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PubMed2005

Behavioral and neuropsychiatric outcomes in Alzheimer's disease.

Behavioral and psychological symptoms of dementia pose significant challenges in the management of patients with Alzheimer's disease. Neuropsychiatric symptoms are associated with cognitive decline, highly impaired activities of daily living, and frontal lobe pathology. Moreover, behavioral and psychological symptoms can diminish patient quality of life, increase caregiver distress, and accelerate nursing home placement. Although these symptoms are often associated with the later stages of Alzheimer's disease, a high percentage of individuals with mild cognitive impairment or mild Alzheimer's report symptoms as well. This article provides an overview of behavioral and neuropsychiatric symptoms associated with Alzheimer's disease and discusses nonpharmacologic and pharmacologic approaches to the management of such symptoms. For patients with severe behavioral and psychological symptoms of dementia, psychotropic agents may be warranted, whereas approved therapies for Alzheimer's, including cholinesterase inhibitors and the N-methyl-d-aspartate receptor antagonist memantine, may be appropriate in less severe cases.

Aged↗
PubMed2004

Cognitive deficits following coronary artery bypass grafting: prevalence, prognosis, and therapeutic strategies.

There is increasing recognition that coronary artery bypass grafting (CABG) may be a risk factor for subtle cognitive decline although the presence and pattern of such decline has varied across studies. Cognitive deficits may present as short-term memory loss, executive dysfunction and psychomotor slowing. Although they are usually are not severe enough to meet criteria for mild cognitive impairment or vascular dementia, they lower quality of life and add to hospitalization and out-of-hospital costs. Proposed mechanisms include surgical-related trauma, genetic susceptibility (eg, apolipoprotein E4 allele), microembolization, other vascular or ischemic changes, and temperature during surgery. Depression and anxiety levels predict subjective perception of these deficits more than objective cognitive performance. Both nonpharmacologic (eg, emboli reduction, temperature, or glucose management) and pharmacologic (eg, dexanabinol, glypromate, nootropics) strategies to prevent post-CABG cognitive deficits are under investigation. Given the large numbers of subjects who may already have CABG associated cognitive deficits, clinical trials of agents being tested for Alzheimer's disease (eg, donepezil, rivastigmine, memantine, neramexane, ginkgo) may also be informative. The results of multicenter long-term outcome studies (with matched control groups) as well as ongoing treatment trials will more conclusively address some of these issues. These data emphasize the need for clinicians to monitor cognitive function before and after coronary bypass surgery, and to educate patients.

Cognition Disorders↗
PubMed2002

Depolarization-induced superoxide radical formation in rat hippocampal slices.

Glutamate is the major excitatory neurotransmitter in the brain. Activation of glutamatergic receptors induces neuronal depolarization, and if this activation is excessive, it can lead to cellular damage. Evidence for the participation of glutamatergic receptor systems in the production of oxygen free radicals in neuronal cells is accumulating. In the present study, we have kept hippocampal slices under depolarization conditions induced by including 50 mM K+ in artificial cerebrospinal fluid (dACSF) and followed superoxide radical formation. Superoxide radical formation was increased in dACSF-incubated hippocampal slices. We have also attempted to determine the relative contribution of agonist- and voltage-sensitive channels to superoxide radical formation by using their selective blockers. Superoxide radical formation was suppressed by MK 801, memantine, APV, CNQX, and TTX application to dACSF-incubated hippocampal slices. Similar studies on different experimental systems may help to unravel the underlying critical events and active mechanisms that may lead to superoxide radical generation and subsequent neuronal cell death.

Animals↗
PubMed2004

Studies of the roles of NMDA and AMPA glutamate receptors in the mechanism of corasole convulsions in mice.

Experiments on mice were performed to study the ability of monocationic and dicationic adamantane and phenylcyclohexyl derivatives to prevent convulsive syndrome induced by i.p. corasole (pentylenetetrazole; 80 mg/kg). Monocationic phenylcyclohexyl derivatives, which are selective blockers of NMDA glutamate receptor channels, along with memantine and MK-801, effectively prevented the appearance of the clonic and tonic components of convulsions at micromolar concentrations. Their dicationic analogs, which block both NMDA and AMPA receptor channels, were ineffective against clonic convulsions, but prevented corasole-induced tonic convulsions at much lower concentrations. The convulsive action of corasole, whose primary target is weakening of the inhibitory action of GABA, appears to be mediated by glutamatergic synaptic transmission. NMDA receptors have a much greater involvement than AMPA receptors in the genesis of clonic convulsions, while AMPA receptor activation appears to be an important component of tonic convulsions.

