Treatment of Psychosis and Agitation in Alzheimer's Disease

Symptoms of psychosis or agitation are common in Alzheimer's disease. These symptoms are associated with distress for the patient, an increased burden for caregivers, more rapid cognitive decline, greater risk of institutionalization and mortality, and increased health care costs. In a recent meta-analysis, caregiver education and behavior modification studies revealed a small to medium effect size in treating agitation in these patients. However, none of these studies were double-blind (difficult to achieve in such studies) and none had a control group that received the same amount of staff time as the intervention group, thereby biasing the results toward the active intervention.

Among the psychotropic medications that have been studied, only antipsychotics have shown superiority over placebo for the treatment of psychosis and agitation in patients with dementia.

However, most studies show only moderate superiority for antipsychotic over placebo and a few studies have been negative. The side effects of antipsychotic medications include sedation, extrapyramidal signs, tardive dyskinesia, weight gain, and the metabolic syndrome. A pooled analysis from 17 short-term trials showed that the mortality rate in patients with dementia receiving antipsychotic medications was 1.6 to 1.7 times as high (60-70% increase in mortality rate) as the mortality rate in patients receiving placebo. These findings led the FDA to issue a black-box warning for antipsychotic medication use in patients with dementia; a more recent meta-analysis reported a slightly lower odds ratio of 1.54 (54% increase in mortality rate).

Lithium has several different actions from anticonvulsants, though both are effective in bipolar disorder, especially mania. Lithium is not being proposed here to treat mania in AD though the investigators will monitor symptoms on the Young Mania Rating Scale. In patients with AD, lithium has been studied for its putative cognitive enhancing effects. A few reports suggest that chronic lithium use reduces the risk of dementia, but other data show increased dementia risk with lithium use. A placebo-controlled, single-blind lithium trial showed no cognitive effects in patients with AD, but a recent trial of lithium in 45 patients with mild cognitive impairment (MCI, which often leads to clinically diagnosable AD) showed a small advantage for lithium (n=24) over placebo (n=21) in attention and other cognitive domains. None of these studies with lithium were intended to treat psychosis or agitation in AD, and patients with these symptoms typically were excluded in these clinical trials.

There has been no systematic placebo-controlled trial of lithium to treat agitation/aggression with or without psychosis in AD even though lithium is a highly effective treatment for mania with psychosis and symptoms of agitation or aggression. Nonetheless, the published studies of lithium to treat cognitive decline in older patients show that low-dose lithium is safe in patients with MCI or AD.

Specific Aims and Hypotheses Specific Aim 1. To compare changes in agitation/aggression with or without psychosis in patients with AD who receive 12 weeks of randomized, double-blind treatment with lithium or placebo.

Primary Hypothesis. Over these 12 weeks, the agitation/aggression domain score on the Neuropsychiatric Inventory (NPI) will decrease significantly more on lithium than placebo.

Secondary Hypothesis. Over these 12 weeks, the proportion of responders on lithium will be significantly greater than the proportion of responders on placebo. Response is defined as a 30% decrease in NPI core score (defined as the sum of domains for agitation/aggression, delusions and hallucinations) plus a CGI Change score of much improved or very much improved (CGI based on these behavioral symptoms only). Exploratory hypothesis. Over these 12 weeks, the psychosis score, measured by the sum of the NPI domain scores for delusions and hallucinations, will decrease significantly more on lithium than placebo. Specific Aim 2. To evaluate the tolerability of low dose lithium by assessing emergent somatic side effects over the course of the 12-week trial on lithium compared to placebo. Specific Aim 3. To explore associations between improvement on lithium (decrease in agitation/aggression and psychosis scores) and serum brain-derived neurotrophic factor (BDNF) levels (baseline, 12 weeks), a SNP in intron 1 of the ACCN1 gene, and variation at the 7q11.2 gene locus, because these indices are associated with lithium response in bipolar disorder. The investigators do not postulate a specific mechanism of action for lithium in the investigators trial, but will evaluate these three potential predictors of lithium response with the aim of improving patient selection for personalized treatment. The investigators will examine BDNF serum levels as a biomarker correlate of lithium treatment by correlating change in BDNF levels with change in NPI agitation/aggression and psychosis scores.

