Treatment of Psychosis and Agitation in Alzheimer's Disease

Phase

Condition

Dementia

Manic Disorders

Williams Syndrome

Treatment

Placebo

Lithium

Clinical Study ID

NCT02129348

#6915

1R01AG047146-01

All Genders

Study Summary

Clinically, many patients with AD show no response or minimal response to antipsychotics for symptoms of agitation/aggression or psychosis, or they have intolerable side effects on these medications. Antipsychotics have a wide range of side effects, including the risk of increased mortality (60-70% higher rate of death on antipsychotic compared to placebo) that led to an FDA black box warning for patients with dementia; a more recent review and meta-analysis showed a 54% increased risk of mortality. In addition, some patients show only partial response to antipsychotics and symptoms persist. For these reasons, the investigators need to study alternative treatment strategies. Currently, there is no FDA-approved medication for the treatment of psychosis or agitation in AD.

The investigators innovative project will examine the efficacy and side effects of low dose lithium treatment of agitation/aggression with or without psychosis in 80 patients with AD in a randomized, doubleblind, placebo-controlled, 12-week trial (essentially a Phase II trial). The results will determine the potential for a large-scale clinical trial (Phase III) to establish the utility of lithium in these patients.

Eligibility Criteria

Inclusion

Inclusion Criteria:

Male and female adults.
Diagnosis of possible or probable AD by standard NIA criteria (McKahnn et al, 1984;McKhann et all, 2011)
Folstein MMSE 5-26 out of 30
Neuropsychiatric Inventory (NPI) agitation/aggression subscale score > 4. On eachsubscale (frequency X severity), a score higher than 4 represents moderate to severesymptoms.
Female patients need to be post-menopausal
Availability of informant; patients without an informant will not be recruited.Patients who lack capacity must have a surrogate.

Exclusion

Exclusion Criteria:

Medical contraindication to lithium treatment or prior history of intolerability tolithium treatment. Contraindications to lithium in this study include: resting tremor causing functionalimpairment, history of falls in the last month, untreated thyroid disease or anyabnormal thyroid function test (T3, T4, or TSH), creatinine level greater than 1.5mg/100ml or a glomerular filtration rate less than 44ml/min/ 1.73m2; blood pressure > 150/90 mm Hg; heart rate < 50 bpm; unstable cardiac disease based on history, physicalexamination, and ECG.
Medications, in combination with lithium, known to have adverse renal effects,including therapeutic or higher doses of diuretics, i.e. hydrochlorothiazide greaterthan 25mg daily or furosemide greater than 10mg daily. Whenever feasible, patientsreceiving concomitant antidepressants or antipsychotics will be washed off thesemedications for at least 24 hours before starting lithium. Patients who do not wish todiscontinue antipsychotics or antidepressants, typically because of familymember/caregiver objection, will be allowed to enter the trial provided there is nocontraindication to concomitant lithium use with that specific psychotropicmedication. During the trial, patients will be permitted to receive lorazepam asneeded up to 1 mg/day for anxiety/insomnia, and non-benzodiazepine hypnotics, e.g.,zolpidem.
Current clinical diagnosis of schizophrenia, schizoaffective disorder, otherpsychosis, or bipolar 1 disorder (DSM-IV TR criteria).
Current or recent (past 6 months) alcohol or substance dependence (DSM-IV TRcriteria).
Current major depression or suicidality as assessed by the study psychiatrist.
Suicidal behavior or dangerous behavior with serious safety risk or risk of physicalharm to self or others.
Parkinson's disease, Lewy body disease, multiple sclerosis, CNS infection,Huntington's disease, amyotrophic lateral sclerosis, other major neurologicaldisorder.
Clinical stroke with residual neurological deficits. MRI findings of cerebrovasculardisease (small infarcts, lacunes, periventricular disease) in the absence of clinicalstroke with residual neurological deficits will not lead to exclusion.
Acute, severe, unstable medical illness. For cancer, patients with active illness ormetastases will be excluded, but past history of successfully treated cancer will notlead to exclusion.
QTc interval > 460 ms at the time of baseline EKG is an exclusion criterion fortreatment.
Hypernatremia as determined by serum sodium level > 150 meq/L.

