Dementia: A review of the evidence.

To make my discussions with Health Professionals a.k.a. "experts" more effective, I need to know what they know. To help me with this task, I have been rummaging through The Cochrane Library. The results for Dementia NOT "Down Syndrome" NOT Vascular NOT Aids NOT carer and Reviews only produced 44 results. Some weren't relevant. The following are relevant and I have added the plain language summary:-

Acetyl-l-carnitine for dementia. No evidence of benefit of Acetyl-l-carnitine for dementia.
Alpha lipoic acid for dementia. No evidence of efficacy of alpha lipoic acid for dementia.
Antidepressants for treating depression in dementia. Insufficient evidence for the efficacy and safety of antidepressants for depression in dementia.
Aroma therapy for dementia. The one small trial published is insufficient evidence for the efficacy of aroma therapy for dementia.
Cannabinoids for the treatment of dementia. No evidence that cannabinoids are effective in the improvement of disturbed behaviour in dementia or in the treatment of other symptoms of dementia.
Cholinesterase inhibitors for dementia with Lewy bodies. No convincing evidence from one trial of the efficacy of cholinesterase inhibitors for dementia with Lewy bodies.
Cholinesterase inhibitors for Parkinson's disease dementia. Rivastigmine appears to moderately improve cognition and to a lesser extent activities of daily living in patients with PDD.
Donepezil for dementia due to Alzheimer's disease. Donepezil is beneficial for people with mild, moderate and severe dementia due to Alzheimer's disease.
Ginkgo biloba for cognitive impairment and dementia. There is no convincing evidence that Ginkgo biloba is efficacious for dementia and cognitive impairment.
Haloperidol for agitation in dementia. No evidence has been found of any significant general improvement in manifestations of agitation, other than aggression, among demented patients treated with haloperidol, compared with controls.
Homeopathy for dementia. No evidence that homeopathy is effective in treating dementia.
Hormone replacement therapy to maintain cognitive function in women with dementia. There is no evidence of a positive effect that oestrogen replacement therapy can maintain cognitive function for a longer period of time (> five months) in women with Alzheimer's disease.
Hydergine for dementia. Uncertainty about the efficacy of hydergine in dementia.
Lecithin for dementia and cognitive impairment. Doubtful effect of lecithin as a treatment for dementia.
Light therapy for managing cognitive, sleep, functional, behavioural, or psychiatric disturbances in dementia. There is insufficient evidence to determine whether light therapy is effective in the management of cognitive, sleep, functional, behavioural or psychiatric disturbances in dementia.
Massage and touch for dementia. Insufficient evidence to draw conclusions about the possibility that massage and touch interventions are effective for dementia or associated problems.
Memantine for dementia. Some evidence of efficacy of memantine for dementia.
Music therapy for people with dementia. There is no substantial evidence to support nor discourage the use of music therapy in the care of older people with dementia.
Nicergoline for dementia and other age associated forms of cognitive impairment. Nicergoline may improve cognition and behavioural function of people with mild to moderate dementia.
Omega 3 fatty acid for the prevention of dementia. There is no evidence that dietary or supplemental omega 3 polyunsaturated fatty acid (PUFA) reduces the risk of cognitive impairment or dementia in healthy elderly persons without pre-existing dementia. This review yielded no clinical trials that could confirm or refute the utility of omega 3 PUFA in preventing cognitive impairment or dementia. This is an important area that is in pressing need of further research.
Physical activity programs for persons with dementia. There is insufficient evidence to determine the effectiveness of physical activity programs in managing or improving cognition, function, behaviour, depression, and mortality in people with dementia.
Physostigmine for dementia due to Alzheimer's disease. Limited evidence of effectiveness of physostigmine for the symptomatic treatment of Alzheimer's disease.
Piracetam for dementia or cognitive impairment. Evidence for the efficacy of piracetam for dementia or cognitive impairment is inadequate for clinical use but sufficient to justify further research.
Procaine treatments for cognition and dementia. In analysing the effect of procaine and its preparations, there was no evidence for benefit in the prevention or treatment of dementia or cognitive impairment.
Propentofylline for dementia. Limited evidence that propentofylline benefits cognition, global function and activities of daily living in people with Alzheimer's disease and/or vascular dementia.
Reminiscence therapy for dementia. Inconclusive evidence of the efficacy of reminiscence therapy for dementia.
Snoezelen for dementia. No evidence of the efficacy of snoezelen or multi-sensory stimulation programmes for people with dementia.
Statins for the prevention of dementia. There (is) good evidence that statins given in late life to individuals at risk of vascular disease have no effect in preventing dementia.
Thioridazine for dementia. No evidence to support the use of thioridazine for dementia.
Transcutaneous Electrical Nerve Stimulation (TENS) for dementia. Insufficient data to determine the efficacy of transcutaneous electrical nerve stimulation for dementia.
Trazodone for agitation in dementia. Insufficient evidence from randomized, placebo-controlled studies to support a recommendation that trazodone should be prescribed, or not prescribed, for BPSD.
Validation therapy for dementia. No new evidence of the efficacy of validation therapy for people with dementia or cognitive impairment has been identified.
Valproate preparations for agitation in dementia. No evidence of efficacy of valproate preparations for treatment of agitation in people with dementia.
Vinpocetine for cognitive impairment and dementia. Insufficient evidence of benefits of vinpocetine for people with dementia.

So there you have it. Virtually everything that's been thoroughly tested is ineffective for the treatment of dementia.
There are a whole load of things that haven't been properly tested yet e.g. Omega-3, Vitamin D3, Vitamin K2, Curcumin, Berberine, Trans-dermal Progesterone, Sub-lingual B12, S-Adeno-Methionine and The Ketogenic Diet. What is The Alzheimer's Society doing with all of the money that they get?

