europe following consultations with our member associations and with the European Working Group of People with Dementia. Beyond questions of drug efficacy, safety and cost, we highlight important issues that must be addressed by industry, regulators, payers, healthcare systems and governments, to ensure that patients have timely, appropriate and equitable access to innovative treatments, regardless of their socio-economic background, insurance status, or place of residence. We also call for continued investment in research on treatments that might benefit people with more advanced Alzheimer's disease - as well as support and care services that can help people live well with dementia at all stages of the disease.

Validation, Deployment, and Real-World Implementation of a Modular Toolbox for Alzheimer's Disease Detection and Dementia Risk Reduction: The AD-RIDDLE Project

The Real-World Implementation, Deployment, and Validation of Early Detection Tools and Lifestyle Enhancement (AD-RIDDLE) project, recently launched with the support of the EU Innovative Health Initiative (IHI) public-private partnership and UK Research and Innovation (UKRI), aims to develop, test, and deploy a modular toolbox platform that can reduce existing barriers to the timely detection, and therapeutic approaches in Alzheimer's disease (AD), thus accelerating AD innovation. By focusing on health system and health worker practices, AD-RIDDLE seeks to improve and smooth AD management at and between each key step of the clinical pathway and across the disease continuum, from at-risk asymptomatic stages to early symptomatic ones. This includes innovation and improvement in AD awareness, risk reduction and prevention, detection, diagnosis, and intervention. The 24 partners in the AD-RIDDLE interdisciplinary consortium will develop and test the AD-RIDDLE toolbox platform and its components individually and in combination in six European countries. Expected results from this cross-sectoral research collaboration include tools for earlier detection and accurate diagnosis; validated, novel digital cognitive and blood-based biomarkers; and improved access to individualized preventative interventions (including multimodal interventions and symptomatic/disease-modifying therapies) across diverse populations, within the framework of precision medicine. Overall, AD-RIDDLE toolbox platform will advance management of AD, improving outcomes for patients and their families, and reducing costs.

What Matters to Patients with Alzheimer's Disease and Their Care Partners? Implications for Understanding the Value of Future Interventions

Alzheimer's Disease (AD) is the most common cause of dementia. Recent thinking portrays AD as a continuum consisting of three stages: an asymptomatic preclinical period, a mild cognitive impairment phase, and dementia, which can be further classified as mild, moderate or severe. While many studies explore the cognitive and functional aspects of AD, fully understanding AD pathophysiology, as well as the potential value of pharmacological and psycho-social interventions, requires a deeper understanding of patient and care partner priorities, particularly in the early stages where such interventions may have the greatest impact in slowing or delaying progression. Available studies highlight a diverse range of patient and care partner priorities, including impacts on their emotions, moods, and social lives. These priorities have not been systematically incorporated in the clinical and value assessments of potential interventions. We propose approaches to better understand the humanistic impact of AD including conducting additional research into the impacts of interventions from the point of view of patients and care partners, expanding notions of 'value' and improving health system capacity for diagnosis.

A European Academy of Neurology guideline on medical management issues in dementia

BACKGROUND AND PURPOSE

Dementia is one of the most common disorders and is associated with increased morbidity, mortality and decreased quality of life. The present guideline addresses important medical management issues including systematic medical follow-up, vascular risk factors in dementia, pain in dementia, use of antipsychotics in dementia and epilepsy in dementia.

METHODS

A systematic review of the literature was carried out. Based on the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework, we developed a guideline. Where recommendations based on GRADE were not possible, a good practice statement was formulated.

RESULTS

Systematic management of vascular risk factors should be performed in patients with mild to moderate dementia as prevention of cerebrovascular pathology may impact on the progression of dementia (Good Practice statement). Individuals with dementia (without previous stroke) and atrial fibrillation should be treated with anticoagulants (weak recommendation). Discontinuation of opioids should be considered in certain individuals with dementia (e.g. for whom there are no signs or symptoms of pain or no clear indication, or suspicion of side effects; Good Practice statement). Behavioral symptoms in persons with dementia should not be treated with mild analgesics (weak recommendation). In all patients with dementia treated with opioids, assessment of the individual risk-benefit ratio should be performed at regular intervals. Regular, preplanned medical follow-up should be offered to all patients with dementia. The setting will depend on the organization of local health services and should, as a minimum, include general practitioners with easy access to dementia specialists (Good Practice statement). Individuals with dementia and agitation and/or aggression should be treated with atypical antipsychotics only after all non-pharmacological measures have been proven to be without benefit or in the case of severe self-harm or harm to others (weak recommendation). Antipsychotics should be discontinued after cessation of behavioral disturbances and in patients in whom there are side effects (Good Practice statement). For treatment of epilepsy in individuals with dementia, newer anticonvulsants should be considered as first-line therapy (Good Practice statement).

