Dementia patients do better without drugs


Meta-analysis finds non-pharmacological interventions are more effective for easing behavioural symptoms. Paul Biegler reports.


Study adds to concerns about overmedicating people with dementia.

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An analysis of studies involving more than 23,000 people with dementia has found outdoor activities and massage are more effective than drugs in treating aggression and agitation.

The authors, led by geriatrician Jennifer Watt from St. Michael's Hospital and the University of Toronto in Canada, have called on policymakers to prioritise non-drug treatments for the behavioural and psychological symptoms of dementia.

Dementia affects 50 million people worldwide with up to 75% experiencing so-called neuropsychiatric symptoms, including aggressive behaviour, agitation and anxiety.

The triad bodes ill for sufferers, who are marked out for earlier institutionalisation, greater cognitive decline and worse quality of life, the authors write.

The symptoms also mean misery for caregivers, who report lower quality of life than carers of dementia patients without those behaviours.

Despite the fact that drugs such as antidepressants and antipsychotics can increase the risk of falls, broken bones and death, the authors note their prescribing rates remain high.

At the same time, a lack of reliable data on the relative merits of drug and non-drug treatments for neuropsychiatric symptoms has stymied informed decision-making about treatment options.

“Unfortunately, our understanding of the comparative efficacy of medication versus non-medicine interventions for treating psychiatric symptoms has been limited due to a lack of head-to-head randomised controlled trials of the two routes,” says Watt.

To fill the knowledge gap Watt’s team trawled a raft of databases to collect information for a multi-study analysis.

Their haul took in 163 studies covering 23,143 patients with dementia of at least moderate severity. The mean age of patients was over 70 in almost all studies, with 65% living in a nursing home or assisted living facility.

For people with aggression, the authors found, getting outdoors may be just what the doctor ordered.

The team found that “outdoor activities” – including gardening – were more effective than anti-psychotic medication for treating physical aggression.

Another finding was that massage and touch therapy were better than the patient’s usual care for treating physical agitation.

What is it then, about digging your hands through the earth or feeling the soothing touch of another human being that seems to do the trick?

The success of non-drug treatments, the authors believe, may lie in the simple fact that aggression and agitation are not random manifestations of dementia but signal an issue requiring attention.

“Nonpharmacologic interventions may be efficacious because behaviour has meaning, which needs to be uncovered through multidisciplinary assessments and care that addresses underlying needs,” they write.

The study comes just months after Australia’s Royal Commission into Aged Care Quality and Safety heard that antipsychotic drugs are overprescribed in Australian nursing homes.

Chief medical officer Professor Brendan Murphy said doctors come under pressure from staff with real or perceived workload issues to prescribe drugs for agitated residents.

Authors of the current study say more research is needed to clarify the relative cost-effectiveness of drug and non-drug treatments for aggression and agitation in dementia.

Nonetheless, they are forthright in their recommendations for the treatment of dementia patients.

“These persons and their care partners should consider prioritising nonpharmacologic over pharmacologic interventions for aggression and agitation, given the potential harms associated with certain pharmacologic interventions,” they conclude.

The study appears in the journal Annals of Internal Medicine.

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Paul Biegler is a philosopher, physician and Adjunct Research Fellow in Bioethics at Monash University. He received the 2012 Australasian Association of Philosophy Media Prize and his book The Ethical Treatment of Depression (MIT Press 2011) won the Australian Museum Eureka Prize for Research in Ethics.
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