Animals↗
PubMed2002

Excitatory glycine receptors containing the NR3 family of NMDA receptor subunits.

The N-methyl-D-aspartate subtype of glutamate receptor (NMDAR) serves critical functions in physiological and pathological processes in the central nervous system, including neuronal development, plasticity and neurodegeneration. Conventional heteromeric NMDARs composed of NR1 and NR2A-D subunits require dual agonists, glutamate and glycine, for activation. They are also highly permeable to Ca2+, and exhibit voltage-dependent inhibition by Mg2+. Coexpression of NR3A with NR1 and NR2 subunits modulates NMDAR activity. Here we report the cloning and characterization of the final member of the NMDAR family, NR3B, which shares high sequence homology with NR3A. From in situ and immunocytochemical analyses, NR3B is expressed predominantly in motor neurons, whereas NR3A is more widely distributed. Remarkably, when co-expressed in Xenopus oocytes, NR3A or NR3B co-assembles with NR1 to form excitatory glycine receptors that are unaffected by glutamate or NMDA, and inhibited by D-serine, a co-activator of conventional NMDARs. Moreover, NR1/NR3A or -3B receptors form relatively Ca2+-impermeable cation channels that are resistant to Mg2+, MK-801, memantine and competitive antagonists. In cerebrocortical neurons containing NR3 family members, glycine triggers a burst of firing, and membrane patches manifest glycine-responsive single channels that are suppressible by D-serine. By itself, glycine is normally thought of as an inhibitory neurotransmitter. In contrast, these NR1/NR3A or -3B 'NMDARs' constitute a type of excitatory glycine receptor.

Animals↗
PubMed1998

Selected peptides targeted to the NMDA receptor channel protect neurons from excitotoxic death.

Excitotoxic neuronal death, associated with neurodegeneration and stroke, is triggered primarily by massive Ca2+ influx arising from overactivation of glutamate receptor channels of the N-methyl-D-aspartate (NMDA) subtype. To search for channel blockers, synthetic combinatorial libraries were assayed for block of agonist-evoked currents by the human NR1-NR2A NMDA receptor subunits expressed in amphibian oocytes. A set of arginine-rich hexapeptides selectively blocked the NMDA receptor channel with IC50 approximately 100 nM, a potency similar to clinically tolerated blockers such as memantine, and only marginally blocked on non-NMDA glutamate receptors. These peptides prevent neuronal cell death elicited by an excitotoxic insult on hippocampal cultures.

Animals↗
PubMed1999

Mechanisms involved in the metabotropic glutamate receptor-enhancement of NMDA-mediated motoneurone responses in frog spinal cord.

