key: cord-0711280-al5qmch7
authors: Forcano, Laura; Fauria, Karine; Soldevila‐Domenech, Natalia; Minguillón, Carol; Lorenzo, Thais; Cuenca‐Royo, Aida; Menezes‐Cabral, Sofia; Pizarro, Nieves; Boronat, Anna; Molinuevo, José Luis; de la Torre, Rafael
title: Prevention of cognitive decline in subjective cognitive decline APOE ε4 carriers after EGCG and a multimodal intervention (PENSA): Study design
date: 2021-03-31
journal: Alzheimers Dement (N Y)
DOI: 10.1002/trc2.12155
sha: 51543640b3ea902ba7a4826f5c1b77ef504a84c5
doc_id: 711280
cord_uid: al5qmch7

INTRODUCTION: Subjects exhibiting subjective cognitive decline (SCD) are at an increased risk for mild cognitive impairment and dementia. Given the delay between risk exposure and disease onset, SCD individuals are increasingly considered a good target population for cost‐effective lifestyle‐based Alzheimer's disease prevention trials. METHODS: The PENSA study is a randomized, double‐blind, controlled clinical trial that aims to evaluate the efficacy of a personalized multimodal intervention in lifestyle (diet counseling, physical activity, cognitive training, and social engagement) combined with the use of epigallocatechin gallate (EGCG) over 12 months, in slowing down cognitive decline and improving brain connectivity. The study population includes 200 individuals meeting SCD criteria and carrying the apolipoprotein E ε4 allele, who will be randomized into four treatment arms (multimodal intervention + EGCG/placebo, or lifestyle recommendations + EGCG/placebo). The primary efficacy outcome is change in the composite score for cognitive performance measured with the Alzheimer's Disease Cooperative Study Preclinical Alzheimer Cognitive Composite (ADCS‐PACC‐like) adding to the original version the Interference score from the Stroop Color and Word Test and the Five Digit Test. Secondary efficacy outcomes are (1) change in functional magnetic resonance imaging (fMRI) and structural neuronal connectivity (structural MRI) and (2) the safety assessment of the EGCG compound. This study is framed within the WW‐FINGERS consortium. DISCUSSION: The use of new technologies (i.e., mobile ecological momentary assessments [EMAs], activity tracker) in the PENSA study allows the collection of continuous data on lifestyle behaviors (diet and physical activity) and mood, enabling a personalized design as well as an intensive follow‐up of participants. These data will be used to give feedback to participants about their own performance along the intervention, promoting their involvement and adherence. The results of the study may aid researchers on the design of future clinical trials involving preventive lifestyle multicomponent interventions.

magnetic resonance imaging (fMRI) and structural neuronal connectivity (structural MRI) and (2) the safety assessment of the EGCG compound. This study is framed within the WW-FINGERS consortium.

Discussion: The use of new technologies (i.e., mobile ecological momentary assessments [EMAs], activity tracker) in the PENSA study allows the collection of continuous data on lifestyle behaviors (diet and physical activity) and mood, enabling a personalized design as well as an intensive follow-up of participants. These data will be used to give feedback to participants about their own performance along the intervention, promoting their involvement and adherence. The results of the study may aid researchers on the design of future clinical trials involving preventive lifestyle multicomponent interventions.

apolipoprotein E ε4, epigallocatechin gallate, lifestyle multimodal intervention, PENSA study, preclinical Alzheimer's disease, prevention, randomized clinical trial, subjective cognitive decline

Dementia affected nearly 50 million people worldwide in 2018, with

Alzheimer's disease (AD) the most common cause. Its prevalence has risen over the past decades mainly due to the increase in life expectancy, and is expected to triple by 2050. 1, 2 Currently, there is no effective treatment to slow down or ameliorate AD neuropathological changes, symptomatic approaches being the only therapeutic option.

Therefore, it is a research priority to find effective interventions to prevent or delay the onset of cognitive impairment and AD. 3 AD is understood as a continuum in which preclinical physiopathological events may occur even 20 years before the appearance of the first symptoms. 4 In this continuum, there are a number of cognitively unimpaired individuals, who are concerned that they have reduced cognitive function. This condition is known as subjective cognitive decline (SCD). Subjects with SCD are at an increased risk for mild cognitive impairment (MCI) and dementia. 5 Given the delay between risk exposure and disease onset, SCD individuals with biomarkers of neurodegeneration are increasingly considered a good target population for cost-effective lifestyle-based AD prevention trials. 6 Furthermore, the presence of the ɛ4 allele in apolipoprotein E (APOE) represents the strongest genetic risk factor for late onset AD, with about a 3-fold increased risk for heterozygotes and 8-to 12 -fold for homozygotes compared to the ε3/ε3 genotype. 7, 8 APOE is the major cholesterol transporter to the central nervous system. APOE ɛ4 contributes to AD pathology by different mechanisms. 7, 9 International research agencies have underlined the importance of prioritizing well-designed randomized controlled clinical trials (RCTs) involving interventions that have already shown promising effects on the prevention of cognitive decline such as cognitive training and physical activity 10 and healthy dietary patterns such as the Mediterranean diet. 11 Given the multifactorial causes of AD, the report also recommends testing interventions that target several risk factors and mech-anisms simultaneously. These risk factors, including diabetes, midlife hypertension, midlife obesity, smoking, depression, cognitive inactivity, and physical inactivity, explain ≈50% of AD cases. 12 EGCG is a flavanol from green tea that already has been shown to be safe in humans at the doses proposed. 15 According to previous studies, the underlying mechanism of action of EGCG is the improvement of synaptic plasticity and brain connectivity. In a phase 2 clinical trial with Down syndrome adults, it has been shown that EGCG combined with cognitive training improves cognitive performance (executive functions), adaptive functionality, and brain connectivity (monitored with functional magnetic resonance imaging [fMRI] and transcranial magnetic stimulation). 16 The most relevant additional mechanisms 17, 18 by which EGCG may confer neuroprotection to different AD insults are:

(2) antioxidant activity via the Nrf2-pathway, 19 (2) protection in neuroinflammation via the brain-derived neurotrophic factor (BDNF), 20 (3) regulation of insulin signaling, 21 and (4) targeting amyloidogenesis and tau hyperphosphorylation. EGCG modulates amyloid precursor protein (APP) processing favoring the non-amyloidogenic pathway by activating ADAM10, and inhibiting BACE-1. 22 EGCG inhibits DYRK1A activity, a gene associated with AD, involved in the phosphorylation of both APP and tau. 23, 24 All of this is expected to be translated into an improvement of cognitive performance in the PENSA study participants. 25 It is expected that EGCG combined with a lifestyle multimodal intervention will result in longer lasting and sustainable effects than those 

Inclusion criteria include male or female individuals aged 60 to 80 years with SCD 26 (based on a positive answer to the question Have you experienced a decrease in your cognitive ability [e.g., memory, concentration, planning, orientation, or language) compared to a few years ago]?) and APOE ε4 carriers (either hetero or homozygotes), fulfilling at least two additional SCD "plus" criteria (memory complaints rather than other domains of cognition, onset of symptoms within the last 5 years, concern about symptoms, perception of lower performance F I G U R E 1 Schematic diagram of the trial design compared to same age group and/or confirmation of symptoms by an informant). 26, 27 Exclusion criteria include (1) history of neurological or psychiatric conditions according to DSM-5 criteria, (2) clinically significant abnormalities in laboratory test, (3) any contraindication for brain MRI, (4) presence of mild to moderate leukoaraiosis (scoring <3 on Fazekas scale, 28 and/or less than three lacunar infarcts not localized on strategic territory [e.g., bilateral thalamic]), (5) primary or recurrent malignant disease treated within the last 2 years, (6) evidence of medical conditions/medications that may interfere with study assessments, (7) body mass index < 18.5 or ≥35 kg/m 2 , or (8) current intake of vitamins or products containing EGCG supplements for at least 3 months previous to the screening visit.

As a general procedure, all participants have to fill out a web-based questionnaire including information about their subjective cognitive performance designed for study recruitment. Based on SCD status, a priori eligible participants are invited to perform a short face-toface pre-screening visit to allow the collection of a buccal swab for APOE genotyping. In this visit, researchers explain the implications of knowing their APOE genotype (i.e., that the presence of the allele ε4 increases the risk of AD but it is not a diagnostic factor). To ensure the participants' ability to receive and understand the results of genotyping, the absence of anxious and depressive symptomatology is assessed before the APOE status disclosure. Disclosure of APOE status is postponed in those individuals with relevant anxiety symptoms.

APOE ɛ4 carriers undergo a second screening that includes neurological and neuropsychological examination 29, 30 and neuroimaging tests.

After this assessment procedure, only participants with cognitive performance within normal values (normal scoring on psychometric evaluation, adjusted for age and education) and no abnormalities in the neuroimaging tests are eligible. Table 1 summarizes the details of study assessments in each visit.

Participants are randomized to one of the four treatment arms following a randomization list balanced by sex. The electronic Case Report Form (eCRF, SAIL Biometria SA) automatically performs treatment allocation based on randomization. Treatment allocation will be concealed until the end of the study.

After randomization, individuals are pooled in groups of 10 to 12 people allocated to the multimodal intervention or to the control groups. The group size is based on optimal ratios for behavior-change group interventions, which allows optimal interactions between participants as well as promotes social change processes. Every group partic- 

To continuously monitor the adherence to the multimodal intervention, motivate participants, and promote engagement in healthy behaviors, a digital platform collects information on participants' diet (daily) and mood and perceived mental health (weekly) using ecological momentary assessments (EMAs), and registers the attendance at social engagement activities and gymnasium classes.

Continuous measures of physical activity, heart rate, and sleep quality are collected from an activity tracker (Fitbit© Charge 3).

