A significant proportion of older adults diagnosed with dementia continue to receive prescriptions for neuroactive medications, despite established medical guidance recommending extreme caution due to heightened risks of adverse effects including falls, cognitive deterioration, and hospitalization. New findings, published on January 12 in the esteemed peer-reviewed journal JAMA, reveal that approximately one in every four individuals enrolled in Medicare who have dementia are being prescribed these potent drugs. This trend persists even as overall prescribing of these medications across the broader Medicare beneficiary population has seen a gradual decrease over the past decade.
The research team meticulously analyzed extensive data spanning nine years, from January 1, 2013, to December 31, 2021, drawing from both the Health and Retirement Study and linked Medicare fee-for-service claims. Their objective was to comprehensively map the prescribing patterns of central nervous system (CNS)-active medications, categorizing older adults into three distinct cognitive groups: those with normal cognitive function, individuals experiencing cognitive impairment without a dementia diagnosis, and those formally diagnosed with dementia. This detailed stratification allowed for a nuanced understanding of how medication use varies across different levels of cognitive health.
Within the broad spectrum of Medicare beneficiaries, the study observed a downward trend in the utilization of these CNS-active drugs, with overall usage declining from 20% at the commencement of the study period to 16% by its conclusion. However, this encouraging general decline is overshadowed by the persistent over-prescription among individuals with cognitive impairment. These patients, by definition, are more susceptible to the detrimental consequences associated with these medications, making their continued high prescription rates a matter of significant concern for patient safety and quality of care.
Dr. John N. Mafi, a senior author of the study and an associate professor-in-residence in medicine at the David Geffen School of Medicine at UCLA, emphasized the gravity of the findings. "While the general decline in prescriptions is a positive step, our analysis at the close of the study period in 2021 indicated that over two-thirds of patients receiving these prescriptions lacked a clearly documented clinical justification," he stated. "This strongly suggests a pervasive pattern of potentially inappropriate and harmful prescribing practices." Dr. Mafi further highlighted the disparity, noting, "Compared to patients with intact cognition, we identified significantly higher rates of these medications being prescribed to older adults with cognitive impairment. These individuals are inherently at a greater risk for severe adverse outcomes from these drugs. The results unequivocally point to substantial unmet needs and opportunities to enhance the quality and safety of healthcare for millions of elderly Americans."
The investigation specifically focused on five critical classes of CNS-active medications known for their potential to profoundly affect brain function and behavior. These include antidepressants with significant anticholinergic properties, antipsychotic medications, barbiturates, benzodiazepines, and non-benzodiazepine hypnotic agents, commonly prescribed for sleep disturbances. The anticholinergic properties, in particular, are associated with a range of side effects, including dry mouth, blurred vision, constipation, urinary retention, and importantly, confusion and delirium, which can be particularly debilitating for individuals with pre-existing cognitive decline. Antipsychotics, while sometimes used for behavioral disturbances associated with dementia, carry risks of movement disorders, sedation, and metabolic changes. Benzodiazepines and similar sedatives can exacerbate confusion, increase the risk of falls, and lead to dependence, making them problematic for long-term use, especially in vulnerable populations.
The study’s detailed breakdown of prescribing rates across the cognitive groups revealed stark differences. While 17% of older adults with normal cognition received CNS-active medications, this figure rose to nearly 22% among those with cognitive impairment but without a dementia diagnosis. The most striking statistic, however, was reserved for individuals with diagnosed dementia, where a substantial 25% were prescribed these potentially hazardous drugs. This indicates that as cognitive function declines, the reliance on these medications, despite their known risks, appears to increase.
Further granular analysis of prescription trends among all Medicare fee-for-service beneficiaries showcased a varied landscape of prescribing patterns for different drug classes. While the original article does not detail these specific variations, the implication is that certain drug categories within the CNS-active umbrella might be more prevalent or declining at different rates, warranting further targeted investigation into their specific use cases and risks within the dementia population.
Despite the concerning prevalence, the research did identify glimmers of progress. Prescriptions that were deemed clinically justified showed a modest decline, decreasing from 6% in 2013 to 5.5% by 2021. More significantly, prescriptions viewed as likely inappropriate experienced a more pronounced reduction, falling from 15.7% to 11.4% over the same period. This improvement is largely attributed to a noticeable decrease in the prescribing of benzodiazepines and sleep medications, alongside an overall reduction in prescriptions lacking clear clinical rationale. This suggests that awareness campaigns and guideline adherence may be having a positive impact on certain classes of these drugs.
However, the researchers were candid about the limitations inherent in their study. Notably, the analysis did not encompass data from Medicare Advantage plans, which cover a significant portion of the elderly population. This omission means the findings might not fully represent the complete picture of medication use. Furthermore, the study’s methodology focused on the prevalence of prescriptions rather than the precise quantity or duration of drug exposure, which could offer a more refined understanding of the cumulative impact. The data also may not have fully captured specific clinical nuances such as the presence or severity of agitation, a common symptom in dementia that sometimes prompts the use of these medications.
Dr. Annie Yang, a scholar in the National Clinician Scholars Program at Yale University and a lead author of the study during her tenure as a UCLA internal medicine resident, stressed the crucial need for a collaborative approach between patients, caregivers, and healthcare providers. "While CNS-active prescriptions can indeed be appropriate in certain specific clinical circumstances, it is paramount that older patients and their families engage in open and thorough discussions with their physicians," Dr. Yang advised. "The goal must be to ensure that these medications are truly necessary and beneficial for each individual’s unique situation. When prescriptions are found to be inappropriate or no longer serving a clear purpose, patients and their care teams should actively explore alternative treatment strategies. This includes considering the potential safety and efficacy of gradually reducing or discontinuing the medication altogether, under careful medical supervision."
The research was a collaborative effort involving several distinguished academics. Co-authors include Mei Leng, Dr. Dan Ly, Chi-Hong Tseng, Dr. Catherine Sarkisian, and Nina Harawa from UCLA. Cheryl Damberg of RAND and Dr. A. Mark Fendrick of the University of Michigan also contributed significantly. Dr. Ly and Dr. Sarkisian hold affiliations with the VA Greater Los Angeles Healthcare System, underscoring a multidisciplinary approach to the research. Funding for this vital investigation was generously provided by the National Institutes of Health and the National Institute on Aging, specifically through grant R01AG070017-01, highlighting the national importance placed on understanding and improving care for the aging population.
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