alzheimer disease

An evidence-based review of monoclonal antibody treatment of patients with Alzheimer's Disease. Very little benefit and significant risk. James W. Mold, MD, MPH

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Purpose: We conducted a meta-analysis to evaluate clinically meaningful benefits and harms of monoclonal antibodies targeting amyloid in patients with Alzheimer dementia.

Methods: We searched PubMed, Cochrane CENTRAL, and 5 trial registries, as well as the reference lists of identified studies. We included randomized controlled trials comparing a monoclonal antibody with placebo at a dose consistent with that used in phase 3 trials or for Food and Drug Administration approval. Studies had to report at least 1 clinically relevant benefit or harm. Data were extracted independently by at least 2 researchers for random effects meta-analysis. Changes in cognitive and functional scales were compared between groups, and each difference was assessed to determine if it met the minimal clinically important difference (MCID).

Results: We identified 19 publications with 23,202 total participants that evaluated 8 anti-amyloid antibodies. There were small improvements over placebo in the Alzheimer's Disease Assessment Scale (ADAS)-Cog-11 to -14 score (standardized mean difference = -0.07; 95% CI, -0.10 to -0.04), Mini Mental State Examination score (0.32 points; 95% CI, 0.13 to 0.50), and Clinical Dementia Rating-Sum of Boxes scale score (mean difference =-0.18 points; 95% CI, -0.34 to -0.03), and the combined functional scores (standardized mean difference = 0.09; 95% CI, 0.05 to 0.13). None of the changes, including those for lecanemab, aducanumab, and donanemab, exceeded the MCID. Harms included significantly increased risks of amyloid-related imaging abnormalities (ARIA)-edema (relative risk [RR] = 10.29; number needed to harm [NNH] = 9), ARIA-hemorrhage (RR = 1.74; NNH = 13), and symptomatic ARIA-edema (RR = 24.3; NNH = 86).

Conclusions: Although monoclonal antibodies targeting amyloid provide small benefits on cognitive and functional scales in patients with Alzheimer dementia, these improvements are far below the MCID for each outcome and are accompanied by clinically meaningful harms.

Keywords: ARIA; Alzheimer dementia; Alzheimer disease; aducanumab; aged; amyloid; antibodies, monoclonal; biological therapy; cerebral edema; cerebral hemorrhage; chronic disease; dementia; donanemab; drug approval; lecanemab; meta-analysis; risks and benefits; systematic review.

Author/s:

Mark H Ebell, Henry C Barry, Kanishka Baduni, Gabrielle Grasso

Frontotemporal dementia

Erin Blanchette — Wed, 13 Dec 2023 17:01:01 +0000

Date Added:

December 13, 2023

Journal/Publication:

Canadian Medical Association Journal

Publisher:

Canadian Medical Association

Publication Date:

December 10, 2023

Issue:

Volume:

195

Pages:

E1660

URL:

Frontotemporal dementia

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1503/cmaj.230407

Keywords

Frontotemporal Dementia

neurology

dementia

Alzheimer Disease

PMID (1):

38081627

MeSH

Frontotemporal Dementia

alzheimer disease

Pick Disease of the Brain

Cognition

brain

Temporal Lobe

Behavioral Symptoms/diagnosis

Magnetic Resonance Imaging

A concise review of fronto-temporal dementia. James W. Mold, MD, MPH

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Frontotemporal dementia should be considered in adults aged 50–75 years presenting with behavioural or language changes. After Alzheimer disease, it is the second most common cause of dementia among adults younger than 65 years.1 Frontal and temporal lobe degeneration results in behavioural or language impairment.

Author/s:

Raul Medina-Rioja, Gina Gonzalez-Calderon, Mario Masellis

APOE ɛ4 Allele Testing and Risk of Alzheimer Disease

Devin Evans — Thu, 21 Jan 2021 06:00:00 +0000

Date Added:

January 21, 2021

Journal/Publication:

The Journal of the American Medical Association

Publication Date:

January 14, 2021

URL:

APOE ɛ4 Allele Testing and Risk of Alzheimer Disease

Type:

Clinical Decision Aids

Format:

Article

DOI (1):

10.1001/jama.2020.15085

Keywords

PMID (1):

33443531

MeSH

A brief review of the interpretation of APOE tests for diagnosing and predicting dementia of the Alzheimer’s type. James W. Mold, MD, MPH

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A 64-year-old man presented with concern about an abnormal genetic test result for apolipoprotein E (APOE) obtained through his primary care physician. He reported forgetfulness and word-finding difficulties for 3 years but performed all activities of daily living independently and was generally healthy. His father and maternal great aunt developed dementia in their 70s. Physical (including neurologic) examination, basic laboratory studies, and brain magnetic resonance imaging results were normal. The Short Test of Mental Status (STMS) score was 33 (maximal attainable score of 38 indicates best performance). Neuropsychological assessment showed average to above-average performance in all cognitive domains, accounting for age and education. Results of his genetic testing for APOE were reported as follows: “This individual possesses an apolipoprotein E genotype (3 and 4) that indicates, with high specificity, that Alzheimer’s disease is the cause of or a contributor to the observed dementia.”