CONCLUSION

This GRADE-based guideline offers recommendations on several important medical issues in patients with dementia, and thus adds important guidance for clinicians. For some issues, very little or no evidence was identified, highlighting the importance of further studies within these areas.

Advantages and limitations of thermal lens spectrometry over conventional spectrophotometry for absorbance measurements

This review considers the advantages and the limitations that thermal lens spectrometry has over conventional spectrophotometry for the measurement of optical absorption in specific applications. The photothermal method is characterized by its intrinsic sensitivity resulting from the indirect nature of the measurement and amplified by physical and thermo-optical parameters which are not effective in absorbance measurements. Other advantages include a weak dependence on light scattering and the complementary nature of photothermal spectra with respect to absorption and emission spectra for speciation studies at very low concentrations. The main drawbacks are the convective noise, the background absorbance and the complexity of the experimental set-up, especially when differential or wavelength scanning measurements are required.

The economic impact of dementia in Europe in 2008-cost estimates from the Eurocode project

OBJECTIVE

Care for demented people is very resource demanding, the prevalence is increasing and there is so far no cure. Cost of illness (CoI) studies are important by identifying the distribution of costs between different payers of care. The European Union (EU) funded the European Collaboration on Dementia (Eurocode) as part of the EU's 2005 work plan of the Community public health programme. Eurocode was administered by Alzheimer Europe. The aim was to describe the economic impact of dementia in Europe in 2008.

METHODS

Eurocode's new estimates for dementia prevalence were included in a cost model based on published European CoI papers. For countries where no CoI figures were available, imputation was used.

RESULTS

The total CoI of dementia in the EU27 in 2008 was estimated to be €160 billion (€22 000 per demented per year), of which 56% were costs of informal care. The corresponding costs for the whole Europe was €177 billion. In northern Europe, the direct costs are estimated to be considerabe, while the cost of informal care is the major cost component in southern Europe. The sensitivity analysis showed a range for total EU27 costs between €111 and 168 billion.

CONCLUSIONS

The estimated CoI in this study is higher than in previous studies. There are also large differences in different European regions. Notwithstanding the methodological challenges, the societal costs of dementia in Europe are very high which in turn have substantial resource impacts on the social and health care systems in Europe.

Epidemiological studies of cognitive impairment and dementia across Eastern and Middle European countries (epidemiology of dementia in Eastern and Middle European Countries)

OBJECTIVE

To determine the availability and the consistency of prevalence findings of epidemiological studies on cognitive impairment and dementia conducted in Eastern and Middle Europe.

METHODS

We adopted a stepwise multimethod study approach consisting of iterative literature searches for epidemiological articles published between 1990 and 2006 and subsequent data analyses of published material, reanalyses of existing accessible epidemiological data sets and expert inquiries in Eastern and Middle European countries. Systematic computer-assisted searches used the keywords: "dementia", "Alzheimer", "cognitive impairment", "incidence", "prevalence", "epidemiology" in combination with the name of the relevant countries or "Europe" in English and Polish language. We supplemented the literature search with a review of the references in the articles that were identified during the initial search.

RESULTS

We were able to find few regional and country-specific epidemiological studies of various kinds (population-based, cohort, cross-sectional studies) and conducted on different restricted population groups of patients (from neurological units, out-patients units, residential homes). No studies were identified from most of the countries taken under consideration and the ones we found were characterized by an immense diversity with a considerable degree of clinical and methodological variations. The few studies that there are suggest prevalence rates of dementia in Eastern Europe similar to those in Western Europe.

