Exploring the Use of Transdermal Methylphenidate to Reduce Fall Risk in Patients With Dementia.

Falls in the elderly are a very common and serious health problem with devastating consequences. Those with dementia are 5 times more likely to experience falls than older people without significant cognitive impairment. Despite a growing awareness and the use of available treatments, the number of falls and fall related injuries continue to increase. It is important to develop more effective treatments to help reduce the number of falls and prevent injury. The assessments used in this study determine fall risk which predicts the likelihood of falls in the future.

This study will evaluate the possible role of Methylphenidate, Ritalin, in preventing falls and improving symptoms of apathy, or indifference. Methylphenidate is FDA approved for the treatment of ADHD but is not currently approved by the FDA for preventing falls or improving apathy(lack of interest) in the elderly. The methylphenidate used in this study will be absorbed through the skin by wearing a small patch near the hip area.

The specific primary aim of this open label study is to determine if use of transdermal Methylphenidate (t-MPH) causes a reduction in fall risk in patients with dementia.

The hypotheses to be tested is that after receiving t-MPH for 4 weeks, subjects will show improvement in gait and mobility assessment scores when compared to gait and mobility scores at screening.

This is an open label pilot study; consenting subjects with dementia and identified as a fall risk, who meet inclusion criteria will undergo 3 phases of involvement. Phase 1 is a 1 week period before initiating study drug. Phase 2 is a 2 week treatment period with 10mg of Transdermal Methylphenidate. Phase 3 is the final two week treatment period with 15mg of Transdermal Methylphenidate.

Measurements obtained at each phase will include:

Vital Signs (blood pressure and pulse rate) weight , Timed Get Up and Go Test (TUG) , Tinetti Performance Oriented Mobility Assessment (POMA), Clinical Apathy Evaluation Scale (AES-C) and the St. Louis University Mental Status Examination (SLUMS).

The primary endpoint is the change in TUG and POMA scores at end of phase 3 compared to beginning of phase 2

Falls are a cause of substantial morbidity and mortality in patients with dementia and occur at twice the rate of older adults without cognitive impairment. The consequences of falls in older adults with dementia are serious; fallers with cognitive problems are approximately five times as likely to be admitted to institutional care as people with cognitive problems who do not fall.\[3\] They are also at high risk of major fall-related injuries such as fractures and head injuries that increase mortality risk.

Walking requires paying attention to various environmental features and recovering from postural variations to avoid stumbles or falls. Consequently, deficits in attention and executive function are independently associated with risk of postural instability, impairment in activities of daily living, and fall risk.

Executive function refers to higher cognitive processes that allocate attention among tasks and a critical cognitive resource for normal walking. Lower scores on executive function measures are associated with both dementia and a higher fall risk. Although significant progress towards understanding the factors involved in falls has been made, the number of falls and fall related injuries continue to increase.

Changes in aging demographics are expected to dramatically increase the aging population and dementia prevalence, underscoring the importance of developing more effective fall prevention strategies.

Recent studies have shown that improving certain aspects of cognition, specifically attention and executive function, in older adults can improve mobility decline and risk of falls. Particularly in cognitively impaired individuals, this may be critical to reducing fall risk.

Why Methylphenidate?

Pharmacological properties of psychostimulants, such as methylphenidate (MPH), are known to increase executive function. Methylphenidate was chosen because of the studies demonstrating the safe use of MPH for treatment of depression and apathy in the cognitively impaired elderly and the well-studied effects of MPH on executive function and attention in children and adults with ADHD.

Also a small study published in April 2008 in J Am Geriatric Society, evaluated the use of methylphenidate in reducing fall risk among community living older adults. The study concluded that among study subjects receiving methylphenidate, significant improvement in mobility and gait assessments were observed as well as drug tolerability.

The basis for our study is to further explore the pharmacotherapeutic role of Transdermal-MPH in reducing fall risk in dementia patients.

Mobility and gait assessment performance is strongly correlated with fall risk. Therefore we will use subject's scores before, during and after medication administration to measure response and evaluate use as a fall prevention strategy.

Eligibility Criteria:
Inclusion Criteria:

1. 65- 95 years of age
2. Ability to ambulate (may use walking aid)
3. Male or Female
4. Clinical diagnosis of Dementia
5. Identified as fall risk by nursing staff

Exclusion Criteria:

1. Clinically significant musculoskeletal, cardiovascular or respiratory diseases.
2. Clinically significant vestibular disorder
3. History of significant head trauma
4. Any medically unstable condition, as determined by the PI that would expose patient to potential harm.
5. Patients taking medications that may interact with MPH, as determined by manufacture's package insert.

   Including but not limited to: Warfarin, anticonvulsants, MAOIs, alpha2-agonists, tri-cyclic antidepressants.
6. Legally Blind
7. History of seizures,
8. Poorly controlled hypertension, cardiac arrhythmia or cardiovascular disease, heart failure.
9. Known or suspected allergy to MPH or similar compounds
10. Glaucoma
11. Motor tics
12. History of significant agitation or anxiety
13. Family history of Tourette's syndrome
14. History of significant anxiety
15. History of significant agitation
16. History of significant tension.