R G Marriott1, W Neil, S Waddingham. 1. South Yorkshire Mental Health Trust, Calder Unit, Fieldhead Hospital, Ouchthorpe Lane, Wakefield, Yorkshire, UK, WF1 3SP. rmarriott@doctors.org.uk
Abstract
BACKGROUND: A large and growing number of older people across the world suffer from schizophrenia. Recommendations for their treatment are largely based on data extrapolated from studies of the use of antipsychotic medications in younger populations. In addition most manufacturers of such medications recommend prescription of reduced doses to the elderly. The evidence base for these assumptions is unclear and raises obvious questions regarding the appropriateness of such prescribing practice. OBJECTIVES: To find and assimilate good evidence of the effects of antipsychotic medication for treatment of schizophrenia in people over 65 years of age. SEARCH STRATEGY: We searched the Cochrane Schizophrenia Group's Register (May 2003). We inspected references of all included studies for further trials and contacted relevant pharmaceutical companies. SELECTION CRITERIA: All clinical randomised trials evaluating antipsychotic drugs for schizophrenia and schizophrenia-like psychoses in older people. DATA COLLECTION AND ANALYSIS: We extracted data independently. For homogenous dichotomous data, the random effects, relative risk (RR), and 95% confidence interval (CI) and, where appropriate, the numbers needed to treat (NNT) were calculated on an intention-to-treat basis. For continuous data, we calculated weighted mean differences (WMD). MAIN RESULTS: Two hundred and fifty two elderly people with schizophrenia participated in three relevant randomised controlled studies. We were unable to extract usable data on quality of life, satisfaction, service use, or economic outcomes. One small study (n=18) compared thioridazine with remoxipride (RR leaving the study early 1.0 CI 0.07 to 13.6). A second study (n=175) compared risperidone with olanzapine. Global state 'not improved/worse' was not significantly different between treatments (n= 171, RR 1.26 CI 0.8 to 1.9); mental state PANSS total endpoint scores were also equivocal (n=171, RR 0.98 CI 0.76 to 1.26) as were all cognitive function tests. The third study (subset n=59) compared olanzapine with haloperidol and mental state change scores (BPRS WMD -3.60 CI -10.8 to 3.6; PANSS WMD -6.00 CI -18.3 to 6.3) were equivocal. AUTHORS' CONCLUSIONS: Antipsychotics may be widely used in the treatment of elderly people with schizophrenia, however, based on this systematic review, there are little robust data available to guide the clinician with respect to the most appropriate drug to prescribe. Clearly reported large short, medium and long-term randomised controlled trials with participants, interventions and primary outcomes that are familiar to those wishing to help elderly people with schizophrenia are long overdue.
BACKGROUND: A large and growing number of older people across the world suffer from schizophrenia. Recommendations for their treatment are largely based on data extrapolated from studies of the use of antipsychotic medications in younger populations. In addition most manufacturers of such medications recommend prescription of reduced doses to the elderly. The evidence base for these assumptions is unclear and raises obvious questions regarding the appropriateness of such prescribing practice. OBJECTIVES: To find and assimilate good evidence of the effects of antipsychotic medication for treatment of schizophrenia in people over 65 years of age. SEARCH STRATEGY: We searched the Cochrane Schizophrenia Group's Register (May 2003). We inspected references of all included studies for further trials and contacted relevant pharmaceutical companies. SELECTION CRITERIA: All clinical randomised trials evaluating antipsychotic drugs for schizophrenia and schizophrenia-like psychoses in older people. DATA COLLECTION AND ANALYSIS: We extracted data independently. For homogenous dichotomous data, the random effects, relative risk (RR), and 95% confidence interval (CI) and, where appropriate, the numbers needed to treat (NNT) were calculated on an intention-to-treat basis. For continuous data, we calculated weighted mean differences (WMD). MAIN RESULTS: Two hundred and fifty two elderly people with schizophrenia participated in three relevant randomised controlled studies. We were unable to extract usable data on quality of life, satisfaction, service use, or economic outcomes. One small study (n=18) compared thioridazine with remoxipride (RR leaving the study early 1.0 CI 0.07 to 13.6). A second study (n=175) compared risperidone with olanzapine. Global state 'not improved/worse' was not significantly different between treatments (n= 171, RR 1.26 CI 0.8 to 1.9); mental state PANSS total endpoint scores were also equivocal (n=171, RR 0.98 CI 0.76 to 1.26) as were all cognitive function tests. The third study (subset n=59) compared olanzapine with haloperidol and mental state change scores (BPRS WMD -3.60 CI -10.8 to 3.6; PANSS WMD -6.00 CI -18.3 to 6.3) were equivocal. AUTHORS' CONCLUSIONS: Antipsychotics may be widely used in the treatment of elderly people with schizophrenia, however, based on this systematic review, there are little robust data available to guide the clinician with respect to the most appropriate drug to prescribe. Clearly reported large short, medium and long-term randomised controlled trials with participants, interventions and primary outcomes that are familiar to those wishing to help elderly people with schizophrenia are long overdue.