Withdrawal of Antidementia Drugs in Advanced Dementia (WADAD) (WADAD)

Withdrawal of Antidementia Drugs in Advanced Dementia (WADAD): a Randomized Clinical Trial and Cost-utility Analysis

Dementia is a chronic progressive mental disorder that adversely affects higher cortical functions, including cognition and behavior leading up to disability and dependence in daily life activities. It has become a major public health concern because of its increasing prevalence, chronicity, burden for caregivers, and the high personal and financial costs needed for care. Alzheimer disease (AD) is the most prevalent form of dementia, occurring in 5% to 7% of individuals older than 60. In Portugal, Santana et al study estimated that 160 287 people above 60 years had a diagnosis of dementia in 2013 (prevalence of 5,9%).The increasing national and international prevalence of dementia and its associated burden then imparts a high priority on delivering safe and effective treatment options.

Currently approved treatments available for the symptomatic management of mild to moderate AD include cholinesterase inhibitors (ChEIs) (donepezil, rivastigmine, and galantamine) and a N-methyl- D-aspartate receptor antagonist (memantine). These drugs are also given off-label for other types of dementia (vascular and mixed dementias), with treatment continuing through advanced disease stages. Given that ChEIs have demonstrated short-term modest stabilization on measures of cognition and global functioning in randomized controlled trials (RCTs), several practice guidelines have proposed ChEIs for the treatment of all stages of AD, with some advocating ChEI discontinuation if tolerability issues arise, or if there is no longer a noticeable clinical benefit. Further studies in this setting are important as patients with severe dementia are more functionally impaired, present with comorbid illnesses, posing a higher risk of polypharmacy. In addition, ChEIs have a potential risk of adverse events including nausea, diarrhea, insomnia, vomiting, muscle cramping, fatigue, and weight loss. Less commonly, ChEI might be associated with rhabdomyolysis, convulsions, falls, syncope, pneumonia and death. Because cognitive and behavioral impairments change during the progressive disease course, the effects of medications may be unpredictable, especially over long durations of treatment. It might be challenging to weigh minimally beneficial effects against predicted harms of continued treatment, considering both patient and caregiver-centered care goals besides less clinically relevant cognitive outcomes.

Only a small number of discontinuation RCTs were conducted to date but involved relatively few participants with heterogeneous designs, disease severities and outcomes. As so, clinicians take individualized discontinuation decisions and the only consensual domains are a lack of response and a loss of effectiveness. The present pragmatic clinical trial will compare the efficacy of maintaining pharmacological treatment versus treatment cessation on cognition, behavior, functional disability and quality of life of patients and caregivers, among patients with severe dementia due to AD, with or without small vessel subcortical vascular disease. The investigators will consider other important endpoints besides cognitive functioning including mood, apathy, energy and neuropsychiatric symptoms. Moreover, this trial will try to look for outcomes that engage patients and families in treatment decisions.

Study Overview

• Status: Completed
• Conditions: Dementia
• Intervention / Treatment: Other: Treatment withdrawal

Detailed Description

Specific aim 1. Explore the effects of discontinuing ChEI and/or memantine on global impression, disease severity, function, behavior and cognitive outcomes;

Hypothesis:

1. Progression to disability (defined as a loss of 2 of 4 basic functions, or 6 of 11 instrumental functions, according to the BADLS), at 6 months, is significantly higher in patients discontinuing therapy;
2. Patients with severe dementia who discontinue ChEI and/or memantine show a significantly higher decline on ratings of cognitive function, behavior and activities of daily living over 6 months than those continuing these drugs;
3. Patients with severe dementia who discontinue ChEI and/or memantine experience increased adverse events including healthcare visits and other several medical intercurrences.

Specific aim 2. Explore the effects of discontinuation strategies in patients and caregiver's health related quality of life.

Hypothesis:

a) Patients with severe dementia and their caregivers experience lower levels of health-related quality of life after treatment discontinuation.

