Treatment of Alzheimer's disease in Brazil: I. Cognitive disorders

Vale, Francisco de Assis Carvalho do; Corrêa Neto, Ylmar; Bertolucci, Paulo Henrique Ferreira; Machado, João Carlos Barbosa; Silva, Delson José da; Allam, Nasser; Balthazar, Márcio Luiz Figueredo; ,

doi:10.1590/S1980-57642011DN05030005

Abstract

This article reports the recommendations of the Scientific Department of Cognitive Neurology and Aging of the Brazilian Academy of Neurology for the treatment of Alzheimer's disease (AD) in Brazil, with special focus on cognitive disorders. It constitutes a revision and broadening of the 2005 guidelines based on a consensus involving researchers (physicians and non-physicians) in the field. The authors carried out a search of articles published since 2005 on the MEDLINE, LILACS and Cochrane Library databases. The search criteria were pharmacological and non-pharmacological treatment of cognitive disorders in AD. Studies retrieved were categorized into four classes, and evidence into four levels, based on the 2008 recommendations of the American Academy of Neurology. The recommendations on therapy are pertinent to the dementia phase of AD. Recommendations are proposed for the treatment of cognitive disorders encompassing both pharmacological (including acetyl-cholinesterase inhibitors, memantine and other drugs and substances) and non-pharmacological (including cognitive rehabilitation, physical activity, occupational therapy, and music therapy) approaches. Recommendations for the treatment of behavioral and psychological symptoms of dementia due to Alzheimer's disease are included in a separate article of this edition.

Key words:
Alzheimer's disease; dementia; cognitive disorders; treatment

Resumo

Esse texto apresenta as recomendações da Academia Brasileira de Neurologia, por intermédio do seu Departamento Científico de Neurologia Cognitiva e do Envelhecimento, para o tratamento da doença de Alzheimer (DA) no Brasil, enfocando os transtornos cognitivos. Trata-se de uma revisão ampliada das diretrizes publicadas em 2005, resultada de um consenso envolvendo pesquisadores da área, médicos e não médicos. Os autores realizaram uma busca de artigos publicados a partir de 2005 nas bases MEDLINE, LILACS e Cochrane Library. A busca foi direcionada para tratamento farmacológico e não farmacológico dos transtornos cognitivos da DA. Os estudos foram categorizados em quatro classes e as evidências em quatro níveis, com base nas recomendações da Academia Americana de Neurologia publicadas em 2008. As recomendações terapêuticas referem-se à fase demencial da DA. Apresentam-se recomendações para o tratamento dos transtornos cognitivos, tanto farmacológico (incluindo inibidores da acetilcolinesterase, memantina e outros fármacos e substâncias), como não farmacológico (incluindo reabilitação cognitiva, atividade física, terapia ocupacional e musicoterapia). As recomendações para o tratamento dos sintomas comportamentais e psicológicos da demência da DA são apresentadas em outro artigo desse fascículo.

Palavras-chave:
doença de Alzheimer; demência; transtornos cognitivos; tratamento

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Full text available only in PDF format.

References

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Peters BH, Levin HS. Effects of physostigmine and lecitin on memory in Alzheimer's disease. Ann Neurol 1979;6:219-221.
Sumers WK, Majovski LV, Marsh GM, et al. Oral tetrahydroaminoacridine in long-term treatment of senile dementia, Alzheimer type. N Eng J Med 1986;315:1241-45.
Corey-Bloom J, Anand R, Veach J et al. A randomized trial evaluating the efficacy and safety of ENA 713 (rivastigmine tartrate), a new acetyl-chonesterase inhibitor, in patients with mild to moderately severe Alzheimer's disease. Int. J Geriatr Psychopharmacol 1998;1:55-65.
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Tariot PN, Farlow MR, Grossberg GT, Graham SM, McDonald S, Gergel I. Memantine treatment in patients with moderate to severe Alzheimer disease already receiving donepezil: a randomized controlled trial. JAMA 2004;291:317-324.
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Mix JA, Crews WD Jr. A double-blind, placebo-controlled, randomized trial of Ginkgo biloba extract EGb 761 in a sample of cognitively intact older adults: neuropsychological findings. Hum Psychopharmacol 2002;17:267-277.
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Publication Dates

Publication in this collection
Jul-Sep 2011

History

Received
17 Mar 2011
Accepted
17 June 2011

This is an open-access article distributed under the terms of the Creative Commons Attribution License

[1] Engelhardt E, Brucki SM, Cavalcanti JL, Forlenza OV, Laks J, Vale FA. [Treatment of Alzheimer's disease: recommendations and suggestions of the Scientific Department of Cognitive Neurology and Aging of the Brazilian Academy of Neurology]. Arq Neuropsiquiatr. 2005;63:1104-1112.

[2] Gronseth G, French J. Practice parameters and technology assessments: what they are, what they are not, and why you should care. Neurology 2008; 71:1639-1643.

[3] French J, Gronseth G. Lost in a jungle of evidence: we need a compass. Neurology 2008;71:1634-1638.

