An 18F-labeled PET amyloid-β (Aβ) imaging agent could facilitate the clinical evaluation of late-life cognitive impairment by providing an objective measure for Alzheimer disease (AD) pathology. Here we present the results of a clinical trial with (E)-4-(2-(6-(2-(2-(2-18F-fluoroethoxy)ethoxy)ethoxy)pyridin-3-yl)vinyl)-N-methyl benzenamine (18F-AV-45 or flobetapir F 18). Methods: An open-label, multicenter brain imaging, metabolism, and safety study of 18F-AV-45 was performed on 16 patients with AD (Mini-Mental State Examination score, 19.3 ± 3.1; mean age ± SD, 75.8 ± 9.2 y) and 16 cognitively healthy controls (HCs) (Mini-Mental State Examination score, 29.8 ± 0.45; mean age ± SD, 72.5 ± 11.6 y). Dynamic PET was performed over a period of approximately 90 min after injection of the tracer (370 MBq [10 mCi]). Standardized uptake values and cortical-to-cerebellum standardized uptake value ratios (SUVRs) were calculated. A simplified reference tissue method was used to generate distribution volume ratio (DVR) parametric maps for a subset of subjects. Results: Valid PET data were available for 11 AD patients and 15 HCs. 18F-AV-45 accumulated in cortical regions expected to be high in Aβ deposition (e.g., precuneus and frontal and temporal cortices) in AD patients; minimal accumulation of the tracer was seen in cortical regions of HCs. The cortical-to-cerebellar SUVRs in AD patients showed continual substantial increases through 30 min after administration, reaching a plateau within 50 min. The 10-min period from 50 to 60 min after administration was taken as a representative sample for further analysis. The cortical average SUVR for this period was 1.67 ± 0.175 for patients with AD versus 1.25 ± 0.177 for HCs. Spatially normalized DVRs generated from PET dynamic scans were highly correlated with SUVR (r = 0.58–0.88, P

https://jnm.snmjournals.org/content/jnumed/51/6/913.full.pdf

In vivo imaging of amyloid deposition in Alzheimer disease using the radioligand 18F-AV-45 (florbetapir [corrected] F 18).

Regionally-Specific Diffusion Tensor Imaging in Mild Cognitive Impairment and Alzheimer’s Disease

Objective Depression is common in Alzheimer disease (AD), and antidepressants are commonly used for its treatment, however, evidence for antidepressant efficacy in this population is lacking. The authors conducted a multicenter, randomized, placebo-controlled trial titled "Depression in Alzheimer's Disease-2" to assess the efficacy and tolerability of sertraline for depression in AD. Methods One hundred thirty-one participants from five U.S. medical centers with mild-to-moderate AD (Mini-Mental State Examination scores 10-26) and depression of AD were randomized to double-blinded treatment with sertraline (N = 67) or placebo (N = 64), with a target dosage of 100 mg daily. Efficacy was assessed using logistic regressions and mixed effects models in an intention-to-treat analysis with imputation of missing data. Principal outcome measures were modified Alzheimer's Disease Cooperative Study-Clinical Global Impression of Change (mADCS-CGIC), change in Cornell Scale for Depression in Dementia (CSDD) scores, and remission defined by both mADCS-CGIC score ≤2 and CSDD score ≤6. Results mADCS-CGIC ratings (odd ratio [OR = 1.01], 95% confidence interval [CI]: 0.52-1.97, p=0.98), CSDD scores (median difference at 12 weeks 1.2, 95% CI: 1.65-4.05, p=0.41), and remission at 12 weeks of follow-up (OR = 2.06, 95% CI: 0.84-5.04, p=0.11) did not differ between sertraline (N = 67) and placebo (N = 64). Sertraline-treated patients experienced more adverse events, most notably gastrointestinal and respiratory, than placebo-treated patients. Conclusion Sertraline did not demonstrate efficacy for the treatment depression symptoms in patients with AD. In addition, its use was associated with an increased incidence of adverse events. Thus, selective serotonin reuptake inhibitors may be of limited value for treating depression in patients with AD.