• Lithium (Drug), also known as lithium carbonate
• Placebo (Drug)

Primary outcomes

• Change in Neuropsychiatric Inventory (NPI) Agitation/Aggression Domain Score [Assessed at screening, Week 0, Week 2, Week 4, Week 6, Week 8, Week 10, Week 12]: Neuropsychiatric Inventory (NPI) Agitation/Aggression Domain is the measure used that combines symptoms of agitation and aggression. Frequency X Severity rating score, range 0-12. Minimum score is 0, maximum score is 12. Higher score is a worse outcome and indicates more agitation and aggressive behavior.

Secondary outcomes

• Clinical Responder Defined as a 30% Decrease in NPI Core Score (Sum Score of NPI Domains of Agitation/Aggression, Delusions and Hallucinations) Together With a Clinical Global Impression (CGI) Behavior Change Score of 1 or 2 [Week 12]: The patient is classified as a responder (score=1) if both criteria are met or as a non-responder (score=0) if both criteria are not met. The first criterion to determine responder status, NPI core score, has a scoring range 0-36; each of the three component scores for symptoms of agitation/aggression, delusions and hallucinations has a scoring range 0-12. For each symptom and the total score, higher score indicates more symptoms. The second criterion to determine responder status, Clinical Global Impression (CGI), is used to assess change in overall behavior; scoring range 1-7 with higher scores indicating worsening over time and lower scores indicating improvement over time. Only patients who met both criteria, assessed as change compared to baseline, were counted as responders; all other patients were non-responders. Patients that demonstrated improvement at week 12 were reported; scores for earlier weeks were only used to assess progress throughout the study.
• Clinical Global Impression (CGI) Behavior Change [Week 12]: Clinical Global Impression (CGI) Behavior Change score is the measure used to assess change in overall behavior; scoring range 1-7 with higher scores indicating worsening over time and lower scores indicating improvement over time. Scores ranging from 1-3 indicate improvement. Only patients that demonstrated improvement at week 12 were reported; scores for earlier weeks were only used to assess progress throughout the study.
• Young Mania Rating Scale [Assessed at Week 0, Week 2, Week 4, Week 6, Week 8, Week 10, Week 12]: Young Mania Rating Scale total score is the measure used to assess symptoms that occur in mania; each item is a symptom that is rated for severity. Scoring range 0-60. Minimum score is 0 and maximum score is 60. Higher scores mean a worse outcome.
• Treatment Emergent Signs and Symptoms [Assessed at Week 0, Week 2, Week 4, Week 6, Week 8, Week 10, Week 12]: Treatment Emergent Symptom Scale that covers 26 somatic symptoms, each rated as present (score=1) or absent (score=0). Total score is the measure used with scoring range 0-26; higher scores indicate more somatic symptoms.
• Simpson-Angus Scale [Assessed at Week 0, Week 2, Week 4, Week 6, Week 8, Week 10, Week 12]: Simpson Angus Scale for Extrapyramidal Sign requires in-person examination to assess gait, arm dropping, shoulder shaking, elbow rigidity, wrist rigidity, leg pendulousness, head dropping, glabella tap, tremor, and salivation. Total score is the measure used, range 0-40; higher scores indicate increased severity of signs.
• Basic Activities of Daily Living (BADL) [Assessed at Week 0, Week2, Week 4, Week 6, Week 8, Week 10, Week 12]: Basic Activities of Daily Living with items for 6 functions: bathing, dressing, toileting, transferring, continence, and feeding. Each item is scored as unimpaired=1, impaired=0. Total score is the measure used, range 0-6; higher scores indicate better functioning.
• Zarit Caregiver Burden Interview [Assessed at Week 0, Week 4, Week 8, Week 10, Week 12]: Zarit Caregiver Burden Interview with the caregiver asked to rank 22 items on a scale with responses for each item from 'never' (score 0) to 'nearly always' (score 4). Total score is the measure used; range 0-88 with higher scores indicating greater caregiver burden.