[4] McKhann GM, Knopman DS, Chertkow H, et al. The diagnosis of dementia due to Alzheimer's disease: Recommendations from the National Institute on Aging and the Alzheimer's Association workgroup. Alzheimers Dement 2011;7:263-269.

[5] McKhann G, Drachman D, Folstein M, Katzman R, Price D, Stadlan EM. Clinical diagnosis of Alzheimer's disease: report of the NINCDS-ADRDAWork Group under the auspices of Department of Health and Human Services Task Force on Alzheimer's Disease. Neurology 1984;34:939-44.

[6] Albert MS, Dekosky ST, Dickson D, et al. The diagnosis of mild cognitive impairment due to Alzheimer's disease: Recommendations from the National Institute on Aging and Alzheimer's Association workgroup. Alzheimers Dement 2011;7:270-279.

[7] Sperling RA, Aisen PS, Beckett LA, et al. Toward defining the preclinical stages of Alzheimer's disease: Recommendations from the National Institute on Aging and the Alzheimer's Association workgroup. Alzheimers Dement. 2011;7:280-292.

[8] Nordberg A. Nicotinic receptor abnormalities of Alzheimer's disease: therapeutic implications. Biol Psychiatry 2001;49:200-210.

[9] Peters BH, Levin HS. Effects of physostigmine and lecitin on memory in Alzheimer's disease. Ann Neurol 1979;6:219-221.

[10] Sumers WK, Majovski LV, Marsh GM, et al. Oral tetrahydroaminoacridine in long-term treatment of senile dementia, Alzheimer type. N Eng J Med 1986;315:1241-45.

[11] Corey-Bloom J, Anand R, Veach J et al. A randomized trial evaluating the efficacy and safety of ENA 713 (rivastigmine tartrate), a new acetyl-chonesterase inhibitor, in patients with mild to moderately severe Alzheimer's disease. Int. J Geriatr Psychopharmacol 1998;1:55-65.

[12] Rogers SL, Farlow M, Mohs R, et al. A 24-week, double-blind, placebo-controlled trial of donepezil in patients with Alzheimer's disease. Neurology 1998;50:136-145.

[13] Raskind MA, Perskind ER, Wessel T et al. Galantamine in AD: a 6-month randomized, placebo-controlled trial with a 6-month extension. Neurology 2000;554:2261-2268.

[14] Hansen RA, Gartlehner G, Webb AP et al. Efficacy and safety of donepezil, galantamine, and rivastigmine for the treatment of Alzheimer's disease: a systematic review and meta-analysis. Clin Interv Aging 2008;3:211-225.

[15] Lockhart IA, Mitchell SA, Kelly S. Safety and tolerability of donepezil, rivastigmine and galantamine for patients with Alzheimer's disease: systematic review of the "real-world". Dem Geriat Cog Dis 2009;28:389-403.

[16] Winblad B, Gauthier S, Scinto L, et al. Safety and efficacy of galantamine in subjects with mild cognitive impairment. Neurology 2008;70:2024-2035.

[17] Burns A, Bernabei R, Bullock R, et al. Safety and efficacy of galantamine (Reminyl) in severe Alzheimer's disease (the CERAD study): a randomized, placebo-controlled, double-blind trial. Lancet Neurol 2009;8: 39-47.

[18] Farlow M, Grossberg GT, Meng X, et al. Rivastigmine transdermal patch and capsule in Alzheimer's disease: influence of disease stage on response to therapy. Int J Geriatr Psychiatry 2010 Dec;23. [Epub ahead of print].

[19] Winblad B, Black SE, Homma A et al. Donepezil treatment in severe Alzheimer's disease: a pooled analysis of three clinical trials. Curr Med Res Opin 2009;25:2577-2587.

[20] Jarvis B, Figgitt DP. Memantine. Drugs Aging 2003;20:465-476; discussion 77-78.

[21] Reisberg B, Doody R, Stoffler A, Schmitt F, Ferris S, Mobius HJ. Memantine in moderate-to-severe Alzheimer's disease. N Engl J Med. 2003;348:1333-1341.

[22] Tariot PN, Farlow MR, Grossberg GT, Graham SM, McDonald S, Gergel I. Memantine treatment in patients with moderate to severe Alzheimer disease already receiving donepezil: a randomized controlled trial. JAMA 2004;291:317-324.

[23] Winblad B, Jones RW, Wirth Y, Stoffler A, Mobius HJ. Memantine in moderate to severe Alzheimer's disease: a meta-analysis of randomised clinical trials. Dement Geriatr Cogn Disord 2007;24:20-27.

[24] Atri A, Shaughnessy LW, Locascio JJ, Growdon JH. Long-term course and effectiveness of combination therapy in Alzheimer disease. Alzheimer Dis Assoc Disord 2008;22:209-221.

