The Persistent Problem of Inappropriate Medication Use in Dementia Care
Despite decades of warnings about the risks, a significant number of individuals with dementia continue to receive medications that can worsen confusion, increase fall risk, and lead to hospitalizations. A recent study published in JAMA on January 12th reveals that roughly one in four medicare beneficiaries diagnosed with dementia are prescribed these possibly harmful brain-altering drugs. While overall prescribing rates have decreased slightly, the disproportionately high use among those with cognitive impairment remains a serious concern, highlighting a critical gap in the quality and safety of care for older Americans.
Declining, But Still Too High: A Look at the trends
The study, analyzing data from 2013 to 2021, shows a modest decline in the overall prescribing of potentially inappropriate central nervous system (CNS)-active medications across the entire Medicare population – from 20% to 16%. However, this improvement doesn’t tell the whole story. Individuals already experiencing cognitive decline are significantly more vulnerable to the adverse effects of these drugs, yet they continue to receive them at higher rates.
Dr. John N. Mafi, senior author of the study and an associate professor at UCLA, emphasizes the concerning persistence of inappropriate prescribing: “Over two-thirds of patients receiving these prescriptions lacked a documented clinical indication in 2021, suggesting high levels of potentially inappropriate and harmful prescribing.” This indicates a systemic issue where medications are being used without clear justification, potentially exposing vulnerable patients to unnecessary risks.
Understanding CNS-Active Medications
The study focused on five key categories of CNS-active medications known for their potential to cause harm in individuals with cognitive impairment:
- Antidepressants with strong anticholinergic properties: these drugs can block acetylcholine, a neurotransmitter crucial for memory and learning, exacerbating cognitive decline.
- antipsychotics: While sometimes used to manage behavioral symptoms in dementia, antipsychotics carry a black box warning from the FDA due to increased risk of stroke and death in older adults with dementia.
- Barbiturates: These are sedatives that can cause significant cognitive impairment, confusion, and falls.
- Benzodiazepines: Commonly prescribed for anxiety and insomnia, benzodiazepines can lead to sedation, falls, and increased risk of dementia.
- Non-benzodiazepine hypnotics: Often used as sleep aids, these medications share similar risks to benzodiazepines, including cognitive impairment and falls.
How the Study Was Conducted: A deep Dive into the Data
Researchers meticulously analyzed data from the health and Retirement Study,a nationally representative survey of older Americans,and linked it to Medicare claims data. This allowed them to track the use of CNS-active medications over a nine-year period (2013-2021).Participants were categorized into three groups based on their cognitive status:
- Normal Cognition: Individuals with no signs of cognitive impairment.
- Cognitive Impairment Without Dementia: Individuals experiencing cognitive decline that doesn’t yet meet the criteria for a dementia diagnosis.
- Dementia: Individuals diagnosed with a dementia-related condition, such as Alzheimer’s disease or vascular dementia.
This robust methodology allowed researchers to identify prescribing patterns within each group and assess the prevalence of potentially inappropriate medication use.
Prescribing Rates: A Closer Look at the Numbers
The study revealed significant disparities in prescribing rates across the three cognitive groups:
- Normal Cognition: 17% of older adults received a CNS-active medication.
- Cognitive Impairment (No Dementia): Nearly 22% received a CNS-active medication.
- Dementia: Approximately 25% received a CNS-active medication.
These figures clearly demonstrate that individuals with cognitive impairment,notably those with a dementia diagnosis,are more likely to be prescribed medications with potentially harmful side effects.
Shifting Trends in Specific Medication Classes
beyond overall prescribing rates, the study also identified trends within specific medication classes:
- Benzodiazepines: Decreased from 11.4% to 9.1%
- Nonbenzodiazepine hypnotics: Fell significantly from 7.4% to 2.9%
- Antipsychotics: Increased from 2.6% to 3.6%
- Anticholinergic antidepressants: Remained relatively stable at 2.6%
- Barbiturates: Decreased slightly from 0.4% to 0.3%
The increase in antipsychotic prescriptions is particularly concerning, given the serious risks associated with their use in older adults with dementia. The decline in benzodiazepine and hypnotic use is a positive sign, but further reductions are needed.
Signs of Progress and Remaining Challenges
The study did find some encouraging signs of improvement. Prescriptions considered clinically justified remained relatively stable, while those deemed likely inappropriate decreased from 15.7% to 11.4%. This progress is largely attributed to reduced use of benzodiazepines and sleep medications, and a general decrease in inappropriate prescribing practices. However, the fact that nearly 11.4% of prescriptions were still considered inappropriate in 2021 underscores the need for continued efforts to improve medication safety.
Limitations and Future Research
The researchers acknowledge several limitations to their study. the analysis did not include data from Medicare Advantage plans, potentially underestimating the overall prevalence of inappropriate prescribing. Additionally, the study relied on claims data, which may not capture all clinical details, such as the presence of agitation or other behavioral symptoms that might justify medication use. the study measured prescription rates rather than the total amount of drug exposure over time,meaning it didn’t account for dosage or duration of treatment.
Future research should address these limitations by including Medicare Advantage data, incorporating more detailed clinical data, and examining drug exposure over time. Further investigation is also needed to understand the reasons behind the increase in antipsychotic prescriptions and to identify strategies to reduce their inappropriate use.
What Can Be Done? A call to Action
Dr.Annie Yang,the study’s lead author,emphasizes the importance of collaborative decision-making: “While CNS-active prescriptions might potentially be appropriate in certain specific cases,it is indeed significant for older patients or their caregivers to work closely with their physicians to ensure that these medications are appropriate to their cases. When inappropriate, patients and their care teams should consider choice treatments and consider whether it might be safe to taper or stop the medication.”
Here are some key steps that can be taken to improve medication safety for individuals with dementia:
- Regular Medication Reviews: Patients and caregivers should regularly review all medications with their physician, including over-the-counter drugs and supplements.
- Non-Pharmacological Approaches: Explore non-drug strategies to manage behavioral symptoms, such as music therapy, aromatherapy, and structured activities.
- Caregiver Education: Educate caregivers about the risks and benefits of CNS-active medications and empower them to advocate for their loved ones.
- Deprescribing Initiatives: implement programs to help physicians safely taper and discontinue inappropriate medications.
Key Takeaways
- Approximately 25% of Medicare beneficiaries with dementia receive potentially harmful brain-altering medications.
- Prescribing rates of these medications remain disproportionately high among individuals with cognitive impairment.
- While overall prescribing has declined, inappropriate prescribing persists, highlighting a need for continued improvement.
- Collaborative decision-making between patients,caregivers,and physicians is crucial to ensure medication safety.
Addressing the issue of inappropriate medication use in dementia care requires a multifaceted approach involving healthcare providers, patients, caregivers, and policymakers. By prioritizing medication safety and embracing non-pharmacological approaches, we can improve the quality of life for millions of older Americans living with dementia.
Authors and Funding
The study was co-authored by Mei Leng, Dr.Dan Ly, Chi-Hong tseng, Dr. catherine Sarkisian, and Nina Harawa of UCLA, along with Cheryl Damberg of RAND and Dr. A.Mark Fendrick of University of Michigan. Ly and Sarkisian are also affiliated with VA Greater Los Angeles Healthcare System.
Funding for the research was provided by the National Institutes of Health and the National Institute on Aging (R01AG070017-01).
