Clinical trial NCT01876823: Memantine Plus Es-citalopram in Elderly Depressed Patients With Cognitive Impairment
Official title: Effects of Combined Memantine (Namenda) Plus Escitalopram (Lexapro) Treatment in Elderly Depressed Patients With Cognitive Impairment
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: PHASE2
PHASE3
Conditions: Mild Cognitive Impairment
Major Depressive Disorder
Alzheimer's Disease
Keywords: Memory Decline
Depression
Elderly
Antidepressants
Treatment
memantine
Lead sponsor: New York State Psychiatric Institute
Sponsor class: OTHER
First posted: 2013-06-13
Enrollment: 60
Sex: ALL
Minimum age (years): 50
Maximum age (years): 90
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: NA
Intervention model: SINGLE_GROUP
Primary purpose: TREATMENT

Brief summary: Alzheimer's disease (AD), the most common dementing disorder of later life, is a major cause of disability and death in the elderly. Although a number of theoretical causes exist, the etiology of AD is still unknown. Consequently, the focus of treatments has been palliative, designed to ameliorate AD symptoms. Recent efforts, however, have revealed some surprising data suggesting that cholinesterase inhibitors (AchEIs), used over the last decade, and recently released memantine (an N-methyl-D-aspartate (NMDA) receptor antagonist), may confer protection to neurons. Thus, they may offer a slowing of cognitive decline and/or improvement in behavioral symptoms associated with memory impairment.

Over the last decade, it has been well documented that mild cognitive impairment (MCI) increases the risk of conversion to AD and that coincident depression and MCI (Dep-MCI) further increases the risk 2 to 3 fold. The primary focus of this line of investigation is to treat the very high risk to dement patient population with Dep-MCI, before they develop AD, in the hopes of delaying AD onset.

Memantine had not been studied in DEP-MCI patients. Since treatment of these patients with combined antidepressant and AChEIs has been associated with cognitive improvement in pilot studies, we explore whether treatment of DEP-MCI with memantine in addition to antidepressant treatment would benefit cognitive performance and lead to a low rate of conversion to dementia. We evaluate the cognitive and antidepressant benefit of combined open-label es-citalopram and memantine treatment over 48 weeks in a DEP-CI sample.

Detailed description: The study is conducted in a sample of 35 elderly (50-90 years old) outpatients who meet study inclusion criteria for depression (DEP) (DSM-IV criteria for major depression, dysthymic disorder, or depression NOS) and mild cognitive impairment (MCI; e.g. operationally defined as between "normal" and "dementia"), i.e., Dep-MCI. The research plan includes: i) Obtaining a baseline psychiatric and neuropsychological test profile, ii) If currently on an ineffective antidepressant, having a one week washout (3 weeks for fluoxetine), iii) A treatment trial beginning with a two-week es-citalopram lead-in period. At two weeks, memantine (Namenda) is added starting at 5 mg/day and increased until the maximum dose of 20 mg/day is reached by six weeks. The study psychiatrist administers: the 24-item Hamilton Depression Rating Scale (HAM-D); the Clinical Global Impression (CGI, 1-7 scale) initial severity and subsequent change ratings separately for depression, cognition, and overall clinical status; the Treatment Emergent Symptom Scale (TESS) for somatic side effects. A trained technician administers the neuropsychological battery at baseline, 12, 24 and 48 weeks. If the patient is an antidepressant non-responder during the first 12-weeks, the es-citalopram is changed to an alternative antidepressant, as clinically indicated by the treating psychiatrist. The patient remains on the memantine for the entire 48-weeks, irrespective of antidepressant response.

This will tell us about the efficacy and tolerability of es-citalopram+memantine on both cognitive and depressive symptoms in Dep-MCI patients and will potentially have broader public health implications because Dep-MCI is a wide-spread clinical problem where management needs to be improved.

