ORIGINAL RESEARCH
Rivastigmine in Chinese patients with subcortical
vascular dementia
Vincent Mok 1
Adrian Wong 1
Simon Ho 2
Thomas Leung 1
Wynnie WM Lam 2
Ka Sing Wong 1
Department of Medicine and Therapeutics; 2Department of Radiology
and Organ Imaging, The Chinese
University of Hong Kong, Shatin,
Hong Kong, China
1
Background: We explored the efficacy and tolerability of rivastigmine among Chinese patients
with subcortical vascular dementia.
Methods: Forty subjects were randomized to either placebo (n = 20) or rivastigmine (n = 20)
in a double-blind 26-week trial. Outcome measures were cognition (mini-mental state examination, frontal assessment battery), neuropsychiatric inventory (NPI), instrumental activities of
daily living, clinical dementia rating scale, and adverse events.
Results: No statistical significant benefit could be observed in the active group in any of the
efficacy measures. A trend favoring active group was observed only in the NPI subscore of
irritability (p = 0.066) and aberrant motor behavior (p = 0.068). Withdrawal rate was 30% and
15% in the active and placebo group, respectively.
Conclusion: Among Chinese subcortical vascular dementia patients, there was no apparent
cognitive benefit associated with use of rivastigmine over the 6 months period. A trend favoring
rivastigmine was observed in certain behavioral measures. Rivastigmine was associated with
more withdrawals relative to placebo.
Keywords: rivastigmine, subcortical vascular dementia, Chinese
Introduction
Correspondence:Vincent Mok
Division of Neurology, Department
of Medicine and Therapeutics, The
Chinese University of Hong Kong, Shatin,
Hong Kong, China
Tel +852 2632 2195
Fax +852 2637 3852
Email vctmok@cuhk.edu.hk
Subcortical vascular dementia is the commonest subtype of vascular dementia (Ikeda
et al 2001). Its underlying vascular pathology is small vessel disease (Erkinjuntti et al
2000). Apart from memory problems, which may be mild, the dementia syndrome
commonly includes prominent executive dysfunction. Behavioral changes are frequent
in subcortical vascular dementia and are present regardless of the severity of cognitive impairment (Aharon-Peretz et al 2000).Other clinical features may include gait
disturbance, parkinsonism, and urinary incontinence.
Although acetylcholinesterase inhibitor has been shown to be effective in Alzheimer’s
disease, its effects upon subcortical vascular dementia remain controversial. Donepezil
was found to be effective in vascular dementia in terms of cognition and daily functions
in 2 randomized controlled studies (Black et al 2003; Wilkinson et al 2003). However,
subgroup analyses showed that it was less effective in subcortical type relative to cortical type of vascular dementia (Salloway 2003). Furthermore, its effects on behavioral
measures had not been explored. Results from 2 randomized studies on galantamine
suggest that it was effective mainly for mixed dementia rather than for probable
vascular dementia (Craig and Birks 2006). A third acetylcholinesterase inhibitor,
rivastigmine, was shown by open labeled studies to be effective among Caucasians
with subcortical vascular dementia in improving cognition, functions, and behavioral
symptoms (Moretti et al 2002, 2003).
Currently, China has the highest number of people with dementia (5 million) and
the growth in dementia was estimated to be more than 300% over the next 40 years
(Ferri et al 2005). Vascular dementia accounts for almost a third of dementia cases
Neuropsychiatric Disease and Treatment 2007:3(6) 943–948
© 2007 Mok et al, publisher and licensee Dove Medical Press Ltd. This is an Open Access article
which permits unrestricted noncommercial use, provided the original work is properly cited.
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Mok et al
(Chiu et al 1998) and a third of the Chinese dementia patients
are illiterate (Zhang et al 2005). Despite its high prevalence,
clinical studies for vascular dementia among Chinese are
scarce (Jirong et al 2004). Since most international clinical
trials included only literate subjects who were able to perform detailed psychometric tests, many demented Chinese
patients would not be eligible for participation to such trials
due to their illiteracy. To date, effects of acetylcholinesterase
inhibitor among Chinese patients with subcortical vascular
dementia are largely unknown. We thus performed a pilot
randomized double-blind placebo-controlled study exploring
the efficacy and tolerability of rivastigmine among Chinese
patients with subcortical vascular dementia. We used simple
validated Chinese version of psychometric tests and questionnaires that allowed participation of subjects who were
illiterate as well.
