Antipsychotic Discontinuation in Alzheimer's Disease

Alzheimer Disease Clinical Trial

— ADAD  

Official title:

Antipsychotic Discontinuation in Alzheimer's Disease

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT00417482
• Other study ID #: #5598R
• Secondary ID: 5R01AG021488
• Status: Completed
• Phase: Phase 4
• First received: December 28, 2006
• Last updated: March 14, 2013
• Start date: August 2004
• Est. completion date: April 2011

Study information

• Verified date: March 2013
• Source: New York State Psychiatric Institute
• Contact: n/a
• Is FDA regulated: No
• Health authority: United States: Institutional Review Board
• Study type: Interventional

Clinical Trial Summary

In patients with Alzheimer's disease (AD) who respond to antipsychotic treatment of psychosis and/or agitation/aggression, the relapse risk after discontinuation is not established. AD patients with psychosis and/or agitation/aggression receive 16 weeks of open risperidone treatment (Phase A). Responders are then randomized, double-blind, to one of three arms in Phase B: (1) continuation risperidone for 32 weeks, (2) risperidone for 16 weeks followed by placebo for 16 weeks, (3) placebo for 32 weeks. The primary outcome is time to relapse of psychosis/agitation.

Description:

This multicenter study (6 academic sites and 2 non-academic sites) involves treating AD patients (assisted living or nursing home patients, and outpatients) using an atypical antipsychotic, risperidone. In Phase A, 180 AD patients with psychosis and/or agitation/aggression receive open treatment with risperidone for 16 weeks. Responders are randomized, double-blind, to one of three arms in Phase B: (1) continuation risperidone for the next 32 weeks, (2) risperidone for the next 16 weeks followed by placebo for 16 weeks, or (3) placebo for the next 32 weeks. The primary hypothesis is that in the first 16 weeks of Phase B, relapse risk will be lower with continuation risperidone (Arms 1 + 2) compared to discontinuation on placebo (Arm 3). The secondary hypothesis is that in the second 16 weeks of Phase B, relapse risk will be lower with continuation risperidone (Arm 1) compared to discontinuation on placebo (Arm 2). For both randomized time periods, the proportions who relapse will be compared for interpretive support. This design provides useful data on the efficacy and side effects of longer term treatment with risperidone, and, in particular, critical information about the time to relapse and likelihood of relapse in patients switched from risperidone to placebo. This information is essential to guide the clinician toward optimal use of such medications in one of the most challenging types of patients: the AD patient with psychosis and/or agitation/aggression. The results of this study will also help to address Federal regulations urging early antipsychotic discontinuation in nursing homes.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 180
• Est. completion date: April 2011
• Est. primary completion date: April 2011
• Accepts healthy volunteers: No
• Gender: Both
• Age group: 50 Years to 95 Years

Eligibility

Inclusion Criteria:

• Dementia, either sex, age 50-95 years

• Probable Alzheimer's disease

• Intellectual impairment present for at least 6 months

• Mini Mental State Exam (MMSE) score of 5-26 for outpatients and 2-26 for nursing home patients

• Availability of informant who has had direct contact with the patient for an average of at least once every week during the 3 months prior to study entry

• Meets Neuropsychiatric Inventory (NPI) criteria for either (1) psychosis, or (2) agitation/aggression

• Able to mobilize independently (if wheelchair-bound, the patient must be able to self-propel)

• Free of psychotropic medication (or able to tolerate washout) for at least 1 week prior to study entry. Low dose antidepressants and sedative/hypnotics allowed if they cannot be washed out and the dose remains stable for the study duration

• Expected to complete the study (including all efficacy evaluations) and be without major sensory impairment that would prevent participation in any aspect of the study

Exclusion Criteria:

• Current primary Axis I psychiatric disorder other than AD

• Substance abuse or dependence currently, or within the past year

• Dementia due to head trauma

• History of allergy to risperidone or intolerance to risperidone

• Diffuse Lewy body disease

• History of seizure disorder, infectious encephalitis, Parkinson's disease, central nervous system (CNS) neoplasm, tardive dyskinesia, stroke, transient ischemic attack (TIA) or uncontrolled atrial fibrillation

• Use of monoamine oxidase inhibitors (MAOIs) and unable to undergo 3-week washout; patients also may not take MAOIs for 2 weeks after completing the study

• In treatment with (a) depot antipsychotic within 2 weeks of the screening visit

• Untreated or incompletely treated hypothyroidism

• Active, unstable medical condition that requires active medication adjustment or surgery

• Need for electroconvulsive treatment (ECT)

• Significant risk for harm to themselves or others as a result of randomization to placebo