Author/s:

Choudhury, Parichita, Ramanan, Vijay K., Boeve, Bradley F.

APOE ɛ4 Allele Testing and Risk of Alzheimer Disease

Carly Hughes — Sat, 16 Jan 2021 19:31:55 +0000

Date Added:

January 16, 2021

Journal/Publication:

Journal of the American Medical Association

Publisher:

Journal of the American Medical Association

Publication Date:

January 14, 2021

URL:

APOE ɛ4 Allele Testing and Risk of Alzheimer Disease

Type:

Clinical Decision Aids

Format:

Article

DOI (1):

doi:10.1001/jama.2020.15085

Keywords

MeSH

A brief review of the interpretation of APOE tests for diagnosing and predicting dementia of the Alzheimer’s type. James W. Mold, MD, MPH

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A 64-year-old man presented with concern about an abnormal genetic test result for apolipoprotein E (APOE) obtained through his primary care physician. He reported forgetfulness and word-finding difficulties for 3 years but performed all activities of daily living independently and was generally healthy. His father and maternal great aunt developed dementia in their 70s. Physical (including neurologic) examination, basic laboratory studies, and brain magnetic resonance imaging results were normal. The Short Test of Mental Status (STMS) score was 33 (maximal attainable score of 38 indicates best performance). Neuropsychological assessment showed average to above-average performance in all cognitive domains, accounting for age and education. Results of his genetic testing for APOE were reported as follows: “This individual possesses an apolipoprotein E genotype (3 and 4) that indicates, with high specificity, that Alzheimer’s disease is the cause of or a contributor to the observed dementia.

Author/s:

Choudhury, Parichita, Boeve, Bradley F., Ramanan, Vijay K

Therapeutic use of cannabis and cannabinoids: an evidence mapping and appraisal of systematic reviews

John Bayhi — Mon, 03 Feb 2020 19:39:52 +0000

Date Added:

February 3, 2020

Journal/Publication:

BMC Complementary Medicine and Therapies

Publisher:

Springer Nature

Publication Date:

January 15, 2020

Issue:

Volume:

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1186/s12906-019-2803-2

Keywords

Another summary of what we know about the therapeutic effects of cannabinoids. The figures appear to be useful. James W. Mold, MD, MPH

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Background

Although cannabis and cannabinoids are widely used with therapeutic purposes, their claimed efficacy is highly controversial. For this reason, medical cannabis use is a broad field of research that is rapidly expanding. Our objectives are to identify, characterize, appraise, and organize the current available evidence surrounding therapeutic use of cannabis and cannabinoids, using evidence maps.

Methods

We searched PubMed, EMBASE, The Cochrane Library and CINAHL, to identify systematic reviews (SRs) published from their inception up to December 2017. Two authors assessed eligibility and extracted data independently. We assessed methodological quality of the included SRs using the AMSTAR tool. To illustrate the extent of use of medical cannabis, we organized the results according to identified PICO questions using bubble plots corresponding to different clinical scenarios.

Results

A total of 44 SRs published between 2001 and 2017 were included in this evidence mapping with data from 158 individual studies. We extracted 96 PICO questions in the following medical conditions: multiple sclerosis, movement disorders (e.g. Tourette Syndrome, Parkinson Disease), psychiatry conditions, Alzheimer disease, epilepsy, acute and chronic pain, cancer, neuropathic pain, symptoms related to cancer (e.g. emesis and anorexia related with chemotherapy), rheumatic disorders, HIV-related symptoms, glaucoma, and COPD. The evidence about these conditions is heterogeneous regarding the conclusions and the quality of the individual primary studies. The quality of the SRs was moderate to high according to AMSTAR scores.

Conclusions

Evidence on medical uses of cannabis is broad. However, due to methodological limitations, conclusions were weak in most of the assessed comparisons. Evidence mapping methodology is useful to perform an overview of available research, since it is possible to systematically describe the extent and distribution of evidence, and to organize scattered data.

