Intervention for Cognitive Reserve Enhancement in Delaying the Onset of Alzheimer's Symptomatic Expression (INCREASE) Study: Results from a Randomized Controlled Study of Medication Therapy Management Targeting a Delay in Prodromal Dementia Symptom Progression

Abstract

Background: Cognitive reserve has been hypothesized as a mechanism to explain differences in individual risk for symptomatic expression of Alzheimer's Disease (AD). Inappropriate medications may diminish cognitive reserve, precipitating the transition from preclinical AD (pAD) to a symptomatic state. To date, there is limited data on the potential impact of medication optimization as a potential tool for slowing the symptomatic expression of AD.

Objectives: (1) To test the efficacy of a medication therapy management intervention designed to bolster cognitive reserve in community-dwelling older adults without dementia. (2) To evaluate the efficacy of intervention by baseline pAD status.

Design: A 1-year randomized controlled trial was conducted in community-dwelling older adults without dementia. Randomization was stratified by amyloid β positron emission tomography levels.

Setting: Community-based, Lexington, Kentucky.

Participants: Adults 65 years or older with no evidence of dementia and reporting at least one potentially inappropriate medication as listed in the Beers 2015 criteria were recruited. The study aimed to enroll 90 participants based on the a priori sample size calculation.

Intervention: Medication therapy management versus standard of care.

Measurements: Primary outcomes were: (1) one-year changes in the Medication Appropriateness Index; (2) one-year changes in Trail Making Test B under scopolamine challenge.

Results: The medication therapy management intervention resulted in significant improvement in Medication Appropriateness Index scores. Overall, there was no beneficial effect of the medication therapy management on Trail Making Test B scores, however stratified analysis demonstrated improvement in Trail Making Test B challenged scores associated with the medication therapy management for those with elevated amyloid β positron emission tomography levels consistent with pAD.

Conclusions: Medication therapy management can reduce inappropriate medication use in older adults at risk for AD. Our study indicated beneficial cognitive effects in those with preclinical Alzheimer's Disease. No statistically significant effects were evident in the study group as a whole, or in those without preclinical cerebral amyloidosis. Further work designed to improve the effectiveness of the medication therapy management approach and defining other preclinical pathologic states that may benefit from medication optimization are readily achievable goals for promoting improved cognitive health and potentially delaying the onset of symptomatic AD.

Keywords: Beers criteria; Medication therapy management; cognitive reserve; deprescribing; randomized controlled trial.

Figures

Figure 1

Study Procedures and Timeline *follow-up visits conducted via telephone; ECG= electrocardiogram; Aβ-PET= amyloid beta positron emission tomography; Screening and baseline testing were completed prior to randomization and intervention. Challenged testing always preceded unchallenged testing by 4 weeks to limit learning effects that would be maximized in an unchallenged state. The intervention was reinforced at 3-month intervals over the one-year study period.

Figure 2

INCREASE Study Intervention Guiding Principles *Physician or Advanced Practice Provider; Optimal medication therapy management requires an interdisciplinary approach partnering the patient with a physician and pharmacist team that takes into consideration and values patient needs and preferences.

Figure 3

INCREASE Flow Diagram