Eligibility criteria: Inclusion Criteria:

1. Of either sex, age greater than 49 years old
2. Meets criteria for both "depression" and "cognitive impairment".
3. Study Criteria for "depression":

   i. Patients who meet DSM-IV criteria for Major Depression, Dysthymic Disorder, or Dysthymia symptoms criteria of minimum 6 month duration (not the 2 year DSM-IV criteria). ii. 24-item HAM-D greater than 13; and iii. Clinical Global Impression (CGI) for severity of Depression greater than 2 (absolute score at least mild to moderate depression on a 7-point scale)
4. Study Criteria for "cognitive deficit":

   i. Subjective memory complaint ii.Mini Mental Status Exam (MMSE) greater than 24; and at least one of a, b, or c:
   1. less than 3 on MMSE 5 min delay on recall
   2. scores on 2 neuropsychological tests greater than 1 Standard Deviation (SD) below standardized norms, or
   3. score on 1 neuropsychological tests greater than 2 SD below standardized norms.

   Neuropsychological tests for inclusion criteria (subset of larger battery):

   Selective Reminding Test with delay Wechsler Memory Scale (WMS): Visual Reproduction - with delay, % savings from immed to delay Controlled Oral Word Association Test Trails B Digit symbol subtest of Wechsler Adult Intelligence Scale (WAIS)-III Continuous Performance Test iii. CGI for severity of Cognitive deficit greater than 2 (absolute score on a 7-point scale:1=no deficit to 7=severe deficit). iv. Clinical Dementia Rating (CDR) = 0 or 0.5
5. Willing and capable of giving informed consent

Exclusion Criteria:

1. Meets Criteria for dementia (DSM-IV) or probable Alzheimer's disease by National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association criteria (NINCDS-ADRDA criteria)
2. Meets criteria for:

   1. schizophrenia
   2. alcohol or substance dependence or abuse within the last 6 months.
3. Suicidal attempt in last 6 months or current suicidal intent.
4. Patients currently on an effective antidepressant medication
5. Use of cholinesterase inhibitors in the last year.
6. Neurological disease including stroke, epilepsy, or other neurodegenerative disorders.
7. An acute, severe or unstable medical condition such as metastatic or active cancer, hepatic disease, or primary renal disease requiring dialysis.
8. Patients who can not tolerate being tapered off antidepressant medication (i.e. greater than a 25% incr. in baseline HAM-D) or has a history indicating patient is unlikely to tolerate psychotropic washout.
9. Patient with a history of non-response to Citalopram or es-citalopram

