Abstract
Agitation is a common and distressing symptom in patients with Alzheimer's disease. Cholinesterase inhibitors improve cognitive outcomes in such patients, but the benefits of these drugs for behavioral disturbances are unclear. We randomly assigned 272 patients with Alzheimer's disease who had clinically significant agitation and no response to a brief psychosocial treatment program to receive 10 mg of donepezil per day (128 patients) or placebo (131 patients) for 12 weeks. The primary outcome was a change in the score on the Cohen-Mansfield Agitation Inventory (CMAI) (on a scale of 29 to 203, with higher scores indicating more agitation) at 12 weeks. There was no significant difference between the effects of donepezil and those of placebo on the basis of the change in CMAI scores from baseline to 12 weeks (estimated mean difference in change [the value for donepezil minus that for placebo], -0.06; 95% confidence interval [CI], -4.35 to 4.22). Twenty-two of 108 patients (20.4%) in the placebo group and 22 of 113 (19.5%) in the donepezil group had a reduction of 30% or greater in the CMAI score (the value for donepezil minus that for placebo, -0.9 percentage point; 95% CI, -11.4 to 9.6). There were also no significant differences between the placebo and donepezil groups in scores for the Neuropsychiatric Inventory, the Neuropsychiatric Inventory Caregiver Distress Scale, or the Clinician's Global Impression of Change. In this 12-week trial, donepezil was not more effective than placebo in treating agitation in patients with Alzheimer's disease. (ClinicalTrials.gov number, NCT00142324 [ClinicalTrials.gov].).
Highlights
Agitation is a common and distressing symptom in patients with Alzheimer’s disease
Trial data suggest a reduced emergence of behavioral and psychiatric symptoms in patients treated with cholinesterase inhibitors[10]; these data suggest improvements in scores on the Neuropsychiatric Inventory (NPI)[11] in patients with behavioral disturbances who continue treatment as compared with those in whom treatment is withdrawn.[12]
Sensitivity Analyses Results for the Cohen–Mansfield Agitation Inventory (CMAI), NPI, NPI Caregiver Distress Scale, Severe Impairment Battery (SIB), and Standardized Mini–Mental State Examination (SMMSE) proved robust with different assumptions about departures from randomization policies and various other ways of handling missing data
Summary
We randomly assigned 272 patients with Alzheimer’s disease who had clinically significant agitation and no response to a brief psychosocial treatment program to receive 10 mg of donepezil per day (128 patients) or placebo (131 patients) for 12 weeks. The original study was a multicenter, blinded, randomized, parallel-group trial in which patients were assigned to receive risperidone (Rispendal, Eisai), donepezil, or placebo for 12 weeks, after 4 weeks of psychosocial treatment. Recruitment started in November 2003 but was suspended in March 2004, following the recommendation by the United Kingdom Committee for Safety of Medicines that risperidone and olanzapine not be used for the treatment of behavioral symptoms in dementia.[19] The trial was restarted in July 2004 with a two-group design (donepezil and placebo), and recruitment ended in September 2005
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