Future Alzheimer’s treatment

Report suggests joint actions and planning in Europe can help provide better coordinated and more timely care for Alzheimer’s patients | RAND Corporation

world-1264062_1920

  • The burden of Alzheimer’s disease in high-income countries is expected to approximately double between 2015 and 2050. Recent clinical trial results give hope that a disease-modifying therapy might become available in the near future. The therapy is expected to treat early-stage patients to prevent or delay the progression to dementia.
  • This preventive treatment paradigm implies the need to screen, diagnose, and treat a large population of patients with mild cognitive impairment. There would be many undiagnosed prevalent cases that would need to be addressed initially, and then the longer-term capacity to address incident cases would not need to be as high.
  • Researchers used a simulation model to assess the preparedness of the health care system infrastructure in six European countries — France, Germany, Italy, Spain, Sweden, and the United Kingdom — to evaluate, diagnose, and treat the expected number of patients.
  • Projected peak wait times range from five months for treatment in Germany to 19 months for evaluation in France. The first year without wait times would be 2030 in Germany and 2033 in France, and 2042 in the United Kingdom and 2044 in Spain. Specialist capacity is the rate-limiting factor in France, the United Kingdom, and Spain, and treatment delivery capacity is an issue in most of the countries.
  • If a disease-modifying therapy becomes available in 2020, we estimate the projected capacity constraints could result in over 1 million patients with mild cognitive impairment progressing to Alzheimer’s dementia while on wait lists between 2020 and 2050 in these six countries.

Recommendations

  • In addition to increasing specialist and infusion capacity in each individual country, joint actions and planning in Europe can help provide better coordinated and more timely care for Alzheimer’s patients.
  • A combination of reimbursement, regulatory, and workforce planning policies, as well as innovation in diagnosis and treatment delivery, is needed to expand capacity and to ensure that available capacity is leveraged optimally to treat patients with early-stage Alzheimer’s disease.

Full report: Assessing the Preparedness of the Health Care System Infrastructure in Six European Countries for an Alzheimer’s Treatment | RAND Corporation

Antidepressants for treating depression in dementia

Dudas,  R., Malouf,  R., McCleery,  J., & Dening,  T.| 2018|  Antidepressants for treating depression in dementia| Cochrane Database of Systematic Reviews 2018 | Issue 8| Art. No.: CD003944|  DOI: 10.1002/14651858.CD003944.pub2.

A new review from Cochrane looks at the efficacy of antidepressants in treating depression in dementia. This study updates an earlier version, first published in 2002. 

woman-65675_1920 (1)

Plain language summary

Antidepressants for treating depression in dementia

Review question

We reviewed the evidence about the effect of antidepressants on depression in people with dementia.

Background

Depression can be hard to recognise in people with dementia, but there is evidence that it is common and associated with increased disability, poorer quality of life, and shorter life expectancy. Many people with dementia are prescribed antidepressants to treat depression, but there is uncertainty about how effective this is.

Study characteristics

We found ten studies with 1592 people to include in the review. On average, the studies lasted only 12 weeks, although one study ran for nine months. Each of them used a set of formal criteria to diagnose both depression and dementia and compared an antidepressant against a dummy pill (placebo).

The older studies used more old‐fashioned antidepressants (imipramine, clomipramine, and moclobemide) and the newer studies used more modern ones, such as venlafaxine, mirtazapine and so‐called SSRI antidepressants (sertraline, fluoxetine, citalopram and escitalopram).

The people taking part in the studies had an average age of 75 and they had mild or moderate dementia. With the exception of two studies, they were being treated as outpatients.

Key results

We found that there was little or no difference in scores on depression rating scales between people treated with antidepressants and those treated with placebo for 12 weeks. The evidence to support this finding was of high quality, which suggests that further research is unlikely to find a different result. There was probably also little or no difference after six to nine months of treatment.

Another way to assess the effect of antidepressants is to count the number of people in the antidepressant and placebo groups who show significant clinical improvement (response) or who recover from depression (remission). There was low‐quality evidence on the number of people showing a significant clinical improvement and the result was imprecise so we were unable to be sure of any effect on this measure. People taking an antidepressant were probably more likely to recover from depression than were those taking placebo (antidepressant: 40%, placebo: 21.7%). There was moderate‐quality evidence for this finding, so it is possible that further research could find a different result.