Primary outcomes:
measure: Change in Selective Reminding Test - Total Immediate Recall (SRT-IR)
timeFrame: baseline, 48 weeks
Secondary outcomes:
measure: Change in Wechsler Memory Scale-III (WMS-III)
timeFrame: Baseline, Week 48
measure: Change in Selective Reminding Test - Delayed Recall (SRT-DR)
timeFrame: Baseline, Week 48
measure: Change in Trails B
timeFrame: Baseline, Week 48
measure: Change in Trails A
timeFrame: Baseline, Week 48
Other outcomes:
measure: Change in 24-item HAMD
timeFrame: Baseline, Week 48
measure: Change in Treatment Emergent Side Effects (TESS)
timeFrame: Baseline, Week 48
measure: Change in Clinical Global Impression - Depression Change
timeFrame: Baseline, Week 48
measure: Change in Clinical Global Impression - Cognitive Change
timeFrame: Baseline, Week 48
measure: Conversion to Dementia Using Clinical Dementia Rating (CDR)
timeFrame: Baseline, Week 48
Locations:
city: New York
country: United States
facility: New York State Psychiatric Institute
state: New York
Study officials:
affiliation: New York State Psychiatric Institute
name: Gregory Pelton, M.D.
role: PRINCIPAL_INVESTIGATOR
affiliation: New York State Psychiatric Institute
name: Davangere Devanand, M.D.
role: STUDY_CHAIR
References:
citation: Alexopoulos GS, Meyers BS, Young RC, Mattis S, Kakuma T. The course of geriatric depression with "reversible dementia": a controlled study. Am J Psychiatry. 1993 Nov;150(11):1693-9. doi: 10.1176/ajp.150.11.1693.
citation: Atri A, Shaughnessy LW, Locascio JJ, Growdon JH. Long-term course and effectiveness of combination therapy in Alzheimer disease. Alzheimer Dis Assoc Disord. 2008 Jul-Sep;22(3):209-21. doi: 10.1097/WAD.0b013e31816653bc.
citation: Bakchine S, Loft H. Memantine treatment in patients with mild to moderate Alzheimer's disease: results of a randomised, double-blind, placebo-controlled 6-month study. J Alzheimers Dis. 2008 Feb;13(1):97-107. doi: 10.3233/jad-2008-13110.
citation: Barnes DE, Yaffe K, Byers AL, McCormick M, Schaefer C, Whitmer RA. Midlife vs late-life depressive symptoms and risk of dementia: differential effects for Alzheimer disease and vascular dementia. Arch Gen Psychiatry. 2012 May;69(5):493-8. doi: 10.1001/archgenpsychiatry.2011.1481.
citation: Bassuk SS, Berkman LF, Wypij D. Depressive symptomatology and incident cognitive decline in an elderly community sample. Arch Gen Psychiatry. 1998 Dec;55(12):1073-81. doi: 10.1001/archpsyc.55.12.1073.
citation: Boyle PA, Wilson RS, Aggarwal NT, Tang Y, Bennett DA. Mild cognitive impairment: risk of Alzheimer disease and rate of cognitive decline. Neurology. 2006 Aug 8;67(3):441-5. doi: 10.1212/01.wnl.0000228244.10416.20.
citation: Burt DB, Zembar MJ, Niederehe G. Depression and memory impairment: a meta-analysis of the association, its pattern, and specificity. Psychol Bull. 1995 Mar;117(2):285-305. doi: 10.1037/0033-2909.117.2.285.
citation: Charney DS, Reynolds CF 3rd, Lewis L, Lebowitz BD, Sunderland T, Alexopoulos GS, Blazer DG, Katz IR, Meyers BS, Arean PA, Borson S, Brown C, Bruce ML, Callahan CM, Charlson ME, Conwell Y, Cuthbert BN, Devanand DP, Gibson MJ, Gottlieb GL, Krishnan KR, Laden SK, Lyketsos CG, Mulsant BH, Niederehe G, Olin JT, Oslin DW, Pearson J, Persky T, Pollock BG, Raetzman S, Reynolds M, Salzman C, Schulz R, Schwenk TL, Scolnick E, Unutzer J, Weissman MM, Young RC; Depression and Bipolar Support Alliance. Depression and Bipolar Support Alliance consensus statement on the unmet needs in diagnosis and treatment of mood disorders in late life. Arch Gen Psychiatry. 2003 Jul;60(7):664-72. doi: 10.1001/archpsyc.60.7.664.
citation: Chen X, Magnotta VA, Duff K, Boles Ponto LL, Schultz SK. Donepezil effects on cerebral blood flow in older adults with mild cognitive deficits. J Neuropsychiatry Clin Neurosci. 2006 Spring;18(2):178-85. doi: 10.1176/jnp.2006.18.2.178.