Materials and methods
Patients
Chinese patients with subcortical vascular dementia of
age between 40 to 90 years old and had mini-mental state
examination (MMSE) score between 3 and 24 were potentially eligible for the study. Patients were recruited from our
neurology clinic. We used standardized diagnostic criteria
to define subcortical vascular dementia (Erkinjuntti et al
2000). In brief, these criteria include all of the following:
(1) cognitive syndrome including both dysexecutive
syndrome and memory deficit that indicate deterioration from
a previous higher level of functioning, and are interfering
with complex (executive) occupational and social activities
not due to physical effects of cerebrovascular disease alone;
and (2) cerebrovascular disease including both evidence
of relevant cerebrovascular disease by brain imaging and
presence or a history of neurological signs such as hemiparesis, sensory deficit, gait disorder, or extrapyrimidal sings
consistent with subcortical brain lesions. We also used the
brain imaging criteria as described by Erkinjuntti et al (2000).
for computerized tomography (CT) or magnetic resonance
imaging (MRI). In brief, patients with extensive white matter
lesion and at least 1 lacune on CT and extensive white matter lesion with at least 1 lacune, or multiple lacunes with at
least moderate white matter lesion on MRI were eligible for
the study. All the subjects had either cerebral CT (65%) or
MRI (35%). A radiologist (SH) reviewed the neuroimaging
films of all potential subjects. Patients were excluded from
the study if they had known other concurrent dementing
diseases (eg, B12 deficiency), unstable medical conditions,
stroke within 3 months of study, concurrent use of cholinergic
944
drugs, frequent change in dose of centrally acting drugs (eg,
benzodiazepines) 3 months prior to entry of study, severe
dementia or language problems making participation in
cognitive testing impossible, and no closed caregivers as
defined by less than 3 visits per week. The Clinical Research
Ethics Committee of the Chinese University of Hong Kong
approved the study protocol. All patients and their carers
gave their written consents for the study.
Study design
The study was a 26-week, double-blind, placebo-controlled,
single-center study in which treatment with 6 mg daily of
rivastigmine or placebo was evaluated. It was conducted at
an university affilitated hospital, Prince of Wales Hospital,
Hong Kong. The recruitment commenced in November
2002 and completed in December 2004. Forty eligible
patients were assigned randomly to either placebo (n = 20)
or rivastigmine (n = 20) via a computer program generated
code. Treatment was started at 1.5 mg bid. The dose was
escalated to 3 mg bid after 4 weeks and to be maintained at
this dose. Patients having any intolerable adverse effects at
a dose of 3 mg bid or lower that did not abate after a maximum of 1 week were discontinued from the study. Since,
based on previous experience, doses higher than 6 mg daily
may be associated with more side-effects among Chinese
subcortical vascular dementia patients, we used the minimal effective dose of 6 mg daily in this study. Patients who
experienced significant deterioration in behavioral problems
and required increase or addition of psychiatric medications
would also be discontinued from the study. All the study
medications were produced by Novartis Pharmaceuticals
(Geneva, Switzerland).