1. The metabotropic glutamate receptor (mGluR) agonist trans-(+/-)-1-amino-1,3-cyclopentanedicarboxylic acid (trans-ACPD) (10-100 microM) depolarized isolated frog spinal cord motoneurones, a process sensitive to kynurenate (1.0 mM) and tetrodotoxin (TTX) (0.783 microM). 2. In the presence of NMDA open channel blockers [Mg2+; (+)-5-methyl-10,11-dihydro-5H-dibenzo[a,d]cyclohepten-5,10-imine hydrogen maleate (MK801); 3,5-dimethyl-1-adamantanamine hydrochloride (memantine)] and TTX, trans-ACPD significantly potentiated NMDA-induced motoneurone depolarizations, but not alpha-amino-3-hydroxy-5-methylisoxazole-4-proprionate (AMPA)- or kainate-induced depolarizations. 3. NMDA potentiation was blocked by (RS)-alpha-methyl-4-carboxyphenylglycine (MCPG) (240 microM), but not by alpha-methyl-(2S,3S,4S)-alpha-(carboxycyclopropyl)-glycine (MCCG) (290 microM) or by alpha-methyl-(S)-2-amino-4-phosphonobutyrate (L-MAP4) (250 microM), and was mimicked by 3,5-dihydroxyphenylglycine (DHPG) (30 microM), but not by L(+)-2-amino-4-phosphonobutyrate (L-AP4) (100 microM). Therefore, trans-ACPD's facilitatory effects appear to involve group I mGluRs. 4. Potentiation was prevented by the G-protein decoupling agent pertussis toxin (3-6 ng ml(-1), 36 h preincubation). The protein kinase C inhibitors staurosporine (2.0 microM) and N-(2-aminoethyl)-5-isoquinolinesulphonamide HCI (H9) (77 microM) did not significantly reduce enhanced NMDA responses. Protein kinase C activation with phorbol-12-myristate 13-acetate (5.0 microM) had no effect. 5. Intracellular Ca2+ depletion with thapsigargin (0.1 microM) (which inhibits Ca2+/ATPase), 1,2-bis(O-aminophenoxy)ethane-N,N,N',N'-tetracetic acid acetyl methyl ester (BAPTA-AM) (50 microM) (which buffers elevations of [Ca2+]i), and bathing spinal cords in nominally Ca2+-free medium all reduced trans-ACPD's effects. 6. The calmodulin antagonists N-(6-aminohexyl)-5-chloro-1-naphthalenesulphonamide (W7) (100 microM) and chlorpromazine (100 microM) diminished the potentiation. 7. In summary, group I mGluRs selectively facilitate NMDA-depolarization of frog motoneurones via a G-protein, a rise in [Ca2+]i from the presumed generation of phosphoinositides, binding of Ca2+ to calmodulin, and lessening of the Mg2+-produced channel block of the NMDA receptor.

Amino Acids, Dicarboxylic↗
PubMed2006

Neuroprotection associated with alternative splicing of NMDA receptors in rat cortical neurons.

Exposure of cultured cortical neurons to elevated extracellular K(+) concentrations (25 mM) induces membrane depolarization and an increase in action-potential firing. Long-term high K(+) treatment was associated with an increased neuronal cell death. In surviving neurons, multiple changes occurred in the proportion of individual NMDA receptor subunit 1 (NR1) splice variant mRNA expression, whereas the overall expression of NR1, NR2A and NR2B transcripts remained unaffected. The high K(+)-induced changes in NR1 splice variant expression were virtually abolished upon a concurrent administration of tetrodotoxin (TTX; 3 microM). In voltage-clamp recordings performed on neurons resistant to high K(+) treatment, inward currents induced by NMDA (1-1,000 microM) were reduced. In K(+)-resistant cells, the activity of calpain but not of caspase-3 was diminished compared with controls kept in regular medium. NR function as well as calpain activity was not affected in cultures concomitantly treated with high K(+) and either TTX or a NR antagonist (CGS19755 (selfotel) or memantine). In conclusion, the present data indicate adaptive changes in NR1 splice variant expression and a decrease in NR function upon a sustained increase in neurotransmission. Accordingly, alternative splicing could be an endogenous mechanism to counteract cellular damage due to overactivation of excitatory NRs and may be associated with an impairment of necrotic mechanisms.

Action Potentials↗
PubMed2006

Survey of management of acquired nystagmus in the United Kingdom.

PURPOSE: To determine the current management of acquired nystagmus by ophthalmologists and neurologists. METHODS: Questionnaires were sent to ophthalmologists (850) and neurologists (434) in the United Kingdom. Estimated numbers of patients seen with acquired nystagmus, treatment options used, and the results of treatment of the patients were collected. RESULTS: Response rate was 37% for ophthalmologists and 34% for neurologists. The most common causes of acquired nystagmus were estimated to be multiple sclerosis and stroke. 58% of ophthalmologists and 94.5% of neurologists reported seeing patients with nystagmus. The most commonly used medical treatment was gabapentin and baclofen. Other drugs used were clonazepam, carbamazepine, benzhexol, ondansetrone, buspirone, memantine, and botulinum toxin (n=3). Eleven ophthalmologists and 52 neurologists noted symptomatic improvement with medical treatment. Eleven ophthalmologists and 44 neurologists noted improvement in visual acuity (VA). Occurrence of side effects noted with baclofen and gabapentin treatments were similar. CONCLUSION: A variety of drugs are used to treat acquired nystagmus in the UK. Baclofen and gabapentin are the drugs most commonly used and are reported to cause significant improvement in symptoms and VA. Better knowledge of the action of drugs in nystagmus is needed to establish guidelines and to give patients wider access to treatment.

