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When drug treatments are described throughout this chapter it is always important to bear in mind the general principles of pharmacotherapy in the person with brain damage, whether caused by injury or disease, which are discussed in Chapterf.!.!!.

Donepezil, an anticholinesterase inhibitor, probably produces an improvement in cognition in a proportion of patients with mild to moderate Alzheimer's disease. It takes a few weeks to take effect/!.8.' and improvements may be sustained for at least a year on continued treatment. At the time of writing the published evidence only comes from one research group. Donepezil seems to be without serious untoward effects, but it is expensive and its effect should be monitored and reviewed at !2 weeks. Treatment should continue only for those who show benefit. (!i.> More recently, rivastigmine has been introduced as an alternative to donepezil in dementia. (29 A recent case series suggests that donepezil may also be effective in patients with brain injury. (2!>

Systematic reviews, to be found in the !998 Cochrane Library, find no support for the use of piracetam, nimodipine, or lecithin in dementia. There is some support for the use of selegiline (deprenyl) in Alzheimer's disease, but this is insufficient to recommend its routine clinical use. Vitamin E may slow the rate of functional decline in moderately impaired patients with Alzheimer's disease, and given its limited potential to cause adverse side-effects its use can possibly be justified. <!3) It has been suggested that hydergine, a mixture of four derivatives of ergotoxine, is effective, particularly if there is evidence of a vascular dementia, but the evidence is fragile. (22,> Many patients take an extract of the leaves of the maidenhair tree ( Ginkgo biloba), whose mechanism of action is unknown but may be similar to that of hydergine. It probably does no harm, but there is no good evidence that it does any good. (23>

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