All data tracked through the platform are accessible from the online platform for researchers. Throughout the intervention, participants receive personalized recommendations based on the collected data, as well as feedback on their behaviors. See Table S1 in 

The intervention consists of ten 90-minute sessions, led by experi- The purpose of these sessions is to provide opportunities for participants to interact with their groupmates, as well as to provide them access to environments and resources that will help keep themselves cognitively stimulated.

Efficacy will be evaluated measuring the effect of the multimodal intervention versus the control intervention on cognitive decline measured at baseline and months 6, 12, and 15 (3 months after intervention discontinuation).

Safety is evaluated at months 6 and 12 with adverse events (AEs) and serious adverse events (SAEs) reported according to the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) guidelines for Good Clinical Practice definitions, as well as with clinically significant changes in heart rate, blood pressure, and in blood analyses (serum creatinine, liver function, thyroid hormones, and serum cholesterol). Additionally, AE of special interest for this study include the following: changes in heart rate (HR) and blood pressure (BP) relative to baseline; observed or suspected clinical seizure that resolves within 3 minutes and does not require treatment, hospitalization, or intervention; cases of elevated alanine transaminase (ALT) or aspartate transaminase; elevated bilirubin or clinical jaundice; and cases of elevated thyroid-stimulating hormone (TSH) and decreased free T4.

Compliance will be assessed by measuring EGCG in plasma, at 6 and 12 months. Additionally, participants will return the empty medication sachets.

Change in global cognition will be evaluated with a composite measure designed for clinical trials conducted at the asymptomatic phase of AD, 

Change in brain connectivity will be evaluated with functional neuronal connectivity (fMRI) and structural connectivity (structural MRI; see supporting information). The safety assessment of the EGCG compound will be based on thyroid, liver, and renal function; TSH; freeT4;

alkaline phosphatase (ALP); ALT; and creatinine.

There are a number of exploratory outcome measures (see supporting information) evaluating additional cognitive performance scores, anxiety and depression, adaptive behavior, quality of life and general health, lifestyle habits (quality of sleep, physical activity and functional capacity, MedDiet adherence), microbiota composition and metabolome derived from gut microorganisms' activity, dietary patterns (metabolomics), olfactory function, plasma AD biomarkers, plasma neuron-derived exosomes, biological age biomarkers (epigenetics, biological aging), and a number of biomarkers.

For the analysis of biomarkers, blood, plasma, urine, and feces are collected (see Table 1 for more details). Plasma neuron-derived exosomes and oral fluid are also collected as exploratory matrices to test their usefulness to derive surrogate biomarkers of efficacy.

Blood samples are collected to assess blood chemistry and safety parameters that focus on liver, renal, and thyroid function; as well as core AD, neuroinflammation, and inflammatory biomarkers; microbiota-related biomarkers; and metabolomics profiles. Plasma for EGCG analysis is collected as a biomarker of treatment compliance. anticipated.

An exhaustive descriptive analysis will be carried out for all variables of interest at all study times. Primary and secondary outcomes will be analyzed with linear mixed models to study their evolution over time in each study group and the differences among them. The effect size measure of interest will be the adjusted mean differences among treatments and pairwise post hoc comparisons controlling a familywise error rate of 0.05 will be performed if statistically significant differences among the study groups are detected.

The process of collection, cleaning, and management of subject data will be compliant with regulatory standards in clinical research. Monitoring is provided along the trial to collect and keep high-quality data.

The eCRF will maintain an audit trial and provide easy identification and resolution of data discrepancies.

The PENSA study is an initiative framed on the WW-FINGERS global network, aimed at assessing the efficacy of a multimodal intervention on lifestyle habits complemented with a dietary supplement containing EGCG in slowing down cognitive decline and improving brain connectivity in subjects with SCD and APOE ε4 carriers.

One of the differential aspects of the PENSA study is the administration of a dietary supplement containing EGCG. Although EGCG has been tested in different pathological conditions 35 The complexity of the multimodal intervention as well as the procedures involved in the study required the inclusion of multiple agents in its design. In this context, we used a co-creation approach in which (diet and physical activity) and mood, enabling an intensive follow-up of participants. These data will also be used to give feedback to participants about their own performance along the intervention, promoting their involvement and adherence. Furthermore, the analyses of these continuous data will allow for the identification of different cognitive performance trajectories based on the lifestyle habits of each participant and their adherence to the intervention. Accordingly, we expect to identify responders and non-responders to the intervention and characterize which factors are associated with such response profiles.

In summary, we expect the data gathered from this study and the innovative analyses of the results may aid researchers in the design of future clinical trials involving preventive lifestyle multicomponent interventions as well as to shed light on effective precision medicine approach strategies.

This project is primarily supported by the Alzheimer Association 

The authors declare no conflicts of interest or other relevant disclosures.

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Prevention of cognitive decline in subjective cognitive decline APOE ε4 carriers after EGCG and a multimodal intervention (PENSA): Study design