Finally, I accept that mum is on her last legs and won't be around for much longer, so here's a song. I normally hate raps, but the Pinky & Perky backing vocals are kinda quirky and the lyrics are poignant. So here's Stay with Me by DJ Ironik. Listen to the words!

"Experts"...again!

As mentioned in A slight hitch, Part 2., I attended a "robust" meeting with social services, representatives of the nursing home, mum's Community Psychiatric Nurse and mum's Memory Clinic consultant. Although the meeting didn't go quite as I'd hoped, the outcome was good as the standard of care at the nursing home has improved. She's moving to a better nursing home on Monday 15th March anyway as I'd had enough of the shenanigans with the management that runs the current nursing home.

After the meeting, I had a long chat with mum's Memory Clinic consultant. He explained that I couldn't give mum supplements based on weak evidence e.g. in-vitro studies, animal studies or epidemiological/observational human studies showing associations between "A" & "B". There had to be a sufficient number of large Randomised Controlled Trials (RCTs). Fair enough.

I recently e-mailed the consultant including a couple of links to RCTs showing the positive effect of Vitamin D3 on mood. He e-mailed back saying that the evidence was still weak and he linked me to The Cochrane Collaboration web-site and also to the book Evidence Based Medicine - How to Practice and Teach EBM. I bought the book and took a look at the web-site.

Due to a bug on Amazon, looking inside the above book showed me a completely different book which contained a very interesting piece of information.

The Flecainide Story
Pre-Ventricular Contractions (PVCs) are a fancy name for cardiac arrhythmias. PVCs often result in Ventricular Fibrillation (VF) & death during heart attacks. A crossover study done in the US in the 1980s showed that Flecainide drastically reduced PVCs compared to placebo. Flecainide was approved by the US Food & Drugs Administration (FDA) and prescribed to hundreds of thousands of American heart attack patients (though it never caught on in Europe or Australia).

Unfortunately a later study, the Cardiac Arrhythmia Suppression Trial (CAST) showed that, over an 18 month period, about 12% of patients taking Flecainide died compared to about 5% of patients taking placebo. Oh, whoops! It took quite a while for the bad news to be accepted (as nobody likes bad news especially when it adversely affects drug sales & profits) and for Flecainide to be taken off the market. In the meantime, tens of thousands of Americans died unnecessarily. This is what happens when "experts" focus on one outcome only and ignore the rather more important outcome of all-cause mortality.

Statins reduce cardiac deaths in men under 50 who have had one or more heart attacks. There's a statistically-insignificant reduction in all-cause mortality though as deaths from other causes increase. There's also no statistically-significant all-cause mortality benefit to men over 50 or all women who have had one or more heart attacks, or people who haven't had a heart attack. However, that hasn't stopped statins being prescribed to all and sundry, whether young or old, whether male or female and whether having had a heart attack or not.


The Cochrane Collaboration web-site was most interesting. During my long chat with mum's Memory Clinic consultant, he explained that mum was prescribed a cholinesterase inhibitor (Donepezil a.k.a. Aricept) as there was strong evidence for its benefit. I found Donepezil for dementia due to Alzheimer's disease which indeed confirmed the benefit to patients with Alzheimer's Disease (AD). The thing is, mum doesn't have AD. She has Dementia with Lewy Bodies (DLB). I then found Cholinesterase inhibitors for dementia with Lewy bodies, which concluded:-

"Patients with dementia with Lewy bodies who suffer from behavioural disturbance or psychiatric problems may benefit from rivastigmine if they tolerate it, but the evidence is weak." (emphasis added by me).

There is a condition called Parkinson's Disease Dementia (PDD) which is similar (but not identical) to DLB and I found Cholinesterase inhibitors for Parkinson's disease dementia which concluded:-

"Rivastigmine appears to improve cognition and activities of daily living in patients with PDD."

Rivastigmine is similar (but not identical) to Donepezil. There were no reviews showing the effect of Donepezil on DLB.

So "experts" can prescribe medications based on weak/no evidence but I can't give mum supplements based on weak evidence. I'm not going to e-mail the consultant pointing this out as he may withdraw Donepezil and it does actually have a slight benefit. I'm going to print the above studies and use them to try to persuade mum's new GP (when mum's moved to the new nursing home) to permit me to supply mum with supplements based on my evidence.

I also found Omega 3 fatty acid for the prevention of dementia which stated:-

"Background
Accruing evidence from observational and epidemiological studies suggests an inverse relationship between dietary intake of omega 3 polyunsaturated fatty acid (PUFA) and risk of dementia. Postulated mechanisms that might qualify omega 3 PUFA as an interventional target for the primary prevention of dementia include its anti-atherogenic, anti-inflammatory, anti-oxidant, anti-amyloid and neuroprotective properties.

Main results
There were no randomized trials found in the search that met the selection criteria. Results of two clinical trials are expected in 2008.

Authors' conclusions
There is a growing body of evidence from biological, observational and epidemiological studies that suggests a protective effect of omega 3 PUFA against dementia. However, until data from randomized trials become available for analysis, there is no good evidence to support the use of dietary or supplemental omega 3 PUFA for the prevention of cognitive impairment or dementia."

It's now 2010 and there are still no results from RCTs showing. So, omega-3 PUFAs will not be prescribed despite the evidence from biological, observational and epidemiological studies. Luckily, I keep mum's mini-fridge stocked with smoked salmon and I will request that the new nursing home gives mum a salmon meal twice a week.