Amines↗
PubMed1995

Regional variations in the pharmacology of NMDA receptor channel blockers: implications for therapeutic potential.

Quantitative receptor autoradiography was used to examine the regional binding characteristics of a diverse group of N-methyl-D-aspartate (NMDA)-receptor channel blockers that varied in potency 10(5)-fold. Full competition curves were generated in each of six brain regions for 11 different compounds. MK-801 was the most potent compound studied, with an IC50 of approximately 10 nM in the forebrain regions and 24 nM in the cerebellar granule cell layer (p < 0.05). The binding affinities of nine of the 11 compounds examined were significantly different in cerebellar granule cell layer than in forebrain regions. In addition, the apparent Hill slopes of five of the compounds were significantly different in cerebellum compared with forebrain. That the rank order of drug potencies in cerebellar diverges from that in forebrain suggests that cerebellar NMDA-receptor ion channels differ pharmacologically from those in forebrain. There was a general trend that drugs known to be well tolerated in humans (remacemide hydrochloride and its metabolites, amantadine, budipine, and memantine) had lower affinities than compounds with severe neurobehavioral or psychotomimetic effects. Moreover, all of the compounds known to be well tolerated in humans had a significantly higher affinity in the cerebellum than in forebrain regions, in contrast to MK-801, 1-[1-(2-thienyl)cyclohexyl]-piperidine hydrochloride (TCP), phencyclidine (PCP), and ketamine, which had lower affinities in cerebellum. Our results are consistent with the notion that low affinity (rapid kinetics) and, possibly, subunit specificity (as indicated by distinct regional pharmacologies) may be important determinants of the clinical tolerability of NMDA-receptor channel blockers.

Acetamides↗
PubMed1995

NMDA receptor subtype selectivity: eliprodil, polyamine spider toxins, dextromethorphan, and desipramine selectively block NMDA-evoked striatal acetylcholine but not spermidine release.

NMDA receptor stimulation concomitantly increases the release of [14C]acetylcholine and [3H]-spermidine from rat striatal slices in vitro. The NMDA-induced release of both acetylcholine and spermidine was blocked with equal potency by the NMDA channel blocker phencyclidine (0.1-10 microM). However, certain other channel blockers, including dextromethorphan (1-100 microM), which antagonized NMDA-evoked acetylcholine release without affecting NMDA-evoked spermidine release, and dextrorphan (1-100 microM) and memantine (1-100 microM), which block NMDA-evoked acetylcholine release more potently than NMDA-evoked spermidine release, showed greater selectivity of action. As previously shown for ifenprodil, eliprodil (SL82.0715; 1-100 microM) blocked NMDA-evoked acetylcholine but not spermidine release. This selectivity is also observed for other agents interacting with the polyamine site(s) on the NMDA receptor, including arcaine (1-1,000 microM), philanthotoxin343, and argiotoxin636 (10 microM) and was also noted for desipramine (1-100 microM). The NMDA-induced release of acetylcholine and spermidine is likely to be mediated by different native NMDA receptor subtypes, and several NMDA antagonists may be candidates for a selective action at a particular NMDA receptor subtype.

Acetylcholine↗
PubMed1999

Pathways of cadmium influx in mammalian neurons.

