Despite the known dangers of older adults’ being prescribed multiple medications for dementia, including death, nearly 14% of older adults with dementia in the United States were prescribed three or more psychotropic and/or opioid medications for more than 30 consecutive days in 2018, according to a study published today in JAMA.
“Although memory impairment is the cardinal feature of dementia, behavioral and psychological symptoms (for example, apathy, delusions, agitation) are common during all stages of illness and cause significant caregiver distress,” wrote Donovan T. Maust, M.D., M.S., of the University of Michigan and colleagues. “Despite limited high-quality evidence of efficacy for pharmacological treatment, clinicians regularly prescribe psychotropic medications to community-dwelling persons with dementia in rates that far exceed use in the general older adult population.”
Maust and colleagues analyzed data on Medicare beneficiaries with dementia who had Part D prescription drug coverage on January 1, 2018. (Those living in long-stay nursing homes were excluded from the analysis.) The study cohort was followed up until the death, loss of Medicare fee-for-service coverage, enrollment in Medicare Advantage, loss of Part D coverage, or December 31, 2018.
The authors analyzed the prescription fills by those in the study cohort that took place between October 1, 2017, and December 31, 2018 (the observation year plus the three preceding months). The authors defined the prevalence of CNS-active polypharmacy in 2018 as “as concurrent exposure to three or more medications for longer than 30 days consecutively from the following six classes: antidepressants, antipsychotics, antiepileptics, benzodiazepines, nonbenzodiazepine benzodiazepine receptor agonist hypnotics (for example, z-drugs), and opioids.”
The final sample included 1,159,968 older adults with dementia (median age 83.0), of whom 13.9% met the criterion for CNS-active polypharmacy. Further analysis of those individuals exposed to CNS-active polypharmacy in 2018 revealed the following:
- They were significantly younger with a higher level of comorbidity compared with those not exposed to polypharmacy.
- 57.8% were exposed to polypharmacy for longer than 180 days and 6.8% for a full year.
- 29.4% were exposed to five or more medications, and 5.2% were exposed to five or more medication classes.
Of the medication classes associated with CNS-active polypharmacy, antidepressants accounted for 92.0% of polypharmacy days, followed by antiepileptics (62.1%), antipsychotics (47.1%), benzodiazepines (40.7%), opioids (32.3%), and z-drugs (6.0%), Maust and colleagues reported. The most common CNS-polypharmacy class combination included at least one antidepressant, one antiepileptic, and one antipsychotic, accounting for 12.9% of polypharmacy days.
“[W]ithout knowing the indication for the medications or examining the range of prescribed dosages, it is not possible to assess the appropriateness of the particular combinations used,” Maust and colleagues wrote. They did caution, however, that there is evidence to suggest that CNS-active polypharmacy increases the risk of respiratory suppression and death, QT-interval prolongation, falls, impaired cognition, and more.
For related information, see the Psychiatric News article “Treating Symptoms of Dementia Requires Trial and Error, Judicious Use of Medication.”
(Image: iStock/fzant)
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