Sertraline for the Treatment of Depression in Alzheimer Disease

Background The fornix is the predominant outflow tract of the hippocampus, a brain region known to be affected early in the course of Alzheimer's disease (AD). The aims of the present study were to: (1) examine the cross-sectional relationship between fornix diffusion tensor imaging (DTI) measurements (fractional anisotropy [FA], mean diffusivity [MD], axial diffusivity, and radial diffusivity), hippocampal volume, and memory performance, and (2) compare fornix DTI measures with hippocampal volumes as predictors of progression and transition from amnestic mild cognitive impairment to AD dementia. Methods Twenty-three mild cognitive impairment participants for whom hippocampal volumetry and DTI were conducted at baseline received detailed evaluations at baseline; 3, 6, and 12 months; and 2.5 years. Six participants converted to AD over the follow-up period. Fornix and posterior cingulum DTI measurements and hippocampal volumes were ascertained using manual measures. Random effects models assessed each of the neuroimaging measures as predictors of decline on the Mini-Mental State Examination, Clinical Dementia Rating-sum of boxes, and memory z scores; receiver operating characteristic analyses examined the predictive value for conversion to AD. Results There was a significant correlation between fornix FA and hippocampal volumes. However, only the fornix measurements (FA, MD, radial diffusivity, and axial diffusivity) were cross-sectionally correlated with memory z scores. Both fornix FA and hippocampal volumes were predictive of memory decline. Individually, fornix FA and MD and hippocampal volumes were very good predictors of progression, with likelihood ratios >83, and better than 90% accuracy. Conclusion Fornix FA both cross-sectionally correlated with and longitudinally predicted memory decline and progression to AD. Manually drawn region of interest within the fornix shows promise comparable with hippocampal volume as a predictive biomarker of progression, and this finding warrants replication in a larger study.

/pdf/fornix-integrity-and-hippocampal-volume-predict-memory-1b7dcf9t3v.pdf

Fornix integrity and hippocampal volume predict memory decline and progression to Alzheimer’s disease

Background Depression and antidepressant use are common in Alzheimer disease (AD), but the effect of antidepressant treatment for depression on longer term outcomes is unknown. The authors report the Week-24 outcomes of patients who participated in a 12-week efficacy study of sertraline for depression of AD. Methods One hundred thirty-one participants (sertraline = 67, placebo=64) with mild-moderate AD and depression participated in the study. Patients who showed improvement on the modified Alzheimer's Disease Cooperative Study Clinical Global Impression-Change (mADCS-CGIC) after 12 weeks of randomized treatment with sertraline or placebo continued double-blinded treatment for an additional 12 weeks. Depression response and remission at 24 weeks were based on mADCS-CGIC score and change in Cornell Scale for Depression in Dementia (CSDD) score. Secondary outcome measures included time to remission, nonmood neuropsychiatric symptoms, global cognition, function, and quality of life. Results One hundred seventeen (89.3%) participants completed all study assessments and 74 (56.5%; sertraline=38, placebo=36) completed all 24 weeks on randomized treatment. By 24 weeks, there were no between-group differences in depression response (sertraline = 44.8%, placebo=35.9%; odds ratio [95% CI] = 1.23 [0.64–2.35]), change in CSDD score (median difference=0.6 [95% CI: −2.26 to 3.46], χ 2 [ df = 2] = 1.03), remission rates (sertraline = 32.8%, placebo=21.8%; odds ratio [95% CI] = 1.61 [0.70–3.68]), or secondary outcomes. Common selective serotonin reuptake inhibitor-associated adverse events, specifically diarrhea, dizziness, and dry mouth, and pulmonary serious adverse events were more frequent in sertraline-randomized patients than in placebo subjects. Conclusions Sertraline treatment is not associated with delayed improvement between 12 and 24 weeks of treatment and may not be indicated for the treatment of depression of AD.

/pdf/sertraline-for-the-treatment-of-depression-in-alzheimer-4qmhhahhwc.pdf

Sertraline for the Treatment of Depression in Alzheimer Disease: Week-24 Outcomes

Adults with cognitive impairment are considered a vulnerable population. The conditions associated with cognitive impairment, such as dementia and delirium, cause great suffering to affected patients and their families. Improving clinical care for these conditions depends on research involving cognitively impaired participants. Cognitive impairment is at times associated with partial or full impairment of the capacity to consent to research. This both limits the ability of the individual to consent personally to research participation, and also increases pressure upon Institutional Review Boards (IRBs) and investigators to place additional safeguards for the appropriate participation of cognitively impaired individuals in research. While the ethical and legal principles permitting and safeguarding the participation of cognitively impaired persons in research are generally agreed upon, there are no specific methods that operationalize these principles in a language that can be used by IRBs and researchers to guide their day-to-day work in this area. This document contains recommendations that IRBs and investigators can use to operationalize the informed consent process for individuals with cognitive impairment. In situations in which IRBs might not have specific policies in this area, this guideline may also serve as the foundation for such policies. The recommendations discuss when to consider that cognitively impaired participants might be involved in a research project, the use of screening for cognitive impairment, the conduct of assessments evaluating capacity to consent to research, situations in which proxies might consent for research participation in the place of cognitively impaired participants, how to go about identifying appropriate proxies, and how to deal with the loss of consent capacity in the course of a research project.

Research consent for cognitively impaired adults: Recommendations for Institutional Review Boards and investigators

/pdf/true-risk-management-physicians-liability-risk-and-the-5gouqpoz06.pdf

True risk management: physicians' liability risk and the practice of patient-centered medicine.

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Research consent for cognitively impaired adults: Recommendations for Institutional Review Boards and investigators

True risk management: physicians' liability risk and the practice of patient-centered medicine.