The influx of the toxic cation Cd2+ was studied in fura 2-loaded rat cerebellar granule neurons. In cells depolarized with Ca2(+)-free, high-KCI solutions, the fluorescence emission ratio (R) increased in the presence of 100 microM Cd2(+). This increase was fully reversed by the Cd2+ chelator tetrakis(2-pyridylmethyl)ethylenediamine, indicating a cadmium influx into the cell. The rate of increase, dR/dt, was greatly reduced (67+/-5%) by 1 microM nimodipine and enhanced by 1 microM Bay K 8644. Concurrent application of nimodipine and omega-agatoxin IVA (200 nM) blocked Cd2+ permeation almost completely (88+/-5%), whereas omega-conotoxin MVIIC (2 microM) reduced dR/dt by 24+/-8%. These results indicate a primary role of voltage-dependent calcium channels in Cd2+ permeation. Stimulation with glutamate or NMDA and glycine also caused a rise of R in external Cd2+. Simultaneous application of nimodipine and omega-agatoxin IVA moderately reduced dR/dt (25+/-3%). NMDA-driven Cd2(+) entry was almost completely prevented by 1 mM Mg2+, 50 microM memantine, and 10 microM 5,7-dichlorokynurenic acid, suggesting a major contribution of NMDA-gated channels in glutamate-stimulated Cd2+ influx. Moreover, perfusion with alpha-amino-3-hydroxy-5-methylisoxazole-4-propionate caused a slow increase of R. These results suggest that Cd2+ permeates the cell membrane mainly through the same pathways of Ca2+ influx.

Animals↗
PubMed2003

Determinants of trapping block of N-methyl-d-aspartate receptor channels.

Open channel blockers of NMDA receptors interact with the channel gate in different ways. Compounds like MK-801 and phencyclidine exhibit pronounced trapping block, whereas 9-aminoacridine and tetrapentylammonium cannot be trapped. Some blockers such as memantine and amantadine exhibit intermediate properties, so called 'partial trapping'. To analyze the determinants of trapping we have synthesized a series of mono- and dicationic derivatives of phenylcyclohexyl. The blocking action of these compounds as well as that of amantadine has been studied on native NMDA receptors of hippocampal pyramidal neurons. Use-dependence and kinetics of the blockade have been analyzed to estimate the degree of trapping. Dimensions of the blocking molecules apparently do not correlate with their trapping. However, the degree of trapping is voltage-dependent and correlates with the kinetics of unblock. For instance, amantadine behaved as non-trapping blocker at positive voltages, but demonstrated significant trapping at negative voltages. The data may be explained by the model in which the NMDA receptor channel has two binding sites: the shallow and deep ones. Binding to the deep but not to the shallow site allows trapping of the blockers.

Amantadine↗
PubMed2003

Medical management of advanced dementia.

A cure for Alzheimer's disease (AD) is still far off, and clinicians face the burden of caring for patients at all stages of dementia for the foreseeable future. Those with advanced disease suffer neurological symptoms and signs that include incontinence; problems with gait and mobility; marked cognitive, language, and functional impairment; and in about 90% of patients, significant behavior problems. Dementia precludes the ability to initiate meaningful activities or social interactions. Whether patients are resident in the community or living in a nursing home, this composite reflects a highly complex medical and neuropsychiatric management challenge. Predictable medical conditions also must be addressed (i.e., those that accompany dementia, such as parkinsonism, and those that are prevalent in any aging population, such as hypertension). Clinicians can better address these problems with awareness of current treatment options. Placebo-controlled trials of some psychotropic agents have shown modest favorable effects on behavior problems. Use of acetylcholinesterase inhibitors (AChEIs) to treat cognitive impairment and secondary behavioral symptoms derives primarily from results of placebo-controlled clinical trials. Trials in patients with moderate to severe AD, outpatients as well as nursing home residents, show overall effects similar to those seen in outpatients with milder dementia. Treatment with AChEIs may delay institutional placement. Memantine has shown benefit in trials in moderate to severe dementia, although it is not yet approved in the United States. Emerging data have expanded physicians' ability to use pharmacotherapy in patients with advanced dementia. Physicians need to enact the principle that something can be done for our afflicted parents and grandparents.

Aged↗
PubMed2002

[Symptomatic therapy of Alzheimer dementia].

No causal treatment or highly effective preventive strategies are available for Alzheimer's disease to date. Symptomatic measures are still essential to improve cognitive and behavioural deficits. Acetylcholinesterase inhibitors, the NMDA-antagonist memantine and the phytopharmaco ginkgo biloba are currently the substances most extensively studied and most widely used to improve cognition and activities of daily living. Behavioural disturbances oftentimes respond to antidementia drugs, but may demand specific treatment with neuroleptics, antidepressants, stabilizers and other substances.

