Jenny Greener, Pam Enderby, Renata Whurr

Aphasia describes language impairment associated with a brain lesion. The objective of this review was to assess the effects of drugs on language abilities when given to people with aphasia following stroke. We searched the Cochrane Stroke Group Register (last searched: May 2001), and reference lists of relevant articles to December 1998. We also contacted academic institutions and other researchers to identify further published and unpublished trials. MEDLINE was searched from 1966-1998, and CINAHL from 1982-1998. We searched the International Journal of Disorders of Communication by hand (known by other names in the past), from 1969 to 1998. Randomised controlled trials comparing: ~bullet~Any drug given to improve language, versus no treatment, or versus placebo ~bullet~Any drug given to improve language versus speech and language therapy ~bullet~One drug given to improve language versus another drug given with the same aim The principal reviewer collected the data, and assessed the quality of the trials with independent data checking and methodological advice. If we could not perform a statistical combination of different studies, we sought missing data. Failing that we provided a description. We sought missing data from authors, or where appropriate, a drug company. We considered fifty two studies in detail, from which we identified ten trials suitable for the review. In most cases the methodological quality was unassessable, and only one trial reported sufficient detail for us to complete a description and analysis. This study did lose a large number of patients during its course. Drugs used in the trials identified were piracetam, bifemalane, piribedil, bromocriptine, idebenone, and Dextran 40. We found weak evidence that patients were more likely to have improved on any language measure at the end of the trial if they had received treatment with piracetam (odds ratio 0.46, 95% confidence interval 0.3 to 0.7). The evidence is considered weak because of the large numbers of drop outs from the trials identified, who were lost to follow up. Patients who were treated with piracetam were no more likely (considering statistical significance) than those who took a placebo to experience unwanted effects, including death (odds ratio 1.29, 95% confidence interval for difference 0.9 to 1.7). However, the differences in death rates between the two groups, even though not not statistically significant, do give rise to some concerns that there may be an increased risk of death from taking piracetam. We could not determine if drug treatment is more effective than speech and language therapy. We could not determine whether one drug is more effective than another. The main conclusion of this review is that drug treatment with piracetam may be effective in the treatment of aphasia after stroke. Further research is needed to explore the effects of drugs for aphasia, in particular piracetam. If a trial is done, this must be large enough to have adequate statistical power. The safety of the drug should be of primary interest. Researchers should examine the long term effects of this treatment, and whether it is more effective than speech and language therapy.