Outcome measures
Efficacy measures were cognition (Chinese version of MMSE
[Chiu et al 1994] and frontal assessment battery [FAB]
[Dubois et al 2000; Mok et al 2004]), behavioral symptoms
(Chinese version of NPI [Leung et al 2001]), Chinese version
of instrumental activities of daily living (IADL) (Tong and
Man 2002), and sum of boxes in clinical dementia rating
scale (CDR) (Morris 1993). The FAB evaluates executive
function and it consists of 6 items, with each item evaluates
one executive domain (conceptualization, mental flexibility,
motor programming, sensitivity to interference, inhibitory
control, and environmental autonomy). The NPI evaluates
12 different neuropsychiatric distrubances including delusion, hallucination, dysphoria, anxiety, euphoria, aggression,
apathy, irritability, disinhibition, troublesome behavior,
Neuropsychiatric Disease and Treatment 2007:3(6)
Rivastigmine in Chinese patients with subcortical vascular dementia
sleep, and appetite. The Lawton IADL was used to assess
performance of daily activities (use of telephone, transportation, shopping, meal preparation, housework, handyman
work, laundry, medication management, and money management). The score for each item ranges from 0 to 3, with a
lower score representing better function. As some items in
the IADL were not scored because these items might not be
applicable to all patients owing to personal habits or motor
impairment, we took the average of all scored items as the
final IADL score.The CDR evaluates global functioning in
the following domains: memory, orientation, judgement
and problem solving, community affairs, home and hobbies,
and personal care. The sum of boxes of CDR was used as
the score for CDR. The above efficacy measures were rated
at baseline, week 12, and week 26 or early termination by
a single trained psychologist. Periodic physical examination including blood pressure, pulse, and reports of adverse
events were done at each visit. Electrocardiogram, laboratory
tests including complete blood count, renal/liver function
test, glucose, bone profile, vitamin B12, folate, and thyroid
function test were done at screening only.
Statistical analysis
Since at the planning stage of this study in 2001, no study
has been published using acetylcholiesterase inhibitor in
subcortical vascular dementia, we thus defined the sample
size as 40 patients based on feasibility consideration. Patients
who had at least one dose of study medication and had at
least one safety evaluation were included for safety analysis.
Efficacy analysis was performed on classical intent to treat
for all randomized patients who had received at least 1 dose
of treatment and were followed up for at least once. In the
baseline comparisons, independent t tests were used for comparison for continuous variables and χ2 tests for categorical
variables. For categorical variables with less than an expected
count of 5 in any of the 2 × 2 table the Fisher’s Exact Test was
used. Since age and education did not differ between the two
groups these variables were not controlled in the comparisons
of psychometric test performances. Post-hoc analysis showed
that results were not altered with or without these variables
co-varied. For analysis of change of efficacy measures, the
outcome measure × group interaction model was created
using a 2 × 2 repeated measure analysis of variance with
group as between-subject factors and outcome measures at
baseline and termination as within-subject variables. This
analysis involved 20 patients in active arm and 19 patients in
placebo arm, as 1 patient in the placebo arm died before second assessment and thus no follow up data was available. All
Neuropsychiatric Disease and Treatment 2007:3(6)
comparisons to placebo were two-tailed, with p values 0.05
being considered statistically significant.
Results
The baseline characteristics of the patients were shown in
Table 1. There was no significant difference in clinical characteristics between the 2 groups at baseline.
There was no statistical significant difference in change from
baseline between the 2 treatment groups in any of the efficacy
measures (Table 2). We observed that the mean total score of NPI
changed from 15 to 11.4 (p = 0.28) in the active group, whereas
score in the placebo group increased slightly. A favorable trend
in 2 behavioral measures (irritability, p = 0.066; aberrant motor
behavior, p = 0.068) was noted in the active group.
More patients in the active group experienced adverse
effects and had withdrawn (n = 6; 30%) compared with those
in the placebo group (n = 3; 15%) (Table 3). However, only
3 out of the 6 patients in the active group who withdrawn had
side effects that were probably related to the study drug and
all these 3 patients had severe dementia with MMSE 11.
One patient in the placebo group died of hemorrhagic
stroke during the study. Types of common adverse effects
(eg, nausea, vomiting, loss of appetite, leg cramp) were
typical to that seen with use of acetylcholinesterase inhibitors (Table 4). None of the patients necessitated change of
psychiatric medications during the study period.
Discussion
The present small randomized double-blind placebo-controlled
study explored the efficacy and tolerability of rivastigmine
among a relatively unselected group of Chinese subcortical
vascular dementia patients. Mean education level was only
around 3 years, which was similar to that of our local elderly
stroke patients(Tang et al 2004) and 40% of our patients were
illiterate. We also allowed participation of patients with more
severe dementia (MMSE 10) as its effects and tolerability among more severe subcortical vascular dementia have
not been explored before. The mean MMSE of our corhot
was 13, which was 7 points lower than that of the cohort of
another open labeled study using rivastigmine in subcortical
vascular dementia (Moretti et al 2003). Note also that using
an upper MMSE cutoff score of 24 as inclusion criteria, we
might have excluded certain subcortical vascular dementia
patients who may have predominant severe executive dysfunction despite having a MMSE score of greater than 24.
