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Full Title: Pharmacological Treatment of Dementia
April 2004
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Structured Abstract
Objectives: To determine on the basis of the evidence whether pharmacotherapy for dementia syndromes improves cognitive symptoms and outcomes; delays cognitive deterioration or disease onset of dementia syndromes; whether certain drugs, including alternative medicines (nonpharmaceuticals), are more effective than others; whether certain patient populations benefit more from pharmacotherapy than others; and whether there is evidence supporting pharmacotherapy of ischemic vascular dementia (VaD).
Data Sources: Studies were identified by searching the Cochrane Central trial registry, MEDLINE®, PreMEDLINE®, EMBASE, AMED, CINAHL®, Ageline, and PsycINFO.
Review Methods: English-language randomized, controlled trials (RCTs) were selected if they evaluated pharmacological agents for adults with a diagnosis of dementia according to three widely-used criteria (ICD, DSM, or NINCDS). Crossover trials and low quality studies were excluded. Data were extracted on type of dementia, severity of disease, setting, regimen of pharmacological agents, study duration, main outcome measures, adverse effects, and results. The quality of studies and of adverse effect reporting was assessed.
Results:
Efficacy: In 186 RCTs evaluating 97 drugs, with findings that varied with the dementia population and the specific outcomes in the various domains, specific pharmacological agents showed consistent effects of benefit on global assessment, cognition (general and specific), behavior/mood, and quality of life/activities of daily living (ADL). Caregiver burden and quality of life/ADL were not frequently evaluated.
Delay of disease progression: Cerebrolysin, selegiline plus vitamin E, and donepezil showed some significant effects in patients with mild-to-moderate and moderately severe Alzheimer's disease.
Head to head comparisons: Superiority was seen for sulphomucopolysaccharides over CDP-choline, donepezil over vitamin E, antagonic-stress over nicergoline, antagonic-stress over meclofenoxate, posatirelin over citicoline, and pyritinol over hydergine.
Patient populations: Stratified analyses included age, gender, Apolipoprotein E (APOE) genotype, disease type, disease severity, race by location, care dependence, and presence of depression. Evidence was inconclusive for differences in benefit for either stratified populations or single populations.
Ischemic VaD: A total of 20 pharmacological interventions in 29 studies were applied to vascular dementias. Drug-specific differences in response were suggested between multi-infarct dementia (MID) and Alzheimer's disease (AD), and for AD and VaD. Trials with VaD patients showed effects for memantine, nicergoline, pentoxyfylline, idebenone, donepezil, and cerebrolysin.
Conclusions: Pharmacotherapy for dementia can improve symptoms and outcomes, including in VaD patients. Adverse events should be more systematically reported. Few studies evaluated delay in either disease onset or progression, but there was some evidence suggesting delay in progression. Few studies compared drugs with one another and data was limited in evaluating the efficacy of pharmacotherapy in different patient subgroups.
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Pharmacological Treatment of Dementia
Evidence-based Practice Center: McMaster University
Topic Nominator: American College of Physicians
Current as of April 2004
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