We found that antidepressants did not affect the ability to manage daily activities and probably had little or no effect on a test of cognitive function (which includes attention, memory, and language).

People taking an antidepressant were probably more likely to drop out of treatment and to have at least one unwanted side effect.

Quality of the evidence

The quality of the evidence varied, mainly due to poorly conducted studies and problems with the relevance of the outcome measures used. This should be taken into consideration when interpreting the different results on depression rating scales and recovery rates, as evidence was of a higher quality for the former than for the latter.

Another major problem is that side effects are very rarely well‐reported in studies.

Therefore, further research will still be useful to reach conclusions that are more reliable and can better help doctors and patients to know what works for whom.

The full paper is available from the Cochrane 

A summary including the abstract and  plain language summary is here 

New leads on treating dementia and Alzheimer’s

A new research study provides an explanation for why clinical trials of drugs reducing proteins in the brain that were thought to cause dementia and Alzheimer’s have failed. The study has opened the way for potential new treatments with existing drugs | Human Molecular Genetics | via ScienceDaily

In an article in the journal, Human Molecular Genetics,  researchers assembled evidence from a wide range of human studies and animal models of dementia-related diseases to show that inflammation is a major cause, not just a consequence. The new work turns previous thinking around. The genetic linkages imply that the inflammation comes first — and the tissue damage second.

Project leader Professor Robert Richards explains that by reducing some elements of inflammation, it may be possible to reduce dementia symptoms:

“With this new understanding of the disease, we now need to test existing anti-inflammatory drugs for their effectiveness in treating dementia,” he says.

Full story at ScienceDaily

Journal reference: Robert I Richards, Sarah A Robertson, Daniel L Kastner |  Neurodegenerative diseases have genetic hallmarks of autoinflammatory disease | Human Molecular Genetics |  April 2018

 

15 years of dementia treatment in 15 papers

Age and Ageing journal has published a free online collection of 15 papers to provide an update on the advances of pharmacological and non-pharmacological interventions in dementia over the last 15 years.

age
Image source: academic.oup.com

The published studies reflect the efficacy of the current anti-dementia treatments, preventive treatments of cardio and cerebrovascular incidents known to be risk factors for dementia, alongside the use of antidepressant medication and non-pharmacological interventions for treatment of behavioural and psychopathological symptoms of dementia. We also address the future preventative steps and therapeutic strategies currently in development to combat the devastating consequences of dementia.

 

These papers are all free to read, download and share from the Age and Ageing journal website. The full collection can be viewed here, or individual papers accessed below.

Currently available anti-dementia treatments

Non-pharmacological interventions

Management of vascular risk factors for dementia

Drug use in people with dementia

Rehabilitation in dementia care

Rehabilitation in dementia care | Age and Ageing

Abstract:

Multidisciplinary rehabilitation is increasingly accepted as valuable in the management of chronic disease. Whereas traditional rehabilitation models focussed on recovery, maintaining independence and delaying functional decline are now considered worthwhile aims even where full recovery is not feasible.

Despite this, rehabilitation is notably absent from dementia care literature and practice. People with dementia report frustration with the lack of availability of structured post-diagnosis pathways like those offered for other conditions.

Alternative terms such as ‘re-ablement’ are used to refer to rehabilitation-like services, but lack an evidence-base to guide care.

This commentary will discuss possible reasons for the resistance to accept multidisciplinary rehabilitation as part of dementia care, and identifies the value of doing so for people with dementia, their families, and for health professionals.

Full reference: Cations, M et al. |  Rehabilitation in dementia care | Age and Ageing Volume 47, Issue 2, no.1 | March 2018 |  Pages 171–174

Neuropsychiatric signs and symptoms of Alzheimer’s disease: New treatment paradigms

