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Alzheimer Disease Medication

The mainstay of therapy for patients with Alzheimer disease (AD) is the use of centrally acting cholinesterase inhibitors to attempt to compensate for the depletion of acetylcholine (ACh) in the cerebral cortex and hippocampus. A partial N -methyl-D-aspartate (NMDA) antagonist is approved for treatment of moderate and severe AD. Various medications are used for treatment of secondary symptoms of AD, including antidepressants, anti-anxiety agents, and antipsychotic agents.

Class Summary

Cholinesterase inhibitors (ChEIs) are used to palliate cholinergic deficiency. All 4 currently approved ChEIs (ie, tacrine, donepezil, rivastigmine, galantamine) inhibit acetylcholinesterase (AChE) at the synapse (specific cholinesterase). Tacrine was the first agent that was approved for AD, but because of its potential to cause hepatotoxicity, it is now rarely used.… [Continue Reading]

Alzheimer Disease Treatment & Management

To date, only symptomatic therapies for Alzheimer disease (AD) are available. All drugs approved by the US Food and Drug Administration (FDA) for the treatment of AD modulate neurotransmitters, either acetylcholine or glutamate. The standard medical treatment for AD includes cholinesterase inhibitors (ChEIs) and a partial N -methyl-D-aspartate (NMDA) antagonist.[65] [66]

Secondary symptoms of AD (eg, depression, agitation, aggression, hallucinations, delusions, sleep disorders) can be problematic. Behavioral symptoms in particular are common and can exacerbate cognitive and functional impairment. The following classes of psychotropic medications have been used to treat these secondary symptoms[67] :

  • Antidepressants
  • Anxiolytics
  • Antiparkinsonian agents
  • Beta-blockers
  • Antiepileptic drugs (for their effects on behavior)
  • Neuroleptics

Most studies of psychotropic drugs for AD have demonstrated no or limited efficacy. However, many issues make interpretation of data from these studies difficult.… [Continue Reading]

Alzheimer Disease

Alzheimer disease (AD) is an acquired disorder of cognitive and behavioral impairment that markedly interferes with social and occupational functioning. It is an incurable disease with a long and progressive course. AD not only has detrimental effects on the patient but often takes a significant toll on patients’ families and caretakers as well.

The most common form of dementia, AD affects about 5.4 million people in the United States alone, and that number is projected to reach 12-16 million by the year 2050[1] (see Epidemiology). Economically, AD is a major public health problem. In the United States in 2011, the cost of health care, long-term care, and hospice services for people aged 65 years and older with AD and other dementias was expected to be $183 billion, and this figure does not include the contributions of unpaid caregivers.[1]

Currently, an autopsy or brain biopsy is the only way to make a definitive diagnosis of AD. In clinical practice, the diagnosis is usually made on the basis of the history and findings on Mental Status Examination (see Presentation).

Symptomatic therapies are the only treatments available for AD. The standard medical treatments include cholinesterase inhibitors and a partial N -methyl-D-aspartate (NMDA) antagonist. Psychotropic medications are often used to treat secondary symptoms of AD, such as depression, agitation, and sleep disorders.… [Continue Reading]

Eating Berries Linked to Delay in Cognitive Decline

Fran Lowry

May 1, 2012 — Increased consumption of blueberries and strawberries appears to slow cognitive decline in older women, according to an analysis of data from the Nurses’ Health Study (NHS).

“Increasing berry intake appears to slow memory decline by up to 2.5 years,” lead author, Elizabeth E. Devore, ScD, from the Channing Laboratory, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, told Medscape Medical News. “By this, we mean that women eating the most berries vs. little to no berries had memory differences equivalent to women 2.5 years apart in age.”

The news study was published online April 25 in the Annals of Neurology.… [Continue Reading]

New AAN Guidelines on Episodic Migraine Prevention

by Susan Jeffrey

April 24, 2012 (New Orleans, Louisiana) — New guidelines for the prevention of episodic migraine, co-developed by the American Academy of Neurology (AAN) and the American Headache Society (AHA), upgrade the level of evidence supporting the use of some drugs but downgrade others.

Major changes include a new Level A endorsement for topiramate, but gabapentin and verapamil and other calcium-channel blockers are now considered Level U, or without sufficient evidence for or against their usefulness.

