Abstract:

Objective: To assess and compare the clinical efficacy and safety of cognitive enhancers (donepezil, galan¬tamine, rivastigmine, and memantine) on cognition, behavior, function, and global status in patients with vascular cognitive impairment.
Data sources: The initial literature search was performed with PubMed, EMBASE, the Cochrane Meth¬odology Register, the Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing & Allied Health (CINAHL) from inception to January 2018 for studies regarding donepezil, galantamine, rivastigmine, and memantine for treatment of vascular cognitive impairment.
Data selection: Randomized controlled trials on donepezil, galantamine, rivastigmine, and memantine as monotherapy in the treatment of vascular cognitive impairment were included. A Bayesian network me¬ta-analysis was conducted.
Outcome measures: Efficacy was assessed by changes in scores of the Alzheimer’s Disease Assessment Scale, cognitive subscale, Mini-Mental State Examination, Neuropsychiatric Inventory scores and Clinician’s In¬terview-Based Impression of Change Scale Plus Caregiver’s Input, Activities of Daily Living, the Clinical Dementia Rating scale. Safety was evaluated by mortality, total adverse events (TAEs), serious adverse events (SAEs), nausea, vomiting. diarrhea, or cerebrovascular accidents (CVAs).
Results: After screening 1717 citations, 12 randomized controlled trials were included. Donepezil and rivastigmine (mean difference (e) = –0.77, 95% confidence interval (CI): 0.25–1.32; MD = 1.05, 95% CI: 0.18–1.79) were significantly more effective than placebo in reducing Mini-Mental State Examination scores. Donepezil, galantamine, and memantine (MD = –1.30, 95% CI: –2.27 to –0.42; MD = –1.67, 95% CI: –3.36 to –0.06; MD = –2.27, 95% CI: –3.91 to –0.53) showed superior benefits on the Alzheimer’s Disease Assessment Scale–cognitive scores compared with placebo. Memantine (MD = 2.71, 95% CI: 1.05–7.29) improved global status (Clinician’s Interview-Based Impression of Change Scale Plus Caregiver’s Input) more than the place¬bo. Safety results revealed that donepezil 10 mg (odds ratio (OR) = 3.04, 95% CI: 1.86–5.41) contributed to higer risk of adverse events than placebo. Galantamine (OR = 5.64, 95% CI: 1.31–26.71) increased the risk of nausea. Rivastigmine (OR = 16.80, 95% CI: 1.78–319.26) increased the risk of vomiting. No agents displayed a significant risk of serious adverse events, mortality, cerebrovascular accidents, or diarrhea.
Conclusion: We found significant efficacy of donepezil, galantamine, and memantine on cognition. Me¬mantine can provide significant efficacy in global status. They are all safe and well tolerated.

Key words: nerve regeneration, vascular cognitive impairment, vascular dementia, pharmacotherapy, cholinesterase inhibitors, donepezil, galantamine, rivastigmine, memantine, systematic review, Bayesian network meta-analysis, neural regeneration