[25] Shua-Haim J, Smith J, Picard F, et al. Steady-state pharmacokinetics of rivastigmine in patients with mild to moderate Alzheimer's disease not affected by co-administration of memantine: an open-label, crossover, single-centre study. Clin Drug Investig. 2008;28:361-374.

[26] Grossberg GT, Edwards KR, Zhao Q. Rationale for combination therapy with galantamine and memantine in Alzheimer's disease. J Clin Pharmacol 2006;46(7 Suppl 1):17S-26S.

[27] Zhu CW, Livote EE, Kahle-Wrobleski K, et al. Longitudinal Medication Usage in Alzheimer Disease Patients. Alzheimer Dis Assoc Disord . 2010 Jul 9. [Epub ahead of print]

[28] McShane R, Areosa SA N M. Memantine for dementia. Cochrane Database of Systematic Reviews. 2011(03): CD003154.

[29] Peskind ER, Potkin SG, Pomara N, et al. Memantine treatment in mild to moderate Alzheimer disease: a 24-week randomized, controlled trial. Am J Geriatr Psychiatry. 2006;14:704-715.

[30] Porsteinsson AP, Grossberg GT, Mintzer J, Olin JT. Memantine treatment in patients with mild to moderate Alzheimer's disease already receiving a cholinesterase inhibitor: a randomized, double-blind, placebo-controlled trial. Curr Alzheimer Res 2008;5:83-89.

[31] Doody RS, Tariot PN, Pfeiffer E, Olin JT, Graham SM. Meta-analysis of six-month memantine trials in Alzheimer's disease. Alzheimers Dement 2007;3:7-17.

[32] Schneider LS. Commentary on "Meta-analysis of six-month memantine trials in Alzheimer's disease." Wuthering forest plots: distinguishing the forest from the plots. Alzheimers Dement 2007;3:18-20.

[33] Knopman DS. Commentary on "Meta-analysis of six-month memantine trials in Alzheimer's disease." Memantine has negligible benefits in mild to moderate Alzheimer's disease. Alzheimers Dement 2007;3:21-22.

[34] Schneider LS, Insel PS, Weiner MW. Treatment with cholinesterase inhibitors and memantine of patients in the Alzheimer's Disease Neuroimaging Initiative. Arch Neurol 2011;68:58-66.

[35] Luo Y, Smith JV, Paramasivam V, et al. Inhibition of amyloid-beta aggregation and caspase-3 activation by the Ginkgo biloba extract EGb761. Proc Natl Acad Sci 2002; 99:12197-12202.

[36] Smith JV, Luo Y. Elevation of oxidative free radicals in Alzheimer's disease models can be attenuated by Ginkgo biloba extract EGb 761. J Alzheimer's Dis 2003;5:287-300.

[37] Mix JA, Crews WD Jr. A double-blind, placebo-controlled, randomized trial of Ginkgo biloba extract EGb 761 in a sample of cognitively intact older adults: neuropsychological findings. Hum Psychopharmacol 2002;17:267-277.

[38] Birks J, Evans G. Ginkgo biloba for cognitive impairment and dementia. Cochrane Database Syst Rev 2009 Jan 21;(1):CD003120.

[39] Dodge HH, Zitzelberger T, Oken BS, et al. A randomized placebo-controlled trial of ginkgo biloba for the prevention of cognitive decline. Neurology 2008;70:1809-1817.

[40] DeKosky ST, Williamson JD, Annette L, et al. Ginkgo biloba for Prevention of Dementia: A Randomized Controlled Trial JAMA 2008;300:2253-2262.

[41] Snitz BE, O'Meara ES, Carlson MC, et al. Ginkgo biloba for Preventing Cognitive Decline in Older Adults: A Randomized Trial. JAMA 2009;302:2663-2670.

[42] Berman K, Brodaty H. Tocopherol (vitamin E) in Alzheimer's disease and other neurodegenerative disorders. CNS Drugs 2004;18:807-825.

[43] Morris MC, Evans DA, Bienias JL, et al. Vitamin E and cognitive decline in older persons. Arch Neurol 2002;59: 1125-1132.

[44] Sano M, Ernesto C, Thomas RG, et al. A controlled trial of selegiline, alphatocopherol, or both as treatment for Alzheimer's disease. The Alzheimer's Disease Cooperative Study. N Engl J Med 1997;336:1216-1222.

[45] Petersen RC, Thomas RG, Grundman , et al. Vitamin E and Donepezil for the Treatment of Mild Cognitive Impairment N Engl J Med 2005;352:2379-88.

[46] Isaac MG, Quinn R, Tabet N. Vitamin E for Alzheimer disease and mild cognitive impairment. Cochrane Database Syst Rev 2008;3:CD002854.

[47] Miller ER3rd, Pastor-Barriuso R, Dalal D, et al. Meta-analysis: high dosage vitamin E supplemention may increase all-cause mortality. Ann Intern Med 2005;142:37-46.

[48] Dysken MW, Kirk LN, Kuskowski M. Changes in vitamin E prescribing for Alzheimer patients. Am J Geriatr Psychiatry . 2009;17:621-624.

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