V. Kirchner

As the need for services for people with dementia grows, and the benefits of early intervention become clear, it has become important to understand what factors may improve access to services for people with early-stage dementia. There are a number of models of service access, and these emphasise different areas, whether individual factors, relationships, or social context. The relevance of these models to variations in service access for people with early-stage dementia, and how well they relate to professional accounts, is not well known. In this study, 30 key professionals were interviewed about access to services for people with early-stage dementia in order to explore how different models of access were reflected in their own understandings. People with early-stage dementia were thought to have a range of complex needs, but participants felt these needs remained largely unmet. When articulating the reasons why they thought needs were unmet, participants focused on the impact of the framework within which services are delivered. The findings highlight the importance of considering relationships and socio-contextual factors, such as the impact of the framework of service delivery, when attempting to understand variations in access to services. In order to improve access to services, it will be necessary to move beyond addressing individual factors relating to access, and to consider the impact of the framework for service delivery and the relationships that influence contact with services.

Neuroleptic drugs are controversial treatments in dementia, with evidence accumulating that they may hasten clinical decline. Despite these concerns, they are commonly prescribed for elderly and demented patients. Thioridazine, a phenothiazine neuroleptic, has been commonly prescribed because it was thought to produce relatively less frequent motor side effects. The drug has significant sedative effect, and it is thought that this is the main mechanism of action in calming and controlling the patient. However, pharmacologically, it also has marked anticholinergic properties that could potentially have a detrimental effect on cognitive function. To evaluate the efficacy of thioridazine in dementia in terms of: 1) efficacy in controlling symptoms 2) cognitive outcome for the patient 3) safety The CDCIG Specialised register of trials was searched on 13 March 2009 using the terms 'thioridazine' and 'melleril'. This register contains up to date references from major health care databases like MEDLINE and EMBASE as well as records from trials databases in the field of dementia. Unconfounded, single‐blind or double‐blind, randomised trials were identified in which treatment with thioridazine was administered for more than one dose and compared to an alternative intervention in patients with dementia of any aetiology. Trials in which allocation to treatment or comparator were not truly random, or in which treatment allocation was not concealed, were reviewed but are not included in the data analysis. Data were extracted independently by the reviewers (VK, CAK and RJH). For continuous and ordinal variables, the main outcome measures of interest were the final assessment score and the change in score from baseline to the final assessment. The assessment scores were provided by behavioural rating scales, clinical global impression scales, functional assessment scales, psychometric test scores, and frequency and severity of adverse events. Data were pooled where appropriate or possible, and the Peto odds ratio (95%CI) or the weighted mean difference (95%CI) estimated. Where possible, intention to treat data were used. The meta‐analysis showed that, compared with placebo, thioridazine reduced anxiety symptoms as evidenced by changes on the Hamilton Anxiety Scale. However, there was no significant effect on clinical global change, and a non‐significant trend for higher adverse effects with thioridazine. Compared to diazepam, thioridazine was superior in terms of some anxiety symptoms, with similar adverse effects. Global clinical evaluation scales did not favour either treatment. Compared to chlormethiazole, thioridazine was significantly inferior when assessed on some items of the CAPE and the Crichton Geriatric Behavioural Rating Scales. Thioridazine was also associated with significantly more dizziness. No superiority for thioridazine was shown in comparisons with etoperidone, loxapine or zuclopenthixol, except to produce fewer side effects than loxapine. Very limited data are available to support the use of thioridazine in the treatment of dementia. If thioridazine were not currently in widespread clinical use, there would be inadequate evidence to support its introduction. The only positive effect of thioridazine when compared to placebo is the reduction of anxiety. When compared to placebo, other neuroleptics, and other sedatives, it has equal or higher rates of adverse effects. Clinicians should be aware that there is no evidence to support the use of thioridazine in dementia, and its use may expose patients to excess side effects. Thioridazine dans la démence Les médicaments neuroleptiques sont des traitements controversés dans la démence ; il existe de plus en plus de preuves indiquant qu'ils pourraient accélérer le déclin clinique. Malgré ces inquiétudes, ils sont souvent prescrits pour les patients âgés et atteints de démence. La thioridazine, un neuroleptique à base de phénothiazine, est couramment prescrite car on estime qu'elle entraîne moins d'effets secondaires moteurs. Ce médicament possède un effet sédatif significatif, lequel serait le principal mécanisme d'action pour calmer et contrôler le patient. Cependant, du point de vue pharmacologique, elle possède également des propriétés anticholinergiques marquées qui pourraient avoir un effet néfaste sur la fonction cognitive. Évaluer l'efficacité de la thioridazine pour traiter la démence en termes : 1) d'efficacité pour contrôler les symptômes 2) de résultat cognitif pour le patient 3) d'innocuité Le 13 mars 2009, une recherche a été effectuée dans le registre d'essais spécialisé du CDCIG à partir des termes thioridazine et melleril. Ce registre contient des références mises à jour de grandes bases de données médicales comme MEDLINE et EMBASE, ainsi que des rapports de bases de données d'essais dans le domaine de la démence. Des essais randomisés, en simple ou double aveugle et non biaisés dans lesquels un traitement par thioridazine était administré avec plus d'une dose et comparé à une intervention alternative chez des patients atteints de démence, quelle qu'en soit l'étiologie, ont été identifiés. Les essais dans lesquels l'assignation au traitement ou au comparateur n'était pas réellement au hasard ou dans lesquels l'assignation au traitement n'était pas dissimulée ont été examinés mais pas inclus dans l'analyse des données. Les données ont été extraites de manière indépendante par les évaluateurs (VK, CAK et RJH). Pour les variables continues et ordinales, les principaux critères de jugement d'intérêt étaient le score...