Study Design

Placebo

June 01, 2014

January 31, 2020

Study Description

Symptoms of psychosis or agitation are common in Alzheimer's disease. These symptoms are associated with distress for the patient, an increased burden for caregivers, more rapid cognitive decline, greater risk of institutionalization and mortality, and increased health care costs. In a recent meta-analysis, caregiver education and behavior modification studies revealed a small to medium effect size in treating agitation in these patients. However, none of these studies were double-blind (difficult to achieve in such studies) and none had a control group that received the same amount of staff time as the intervention group, thereby biasing the results toward the active intervention.

Among the psychotropic medications that have been studied, only antipsychotics have shown superiority over placebo for the treatment of psychosis and agitation in patients with dementia.

However, most studies show only moderate superiority for antipsychotic over placebo and a few studies have been negative. The side effects of antipsychotic medications include sedation, extrapyramidal signs, tardive dyskinesia, weight gain, and the metabolic syndrome. A pooled analysis from 17 short-term trials showed that the mortality rate in patients with dementia receiving antipsychotic medications was 1.6 to 1.7 times as high (60-70% increase in mortality rate) as the mortality rate in patients receiving placebo. These findings led the FDA to issue a black-box warning for antipsychotic medication use in patients with dementia; a more recent meta-analysis reported a slightly lower odds ratio of 1.54 (54% increase in mortality rate).

Lithium has several different actions from anticonvulsants, though both are effective in bipolar disorder, especially mania. Lithium is not being proposed here to treat mania in AD though the investigators will monitor symptoms on the Young Mania Rating Scale. In patients with AD, lithium has been studied for its putative cognitive enhancing effects. A few reports suggest that chronic lithium use reduces the risk of dementia, but other data show increased dementia risk with lithium use. A placebo-controlled, single-blind lithium trial showed no cognitive effects in patients with AD, but a recent trial of lithium in 45 patients with mild cognitive impairment (MCI, which often leads to clinically diagnosable AD) showed a small advantage for lithium (n=24) over placebo (n=21) in attention and other cognitive domains. None of these studies with lithium were intended to treat psychosis or agitation in AD, and patients with these symptoms typically were excluded in these clinical trials.

There has been no systematic placebo-controlled trial of lithium to treat agitation/aggression with or without psychosis in AD even though lithium is a highly effective treatment for mania with psychosis and symptoms of agitation or aggression. Nonetheless, the published studies of lithium to treat cognitive decline in older patients show that low-dose lithium is safe in patients with MCI or AD.

Specific Aims and Hypotheses Specific Aim 1. To compare changes in agitation/aggression with or without psychosis in patients with AD who receive 12 weeks of randomized, double-blind treatment with lithium or placebo.

Primary Hypothesis. Over these 12 weeks, the agitation/aggression domain score on the Neuropsychiatric Inventory (NPI) will decrease significantly more on lithium than placebo.

Secondary Hypothesis. Over these 12 weeks, the proportion of responders on lithium will be significantly greater than the proportion of responders on placebo. Response is defined as a 30% decrease in NPI core score (defined as the sum of domains for agitation/aggression, delusions and hallucinations) plus a CGI Change score of much improved or very much improved (CGI based on these behavioral symptoms only). Exploratory hypothesis. Over these 12 weeks, the psychosis score, measured by the sum of the NPI domain scores for delusions and hallucinations, will decrease significantly more on lithium than placebo. Specific Aim 2. To evaluate the tolerability of low dose lithium by assessing emergent somatic side effects over the course of the 12-week trial on lithium compared to placebo. Specific Aim 3. To explore associations between improvement on lithium (decrease in agitation/aggression and psychosis scores) and serum brain-derived neurotrophic factor (BDNF) levels (baseline, 12 weeks), a SNP in intron 1 of the ACCN1 gene, and variation at the 7q11.2 gene locus, because these indices are associated with lithium response in bipolar disorder. The investigators do not postulate a specific mechanism of action for lithium in the investigators trial, but will evaluate these three potential predictors of lithium response with the aim of improving patient selection for personalized treatment. The investigators will examine BDNF serum levels as a biomarker correlate of lithium treatment by correlating change in BDNF levels with change in NPI agitation/aggression and psychosis scores.

Connect with a study center

University of Miami Miller School of Medicine
Miami, Florida 33136
United States
Site Not Available
McLean Hospital
Belmont, Massachusetts 02478
United States
Site Not Available
New York State Psychiatric Institute
New York, New York 10032
United States
Site Not Available
University of Texas Southwestern Medical Center
Dallas, Texas 75235
United States
Site Not Available

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