Safety and Effectiveness of Botulinum Toxin in Elderly Patients With Dementia and Muscle Stiffness
Study Details
Study Description
Brief Summary
Aim of the study is to perform a pilot study to assess the impact of Botulinum toxin on muscle tone, and caregiver burden in individuals who are cognitively impaired and who are fully dependent.
The primary objective is to confirm proof of principle that paratonic rigidity and the consequences associated with it can be reduced with injection of Botulinum toxin injections resulting in reduced care-giver burden.
The secondary objectives are to determine optimal time points for evaluation of efficacy in this patient population and whether the time period is sufficient for washout of Botulinum toxin effect; determine most salient and sensitive outcome measures; identify obstacles in data gathering; and lastly, to determine feasibility of battery of assessments in this pilot study.
| Condition or Disease | Intervention/Treatment | Phase |
|---|---|---|
|
Phase 2 |
Study Design
Arms and Interventions
| Arm | Intervention/Treatment |
|---|---|
| Placebo Comparator: Saline Saline injection up to 5 cc in arm with paratonia (one time injection) |
Drug: Saline
|
| Active Comparator: Botulinum Toxin Up to 300 U (5 cc) of Botulinum toxin diluted 2:1 (2 cc per 100 U of Botulinum toxin) (one time injection) |
Drug: Botulinum Toxin
Other Names:
|
Outcome Measures
Primary Outcome Measures
- Impact on care-giver burden [6 weeks for primary outcome, 32 weeks for entire study]
Impact on caregiver burden in providing upper extremity care. Measured by the Carer Burden Scale which includes four items (cleaning the palm, cutting the fingernails, dressing, cleaning under the armpit). Each item rated on five point Likert scale ("no difficulty" to "cannot do task").
Secondary Outcome Measures
- Visual Analogue Scale [6 weeks for secondary outcome, 32 weeks for entire study]
Completed by the professional caregiver that is caring for the patient to assess perception of ease of caregiving. Consists of 100 mm line with anchors of 0 "giving care to the residents is very difficult" and 100 "giving care to the residents is very easy"
- Joint angle measurement [6 weeks for secondary outcome, 32 weeks for entire study]
Joint angle measurements were used reflecting range of motion. Used as a surrogate measure for severity of paratonia
- Pain [6 weeks for secondary outcome, 32 weeks for entire study]
Pain Assessment in Advanced Dementia (PAINAD) Scale used to evaluate correlates of pain and determine whether Botulinum toxin treatment reduces discomfort of morning care. Consists of 5 items (breathing, negative vocalization, facial expression, body language and consolability), scored on a 0-2 point scale and then summed to arrive at a total scale.
- Global Assessment [6 weeks for secondary outcome, 32 weeks for entire study]
Overall response to treatment evaluated by study investigator and by professional caregiver caring for patient using the global assessment scale. A score of -4 indicates very marked worsening, 0 no change, and +4 very marked improvement.
Eligibility Criteria
Criteria
Inclusion Criteria:
-
Severe cognitive impairment (complete dependency in all activities of daily living (ADLs)
-
Diagnosis of Alzheimer's disease, vascular dementia,or frontotemporal dementia
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Score> 3 on the paratonic assessment instrument, with paratonic rigidity in an arm(s) interfering in the provision of care
Exclusion Criteria:
-
Alternate etiologies for increased tone
-
Botulinum toxin 6 months preceding the study
Contacts and Locations
Locations
| Site | City | State | Country | Postal Code | |
|---|---|---|---|---|---|
| 1 | Assistive Technology Clinic at Baycrest | Toronto | Ontario | Canada | M6A 2E1 |
Sponsors and Collaborators
- Assistive Technology Clinic, Canada
- Merz Pharmaceuticals GmbH
- Baycrest
Investigators
- Principal Investigator: Galit Kleiner-Fisman, MD, University of Toronto, Baycrest
Study Documents (Full-Text)
None provided.More Information
Publications
- Albright AL, Barron WB, Fasick MP, Polinko P, Janosky J. Continuous intrathecal baclofen infusion for spasticity of cerebral origin. JAMA. 1993 Nov 24;270(20):2475-7.
- Bhakta BB, Cozens JA, Chamberlain MA, Bamford JM. Impact of botulinum toxin type A on disability and carer burden due to arm spasticity after stroke: a randomised double blind placebo controlled trial. J Neurol Neurosurg Psychiatry. 2000 Aug;69(2):217-21. Erratum in: J Neurol Neurosurg Psychiatry 2001 Jun;70(6):821.
- Bhakta BB, Tennant A, Cozens JA, et al. Application of item response theory to measure the disabling effects of severe upper limb spasticity in stroke and the consequent carer burden. Cerebrovascular Dis 1999;9:124.
- Brashear A, Gordon MF, Elovic E, Kassicieh VD, Marciniak C, Do M, Lee CH, Jenkins S, Turkel C; Botox Post-Stroke Spasticity Study Group. Intramuscular injection of botulinum toxin for the treatment of wrist and finger spasticity after a stroke. N Engl J Med. 2002 Aug 8;347(6):395-400.
