Cognitive effects and acceptability of non-invasive brain stimulation on Alzheimer's disease and mild cognitive impairment: a component network meta-analysis

Che-Sheng Chu, Cheng-Ta Li, Andre R Brunoni, Fu-Chi Yang, Ping-Tao Tseng, Yu-Kang Tu, Brendon Stubbs, André F Carvalho, Trevor Thompson, Tarek K Rajji, Ta-Chuan Yeh, Chia-Kuang Tsai, Tien-Yu Chen, Dian-Jeng Li, Chih-Wei Hsu, Yi-Cheng Wu, Chia-Ling Yu, Chih-Sung Liang, Che-Sheng Chu, Cheng-Ta Li, Andre R Brunoni, Fu-Chi Yang, Ping-Tao Tseng, Yu-Kang Tu, Brendon Stubbs, André F Carvalho, Trevor Thompson, Tarek K Rajji, Ta-Chuan Yeh, Chia-Kuang Tsai, Tien-Yu Chen, Dian-Jeng Li, Chih-Wei Hsu, Yi-Cheng Wu, Chia-Ling Yu, Chih-Sung Liang

Abstract

Objectives: To compare cognitive effects and acceptability of repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) in patients with Alzheimer's disease (AD) or mild cognitive impairment (MCI), and to determine whether cognitive training (CT) during rTMS or tDCS provides additional benefits.

Methods: Electronic search of PubMed, Medline, Embase, the Cochrane Library and PsycINFO up to 5 March 2020. We enrolled double-blind, randomised controlled trials (RCTs). The primary outcomes were acceptability and pre-post treatment changes in general cognition measured by Mini-Mental State Examination, and the secondary outcomes were memory function, verbal fluency, working memory and executive function. Durability of cognitive benefits (1, 2 and ≥3 months) after brain stimulation was examined.

Results: We included 27 RCTs (n=1070), and the treatment components included high-frequency rTMS (HFrTMS) and low-frequency rTMS, anodal tDCS (atDCS) and cathodal tDCS (ctDCS), CT, sham CT and sham brain stimulation. Risk of bias of evidence in each domain was low (range: 0%-11.1%). HFrTMS (1.08, 9, 0.35-1.80) and atDCS (0.56, 0.03-1.09) had short-term positive effects on general cognition. CT might be associated with negative effects on general cognition (-0.79, -2.06 to 0.48) during rTMS or tDCS. At 1-month follow-up, HFrTMS (1.65, 0.77-2.54) and ctDCS (2.57, 0.20-4.95) exhibited larger therapeutic responses. Separate analysis of populations with pure AD and MCI revealed positive effects only in individuals with AD. rTMS and tDCS were well tolerated.

Conclusions: HFrTMS is more effective than atDCS for improving global cognition, and patients with AD may have better responses to rTMS and tDCS than MCI.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
(A) Network of eligible comparisons for general cognition: short-term effects. (B) Network of eligible comparisons for general cognition: long-lasting effects after 1 month. atDCS, anodal transcranial direct current stimulation; ctDCS, cathodal transcranial direct current stimulation; HFrTMS, high-frequency repetitive transcranial magnetic stimulation; LFrTMS, low-frequency repetitive transcranial magnetic stimulation; sham_BS, sham brain stimulation; sham_CT, sham cognitive training.
Figure 2
Figure 2
(A) Forest plot of NMA of changes of general cognition: short-term effects. (B) Forest plot of NMA of changes of general cognition: long-lasting effects after 1 month. atDCS, anodal transcranial direct current stimulation; BS, brain stimulation; CT, cognitive training; ctDCS, cathodal transcranial direct current stimulation; HFrTMS, high-frequency repetitive transcranial magnetic stimulation; LFrTMS, low-frequency repetitive transcranial magnetic stimulation; LL, lower limit; MD, mean difference; MMSE, Mini-Mental State Examination; NMA, network meta-analysis; UL, upper limit.
Figure 3
Figure 3
(A) Forest plot of NMA of changes of memory function: short-term effects. (B) Forest plot of NMA of changes of memory function: long-lasting effects after 1 month. atDCS, anodal transcranial direct current stimulation; BS, brain stimulation; CT, cognitive training; ctDCS, cathodal transcranial direct current stimulation; HFrTMS, high-frequency repetitive transcranial magnetic stimulation; NMA, network meta-analysis; SMD, standardised mean difference.
Figure 4
Figure 4
(A) Forest plot of NMA of changes of verbal fluency: short-term effects. (B) Forest plot of NMA of changes of verbal fluency: long-lasting effects after 1 month. atDCS, anodal transcranial direct current stimulation; BS, brain stimulation; CT, cognitive training; ctDCS, cathodal transcranial direct current stimulation; HFrTMS, high-frequency repetitive transcranial magnetic stimulation; LL, lower limit; NMA, network meta-analysis; SMD, standardised mean difference; UL, upper limit.
Figure 5
Figure 5
(A) Forest plot of NMA of changes of working memory: short-term effects. (B) Forest plot of NMA of changes of working memory: long-lasting effects after 1 month. atDCS, anodal transcranial direct current stimulation; BS, brain stimulation; CT, cognitive training; ctDCS, cathodal transcranial direct current stimulation; HFrTMS, high-frequency repetitive transcranial magnetic stimulation; LL, lower limit; NMA, network meta-analysis; SMD, standardised mean difference; UL, upper limit.
Figure 6
Figure 6
NMA estimates and SUCRA values. BS, brain stimulation; CT, cognitive training; HFrTMS, high-frequency repetitive transcranial magnetic stimulation; LFrTMS, low-frequency repetitive transcranial magnetic stimulation; NMA, network meta-analysis; SUCRA, surface under the cumulative ranking curve; tDCS, transcranial direct current stimulation.

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