Despite decades of medical consensus urging restraint, a significant proportion of individuals diagnosed with dementia continue to be prescribed medications known to exacerbate risks of falls, cognitive confusion, and subsequent hospitalizations. New findings published in the esteemed medical journal JAMA on January 12 reveal a concerning pattern: approximately one in every four beneficiaries enrolled in Medicare receives these specific classes of drugs, a rate that disproportionately impacts those with compromised cognitive function. This research highlights a persistent challenge in geriatric pharmacotherapy, where vulnerable patient populations remain exposed to potentially harmful treatments.
The study meticulously examined prescription data spanning a nine-year period, from January 1, 2013, to December 31, 2021, drawing upon comprehensive survey information from the Health and Retirement Study and linking it with Medicare fee-for-service claims. Researchers categorized older adults into three distinct groups based on their cognitive status: those exhibiting normal cognitive function, individuals experiencing cognitive impairment but without a formal dementia diagnosis, and those with a confirmed dementia diagnosis. This granular approach allowed for a precise comparison of prescribing practices across varying degrees of cognitive decline.
The core of the investigation focused on a critical group of central nervous system (CNS)-active medications. These encompass antidepressants with pronounced anticholinergic properties, antipsychotics, barbiturates, benzodiazepines, and non-benzodiazepine hypnotics. These drug categories are often flagged for their potential to induce side effects that can significantly impair an older adult’s quality of life and safety, particularly when cognitive faculties are already compromised. Anticholinergic medications, for instance, are known to interfere with the neurotransmitter acetylcholine, which plays a vital role in memory and learning, thereby potentially worsening confusion and cognitive deficits. Antipsychotics, while sometimes necessary for managing severe behavioral disturbances, carry their own risks, including increased sedation, motor impairment, and an elevated likelihood of falls. Benzodiazepines and hypnotics, commonly prescribed for anxiety and sleep disturbances, can lead to drowsiness, unsteadiness, and an increased propensity for falls, especially in individuals with diminished balance and cognitive processing.
While overall prescribing of these CNS-active medications within the broader Medicare population has shown a downward trend, decreasing from 20% to 16% over the study’s duration, this reduction has not been uniform. The data starkly illustrates that individuals with cognitive impairment, especially those with dementia, are still receiving these medications at significantly higher rates. In 2021, the terminal year of the study, an estimated 17% of older adults with normal cognition were prescribed these drugs. This figure rose to nearly 22% for individuals with cognitive impairment but without dementia, and most alarmingly, reached approximately 25% for those with a diagnosed dementia condition. This persistent disparity underscores a critical gap in care, where the very individuals most susceptible to adverse drug reactions are the most likely to be exposed to them.
Dr. John N. Mafi, a senior author of the study and associate professor-in-residence at the David Geffen School of Medicine at UCLA, articulated the gravity of these findings. He noted that while the overall decline in prescribing was an encouraging sign, the persistence of high prescription rates among vulnerable groups is deeply concerning. A particularly troubling observation was that by 2021, over two-thirds of patients receiving these prescriptions lacked a clearly documented clinical rationale within their medical records. This suggests a substantial volume of potentially inappropriate and harmful prescribing practices that persist despite awareness and established medical guidelines. Dr. Mafi emphasized that compared to individuals with unimpaired cognition, those with cognitive impairment, particularly dementia, face an amplified risk of experiencing adverse effects from these medications. He concluded that these results signal substantial opportunities to enhance the quality and safety of healthcare for millions of older Americans.
The study’s methodology involved a sophisticated analysis that connected self-reported data from the Health and Retirement Study, which captures information on health status and medication use, with objective Medicare fee-for-service claims. This linkage provided a robust dataset for tracking medication patterns over an extended period. The researchers meticulously categorized the use of specific CNS-active drugs, allowing for a detailed examination of trends within and across different patient cohorts.
Within the broader Medicare fee-for-service beneficiary population, prescription trends for specific medication types also revealed nuances. For instance, while the use of benzodiazepines and non-benzodiazepine hypnotics saw a notable decrease, other categories may have remained more stable or seen less pronounced declines. This suggests that while progress has been made in curtailing the use of certain sedative-hypnotics, the prescribing of other potentially problematic CNS-active medications, such as antipsychotics or certain antidepressants, may require more targeted interventions.
Signs of improvement were evident, particularly in the reduction of prescriptions deemed likely inappropriate. Prescriptions considered clinically justified saw a modest decline, falling from 6% in 2013 to 5.5% in 2021. Concurrently, prescriptions identified as likely inappropriate experienced a more significant drop, decreasing from 15.7% to 11.4% over the same period. This progress is largely attributed to a concerted effort to reduce the use of benzodiazepines and sleep medications, alongside an overall decrease in prescriptions lacking clear clinical justification. However, the fact that over half of all CNS-active prescriptions in 2021 were still categorized as likely inappropriate highlights the scale of the challenge that remains.
The authors of the study acknowledged certain limitations inherent in their research. Notably, the analysis did not encompass data from Medicare Advantage plans, which represent a significant portion of Medicare beneficiaries. This omission means the findings might not fully capture the prescribing landscape across all Medicare recipients. Furthermore, the study relied on prescription data and could not account for the precise dosage or duration of drug exposure, nor could it fully capture nuanced clinical details such as the presence or severity of agitation, which might influence prescribing decisions. Measuring prescription frequency rather than total drug exposure also presents a potential limitation in fully understanding the impact of these medications.
Dr. Annie Yang, a scholar in the National Clinician Scholars Program at Yale University who led this study during her tenure as an internal medicine resident at UCLA, underscored the critical importance of patient-physician collaboration. She stressed that while CNS-active prescriptions can indeed be appropriate in specific clinical circumstances, it is paramount for older patients and their caregivers to engage in open and thorough discussions with their healthcare providers. This dialogue is essential to ensure that prescribed medications align with individual patient needs and clinical presentations. When medications are deemed inappropriate, Dr. Yang advised that patients and their care teams should actively explore alternative treatment strategies and carefully consider the potential benefits and risks of tapering or discontinuing the medication under medical supervision. This collaborative approach is fundamental to optimizing geriatric pharmacotherapy and minimizing potential harm.
The research was a collaborative effort involving several esteemed institutions and researchers. Co-authors from UCLA included Mei Leng, Dr. Dan Ly, Chi-Hong Tseng, Dr. Catherine Sarkisian, and Nina Harawa. Additional contributions came from Cheryl Damberg of RAND and Dr. A. Mark Fendrick of the University of Michigan. Dr. Ly and Dr. Sarkisian also hold affiliations with the VA Greater Los Angeles Healthcare System, further broadening the scope of expertise brought to the study. Funding for this significant research initiative was provided by grants from the National Institutes of Health and the National Institute on Aging, specifically under grant number R01AG070017-01. This support underscores the national importance placed on understanding and improving the care of older adults with cognitive impairments.
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