Neuropsychiatric symptoms (NPSs) are hallmarks of Alzheimer’s disease (AD), causing substantial distress for both people with dementia and their caregivers, and contributing to early institutionalization | Alzheimer’s & Dementia: Translational Research & Clinical Interventions

https://wellcomeimages.org/indexplus/result.html?_IXMAXHITS_=1&_IXACTION_=query&_IXFIRST_=4&_IXSR_=XncW7EHtSQt&_IXSS_=_IXMAXHITS_%3d15%26_IXFPFX_%3dtemplates%252ft%26_IXFIRST_%3d1%26c%3d%2522historical%2bimages%2522%2bOR%2b%2522contemporary%2bimages%2522%2bOR%2b%2522corporate%2bimages%2522%2bOR%2b%2522contemporary%2bclinical%2bimages%2522%26%252asform%3dwellcome%252dimages%26%2524%253dsi%3dtext%26_IXACTION_%3dquery%26i_pre%3d%26IXTO%3d%26t%3d%26_IXINITSR_%3dy%26i_num%3d%26%2524%253dsort%3dsort%2bsortexpr%2bimage_sort%26w%3d%26%2524%253ds%3dalzheimers%26IXFROM%3d%26_IXSUBMIT_%3dSubmit%26_IXshc%3dy%26%2524%2b%2528%2528with%2bwi_sfgu%2bis%2bY%2529%2band%2bnot%2b%2528%2522contemporary%2bclinical%2bimages%2522%2bindex%2bwi_collection%2bor%2b%2522corporate%2bimages%2522%2bindex%2bwi_collection%2529%2529%2band%2bnot%2bwith%2bsys_deleted%3d%252e%26_IXrescount%3d4&_IXSPFX_=templates%2ft&_IXFPFX_=templates%2ft
Image source: Florence Winterflood – Wellcome Images // CC BY 4.0

Image shows an artistic interpretation of Alzheimer’s Disease.

They are among the earliest signs and symptoms of neurocognitive disorders and incipient cognitive decline, yet are under-recognized and often challenging to treat. With this in mind, the Alzheimer’s Association convened a Research Roundtable in May 2016, bringing together experts from academia, industry, and regulatory agencies to discuss the latest understanding of NPSs and review the development of therapeutics and biomarkers of NPSs in AD. This review will explore the neurobiology of NPSs in AD and specific symptoms common in AD such as psychosis, agitation, apathy, depression, and sleep disturbances. In addition, clinical trial designs for NPSs in AD and regulatory considerations will be discussed.

Full reference: Lanctôt, K.L. et al. (2017) Neuropsychiatric signs and symptoms of Alzheimer’s disease: New treatment paradigms. Alzheimer’s & Dementia: Translational Research & Clinical Interventions. Published online: 5th August 2017

People with dementia benefit from goal-orientated therapy

Personalised cognitive rehabilitation therapy can help people with early stage dementia significantly improve their ability to engage in important everyday activities and tasks. | via ScienceDaily

A large-scale trial has found that cognitive rehabilitation leads to people seeing satisfying progress in areas that enable them to maintain their functioning and independence.

Cognitive rehabilitation involves a therapist working with the person with dementia and a family carer to identify issues where they would like to see improvements. Together, they set up to three goals, and the therapist helps to develop strategies to achieve these goals.

The goals participants chose were varied, as dementia affects people in a wide range of ways. Some participants wanted to find ways of staying independent, for example by learning or re-learning how to use household appliances or mobile phones. Some wanted to manage daily tasks better, and worked with therapists on developing strategies to prevent them burning their food when cooking meals. Others wanted to stay socially connected, and focussed on being able to remember details like the names of relatives or neighbours, or improving their ability to engage in conversation. Sometimes staying safe was important, so strategies focused on things like remembering to lock the door at home or withdrawing money safely from a cashpoint.

The Goal-oriented Cognitive Rehabilitation in Early-stage Alzheimer’s and Related Dementias: Multi-centre Single-blind Randomised Controlled Trial (GREAT) trial involved 475 people across eight sites in England and Wales. Half of them received ten cognitive rehabilitation sessions over three months, and the other half did not. The group receiving the therapy then took part in four “top-up” sessions over six months.

The researchers found that those who took part in the therapy showed significant improvement in the areas they had identified, after both the ten week and “top-up” sessions. Family carers agreed that their performance had improved. Both participants and carers were happier with the participants’ abilities in the areas identified.

Full story: University of Exeter. “People with dementia benefit from goal-oriented therapy: Personalized cognitive rehabilitation therapy can help people with early stage dementia significantly improve their ability to engage in important everyday activities and tasks.” ScienceDaily. | 18 July 2017.