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. 2020 Jun 16;20(1):212.
doi: 10.1186/s12877-020-01607-7.

Safety of pharmacologic interventions for neuropsychiatric symptoms in dementia: a systematic review and network meta-analysis

Jennifer A Watt  1   2 , Zahra Goodarzi  3   4   5 , Areti Angeliki Veroniki  6   7   8 , Vera Nincic  6 , Paul A Khan  6 , Marco Ghassemi  6 , Yuan Thompson  6 , Yonda Lai  6 , Victoria Treister  6 , Andrea C Tricco  6   9 , Sharon E Straus  6   10   9
Affiliations

Safety of pharmacologic interventions for neuropsychiatric symptoms in dementia: a systematic review and network meta-analysis

Jennifer A Watt et al. BMC Geriatr. .

Abstract

Background: Prescribing trends suggest that pharmacologic alternatives to antipsychotics are gaining in popularity, but randomized trial (RCT) data of their comparative safety is scarce. Our objective was to describe the comparative safety of pharmacologic interventions for treating neuropsychiatric symptoms in dementia.

Methods: We searched MEDLINE, EMBASE, CENTRAL, CINAHL, and PsycINFO, from inception to May 28, 2019, for studies of pharmacologic interventions used to treat neuropsychiatric symptoms in dementia. Dementia care partners selected fracture risk as our primary outcome. Pairs of reviewers, working independently, conducted all study screening, data abstraction, and risk of bias appraisal. We conducted Bayesian random-effects network meta-analyses (NMAs) using data from RCTs to derive odds ratios (ORs). In secondary analyses, we conducted frequentist random-effects NMAs using data from RCTs and Bayesian three-level hierarchical random-effects NMAs incorporating data from RCTs and non-randomized studies.

Results: Our systematic review included 209 randomized and non-randomized studies (889,378 persons with dementia). In NMAs of data from randomized trials, there were no increased odds of fracture associated with any intervention in primary analyses; however, data were sparse. We found increased odds of cerebrovascular events associated with antipsychotics (odds ratio [OR] 2.12, 95% credible interval [CrI] 1.29 to 3.62; number needed to harm [NNH] = 99) and increased odds of falls associated with dextromethorphan-quinidine (OR 4.16, 95% CrI 1.47 to 14.22; NNH = 55) compared to placebo in persons with dementia. In a subgroup of persons with Alzheimer disease, antipsychotics were associated with increased odds of fracture compared to anticonvulsants (OR 54.1, 95% CrI 1.15 to 38,300; NNH = 18). In older persons (mean age ≥ 80 years) with dementia, anticonvulsants were associated with increased odds of death compared to placebo (OR 8.36, 95% CrI 1.17 to 203.4; NNH = 35) and antipsychotics were associated with increased odds of death compared to antidepressants (OR 5.28, 95% CrI 1.06 to 3.51; NNH = 47).

Conclusion: Although antipsychotics were associated with greater harm than antidepressants and anticonvulsants in subgroups of persons with dementia, medications used in lieu of antipsychotics for treating neuropsychiatric symptoms in dementia, such as anticonvulsants and dextromethorphan-quinidine, were also associated with harm. Decision-making concerning treatments prescribed in lieu of antipsychotics should include potential harms.

Prospero registration: CRD42017050130.

Keywords: Dementia; Harm; Meta-analysis; Network meta-analysis; Neuropsychiatric symptoms; Systematic review.

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Conflict of interest statement

JAW was supported by a Canadian Institutes of Health Research (CIHR) doctoral research award and the University of Toronto Department of Medicine Eliot Phillipson Clinician Scientist Training program during the completion of this manuscript. ACT is on the editorial board for BMC Medicine and funded by a Tier 2 Canada Research Chair in Knowledge Synthesis. SES is funded by a Tier 1 Canada Research Chair in Knowledge Translation. AAV is funded by a European Union’s Horizon 2020 grant [No. 754936]. All other authors have nothing to disclose.

Figures

Fig. 1
Fig. 1
PRISMA Flow Diagram
Fig. 2
Fig. 2
Network Diagrams Nodes represent individual interventions and nodes connected by lines indicate that these two interventions have been directly compared in a randomized trial. The nodes are weighted by number of randomized trials evaluating this treatment and lines are weighted by number of randomized trials evaluating this treatment comparison
Fig. 3
Fig. 3
Rank-Heat Plot of Safety Outcomes Associated with Pharmacologic Interventions Prescribed to Treat Neuropsychiatric Symptoms in Persons with Dementia. The scale bar represents the Surface Under the Cumulative Ranking Curve (SUCRA) value for each intervention. The lowest SUCRA values are indicated in red (worst/most dangerous treatments) and the highest SUCRA values are indicated in green (best/safest treatments). An asterisk (*) indicates this is a treatment without data for the outcome of interest
See this image and copyright information in PMC

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