Aged↗
PubMed2000

Successful trial of amantadine hydrochloride for two patients with alternating hemiplegia of childhood.

We report here the efficacy of amantadine hydrochloride for two patients with alternating hemiplegia of childhood (AHC) that did not respond to flunarizine. Amantadine was administered to one patient at age one year and seven months and to the other at age 25 years. The frequencies and duration of the hemiplegic attacks significantly improved in both patients. However, the attacks gradually returned to the previous level after a significant reduction in seizures for three years in the younger patient with ongoing AHC. Our therapeutic results further support the hypothesis that glutamate and NMDA receptors are involved in inducing alternating hemiplegic attacks, because amantadine as well as its derivative, memantine, are clinically available non-competitive N-methyl-D-aspartate (NMDA) receptor antagonists, with neuroprotective effects. Amantadine is worth trying when treating patients with AHC as a first trial or a substitute for flunarizine once the latter agent looses effect.

Adult↗
PubMed2003

The impact of drugs against dementia on cognition in aging and mild cognitive impairment.

OBJECTIVE: To define the actual knowledge of the impact of drugs for the treatment of dementia on the improvement of cognition in aging and mild cognitive impairment. METHOD: We conducted a Medline search for studies with the parameters drug and cognition. Only drugs that had demonstrated cognition improvements in dementia according to actual methodological standards were included. Drugs had to be approved in at least one American or European nation. RESULTS: Donepezil, galantamine, Ginkgo biloba EGb 761 (definition see editorial), memantine and rivastigmine fulfilled these criteria. There were no systematic investigations on the effects of these drugs on cognition in healthy adults or patients with mild cognitive impairment (MCI). Regarding Ginkgo biloba, two studies on MCI patients could be identified. In healthy adults, we could only include one study investigating donepezil and seven investigating Ginkgo biloba EGb 761. According to the findings, donepezil significantly increased the percentage of REM sleep and REM density, whereas REM latency was reduced. This was interpreted as a sign of improved cognition. Ginkgo biloba EGb 761 improved cognition in healthy controls according to Delayed Free Recall and Delayed Recognition of the WAIS-III and the Color Naming of the Stroop Test as well as in MCI in Digit Copying, Dual Coding Task and speed of response on a computerized version of a classification task. The highest effects were observed after 6 weeks of treatment with 180 mg/d. CONCLUSIONS: Due to the lack of standard procedures for investigating cognition improvement in healthy aging, results have to be interpreted cautiously. In healthy adults as well as in individuals categorized as having MCI, Ginkgo biloba EGb 761 improved cognition in some but not all neuropsychological tests. The single positive result with donepezil raises hope that other drugs may also contribute to cognitive improvement, even in healthy adults. However, the data do not allow any conclusions regarding an improvement following a specific "neuropsychological cluster." Studies on prevention have not been completed so far.

Adult↗
PubMed2003

[Pathomechanisms and hypothesis-guided therapeutic strategies for late-onset Alzheimer's disease].

Even though the clinical effectiveness of the presently used pharmaceutical therapy of sporadic Alzheimer Disease seems to be proven sufficient, their effective mechanisms are much less known or are disregarded in the evaluation of the clinical effects. However, it seems to be inevitable to know both clinical effect and effective mechanisms of pharmaceutics in order to be able to judge their adversity and benefit. In reference to the pharmaceutics implemented on sporadic AD in Germany, total different effective mechanisms are shown. In consideration of the shown pathomechanisms which have been recognized for sporadic AD, therapeutic rationales on application of Ginkgo biloba extract (EGb 761) and Memantine are evident. The application of acetylcholinesterase inhibitors, often looked on as agent of choice, is to be considered critically because of the danger of the occurrence of myopathological dysfunction, resp. the Gulf War Syndrome. Sophisticated and hastily advertised therapy strategies with statins or vaccination against beta A4 should not be used because of a lack of sufficient evidence based on the pathophysiological pattern of damage as known in sporadic AD. Future development must take in account that with sporadic AD aging influences cannot or can hardly be influenced. Therapeutic goals should consist to improve the cellular energy status and the membrane functioning.

Aging↗