CONCLUSIONS

There is strong need for epidemiological studies in Eastern and Middle Europe, as well as for greater coordination and standardization of methods to improve the quality and comparability of epidemiological data to determine the prevalences' rates of dementia in all the EU countries.

Recommendations for the diagnosis and management of Alzheimer's disease and other disorders associated with dementia: EFNS guideline

The aim of this international guideline on dementia was to present a peer-reviewed evidence-based statement for the guidance of practice for clinical neurologists, geriatricians, psychiatrists, and other specialist physicians responsible for the care of patients with dementia. It covers major aspects of diagnostic evaluation and treatment, with particular emphasis on the type of patient often referred to the specialist physician. The main focus is Alzheimer's disease, but many of the recommendations apply to dementia disorders in general. The task force working group considered and classified evidence from original research reports, meta-analysis, and systematic reviews, published before January 2006. The evidence was classified and consensus recommendations graded according to the EFNS guidance. Where there was a lack of evidence, but clear consensus, good practice points were provided. The recommendations for clinical diagnosis, blood tests, neuroimaging, electroencephalography (EEG), cerebrospinal fluid (CSF) analysis, genetic testing, tissue biopsy, disclosure of diagnosis, treatment of Alzheimer's disease, and counselling and support for caregivers were all revised when compared with the previous EFNS guideline. New recommendations were added for the treatment of vascular dementia, Parkinson's disease dementia, and dementia with Lewy bodies, for monitoring treatment, for treatment of behavioural and psychological symptoms in dementia, and for legal issues. The specialist physician plays an important role together with primary care physicians in the multidisciplinary dementia teams, which have been established throughout Europe. This guideline may contribute to the definition of the role of the specialist physician in providing dementia health care.

Photothermal spectrometry for detection in miniaturized systems: relevant features, strategies and recent applications

There is a growing interest in using miniaturized analytical devices because they allow to execute the different steps of an analytical process within very short times and with drastic reduction in the amounts of solvents, reagents and samples. As for capillary electrophoresis, these systems require detectors which are sensitive, versatile and adaptable to very small detection volumes. In this respect, photothermal spectrometry which is complementary to fluorescence seems to be a promising detection method. This review describes the basic principle of photothermal spectrometry along with the related methods based on colinear-beam or crossed-beam configuration of the pump and probe lasers. Two experimental set ups especially designed for microfluidic systems as well as for capillary electrophoresis are described. Their characteristics and key features are discussed and the main applications are outlined.

Comprehensive study of the luminescent properties and lifetimes of Eu(3+) and Tb(3+) chelated with various ligands in aqueous solutions: influence of the synergic agent, the surfactant and the energy level of the ligand triplet

The formation and the properties of luminescent complexes of europium and terbium with a variety of organic ligands have been investigated in aqueous solutions. The ligands used include model compounds such as thenoyltrifluoroacetone and pyridine-2,6-dicarboxylic acid and organic analytes of biological or pharmaceutical interest. It is shown that the formation and the luminescent properties of these complexes depend at first on several parameters including the pH and the buffer, the synergic agent and the surfactant. In neutral solutions, trioctylphosphine oxide in the presence of Triton X-100 may act as a co-ligand to promote complex formation and protect the complex from radiationless deactivation processes. Working in slightly alkaline solutions in the presence of EDTA and hexadecyltrimethylammonium chloride may induce the deprotonation of a second coordinating group and favour the formation of a new complex with stronger luminescent properties. In both cases, the luminescence lifetimes are then ultimately related to the energy gap between the ligand triplet and the resonance level of the ion and to the number of water molecules coordinated to the lanthanide ion.

Investigation of the diffusion coefficient of polymers and micelles in aqueous solutions using the Soret effect in cw-laser thermal lens spectrometry

The concentration gradient (Soret effect) induced in cw-laser thermal lens spectrometry subsequently to the formation of the thermal gradient (thermal lens effect) has been investigated in aqueous solutions of various macromolecular species including micelles, mixed micelles and polymers. It is shown that the build-up of the concentration gradient is much shorter than that in classical Soret experiments, reaching steady-state values in less than 1 min. The time evolution of the Soret signal has been used to derive mass-diffusion times from which mass-diffusion coefficients were calculated. Our data are in agreement with previous results obtained from quasi-elastic light scattering studies for the micellar solutions and calculated from a known molecular weight-dependent power law for polymer solutions.