Frequency of traditional vascular risk factors was high and
was similar to that among patients of other vascular dementia
studies (Black et al 2003; Wilkinson et al 2003).
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Mok et al
Table 1 Baseline characteristics
Age
Education (years)
Illiterate
Sex (% female)
Vascular risk factors
Hypertension
Diabetes mellitus
Hyperlipidemia
History of myocardial infarction
History of stroke
Psychiatric medications
Anti-psychotic
Anti-depressant
Benzodiazepam
Cognition, behavior, daily activities,
and global function
MMSE
MMSE 19–24
MMSE 11–18
MMSE 3–10
FAB (total score)
NPI total score
IADL
CDR (sum of boxes)
Active (n = 20)
Placebo (n = 20)
p
75.7 (5.1)
3.5 (4.4)
7 (35%)
13 (65%)
74.1 (6.6)
3.1 (4.5)
9 (45%)
11 (55%)
0.39
0.76
0.90
0.52
19 (95%)
5 (25%)
5 (25%)
0 (0%)
14 (70%)
16 (80%)
3 (15%)
9 (45%)
1 (5%)
14 (70%)
0.34
0.70
0.19
1.00
1.00
2 (10%)
1 (5%)
1 (5%)
1 (5%)
1 (5%)
0 (0%)
13.0 (4.2)
3 (15%)
12 (60%)
5 (25%)
6.0 (2.6)
15.0 (40.4)
2.3 (0.7)
8.7 (5.1)
13.4 (5.9)
5 (25%)
9 (45%)
6 (30%)
5.9 (2.4)
10.6 (14.5)
2.4 (0.6)
9.5 (4.8)
0.83
0.90
0.14
0.70
0.61
Notes: Values in ( ) are standard deviation when not indicated otherwise.
Abbreviations: AVF, animal verbal fluency; CDR, clinical dementia rating; FAB, frontal assessment battery; IADL, instrumental activities of daily living; MMSE, mini-mental
state examination; no., number; NPI, neuropsychiatric inventory.
Although an earlier open labeled study showed a
siginifcant cognitive benefit with rivastigmine even with a
small sample size of 8 subjects per treatment arm (Moretti et al
2002), our present study failed to demonstrate any favorable
trend in cognitive response even with a slightly larger sample
size. Although it is possible that positive effects in open labeled
studies may be due to bias favoring active groups, the 6 months
duration of our study may also be too short to yield a significant benefit. Previous positive studies spanned 22 months
and continuous cognitive improvement was observed beyond
6 months (Moretti et al 2002). Furthermore, since our patients
probably had more severe dementia than those in the preivous
studies (Moretti et al 2002, 2003), rivastigmine may be less
effective among those with more severe subcortical vascular
dementia. It is also uncertain whether ethinicty and literacy
level affect treatment responses. However, further subgroup
analysis stratified by cognitive severity or educational level
was not feasible due to the small sample size of this study.
The lack of any apparent cognitive benefit in the active group
may also be explained by the fact that our brief cognitive
measures (MMSE and FAB) were not sensitive for detection
of cognitive changes among patients with subcortical vascular
dementia. Yet, since there was also no apparent improvement
946
in IADL or CDR in the active group, any cognitive benefit
related to rivastigmine, even if present, may only be subtle and
not clinically relevant. Furthermore, the dosage of 6 mg daily
may not be able to yield a positive benefit as study among
Alzheimer’s disease used dose as high as 12 mg daily (Rosler
et al 1999). Note that prior positive open labeled studies in
subcortical vascular dementia also used a maxium dose of 6
mg daily (Moretti et al 2002, 2003). Last, the lack of cognitive
benefit may simply be explained by the small sample size,
which lacks the power to detect any significant benefit. Yet, as
mentioned earlier, a favorable trend in cognition was already
observed in the previous open labeled study involving only 8
subjects per group at 6 months time point (Moretti et al 2002).