Other outcomes

• Folstein Mini-Mental Status Exam [Assessed at Screening, Week 12]: 30 item questionnaire used to assess degree of cognitive impairment. Orientation, registration, attention/calculation, recall, language, repetitions and commands are assessed. Total score is the measure used; range 0-30, higher scores indicate better global cognitive function.
• Severe Impairment Battery [Assessed at Week 0, Week 12]: Neuropsychological test used to assess a patient's cognitive ability. The patient is asked to complete small tasks such as drawing shapes and printing their name. They are also asked to remember certain names and objects, such as a cup and a spoon, and the evaluator's first name. Total score is the measure used; range 0-100, higher scores indicate better cognition.

Sex: All

Inclusion Criteria:

1. Male and female adults.
2. Diagnosis of possible or probable AD by standard NIA criteria (McKahnn et al, 1984; McKhann et all, 2011)
3. Folstein MMSE 5-26 out of 30
4. Neuropsychiatric Inventory (NPI) agitation/aggression subscale score > 4. On each subscale (frequency X severity), a score higher than 4 represents moderate to severe symptoms.
5. Female patients need to be post-menopausal
6. Availability of informant; patients without an informant will not be recruited. Patients who lack capacity must have a surrogate.

Exclusion Criteria:

1. Medical contraindication to lithium treatment or prior history of intolerability to lithium treatment.

   Contraindications to lithium in this study include: resting tremor causing functional impairment, history of falls in the last month, untreated thyroid disease or any abnormal thyroid function test (T3, T4, or TSH), creatinine level greater than 1.5 mg/100ml or a glomerular filtration rate less than 44ml/min/ 1.73m2; blood pressure > 150/90 mm Hg; heart rate < 50 bpm; unstable cardiac disease based on history, physical examination, and ECG.
2. Medications, in combination with lithium, known to have adverse renal effects, including therapeutic or higher doses of diuretics, i.e. hydrochlorothiazide greater than 25mg daily or furosemide greater than 10mg daily. Whenever feasible, patients receiving concomitant antidepressants or antipsychotics will be washed off these medications for at least 24 hours before starting lithium. Patients who do not wish to discontinue antipsychotics or antidepressants, typically because of family member/caregiver objection, will be allowed to enter the trial provided there is no contraindication to concomitant lithium use with that specific psychotropic medication. During the trial, patients will be permitted to receive lorazepam as needed up to 1 mg/day for anxiety/insomnia, and non-benzodiazepine hypnotics, e.g., zolpidem.
3. Current clinical diagnosis of schizophrenia, schizoaffective disorder, other psychosis, or bipolar 1 disorder (DSM-IV TR criteria).
4. Current or recent (past 6 months) alcohol or substance dependence (DSM-IV TR criteria).
5. Current major depression or suicidality as assessed by the study psychiatrist.
6. Suicidal behavior or dangerous behavior with serious safety risk or risk of physical harm to self or others.
7. Parkinson's disease, Lewy body disease, multiple sclerosis, CNS infection, Huntington's disease, amyotrophic lateral sclerosis, other major neurological disorder.
8. Clinical stroke with residual neurological deficits. MRI findings of cerebrovascular disease (small infarcts, lacunes, periventricular disease) in the absence of clinical stroke with residual neurological deficits will not lead to exclusion.
9. Acute, severe, unstable medical illness. For cancer, patients with active illness or metastases will be excluded, but past history of successfully treated cancer will not lead to exclusion.
10. QTc interval > 460 ms at the time of baseline EKG is an exclusion criterion for treatment.
11. Hypernatremia as determined by serum sodium level > 150 meq/L.

