Elucidating the Role of Cholinergic Degeneration in Cognitive Fluctuations in Lewy Body Dementia

Phase 4RecruitingNCT07284290

Virginia Commonwealth University120 enrolled

Overview

The proposed study aims to address the critical gaps in understanding the mechanisms of CF (Cognitive Fluctuations) by leveraging recently emerged molecular biomarkers, advanced neuroimaging techniques to assess measures of cholinergic degeneration, and synchronous EEG and assessments of attention. One of the overarching innovations of study is combining all of these assessments into one integrated research plan

Aim 1 is a cross-sectional case control study in which cholinergic degeneration in 45 participants with DLB or PDD with CF will be compared to a group of 45 individuals with Lewy Body disease without CF and 30 healthy controls. The first 20 participants who are eligible for Aim 2 and consent will also participate in an 8-week pre-post interventional cohort study immediately following Aim 1 procedures. For Aim 3, Aim 1 participants will complete annual follow-up evaluations for 2 years to understand factors influencing the change in cognitive fluctuations over time.

Study Type

INTERVENTIONAL

Allocation

NON_RANDOMIZED

Purpose

BASIC_SCIENCE

Masking

NONE

Enrollment

120

Conditions

Dementia With Lewy Bodies Parkinson Disease Dementia

Interventions

Syn-One skin biopsyPROCEDURE

Detects phosphorylated alpha synuclein in cutaneous nerve fibrils which has \>95% sensitivity in detecting DLB

Multi modal MRIDIAGNOSTIC_TEST

Functional MRI used to investigate the network connectivity changes associated with alterations in the cholinergic system. Using this comprehensive methodology to establish cholinergic degeneration's contribution to CF provides a robust framework for future research and therapeutic strategies.

Assessment of dynamic EEG features over 48-hour periods across all study aimsDIAGNOSTIC_TEST

Implementing prolonged EEG monitoring, to capture dynamic changes in neural activity associated with CF. The methods are designed avoid the limitations identified in a systematic review of EEG studies in DLB, as will use quantitative analysis of EEG, uniformly apply diagnostic criteria, and consider the confounding effects of medications. Concurrent evaluation of PVT performance and EEG This dual assessment will correlate cognitive and neurophysiological dynamics in real-time, providing a more holistic understanding of CF over time and the functional brain activity that underlies them. Temporal integration of PVT with EEG data collection will enable the identity of specific correlates of CF.

Plasma biomarkersDIAGNOSTIC_TEST

A blood sample will be collected and sent for processing by C2N Diagnostics for the detection of Aβ42/40 and p-tau217 via mass spectrometry, a method shown to be highly accurate for predicting amyloid positivity on PET (AUC=0.94). Exploratory Biomarkers: The additional blood sample will be used for analysis of exploratory biomarkers and future research. A total of up to 20mL of blood will be taken.

Galantamine HBr extended-release 8mg capsules (8mg ER).DRUG

20 participants from the arm 1. Participants will take 1 capsule daily of galantamine 8mg ER for 4 weeks and then increase to 2 capsules daily of galantamine 8mg ER (16mg) for 4 weeks. This titration will mitigate potential for cholinergic side effects. At 2 weeks, 4 weeks and 6 weeks of the treatment period, safety and compliance will be assessed during phone call visits. Any adverse event rated as Grade 2 or greater according to the Common Terminology Criteria for Adverse Events (CTCAE) v5.0 and that is definitely or possibly attributable to the study drug will result in study drug withdrawal or dose reduction.

Eligibility

Sex: ALLMin age: 50 YearsMax age: 89 YearsHealthy volunteers:

Medical Language ↔ Plain English

Inclusion Criteria: Arm 1: * Age range: 50 ≤ age \< 90. * Diagnosis of dementia with Lewy bodies (DLB), Parkinson disease dementia (PDD), Parkinson disease with Mild Cognitive Impairment (PD-MCI), Mild Cognitive Impairment with Lewy bodies (MCI-LB). * DLB participants must fulfill criteria for clinically probable DLB based on the 2017 4th consensus report of the DLB consortium. * PDD participants must meet criteria for clinically probable PD according to the MDS Clinical Diagnostic Criteria for Parkinson's Disease and must also meet criteria for probable PDD based on the 2007 Movement Disorders Society clinical diagnostic criteria. * PD-MCI participants must meet criteria for clinically probable PD according to the MDS Clinical Diagnostic Criteria for Parkinson's Disease and meet criteria for Mild Cognitive Impairment on cognitive testing at screening. * MCI-LB participants with must meet established research criteria. * Capacity to provide informed consent or, if unable, availability of a legally authorized representative or guardian who can provide informed consent. * Availability of informant (for participants meeting criteria for dementia). * Ability and willingness to comply with the study-related procedures. * Fluent in spoken and written English (due to cognitive testing) Exclusion Criteria: Arm 1 * History of cognitive disorder or psychiatric disorder other than that related to dementia with Lewy bodies or Parkinson disease dementia. * History of deep brain stimulation or any neurosurgical procedure. * History of structural brain disease or known significant cerebrovascular disease. * History of seizures or epilepsy and/or use of sodium channel blockers, i.e. carbamazepine, oxcarbazepine, phenytoin, topiramate, lamotrigine, felbamate, zonisamide, rufinamide, lacosamide, eslicarbazepine, and valproate. * Greater than two alcoholic drinks per day for men and one per day for women. * Regular use of benzodiazepines or barbiturates. (If benzodiazepines are taken as needed only, these medications cannot be taken within 5 half-lives of screening visit or between screening visit and EEG.) * Severe dementia (based on PI assessment of subject dependence level for instrumental activities of daily living) * Any contraindication to brain MRI. * Any medical condition that would interfere with ability to complete all study procedures. * Participants must not be pregnant, planning to become pregnant, or father a child for the duration of the study Inclusion Criteria: Arm 2 (Cholinesterase inhibitor cohort) inclusion criteria: * Completed Aim 1. * Clinical diagnosis of LBD (DLB or PDD) with CF. * Not taking a cholinesterase inhibitor and has not taken a cholinesterase inhibitor in the previous 90 days. * Ability and willingness to comply with the ChEI Cohort procedures (including galantamine administration), or a caregiver willing and able to ensure compliance. Exclusion Criteria: Arm 2 (Cholinesterase inhibitor cohort) exclusion criteria: * Severe hepatic impairment. * Renal failure. * Significant bradycardia (\<50 bpm) at screening or history of AV block. * Any contraindication to galantamine administration based on PI discretion. Inclusion criteria: Arm 3 (Healthy Controls) * Age range: 50 ≤ age \< 90. * Healthy controls should not have any known neurologic conditions that could interfere with study procedures or results. * Capacity to provide informed consent or, if unable, availability of a legally authorized representative or guardian who can provide informed consent. * Availability of informant (for participants meeting criteria for dementia). * Ability and willingness to comply with the study-related procedures. * Fluent in spoken and written English (due to cognitive testing). Exclusion Criteria: Arm 3 (Healthy Controls) * No History of cognitive disorder or psychiatric disorder other than that related to dementia with Lewy bodies or Parkinson disease dementia. * No History of deep brain stimulation or any neurosurgical procedure. * No History of structural brain disease or known significant cerebrovascular disease. * No History of seizures or epilepsy and/or use of sodium channel blockers, i.e. carbamazepine, oxcarbazepine, phenytoin, topiramate, lamotrigine, felbamate, zonisamide, rufinamide, lacosamide, eslicarbazepine, and valproate. * Any medical condition that would interfere with ability to complete all study procedures. * Participants must not be pregnant, planning to become pregnant, or father a child for the duration of the study

Outcomes

Primary Outcomes

Clinical Assessment of Fluctuations (CAF) (frequency and duration score)

The scoring for the Clinical Assessment of Fluctuations (CAF) is a two-step process that uses both a frequency and a duration score. The two scores are multiplied together to get the final severity rating. A higher score indicates more severe cognitive fluctuations. After rating the frequency and duration, the two scores are multiplied to get the final CAF score. Frequency score x Duration score=Total CAF score

Time frame: Screening, Baseline, ChEI Cohort Day 56, 1 year follow-up visit, and 2 year follow-up visit

Dementia Cognitive Fluctuations Scale-Research Version (DCFS-R) (total score)

The DCFS-R is measured as a total score from 4 to 20, with higher scores indicating more severe cognitive fluctuations in dementia. It is calculated by summing a nurse's ratings on four items, each scored on a 5-point Likert scale (1=no difference, 5=very large difference). The four items assess the difference between a person's best and worst functioning, which includes daytime somnolence, drowsiness, and altered levels of consciousness.

Time frame: Screening, Baseline, ChEI Cohort Day 56, 1 year follow-up visit, and 2 year follow-up visit

Mayo Fluctuations Scale (Four questions)

The four questions included in the Mayo Fluctuations Scale have been found to significantly differentiate Alzheimer's Disease from DLB. Positive items are summed to create a "fluctuations composite score" with a score of 3 or 4 associated with DLB.

Time frame: Screening, Baseline, ChEI Cohort Day 56, 1 year follow-up visit, and 2 year follow-up visit

Functional Activities Questionnaire (FAQ Assessment)

The FAQ is a number from 0 to 30 that represents a person's independence in daily tasks, with higher scores indicating more difficulty. The score is calculated by summing the ratings (0-3) for 10 activities, and a cut-off score of 9 or higher is often used to suggest potential cognitive or functional impairment.