However, such robustness of drug effects in cognition could
not be observed in our present study eventhough we used a
larger sample size. Overall, our findings are consistent with that
of other larger randomized double-blind placebo-controlled
studies in vascular dementia, which showed that cognitive benefits of other acetylcholinesterase inhibitors among subcortical
(Salloway 2003) or probable vascular dementia (Erkinjuntti
et al 2002) was small or negligible.
Although no apparent cognitive benefit was observed with
use of rivastigmine, we observed that the mean total score of
Neuropsychiatric Disease and Treatment 2007:3(6)
Rivastigmine in Chinese patients with subcortical vascular dementia
Table 2 Efficacy measures
Active (n = 20)
Cognition
MMSE
FAB total
FAB sub-items:
1. Conceptualization
2. Mental flexibility
3. Programming
4. Sensitivity to interference
5. Inhibitory control
6. Environmental autonomy
Behavioral symptoms
NPI total
NPI sub-items:
1. Delusions
2. Hallucinations
3. Aggression
4. Dysphoria
5. Anxiety
6. Euphoria
7. Apathy
8. Disinhibition
9. Irritability/lability
10. Aberrant motor behavior
11. Sleep disturbance
12. Appetite/eating disturbance
Daily functions
IADL
Global function
CDR (sum of boxes)
Placebo (n = 19)
p
Baseline
Termination
Baseline
Termination
13.0 (4.2)
6.0 (2.6)
13.6 (5.8)
6.2 (2.7)
13.6 (6.0)
6.0 (2.4)
13.5 (6.8)
6.6 (2.8)
0.563
0.48
0.1 (0.3)
0.7 (0.8)
1.4 (0.8)
0.6 (1.0)
0.6 (0.6)
2.7 (0.9)
0.1 (0.3)
0.7 (0.8)
1.3 (1.1)
0.6 (1.2)
0.6 (0.8)
3.0 (0.2)
0.3 (0.5)
0.8 (0.8)
0.8 (0.8)
0.6 (0.8)
0.8 (0.5)
2.9 (0.5)
0.5 (0.6)
0.8 (0.8)
1.3 (1.0)
0.7 (0.8)
0.9 (0.8)
2.8 (0.7)
0.119
1
0.092
0.876
0.648
0.265
15.0 (14.6)
11.4 (9.4)
9.5 (6.5)
10.4 (11.3)
0.282
0.8 (2.4)
0.0 (0.0)
1.2 (2.1)
0.4 (0.9)
0.8 (1.9)
0.0 (0.0)
3.6 (4.4)
0.3 (0.9)
2.4 (3.2)
2.4 (4.2)
2.3 (3.0)
1.0 (2.6)
0.2 (0.9)
0.1 (0.2)
1.7 (2.8)
0.5 (1.1)
0.3 (0.7)
0.1 (0.2)
3.7 (4.4)
0.0 (0.0)
0.6 (1.6)
1.1 (2.9)
1.6 (1.8)
1.9 (3.8)
0.5 (1.0)
0.0 (0.0)
1.0 (2.1)
1.0 (1.9)
0.2 (0.5)
0.0 (0.0)
3.3 (3.6)
0.3 (0.8)
1.0 (1.5)
0.4 (1.1)
1.1 (1.8)
0.8 (2.9)
0.2 (0.9)
0.1 (0.2)
0.9 (1.8)
1.5 (3.0)
0.2 (0.7)
0.0 (0.0)
2.5 (3.8)
0.1 (0.3)
1.2 (2.1)
1.3 (2.3)
1.4 (2.4)
1.1 (2.6)
0.617
0.971
0.529
0.493
0.346
0.336
0.593
0.738
0.066
0.068
0.319
0.583
2.3 (0.7)
2.3 (0.5)
2.3 (0.6)
2.2 (0.8)
0.299
8.7 (5.1)
9.4 (5.5)
9.1 (4.6)
9.5 (5.4)
0.787
Notes: Values in ( ) are standard deviation when not indicated otherwise.
