LETTERS TO THE EDITORS
Treatment of apathy in Alzheimer's disease with transdermal rivastigmine: report of three cases
Tratamento da apatia na doença de Alzheimer com rivastigmina transdérmica: relato de três casos
Dear Editor,
Apathy in Alzheimer's disease is one of the most difficult behavioral and psychological symptoms to treat. Anticholinesterasic drugs, dopaminergic agonists, and psychostimulants are treatment alternatives based on studies with contradictory results.1 The use of transdermal rivastigmine has not been sufficiently studied in clinical trials, especially regarding the treatment of apathy. We report below 3 cases of dementia and apathy treated with transdermal rivastigmine, with behavioral symptoms analysis, cognitive testing and outcome measurement in the first, second, third and sixth months.
Case reports: Three female patients were evaluated - MO (81 years old), ECN (74 years old) and DM (84 years old) - all of them meeting the criteria for Alzheimer's Disease (based on DSMIV) and for apathy (based on the following criteria proposed by Robert P, 2009:2 1) the core feature of apathy, diminished motivation, must be present for at least four weeks; 2) two of the three dimensions of apathy (reduced goal-directed behaviour, goal-directed cognitive activity, and emotions) must also be present; 3) there should be identifiable functional impairments attributable to apathy; 4) exclusion criteria are specified to exclude symptoms and states that mimic apathy. After the diagnosis of Alzheimer's disease, the patients were treated with transdermal rivastigmine (4.6mg in the first month and 9.5mg after the second month).The improvement of apathy was observed after the introductions of anticholinesterasic treatment. The three cases are presented below:
1) DM presented at first meeting with: Mini Mental State Examination (MMSE) of 15/30, poor verbal contact, walking impairment, loss of manual abilities, and social isolation. After two months of treatment, the patient started to interact during the examination, returned to her manual and social activities, improved her walking balance and presented a MMSE of 21/30. After six months, the improvements were maintained.
2) ECN presented at first meeting with: MMSE of 20/30, difficulties in verbal contact, loss of instrumental activities of daily living (iADL), and social isolation. After two months of treatment, the patient returned with great improvement in verbal contact, returned to her iADL and presented a MMSE of 22/30. After six months, the improvements were maintained.
3) MO presented at first meeting with: MMSE of 13/30, poor verbal contact, loss of iADL and interruption of her morning exercise (walking). After two months of treatment, the patient was more collaborative, showed iADL improvement, returned to her physical activity and presented an MMSE of 10/30. The improvements were maintained after 6 months.
Discussion: Apathy is the most common neuropsychiatric syndrome in Alzheimer's disease, affecting 30 to 60% of patients.1,2 Its pharmacologic therapy is based on three strategies: psychostimulants, dopaminergic agonists and anticholinesterasic drugs.1
Despite being first tested and developed for the improvement of cognition in Alzheimer's disease, anticholinesterasic drugs showed many benefits in the treatment of behavioral and psychological symptoms related to dementia, including apathy. Although systematic reviews point to a lack of well-designed studies concerning this issue, anticholinesterasic drugs remain as an appropriate therapy for apathy.3,4 The new presentation of transdermal rivastigmine has been studied as an option with fewer adverse effects (nausea and vomiting) when compared to other oral anticholinesterasic drugs,5 but no studies concerning their use in behavioral symptoms have been conducted. In the cases reported above, there was a surprising improvement in the apathy of all patients, regardless of the changes in cognitive function. This finding brings new perspectives for the conduction of future randomized and double-blind studies evaluating the use of transdermal rivastigmine.
Alessandra Lamas Granero, Giancarlo Lucchetti
Interdisciplinary Center for Assistance and Research on
Aging, Medical Sciences School of Minas Gerais,
Belo Horizonte (MG), Brazil
Geriatric Clinic - São Paulo Commerce Workers Union, Brazil
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- 1. Teixeira-Jr AL, Caramelli P. Apathy in Alzheimer's disease. Rev Bras Psiquiatr 2006;28(3):238-41.
- 2. Robert P, Onyike CU, Leentjens AF, Dujardin K, Aalten P, Starkstein S, Verhey FR, Yessavage J, Clement JP, Drapier D, Bayle F, Benoit M, Boyer P, Lorca PM, Thibaut F, Gauthier S, Grossberg G, Vellas B, Byrne J. Proposed diagnostic criteria for apathy in Alzheimer's disease and other neuropsychiatric disorders. Eur Psychiatry 2009;24(2):98-104.
- 3. Rodda J, Morgan S, Walker Z. Are cholinesterase inhibitors effective in the management of the behavioral and psychological symptoms of dementia in Alzheimer's disease? A systematic review of randomized, placebo-controlled trials of donepezil, rivastigmine and galantamine. Int Psychogeriatr 2009;21(5):813-24.
- 4. Figiel G, Sadowsky C. A systematic review of the effectiveness of rivastigmine for the treatment of behavioral disturbances in dementia and other neurological disorders. Curr Med Res Opin 2008;24(1):157-66.
- 5. Winblad B, Cummings J, Andreasen N, Grossberg G, Onofrj M, Sadowsky C, Zechner S, Nagel J, Lane R. A six-month double-blind, randomized, placebo-controlled study of a transdermal patch in Alzheimer's disease--rivastigmine patch versus capsule. Int J Geriatr Psychiatry 2007;22(5):456-67.
Publication Dates
-
Publication in this collection
22 Mar 2010 -
Date of issue
Mar 2010