Pulsed-laser mode-mismatched crossed-beam thermal lens spectrometry within a small capillary tube: effect of flow rate and beam offset on the photothermal signal

Pulsed-laser crossed-beam thermal lens spectrometry within a small capillary tube has been investigated using static as well as flowing samples. It is shown that when both the excitation and probe beams are perfectly aligned, time-resolved and peak signals are adequately described by the theoretical relations previously reported for infinite samples. Depending on flow velocity and/or the lateral offset between excitation and probe beam axis, the optical element formed by the excitation beam may have a diverging or converging effect on the probe beam. However, optimization of the photothermal signal with pulsed excitation and flowing samples does not require offsetting the pump and probe beams and the peak signal is almost independent on the flow rate. The performance of the method has been checked with samples injected in a flowing stream. The response is linear over three orders of magnitude and the limit of detection obtained for cobalt nitrate in ethanol corresponds to an average absorbance of 5 x 10(-7) inside the capillary.

Perspectives on legislation relating to the rights and protection of people with dementia in Europe

This article focuses on the main legal provisions in Europe relating to the protection and rights of people with dementia. The information referred to was obtained in the framework of two EC funded projects, which involved the collection, translation and comparison of relevant legislation, and then the writing of legal recommendations to improve the legal rights and protection of people with dementia. The first project started in 1997 and was completed in 1999. The second project started in 1999 and was completed in November 2000. The article provides an overview of the main features of some of the laws in Europe on a few key issues, i.e. guardianship, coercive measures and bioethical issues. Some of the main differences between the systems in different countries are highlighted. An attempt is made to show how the adequacy and appropriateness of legal provisions differ vastly from one country to the next and also to identify the emergence of a few trends, which seem to reflect a movement towards a greater awareness of the nature of mental incapacity and hence a better provision for the rights and protection of people with dementia.

Sensitive detection of tetracyclines using europium-sensitized fluorescence with EDTA as co-ligand and cetyltrimethylammonium chloride as surfactant

The determination of tetracyclines (TC) in aqueous solutions, based on europium-sensitized fluorescence, has been improved using EDTA as co-ligand and cetyltrimethylammonium chloride as surfactant. The method involves working in slightly alkaline solutions with the formation of a new chelate where the lanthanide ion is bound to the beta-diketone group. The method is about 6 times more sensitive than that with the Eu-TC-Triton system and LODs are 2.5 x 10(-10), 5 x 10(-10), 1.5 x 10(-9) and 2 x 10(-9) mol l-1 for TC, oxytetracycline, chlortetracycline and doxycycline, respectively. The method has been applied to the determination of TC in calf serum without sample pretreatment. The mean recovery was close to 102% and the lowest concentration attainable in serum samples was better than 0.1 microgram ml-1.

Investigation of the thermal lens effect in water-ethanol mixtures: composition dependence of the refractive index gradient, the enhancement factor and the Soret effect

The thermal lens effect produced in binary mixtures of water and ethanol has been investigated. It is shown that the sensitivity of the thermal lens method upon the addition of ethanol in water varies as the temperature-dependent refractive index gradient to thermal conductivity ratio of the mixture. The dependence of k and dn/dT upon the ethanol volume fraction follows a second-order and fourth-order polynomial, respectively, and cannot be precisely predicted using the additive rule. Moreover, depending on the experimental conditions and the mixture composition, the temperature gradient produced subsequently to relaxation of the excited species induces mutual migration of the solvent molecules and the formation of a concentration gradient in the irradiated area. This effect, known as the Soret effect, can locally change the thermo-optical properties of the solution and produce an additional signal, especially when steady-state experiments are done. This may result in errors as large as 20% when quantitative informations have to be derived from experimental data.