Abbreviations: AVF, animal verbal fluency; CDR, clinical dementia rating; FAB, frontal assessment battery; IADL, instrumental activities of daily living; MMSE, mini-mental
state examination; no., number; NPI, neuropsychiatric inventory.
NPI changed from 15 to 11.4 in the active group, whereas
patients’ behavioral symptoms in the placebo group remained
similar. This positive treatment effect of about 4 points in NPI
score was of similar magnitude as observed in the previous
open labeled study (Moretti et al 2002). A trend favoring active
group with p values approaching statistical significance was
particularly noted in irritability and abberant motor behavior.
A study with a larger sample size may possibly yield a signicant treatment benefit. If such study is to be carried out, the
sample size can be estimated based on data from this pilot
study. The standard deviation of NPI score of our 40 Chinese
subjects was 11.5, which was similar to that of another cohort
of vascular dementia patients (Erkinjuntti et al 2002). Assuming a treatment effect of 4 points is clinically relevant (Mega
et al 1999) and that it can be achieved by rivastigmine as had
been suggested in this pilot study, 125 subjects per group are
needed to have 80% power at a significance level of 5% to
detect such effect. Assuming an expected drop out rate of
Neuropsychiatric Disease and Treatment 2007:3(6)
30%, then 180 subjects per group will be needed. Such study
is warranted given the high prevalence and disabling nature
of behavioral symptoms in subcortical vascular dementia and
use of traditional antipscyhotics is discouraged in patients
with multiple vascular risk factors due to its association with
stroke and other vascular events (Bullock 2005). Availability
of another agent that proves safe and effective in controlling
behavioral symptoms in subcortical vascular dementia will
thus be extremely helpful.
The use of rivastigmine among our local elderly patients
with multiple concurrent medical conditions was generally
safe. The types of adverse effects were similar to that seen
in studies using acetylcholinesterase inhibitors in dementia
patients (Table 4). Mortality was noted only in the placebo
group. The withdrawal rate of 30% in the active group was
slightly higher than that (20%) observed in other clinial studies
using acetylcholinesterase inhibitor among vascular dementia
(Black et al 2003; Wilkinson et al 2003). This may be related
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Mok et al
Table 3 Overview of adverse effects
Any side effects
Withdrawals
Recurrent stroke
Death
Active (n = 20)
Placebo (n = 20)
12 (60%)
6 (30%)
1 (5%)
0
10 (50%)
3 (15%)
4 (20%)
1 (hemorrhagic stroke)
to the fact that our patients were more demented than those
in other studies. Note however that among the 6 withdrawn
patients in the active group, only half of the withdrawal reasons were probably drug-related and that all these 3 withdrawn
patients had MMSE less than 11. This may suggest that drug
intolerability among those with more severe dementia may
be high. Whether a slower and more flexible titration regime
may lead to lesser side effects requires further study.
To conclude, although we could not find a positive treatment effect of rivastigmine, findings from this pilot randomized double-blind placebo-controlled study among Chinese
patients with subcortical vascular dementia provides useful
insights for future study. We propose that future study should
particularly investigate the behavioral effects of rivastigmine in
subcortical vascular dementia given that behavioral symptoms
are often the most distressing problems to both patients and
carers and that vascular risk of existing antipsychotic drugs
may be particularly high in patients with subcortical vascular
dementia. Furthermore, a study longer than 6 months may be
needed to demonstrate a cognitive benefit of rivastigmine.
Disclosure
This study was supported by a research grant from Novartis
Pharmaceuticals (Hong Kong), Ltd. Apart from this grant,
Novartis Pharmaceuticals had no participation in the collection, analysis, and interpretation of data, nor in the preparation of the manuscript.
Table 4 Adverse effects of the rivastigmine group
N
Nausea and/or vomiting*
Confusion*
Urinary tract infection
Dizziness*
Leg cramp*
Restroke
Gouty attack
Renal failure
Increased insomnia and loss of appetite*
Loss of appetite*
Total
2(#, 1 withdrawn)
1
2
1
1
1#
1#
1#
1#
1#
12
Notes: *probably related to study drug; #adverse effects leading to withdrawal.
948
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