“The guidelines tell us about the evidence,” Stephen D. Silberstein, MD, from the Jefferson Headache Center at Thomas Jefferson University in Philadelphia, Pennsylvania, lead author of the guidelines, told Medscape Medical News. “If there’s a drug out there that’s never been tested in migraine, that doesn’t mean it doesn’t work. The example is topiramate, which in the first guideline we didn’t have good evidence for.”… [Continue Reading]

New AHA/ASA Guideline on Aneurysmal Subarachnoid Hemorrhage

by Megan Brooks

May 3, 2012 — Patients diagnosed with aneurysmal subarachnoid hemorrhage (aSAH) in hospitals that manage fewer than 10 cases per year should be considered for immediate transfer to a hospital that treats at least 35 cases a year, according to updated guidelines on management of aSAH from the American Heart Association/American Stroke Association (AHA/ASA).

Research has shown that 30-day death rates are significantly higher in low-volume facilities (39% in hospitals treating fewer than 10 patients compared with 27% in hospitals treating more than 35 patients each year), the AHA/ASA notes in a statement.

The new guideline, published online May 3 in Stroke, updates guidelines issued in 2009 and reported by Medscape Medical News at that time.… [Continue Reading]

Resistance Training May Delay Dementia Onset

by Megan Brooks

May 2, 2012 — Six months of twice-weekly resistance training (RT) improved executive function, associative memory, and regional patterns of functional brain plasticity in a group of older women with probable mild cognitive impairment (MCI).

“We provide novel evidence that RT can benefit multiple domains in those at risk for dementia,” the researchers report.

“We found improvement in both cognitive and brain function with resistance training — not just maintenance — over the 6 months. Thus, our results imply that resistance training can delay the onset of dementia in older adults,” first author Teresa Liu-Ambrose, PhD, PT, from the Aging, Mobility, and Cognitive Neuroscience Laboratory, University of British Columbia, Vancouver, Canada, told Medscape Medical News.

In a previous study reported by Medscape Medical News, she and her colleagues found that 12 months of twice-weekly RT significantly improved executive function in cognitively healthy older women. Their latest study found improvement after only 6 months and in women with MCI. Thus, the benefits of RT on executive function “may be more potent among those at greater risk for dementia,” the researchers say.… [Continue Reading]

Is Marijuana Medicinal?

A point/counterpoint from Dr. Donald I. Abrams and Jodie Trafton, Ph.D.

By: DONALD I. ABRAMS, M.D. and JODIE TRAFTON, PH.D.

POINT: Cannabis can relieve neuropathic pain.

As an oncologist, I treat cancer patients who have nausea, vomiting, weight loss, pain with and without opioids, insomnia, and depression. With cannabis, I can recommend that they try one medicine instead of five or six prescriptions that will interact either with one another or with their cancer chemotherapy.… [Continue Reading]

Recommended Standard of Cerebrospinal Fluid Analysis in the Diagnosis of Multiple Sclerosis

New criteria for the diagnosis of multiple sclerosis (MS) were published as the result of an internationally formed committee. To increase the specificity of diagnosis and to minimize the number of false diagnoses, the committee recommended the use of both clinical and paraclinical criteria, the latter involving information obtained from magnetic resonance imaging, evoked potentials, and cerebrospinal fluid (CSF) analysis. Although rigorous magnetic resonance imaging requirements were provided, the “new criteria paper” fell short in terms of guidelines as to how the CSF analysis should be performed and simply equated the IgG index with isoelectric focusing, without any justification. The spectrum of parameters analyzed and methods for CSF analysis differ worldwide and often yield variable results in terms of sensitivity, specificity, accuracy, and reliability, with no decided “optimal” CSF test for the diagnosis of MS. To address this question specifically, an international panel of experts in MS and CSF diagnostic techniques was convened and the result was this article, representing a consensus of all the participants. These recommendations for establishing a standard for the evaluation of CSF in patients suspected of having MS should greatly complement the new criteria in ensuring that a correct diagnosis of MS is being made.… [Continue Reading]

Depression: When Initial Therapy Fails

Among patients with MDD, almost 90% have moderate to very severe depression.1 Kessler et al1 reported that almost half of patients who experienced a depressive episode received no health care treatment during a 1-year follow-up, and of those who did, nearly 60% received inadequate treatment. Unfortunately, even among patients being treated adequately, response (ie, symptom reduction ≥ 50%)7 without remission is common; the STAR*D study8 found that initial treatment led to remission in only one-third of patients. Further, relapse occurred in 34% of patients who reached remission after 1 treatment step and 50% of patients who required 4 treatment steps to reach remission.

The impact of MDD on quality of life can be as great as or greater than that of chronic medical diseases such as diabetes.9,10 Depending on depression severity, an average of 59% of patients with MDD report severe or very severe role impairment in at least 1 of the following domains: work, home, relationship, and social roles (AV 2).1… [Continue Reading]

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