The Pharmaceutical Journal
Vol 274 No 7335 p138
5 February 2005

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No magic pill for symptoms related to dementia

There is convincing evidence to support use of the atypical antipsychotics risperidone (Risperdal) and olanzapine (Zyprexa) to treat the neuropsychiatric symptoms of dementia, according to US researchers. However, they say that no agent offers a “magic pill” against these symptoms.

The researchers reviewed 25 randomised controlled trials and four meta-analyses that involved drug therapy commonly used for patients with dementia-related neuropsychiatric symptoms. They found evidence that daily doses of 1mg risperidone and 5–10mg olanzapine are at least modestly effective but say that trials of other atypical agents are lacking.

Cholinesterase inhibitors were the only other class of drug that appeared to offer relief from the neuropsychiatric symptoms of dementia. However, the magnitude of effect appears small and is of questionable clinical significance.

No clear evidence was found to support use of mood stabilisers or typical antipsychotics. And although selective serotonin reuptake inhibitors were well tolerated they did not appear to be effective against symptoms other than depression.

“It is clear that none of the drugs in use for neuropsychiatric symptoms offers a magic pill. The effect sizes have been modest at best,” the researchers conclude.

They go on to suggest two approaches to drug treatment. The first is to identify the target symptom and choose a drug to treat it. The alternative is to combine efficacy with the goal of minimising adverse effects, ie, begin with a cholinesterase inhibitor, since they are well tolerated and may benefit cognition and function (JAMA 2005;293:596).

Stephen Bazire, chief pharmacist, Norfolk and Waveney Mental Health Partnership NHS Trust, echoed the view taken by the study authors that, for the drugs available, there was most evidence to support use of risperidone and olanzapine. “However, these are the two drugs that we have been advised by UK regulators not to use because of a small increased risk of stroke.” He added that quetiapine (Seroquel) was becoming more widely used to treat the neuropsychiatric symptoms of dementia since it had sedative properties. It could be argued, however, that its use was based on a lack of evidence of harm rather than evidence that is was safe, he said.