• History of malignant neoplasm during the last 5 years

Study Design

Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Parallel Assignment, Masking: Double Blind (Subject, Caregiver, Investigator, Outcomes Assessor), Primary Purpose: Treatment

Related Conditions & MeSH terms

• Aggression
• Agitation
• Alzheimer Disease
• Mental Disorders
• Psychotic Disorders

Intervention

Drug:
• risperidone
Risperidone open label flexible dose 0.25 to 3 mg daily for first 16 weeks; dose at 16 weeks then fixed for randomized trial

Locations

Country	Name	City	State
United States	University of Iowa College of Medicine	Iowa City	Iowa
United States	WLA VA Medical Center/UCLA, Psychiatry	Los Angeles	California
United States	Mount Sinai School of Medicine, Alzheimer's Disease Research Center	New York	New York
United States	New York State Psychiatric Institute, Columbia University	New York	New York
United States	Medical University of South Carolina	North Charleston	South Carolina
United States	Research Center for Clinical Studies, Inc.	Norwalk	Connecticut
United States	Tuscaloosa VA Medical Center, Department of Psychiatry	Tuscaloosa	Alabama

Sponsors (3)

Lead Sponsor	Collaborator
New York State Psychiatric Institute	Columbia University, National Institute on Aging (NIA)

Country where clinical trial is conducted

United States, 

References & Publications (1)

Devanand DP, Mintzer J, Schultz SK, Andrews HF, Sultzer DL, de la Pena D, Gupta S, Colon S, Schimming C, Pelton GH, Levin B. Relapse risk after discontinuation of risperidone in Alzheimer's disease. N Engl J Med. 2012 Oct 18;367(16):1497-507. doi: 10.1056 — View Citation

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Relapse by Study Week 32	A relapse occurred in Phase B (post-randomization) if both of the following criteria were met: Increase in the Neuropsychiatric Inventory (NPI) core score of 30% or more OR a 5-point increase from the baseline NPI score at the end of Phase A; A score of 6 (much worse) or 7 (very much worse) on the Clinical Global Impression-Change (CGI-C) at any visit.	0-16 weeks in Phase B (16-32 weeks in study)	No
Secondary	Relapse by Study Week 48	Same definition and criteria as the primary outcome	16-32 weeks in Phase B (32-48 weeks in study)	No
Secondary	Mini Mental State Exam (MMSE)	The MMSE assesses cognition. Scores range from 0-30, with higher scores indicating better cognition. For each subject, the change in MMSE between week 16 and baseline (randomization) was calculated by subtraction, so that a positive value indicates an increase in MMSE over time.	Phase B, weeks 1-16 (study weeks 16-32)	Yes
Secondary	Treatment Emergent Symptoms Scale (TESS)	The Treatment Emergent Symptom Scale (TESS) assesses 26 somatic symptoms. Total scores range from 0-26, with a score of 0 or 1 for each item. Higher scores indicate more somatic symptoms. For each subject, the change in TESS between week 16 and baseline (randomization) was calculated by subtraction, so that a positive value indicates an increase in TESS over time.	Phase B, weeks 1-16 (study weeks 16-32)	Yes
Secondary	Extrapyramidal Signs (EPS)	Extrapyramidal signs, also known as Parkinsonian signs, refer to signs of tremor, rigidity, and bradykinesia (slowed movement) that are seen in Parkinson's disease. Assessment of extrapyramidal signs (EPS) were made with the use of the Simpson-Angus scale (which ranges from 1-40) with higher scores indicating more extrapyramidal signs. For each subject, the change in EPS between week 16 and baseline (randomization) was calculated by subtraction, so that a positive value indicates an increase in EPS over time.	Phase B, weeks 1-16 (study weeks 16-32)	Yes
Secondary	AIMS	The Abnormal Involuntary Movement Scale (AIMS) assesses signs of tardive dyskinesia, a movement disorder that can occur with prolonged use of antipsychotic medication. The AIMS score ranges from 0 to 35, with higher scores indicating more severe symptoms. For each subject, the change in AIMS score between week 16 and randomization was calculated by subtraction, so that a positive value indicates an increase in AIMS over time.	Phase B, weeks 1-16 (study weeks 16-32)	Yes
Secondary	Physical Self-Maintenance Scale (PSMS)	Physical Self-Maintenance Scale, which ranges from 1 to 30, with higher scores indicating WORSE functioning. For each subject, the change in PSMS between week 16 and randomization was calculated by subtraction, so that a positive value indicates an increase in PSMS (worse functioning) over time.	Phase B, weeks 1-16 (study weeks 16-32)	Yes
Secondary	Weight	For each subject, the change in weight in pounds between week 16 and randomization was calculated by subtraction, so that a positive value indicates an increase in weight over time.	Phase B, weeks 1-16 (study weeks 16-32)	Yes

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