Author/s:

Montero-Oleas, N, Arevalo-Rodriguez, I, Nunez-Gonzalez, S, Viteri-Garcia, A, Simancas-Racines, D

The Potential Emergence of Disease-Modifying Treatments for Alzheimer Disease: The Role of Primary Care in Managing the Patient Journey

Brian Desmarais — Thu, 09 Jan 2020 15:51:26 +0000

Date Added:

January 9, 2020

Journal/Publication:

Journal of the American Board of Family Medicine

Publication Date:

November 1, 2019

Issue:

Volume:

Pages:

931-940

URL:

The Potential Emergence of Disease-Modifying Treatments for Alzheimer Disease: The Role of Primary Care in Managing the Patient Journey

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.3122/jabfm.2019.06.180328

Keywords

MeSH

This opinion piece provides an update on the status of diagnostic tests and possible new treatments for Alzheimer’s Disease. I am posting it so that you can answer patients’ and families’ questions. I do believe that adding a brief cognitive test to the AWV makes sense, since, for clinical purposes, you need to know whether patients have short term memory deficits, and the only way to reliably determine that is with testing. In my practice and in the one I now attend as a patient, we/they use(d) the Short Blessed Test (SBT), which only takes the nurse about 2-3 minutes to administer. James W. Mold, MD, MPH

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Despite recent setbacks, disease-modifying treatments (DMTs) for Alzheimer disease (AD) might become available within a few years. These DMTs are likely to be used in the early stages of AD to avoid the progression to manifest dementia, which implies that a large reservoir of prevalent cases would need to be evaluated when DMTs first become available. Primary care providers (PCPs) would play a vital role in managing the patient flow to specialty care. We review the literature on diagnostic tests that could be used by PCPs and estimate the impact of different testing approaches on demand for specialty care.While many tests have been evaluated, only the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA) perform acceptably for detection of early-stage cognitive decline with sensitivities and specificities of 55% to 82% and 72% to 84%, respectively, for the MMSE; and 77% to 96% and 73% to 95%, respectively, for the MoCA. However, neither test is sufficiently specific for the AD pathology and would result in 4 to 5 false positives for each true positive. Blood-based tests for AD biomarkers may soon become available for clinical use. A plasma amyloid-β (Aβ) test has been shown to have a sensitivity of up to 97% and specificity of up to 81%. Adding this test to the MMSE or MoCA could reduce false positives by approximately 80%.These findings suggest a combination of brief cognitive tests and blood-based biomarker tests will allow PCPs to identify patients with potential early stage AD efficiently and triage them for further evaluation.

Author/s:

Lam, J., Hlávka, J., Mattke, S.

Some benefits from donepezil in Alzheimer’s disease

Brian Desmarais — Thu, 20 Jun 2019 12:57:52 +0000

Date Added:

June 20, 2019

Journal/Publication:

British Journal of General Practice

Publication Date:

March 1, 2013

Issue:

Volume:

608

Pages:

150

URL:

Some benefits from donepezil in Alzheimer’s disease

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.3399/bjgp13X664333

Keywords

MeSH

Cholinesterase Inhibitors

Synaptic Transmission

brain

RPR Commentary: This is a summary of the data available to date on the effectiveness of donepezil for treatment of patients with Alzheimer’s Disease. I told patients and their families that if a small improvement in functional abilities would make a huge difference in quality of life (e.g. could remain at home 6 months longer), it is probably worth trying donepezil. Otherwise the expense and side effects are not worth the very small benefit. 5 to 10mg seems to be enough. James W. Mold, MD, MPH

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CLINICAL QUESTION

How effective is exercise-based cardiac rehabilitation on mortality, morbidity, and health-related quality of life (QOL) in patients with coronary heart disease (CHD)?

BOTTOM LINE

Compared to usual care, in medium to longer-term follow-up (≥12 months) exercise-based cardiac rehabilitation was found to be effective in reducing overall and cardiovascular mortality in patients with CHD, and appeared to reduce the risk of hospital admissions in the shorter term (<12 months follow-up). There was no reduction seen in the risk of total myocardial infarction, coronary artery bypass graft, or percutaneous transluminal coronary angioplasty.

Author/s:

McAvoy, B.R.

What Are the Components to the MIND Diet?

Jeffrey Wilson — Sun, 24 Feb 2019 19:51:26 +0000

Date Added:

February 24, 2019

Journal/Publication:

Journal of the Academy of Nutrition and Dietetics

Publisher:

Elsevier

Publication Date:

September 27, 2015

Issue:

Volume:

115

Pages:

1744

URL:

What Are the Components to the MIND Diet?

Type:

Clinical Decision Aids, Patient Education Materials

Format:

Article

DOI (1):

10.1016/j.jand.2015.08.002

Keywords

PMID (1):

26407649

MeSH

alzheimer disease

dementia

diet

The MIND diet is a combination of the Mediterranean and DASH diets. This short article provides lists of included and excluded foods.

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The MIND diet (Mediterranean-DASH Intervention for Neurodegenerative Delay) has been attributed to improved cognitive thinking and lowering the risk and slowing the progression of Alzheimer disease—the leading cause of dementia.

Author/s:

Marcason, Wendy