- Brin MF. Dosing, administration, and a treatment algorithm for use of botulinum toxin A for adult-onset spasticity. Spasticity Study Group. Muscle Nerve Suppl. 1997;6:S208-20. Review.
- Canadian study of health and aging: study methods and prevalence of dementia. CMAJ. 1994 Mar 15;150(6):899-913.
- Delagi EF, Perotto A, Iazzetti J, Morrison D. Anatomic Guides for the Elecromyographer. In: Charles C.Thomas, ed., 2nd ed Springfield, 1980.
- Dupre E. Debilite mentale and debilite motrice associees. Rev Neurol 1910;20:54-56.
- Elovic EP, Brashear A, Kaelin D, Liu J, Millis SR, Barron R, Turkel C. Repeated treatments with botulinum toxin type a produce sustained decreases in the limitations associated with focal upper-limb poststroke spasticity for caregivers and patients. Arch Phys Med Rehabil. 2008 May;89(5):799-806. doi: 10.1016/j.apmr.2008.01.007.
- Fox PJ, Kohatsu N, Max W, Arnsberger P. Estimating the costs of caring for people with Alzheimer disease in California: 2000-2040. J Public Health Policy. 2001;22(1):88-97.
- Franssen EH, Kluger A, Torossian CL, Reisberg B. The neurologic syndrome of severe Alzheimer's disease. Relationship to functional decline. Arch Neurol. 1993 Oct;50(10):1029-39.
- Giovannelli M, Borriello G, Castri P, Prosperini L, Pozzilli C. Early physiotherapy after injection of botulinum toxin increases the beneficial effects on spasticity in patients with multiple sclerosis. Clin Rehabil. 2007 Apr;21(4):331-7.
- Hobbelen JS, Koopmans RT, Verhey FR, Habraken KM, de Bie RA. Diagnosing paratonia in the demented elderly: reliability and validity of the Paratonia Assessment Instrument (PAI). Int Psychogeriatr. 2008 Aug;20(4):840-52. doi: 10.1017/S1041610207006424. Epub 2008 Jan 7.
- Hobbelen JS, Verhey FR, Bor JH, de Bie RA, Koopmans RT. Passive movement therapy in patients with moderate to severe paratonia; study protocol of a randomised clinical trial (ISRCTN43069940). BMC Geriatr. 2007 Dec 19;7:30.
- Kao I, Drachman DB, Price DL. Botulinum toxin: mechanism of presynaptic blockade. Science. 1976 Sep 24;193(4259):1256-8.
- Knapp M, Comas-Herrera, Somani A, Banerjee S. Dementia: Summary report for the National Audit Office international comparisons. London: Personal Social Services Research Unit London School of Economics and Political Science and Section of Mental Health and Ageing The Institute of Psychiatry, King's College London; 2007.
- Matthews FE, Dening T; UK Medical Research Council Cognitive Function and Ageing Study. Prevalence of dementia in institutional care. Lancet. 2002 Jul 20;360(9328):225-6.
- Naumann M, Yakovleff A, Durif F; BOTOX Cervical Dystonia Prospective Study Group. A randomized, double-masked, crossover comparison of the efficacy and safety of botulinum toxin type A produced from the original bulk toxin source and current bulk toxin source for the treatment of cervical dystonia. J Neurol. 2002 Jan;249(1):57-63.
- Simpson DM, Gracies JM, Yablon SA, Barbano R, Brashear A; BoNT/TZD Study Team. Botulinum neurotoxin versus tizanidine in upper limb spasticity: a placebo-controlled study. J Neurol Neurosurg Psychiatry. 2009 Apr;80(4):380-5. doi: 10.1136/jnnp.2008.159657. Epub 2008 Oct 31.
- Smetanin P, Kobak P, Briante C, Ahmad S. Rising Tide: The Impact of Dementia in Canada 2008 to 2038. RiskAnalytica; 2009.
- Souren LE, Franssen EH, Reisberg B. Neuromotor changes in Alzheimer's disease: implications for patient care. J Geriatr Psychiatry Neurol. 1997 Jul;10(3):93-8. Review.
- Waardenburg H, Elvers W, Van Vechgel F, Oostendorp R. Can paratonia be measured reliably? Evaluation of the reliability of a visual analogue scale and the modified tonus sclae of Ashworth for measuring paratonia. Nederlands Tijdschrift voor Fysiotherapie (in dutch) 1999;102:30-35.
- Waltz CFSOL, Lenz ER. Measurement in Nursing Research, 2nd ed. Philadelphia: F.A. Davis, 1991.
- Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) scale. J Am Med Dir Assoc. 2003 Jan-Feb;4(1):9-15.
- Wells DL, Dawson P, Sidani S, Craig D, Pringle D. Effects of an abilities-focused program of morning care on residents who have dementia and on caregivers. J Am Geriatr Soc. 2000 Apr;48(4):442-9.
- NT-036