citation: Culang ME, Sneed JR, Keilp JG, Rutherford BR, Pelton GH, Devanand DP, Roose SP. Change in cognitive functioning following acute antidepressant treatment in late-life depression. Am J Geriatr Psychiatry. 2009 Oct;17(10):881-8. doi: 10.1097/jgp.0b013e3181b4bf4a.
citation: Devanand DP, Liu X, Tabert MH, Pradhaban G, Cuasay K, Bell K, de Leon MJ, Doty RL, Stern Y, Pelton GH. Combining early markers strongly predicts conversion from mild cognitive impairment to Alzheimer's disease. Biol Psychiatry. 2008 Nov 15;64(10):871-9. doi: 10.1016/j.biopsych.2008.06.020. Epub 2008 Aug 23.
citation: Devanand DP, Pelton GH, Marston K, Camacho Y, Roose SP, Stern Y, Sackeim HA. Sertraline treatment of elderly patients with depression and cognitive impairment. Int J Geriatr Psychiatry. 2003 Feb;18(2):123-30. doi: 10.1002/gps.802.
citation: Devanand DP, Sano M, Tang MX, Taylor S, Gurland BJ, Wilder D, Stern Y, Mayeux R. Depressed mood and the incidence of Alzheimer's disease in the elderly living in the community. Arch Gen Psychiatry. 1996 Feb;53(2):175-82. doi: 10.1001/archpsyc.1996.01830020093011.
citation: Doody RS, Ferris SH, Salloway S, Sun Y, Goldman R, Watkins WE, Xu Y, Murthy AK. Donepezil treatment of patients with MCI: a 48-week randomized, placebo-controlled trial. Neurology. 2009 May 5;72(18):1555-61. doi: 10.1212/01.wnl.0000344650.95823.03. Epub 2009 Jan 28.
citation: Farrimond LE, Roberts E, McShane R. Memantine and cholinesterase inhibitor combination therapy for Alzheimer's disease: a systematic review. BMJ Open. 2012 Jun 11;2(3):e000917. doi: 10.1136/bmjopen-2012-000917. Print 2012.
citation: Feldman HH, Ferris S, Winblad B, Sfikas N, Mancione L, He Y, Tekin S, Burns A, Cummings J, del Ser T, Inzitari D, Orgogozo JM, Sauer H, Scheltens P, Scarpini E, Herrmann N, Farlow M, Potkin S, Charles HC, Fox NC, Lane R. Effect of rivastigmine on delay to diagnosis of Alzheimer's disease from mild cognitive impairment: the InDDEx study. Lancet Neurol. 2007 Jun;6(6):501-12. doi: 10.1016/S1474-4422(07)70109-6.
citation: Ferris S, Schneider L, Farmer M, Kay G, Crook T. A double-blind, placebo-controlled trial of memantine in age-associated memory impairment (memantine in AAMI). Int J Geriatr Psychiatry. 2007 May;22(5):448-55. doi: 10.1002/gps.1711.
citation: Fischer P, Jungwirth S, Zehetmayer S, Weissgram S, Hoenigschnabl S, Gelpi E, Krampla W, Tragl KH. Conversion from subtypes of mild cognitive impairment to Alzheimer dementia. Neurology. 2007 Jan 23;68(4):288-91. doi: 10.1212/01.wnl.0000252358.03285.9d.
citation: Gabryelewicz T, Styczynska M, Luczywek E, Barczak A, Pfeffer A, Androsiuk W, Chodakowska-Zebrowska M, Wasiak B, Peplonska B, Barcikowska M. The rate of conversion of mild cognitive impairment to dementia: predictive role of depression. Int J Geriatr Psychiatry. 2007 Jun;22(6):563-7. doi: 10.1002/gps.1716.
citation: Green RC, Cupples LA, Kurz A, Auerbach S, Go R, Sadovnick D, Duara R, Kukull WA, Chui H, Edeki T, Griffith PA, Friedland RP, Bachman D, Farrer L. Depression as a risk factor for Alzheimer disease: the MIRAGE Study. Arch Neurol. 2003 May;60(5):753-9. doi: 10.1001/archneur.60.5.753.
citation: Grober E, Lipton RB, Hall C, Crystal H. Memory impairment on free and cued selective reminding predicts dementia. Neurology. 2000 Feb 22;54(4):827-32. doi: 10.1212/wnl.54.4.827.
citation: Houde M, Bergman H, Whitehead V, Chertkow H. A predictive depression pattern in mild cognitive impairment. Int J Geriatr Psychiatry. 2008 Oct;23(10):1028-33. doi: 10.1002/gps.2028.