Specific aim 3. Cost-utility and cost-effectiveness analysis of a discontinuation strategy.

a) Treatment with antidementia drugs is the most cost-effective treatment strategy in advanced stages of dementia, delaying progression to disability and reducing formal and informal costs and healthcare utilization;

a) Treatment with antidementia drugs is the strategy associated with better quality of life and lower cost-utility ratio.

• Study Type: Interventional
• Enrollment (Actual): 16
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Portugal
  • Porto, Portugal, 4200-319
    • Centro Hospitalar Universitario de Sao Joao

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child; Adult; Older Adult
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

1. Diagnosis of dementia syndrome defined by clinical criteria (Alzheimer's dementia according to NIA-AA 2011 criteria, vascular dementia or mixed dementia)
2. MMSE≤15
3. Medicated with oral/transdermal patch anti-dementia (donepezil, rivastigmine, galantamine or memantine), alone or in combination, for a minimum period of 3 months;
4. Availability of a designated caregiver who monitors the patient's clinical situation and can collaborate in the assessment of outcomes and the provision of informed consent (ideally 8/h at least 3x/week)
5. Shared perception between the attending neurologist and family members that the drug may no longer have a therapeutic effect, has been ineffective after a therapeutic trial, or the presence of side effects possibly attributed to the drugs.

Exclusion Criteria:

1. Life expectancy presumably less than the follow-up period (6 months);
2. Unstable medical or surgical condition that can significantly interfere with the patient's overall health status;
3. Another pathology interfering with cognitive functioning (HIV, brain tumor, encephalitis, demyelinating disease);
4. Introduction of an antipsychotic drug in the last month.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Treatment withdrawal; discontinuation of treatment (anti-cholinesterase inhibitors including donepezil, rivastigmine and galantamine; and/or memantine)	Other: Treatment withdrawal; Tapering or suspension of antidementia drugs
No Intervention: Treatment continuation; treatment continuation (anti-cholinesterase inhibitors including donepezil, rivastigmine and galantamine; and/or memantine)

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
BADLS (Bristol Activities of Daily Living Scale)	Progression to disability (defined as a loss of 2 of 4 basic functions, or 6 of 11 instrumental functions); total score varies from 0 (totally independent) to 60 (totally dependent)	6 months
Quality of life of patients and caregivers	EuroQol-5D (EQ-5D); score varies from 0 to 100 using a Visual analogue scale	6 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Mortality		6 months
Neuropsychiatric inventory (NPI)	NPI (0-144), higher scores indicating worse behavior	6 months
General Health Questionnaire 12 (caregivers)	score ranges from 0 to 12, with higher scores indicating increased psychological symptoms	6 months
Clinical Global Impression of Change plus Caregiver Input (CGIC-Plus)	The score ranges from 1 (much better) to 7 (much worse), with 4 indicating no change	6 months
Serious adverse events	Inpatient admission, emergency visits, antibiotic prescription, seizures, falls	6 months

Collaborators and Investigators

• Sponsor: Centro Hospitalar De São João, E.P.E.
• Investigators: Principal Investigator: Verónica R Cabreira, MD, Centro Hospitalar São João (Neurology Department)

Study record dates

Study Major Dates

• Study Start (Actual): March 1, 2021
• Primary Completion (Actual): December 1, 2021
• Study Completion (Actual): March 20, 2022

Study Registration Dates

• First Submitted: March 23, 2022
• First Submitted That Met QC Criteria: April 4, 2022
• First Posted (Actual): April 11, 2022

Study Record Updates

• Last Update Posted (Actual): April 11, 2022
• Last Update Submitted That Met QC Criteria: April 4, 2022
• Last Verified: April 1, 2022

More Information

Terms related to this study

• Keywords: dementia; quality of life; cost-utility analysis; antidementia drug
• Additional Relevant MeSH Terms: Mental Disorders; Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Neurocognitive Disorders; Dementia
• Other Study ID Numbers: 68-21

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: Undecided
• IPD Plan Description: Upon request Supplementary data may be published along with study results.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No