Network-Guided Individualized TMS for BPSD in Alzheimer's Disease: A Double-blind Randomized Controlled Trial

All participants will undergo a series of medical evaluations before and after repetitive transcranial magnetic stimulation (rTMS), including physical examination and routine laboratory tests. After meeting the eligibility criteria and providing written informed consent, each participant will complete cognitive assessments and receive rTMS treatment at the First Affiliated Hospital of Anhui Medical University. Eligible participants will be randomly assigned to the real rTMS group or the sham rTMS group using a random-number table. The individualized stimulation target for each participant will be determined based on the participant's own magnetic resonance imaging data and a predefined BPSD network. Participants will then receive either real or sham rTMS treatment for two weeks. Sham stimulation will be delivered using a sham coil. Except for the stimulation coil, all experimental procedures will be identical between the two groups. Based on a statistical power of 0.80, an effect size of 0.98, a two-sided significance level of 0.05, and an anticipated dropout rate of 10%, the final sample size will be 20 participants per group. This is a double-blind study in which both participants and clinical raters will be blinded to group allocation. Only one researcher responsible for randomization will have access to the allocation list. Each participant will receive rTMS treatment for 14 days. Before treatment, a trained researcher will administer cognitive assessments and neuropsychological tests. The primary outcome will be the total score of the Neuropsychiatric Inventory (NPI). Secondary assessments will include measures of cognitive function, including the ADAS-Cog, MoCA, MMSE, DST, Stroop test, BNT-30, VFT, and CDT; memory function assessed by the CAVLT; emotional symptoms assessed by the HAMA and HAMD; and treatment tolerability. All assessments will be completed within two days. Participants will also undergo multimodal MRI and electroencephalography (EEG) examinations. After the final rTMS session, treatment-related adverse events will be assessed, and participants will be instructed to answer relevant questions based on their condition during the previous 14 days. Participants will also complete the same neuropsychological assessment battery as at baseline and undergo multimodal MRI and EEG examinations again.

• Alzheimers Disease Assessment Scale Cognitive section (ADAS-Cog) [Time frame: Baseline and 2 weeks]
• Mini Mental State Examination (MMSE) [Time frame: Baseline and 2 weeks]
• Montreal Cognitive Assessment (MoCA) [Time frame: Baseline and 2 weeks]
• Digital Span Test; Forward and Backward (DST) [Time frame: Baseline and 2 weeks]
• Hamilton Depression Scale (HAMD) [Time frame: Baseline and 2 weeks]
• Hamilton Anxiety Scale (HAMA) [Time frame: Baseline and 2 weeks]
• The Stroop color word test [Time frame: Baseline and 2 weeks]
• TMT (Trail Making Test) [Time frame: Baseline and 2 weeks]