citation: Koontz J, Baskys A. Effects of galantamine on working memory and global functioning in patients with mild cognitive impairment: a double-blind placebo-controlled study. Am J Alzheimers Dis Other Demen. 2005 Sep-Oct;20(5):295-302. doi: 10.1177/153331750502000502.
citation: Lange KL, Bondi MW, Salmon DP, Galasko D, Delis DC, Thomas RG, Thal LJ. Decline in verbal memory during preclinical Alzheimer's disease: examination of the effect of APOE genotype. J Int Neuropsychol Soc. 2002 Nov;8(7):943-55. doi: 10.1017/s1355617702870096.
citation: Lopez OL, Becker JT, Wahed AS, Saxton J, Sweet RA, Wolk DA, Klunk W, Dekosky ST. Long-term effects of the concomitant use of memantine with cholinesterase inhibition in Alzheimer disease. J Neurol Neurosurg Psychiatry. 2009 Jun;80(6):600-7. doi: 10.1136/jnnp.2008.158964. Epub 2009 Feb 9.
citation: Lu PH, Edland SD, Teng E, Tingus K, Petersen RC, Cummings JL; Alzheimer's Disease Cooperative Study Group. Donepezil delays progression to AD in MCI subjects with depressive symptoms. Neurology. 2009 Jun 16;72(24):2115-21. doi: 10.1212/WNL.0b013e3181aa52d3.
citation: Manly JJ, Tang MX, Schupf N, Stern Y, Vonsattel JP, Mayeux R. Frequency and course of mild cognitive impairment in a multiethnic community. Ann Neurol. 2008 Apr;63(4):494-506. doi: 10.1002/ana.21326.
citation: McShane R, Areosa Sastre A, Minakaran N. Memantine for dementia. Cochrane Database Syst Rev. 2006 Apr 19;(2):CD003154. doi: 10.1002/14651858.CD003154.pub5.
citation: Modrego PJ, Ferrandez J. Depression in patients with mild cognitive impairment increases the risk of developing dementia of Alzheimer type: a prospective cohort study. Arch Neurol. 2004 Aug;61(8):1290-3. doi: 10.1001/archneur.61.8.1290.
citation: Morris JC, Storandt M, Miller JP, McKeel DW, Price JL, Rubin EH, Berg L. Mild cognitive impairment represents early-stage Alzheimer disease. Arch Neurol. 2001 Mar;58(3):397-405. doi: 10.1001/archneur.58.3.397.
citation: Nyakas C, Granic I, Halmy LG, Banerjee P, Luiten PG. The basal forebrain cholinergic system in aging and dementia. Rescuing cholinergic neurons from neurotoxic amyloid-beta42 with memantine. Behav Brain Res. 2011 Aug 10;221(2):594-603. doi: 10.1016/j.bbr.2010.05.033. Epub 2010 May 27.
citation: Ownby RL, Crocco E, Acevedo A, John V, Loewenstein D. Depression and risk for Alzheimer disease: systematic review, meta-analysis, and metaregression analysis. Arch Gen Psychiatry. 2006 May;63(5):530-8. doi: 10.1001/archpsyc.63.5.530.
citation: Palmer K, Di Iulio F, Varsi AE, Gianni W, Sancesario G, Caltagirone C, Spalletta G. Neuropsychiatric predictors of progression from amnestic-mild cognitive impairment to Alzheimer's disease: the role of depression and apathy. J Alzheimers Dis. 2010;20(1):175-83. doi: 10.3233/JAD-2010-1352.
citation: Pelton GH, Harper OL, Tabert MH, Sackeim HA, Scarmeas N, Roose SP, Devanand DP. Randomized double-blind placebo-controlled donepezil augmentation in antidepressant-treated elderly patients with depression and cognitive impairment: a pilot study. Int J Geriatr Psychiatry. 2008 Jul;23(7):670-6. doi: 10.1002/gps.1958.
citation: Peskind ER, Potkin SG, Pomara N, Ott BR, Graham SM, Olin JT, McDonald S. Memantine treatment in mild to moderate Alzheimer disease: a 24-week randomized, controlled trial. Am J Geriatr Psychiatry. 2006 Aug;14(8):704-15. doi: 10.1097/01.JGP.0000224350.82719.83.
citation: Petersen RC, Smith GE, Waring SC, Ivnik RJ, Tangalos EG, Kokmen E. Mild cognitive impairment: clinical characterization and outcome. Arch Neurol. 1999 Mar;56(3):303-8. doi: 10.1001/archneur.56.3.303.
citation: Petersen RC, Thomas RG, Grundman M, Bennett D, Doody R, Ferris S, Galasko D, Jin S, Kaye J, Levey A, Pfeiffer E, Sano M, van Dyck CH, Thal LJ; Alzheimer's Disease Cooperative Study Group. Vitamin E and donepezil for the treatment of mild cognitive impairment. N Engl J Med. 2005 Jun 9;352(23):2379-88. doi: 10.1056/NEJMoa050151. Epub 2005 Apr 13.