Thermal lens spectrometry in aqueous solutions of Brij 35: investigation of micelle effects on the time-resolved and steady-state signals

This work investigates the effect of micelles on the time-resolved and steady-state thermal lens signals in aqueous solutions. The temperature gradient produced subsequently to non-radiative relaxation of the sample induces migration of micelles towards the colder region of the irradiated area along with an opposite flow of solute molecules. This phenomenon, known as the Soret effect, produces an additional probe beam signal with a rise time that is much longer than the thermal time constant and depends on the surfactant and solute concentrations. Extrapolation of the mass-diffusion constant at zero solute concentration allowed the determination of diffusion coefficients that are close to those derived by other methods for Brij 35 micelles in water. It is also shown that the surfactant has only a small effect on the thermal lens signal and that the enhancement produced by micelles with respect to pure water originates mainly firom the Soret effect. It follows that interpretation of experimental data without discriminating both components of the probe beam signal can lead to erroneous values of dn/dT.

Investigation of chelate formation, intramolecular energy transfer and luminescence efficiency and lifetimes in the Eu-thenoyltrifluoroacetone-trioctylphosphine oxide-Triton X-100 system using absorbance, fluorescence and photothermal measurements

The formation and the photophysical properties of the europium-thenoyltrifluoroacetone (TTA) trioctylphosphine oxide (TOPO)-Triton X-100 chelate were investigated. When the medium is buffered with acetate, there is a strong competition between acetate and TTA for coordination with europium ions. When TOPO is added into the solution, the Eu-TTA-TOPO ternary chelate forms more easily, probably because the coligand acts as a synergic agent and would favour the formation of the enol form of TTA. Although the stoichiometric composition of the chelate is expected to be Eu(TTA)3(TOPO)2, the Eu-TTA and the Eu-TOPO mole ratios may be within 2-3 and 1-2, respectively, depending on the composition of the solution. However, the fluorescent properties of the chelate seem to be mainly dominated by its actual concentration into the solution rather than by its composition. Time resolution of europium emission spectra in the microsecond range has shown that energy transfer occurs from the TTA ligand to the 5D1 level of europium. Then, the emitting 5D0 level is populated through non-radiative deactivation of 5D1. The observed lifetimes of the 5D1 and 5D0 states are 1.25 and 860 micros, respectively. The overall fluorescence quantum yield of the chelate, measured by the photothermal method, is found to be 0.22. On the basis of the time-resolved photothermal experiments, the fluorescence quantum yield of the 5D0 state is expected to be > 0.8 and the energy transfer efficiency < 0.28.

Improved detection of salicylic acids using terbium-sensitized luminescence in aqueous micellar solutions of cetyltrimethylammonium chloride

The determination of salicylic, p-aminosalicylic and 5-fluorosalicylic acids was investigated using terbium-sensitized luminescence in aqueous solutions. Formation of a ternary chelate between terbium, EDTA and the salicylic acid requires dissociation of the phenol group which is adjacent to the dissociated carboxylic group. The reaction is obtained in alkaline solutions and is enhanced in the presence of cetyltrimethylammonium chloride. As evidenced by absorbance and fluorescence measurements, the cationic surfactant plays an important role in the formation of the ternary chelate and then terbium luminescence depends mainly on the extent of chelate formation. Linearity is found over more than four orders of magnitude and detection limits are in the range (2-4) x 10(-10) mol l-1 for the three acids.

Comparison of diet composition in women with and without functional bowel disorder

Nurses are often involved in helping patients alleviate chronic distressing gastrointestinal symptoms such as those associated with irritable bowel syndrome or functional bowel disorder. One therapeutic strategy is to increase dietary fiber intake and to eliminate gastrointestinal (GI) irritants such as caffeine, alcohol, and tobacco smoking. However, little work has been done to establish a relationship between dietary factors and chronic GI symptoms. In this article, the authors: (a) describe and compare caloric and dietary constituent intake in symptomatic (n = 18) and asymptomatic (n = 37) women, and (b) examine the relationships among diet, GI symptoms, and stool characteristics in the two groups. In particular, total calories, fiber, fat, protein, and carbohydrates as well as alcohol and caffeine intakes were compared in women who do not smoke. Because menstrual cycle phase modulates both symptoms and appetite, women were studied during the follicular phase. Groups had similar caloric, fat, and protein intakes. Fiber intakes were similar and similar to national norms in both groups. When compared with asymptomatic women, the symptomatic women consumed more refined carbohydrates. Relationships were observed among dietary intake of refined carbohydrates, fiber, GI symptoms, and stool characteristics in women with functional bowel disorder.