Participant flow

Outcome results

• Change in Neuropsychiatric Inventory (NPI) Agitation/Aggression Domain Score (Primary), Least squares mean, score on a scale: Lithium Treatment Group 3.2 (1.7 to 4.6); Placebo Group 2.5 (1.1 to 4.0) (p 0.53)
• Clinical Responder Defined as a 30% Decrease in NPI Core Score (Sum Score of NPI Domains of Agitation/Aggression, Delusions and Hallucinations) Together With a Clinical Global Impression (CGI) Behavior Change Score of 1 or 2 (Secondary), Count of participants, Participants: Lithium Treatment Group 12; Placebo Group 7 (p 0.26)
• Clinical Global Impression (CGI) Behavior Change (Secondary), Count of participants, Participants: Lithium Treatment Group 12; Placebo Group 8 (p 0.25)
• Young Mania Rating Scale (Secondary), Least squares mean, score on a scale: Lithium Treatment Group 3.1 (0.9 to 5.3); Placebo Group 1.1 (-1.1 to 3.3) (p 0.21)
• Treatment Emergent Signs and Symptoms (Secondary), Least squares mean, score on a scale: Lithium Treatment Group 0.6 (-1.3 to 2.4); Placebo Group 0.7 (-1.1 to 2.5) (p 0.91)
• Simpson-Angus Scale (Secondary), Least squares mean, score on a scale: Lithium Treatment Group -0.0 (-1.1 to 1.0); Placebo Group 0.0 (-1.0 to 1.0) (p 0.94)
• Basic Activities of Daily Living (BADL) (Secondary), Least squares mean, score on a scale: Lithium Treatment Group 0.3 (-0.1 to 0.7); Placebo Group 0.1 (-0.3 to 0.6) (p 0.63)
• Zarit Caregiver Burden Interview (Secondary), Least squares mean, score on a scale: Lithium Treatment Group 2.8 (-1.1 to 6.6); Placebo Group -0.4 (-4.2 to 3.3) (p 0.24)
• Folstein Mini-Mental Status Exam (Other pre specified), Least squares mean, score on a scale: Lithium Treatment Group 0.9 (-0.3 to 2.2); Placebo Group 0.9 (-0.4 to 2.1) (p 0.96)
• Severe Impairment Battery (Other pre specified), Least squares mean, score on a scale: Lithium Treatment Group 2.1 (-1.1 to 5.4); Placebo Group -0.0 (-3.3 to 3.2) (p 0.35)

Adverse events

Time frame: 12 weeks.

Serious adverse events by term

Other adverse events by term

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• Results publication: Deliyannides DA, Graff JA, Nino I, Lee S, Husain MM, Forester BP, Crocco E, Vahia IV, Devanand DP. Effects of lithium on serum Brain-Derived Neurotrophic Factor in Alzheimer's patients with agitation. Int J Geriatr Psychiatry. 2023 Sep;38(9):e6002. doi: 10.1002/gps.6002. PMID 37732619
• Results publication: Devanand DP, Crocco E, Forester BP, Husain MM, Lee S, Vahia IV, Andrews H, Simon-Pearson L, Imran N, Luca L, Huey ED, Deliyannides DA, Pelton GH. Low Dose Lithium Treatment of Behavioral Complications in Alzheimer's Disease: Lit-AD Randomized Clinical Trial. Am J Geriatr Psychiatry. 2022 Jan;30(1):32-42. doi: 10.1016/j.jagp.2021.04.014. Epub 2021 May 12. PMID 34059401
• Results publication: Devanand DP, Strickler JG, Huey ED, Crocco E, Forester BP, Husain MM, Vahia IV, Andrews H, Wall MM, Pelton GH. Lithium Treatment for Agitation in Alzheimer's disease (Lit-AD): Clinical rationale and study design. Contemp Clin Trials. 2018 Aug;71:33-39. doi: 10.1016/j.cct.2018.05.019. Epub 2018 May 31. PMID 29859917

• Study Protocol (PDF, 2021-03-02)
• Statistical Analysis Plan (PDF, 2021-03-18)

• DP Devanand, MD, Principal investigator, Columbia University

NIH grants: R01AG047146