citation: Porsteinsson AP, Grossberg GT, Mintzer J, Olin JT; Memantine MEM-MD-12 Study Group. Memantine treatment in patients with mild to moderate Alzheimer's disease already receiving a cholinesterase inhibitor: a randomized, double-blind, placebo-controlled trial. Curr Alzheimer Res. 2008 Feb;5(1):83-9. doi: 10.2174/156720508783884576.
citation: Ramakers IH, Visser PJ, Aalten P, Kester A, Jolles J, Verhey FR. Affective symptoms as predictors of Alzheimer's disease in subjects with mild cognitive impairment: a 10-year follow-up study. Psychol Med. 2010 Jul;40(7):1193-201. doi: 10.1017/S0033291709991577. Epub 2009 Nov 11.
citation: Reisberg B, Doody R, Stoffler A, Schmitt F, Ferris S, Mobius HJ; Memantine Study Group. Memantine in moderate-to-severe Alzheimer's disease. N Engl J Med. 2003 Apr 3;348(14):1333-41. doi: 10.1056/NEJMoa013128.
citation: Reynolds CF 3rd, Butters MA, Lopez O, Pollock BG, Dew MA, Mulsant BH, Lenze EJ, Holm M, Rogers JC, Mazumdar S, Houck PR, Begley A, Anderson S, Karp JF, Miller MD, Whyte EM, Stack J, Gildengers A, Szanto K, Bensasi S, Kaufer DI, Kamboh MI, DeKosky ST. Maintenance treatment of depression in old age: a randomized, double-blind, placebo-controlled evaluation of the efficacy and safety of donepezil combined with antidepressant pharmacotherapy. Arch Gen Psychiatry. 2011 Jan;68(1):51-60. doi: 10.1001/archgenpsychiatry.2010.184.
citation: Ritchie K, Artero S, Touchon J. Classification criteria for mild cognitive impairment: a population-based validation study. Neurology. 2001 Jan 9;56(1):37-42. doi: 10.1212/wnl.56.1.37.
citation: Sachs-Ericsson N, Corsentino E, Moxley J, Hames JL, Rushing NC, Sawyer K, Joiner T, Selby EA, Zarit S, Gotlib IH, Steffens DC. A longitudinal study of differences in late- and early-onset geriatric depression: depressive symptoms and psychosocial, cognitive, and neurological functioning. Aging Ment Health. 2013;17(1):1-11. doi: 10.1080/13607863.2012.717253. Epub 2012 Aug 30.
citation: Salloway S, Ferris S, Kluger A, Goldman R, Griesing T, Kumar D, Richardson S; Donepezil 401 Study Group. Efficacy of donepezil in mild cognitive impairment: a randomized placebo-controlled trial. Neurology. 2004 Aug 24;63(4):651-7. doi: 10.1212/01.wnl.0000134664.80320.92.
citation: Steffens DC, Potter GG. Geriatric depression and cognitive impairment. Psychol Med. 2008 Feb;38(2):163-75. doi: 10.1017/S003329170700102X. Epub 2007 Jun 22.
citation: Wilson RS, Barnes LL, Mendes de Leon CF, Aggarwal NT, Schneider JS, Bach J, Pilat J, Beckett LA, Arnold SE, Evans DA, Bennett DA. Depressive symptoms, cognitive decline, and risk of AD in older persons. Neurology. 2002 Aug 13;59(3):364-70. doi: 10.1212/wnl.59.3.364.
citation: Winblad B, Gauthier S, Scinto L, Feldman H, Wilcock GK, Truyen L, Mayorga AJ, Wang D, Brashear HR, Nye JS; GAL-INT-11/18 Study Group. Safety and efficacy of galantamine in subjects with mild cognitive impairment. Neurology. 2008 May 27;70(22):2024-35. doi: 10.1212/01.wnl.0000303815.69777.26. Epub 2008 Mar 5.
citation: Zarate CA Jr, Singh JB, Quiroz JA, De Jesus G, Denicoff KK, Luckenbaugh DA, Manji HK, Charney DS. A double-blind, placebo-controlled study of memantine in the treatment of major depression. Am J Psychiatry. 2006 Jan;163(1):153-5. doi: 10.1176/appi.ajp.163.1.153.
citation: Pelton GH, Harper OL, Roose SP, Marder K, D'Antonio K, Devanand DP. Combined treatment with memantine/es-citalopram for older depressed patients with cognitive impairment: a pilot study. Int J Geriatr Psychiatry. 2016 Jun;31(6):648-55. doi: 10.1002/gps.4375. Epub 2015 Nov 11.