A significant proportion of older Americans diagnosed with dementia continue to be prescribed medications known to elevate the risk of falls, cognitive decline, and hospitalization, a concerning trend that persists despite years of medical guidance emphasizing caution. New analysis published in the esteemed scientific journal JAMA reveals that approximately one in every four individuals enrolled in Medicare who live with dementia are currently receiving these types of drugs. This finding emerges from a comprehensive nine-year study that tracked medication patterns among the vast Medicare beneficiary population.
While the overall prescribing rates for these potentially harmful central nervous system (CNS)-active medications have seen a gradual decrease across the entire Medicare landscape, declining from 20% to 16% over the study’s duration, a critical disparity remains. Individuals experiencing cognitive impairment, and particularly those with a dementia diagnosis, are disproportionately more likely to be prescribed these drugs. This vulnerability is exacerbated by the fact that these patients are inherently more susceptible to the adverse effects associated with such medications, including increased instances of falls, heightened confusion, and a greater likelihood of requiring emergency medical attention or extended hospital stays.
Dr. John N. Mafi, a senior author on the research and an associate professor-in-residence of medicine at UCLA’s David Geffen School of Medicine, expressed his concern regarding the persistent prescribing habits. "While the overall decline in these prescriptions is a positive development, the fact that more than two-thirds of patients receiving them in 2021 lacked a clearly documented clinical reason in their medical records points to a troubling level of potentially inappropriate and harmful prescribing practices," Dr. Mafi stated. He further elaborated on the comparative risk, noting, "When contrasted with individuals who maintain normal cognitive function, we observed significantly higher rates of prescribing these medications among older adults with cognitive impairments. These individuals face a substantially elevated risk of experiencing negative consequences from these drugs. The findings underscore a substantial unmet need for improvements in the quality and safety of healthcare delivered to millions of elderly Americans."
To meticulously investigate these prescribing trends, the research team undertook a rigorous examination of data. They integrated survey responses from the Health and Retirement Study with Medicare fee-for-service claims, creating a robust dataset that allowed for a detailed longitudinal analysis. The study meticulously tracked the utilization of a specific set of CNS-active medications – those known for their potential to significantly impact brain function – from January 1, 2013, through December 31, 2021. Participants in the study were categorized into three distinct groups based on their cognitive status: individuals with normal cognition, those with cognitive impairment but without a formal dementia diagnosis, and finally, individuals with diagnosed dementia.
The core of the investigation focused on five key classes of CNS-active medications that carry a higher risk profile for older adults, particularly those with cognitive challenges. These included antidepressants possessing strong anticholinergic properties, antipsychotic medications, barbiturates, benzodiazepines, and non-benzodiazepine hypnotic drugs commonly used for sleep. These drug classes are often flagged for their potential to induce side effects such as drowsiness, dizziness, impaired balance, and an increased risk of falls, as well as exacerbating confusion and memory problems.
The detailed breakdown of prescribing patterns across these cognitive groups painted a stark picture. Among older adults with preserved cognitive function, 17% were prescribed at least one of these CNS-active medications. This figure rose to nearly 22% for individuals experiencing cognitive impairment but who had not yet received a dementia diagnosis. Most alarmingly, approximately 25% of Medicare beneficiaries with a diagnosed dementia condition were found to be on these medications. This indicates a clear and persistent trend of higher prescribing rates for drugs with known risks in the very population most susceptible to their detrimental effects.
Further granularity in the data revealed nuances in prescription trends across different medication types among the broader Medicare fee-for-service beneficiary population. While the study did not detail these specific breakdowns in the provided abstract, the overall trend of higher utilization in cognitively impaired groups remained consistent.
Despite the concerning prevalence of inappropriate prescribing, the study did identify some encouraging signs of progress and a modest decline in certain categories. Prescriptions that were deemed clinically justified, meaning there was a clear medical rationale for their use, saw a slight decrease, moving from 6% in 2013 to 5.5% by 2021. More significantly, prescriptions identified as likely inappropriate demonstrated a sharper downward trajectory, falling from 15.7% to 11.4% over the study period. This notable reduction in potentially unwarranted prescriptions was largely attributed to a decreased reliance on benzodiazepines and sleep medications, as well as an overall reduction in prescriptions flagged as inappropriate across various classes.
However, the researchers were careful to acknowledge certain limitations inherent in their study design. The analysis did not encompass data from Medicare Advantage plans, which represent a substantial portion of Medicare beneficiaries. This exclusion means the findings might not fully represent the prescribing practices for this segment of the population. Additionally, the study’s methodology, while robust, may not have captured all the nuances of individual patient clinical presentations, such as specific behaviors like agitation that might have influenced prescribing decisions. Furthermore, the research focused on the prevalence of prescriptions rather than the total cumulative exposure to these drugs over time, which could offer further insights into patient risk.
Dr. Annie Yang, a scholar in the National Clinician Scholars Program at Yale University who spearheaded this research during her tenure as an internal medicine resident at UCLA, emphasized the importance of patient-physician collaboration and careful medication management. "While there are certainly instances where CNS-active prescriptions may be clinically appropriate for older patients, it is absolutely crucial for patients, or their designated caregivers, to engage in open and thorough discussions with their healthcare providers," Dr. Yang advised. "This dialogue is essential to ensure that these medications are truly necessary and suitable for their specific health circumstances. If medications are deemed inappropriate, patients and their care teams should actively explore alternative treatment strategies and carefully consider the feasibility and safety of gradually reducing or discontinuing the medication." This proactive approach, she suggested, could significantly mitigate the risks associated with these drugs and improve the overall well-being of vulnerable older adults.
The foundational work for this impactful study was a collaborative effort involving several esteemed researchers. Co-authors included Mei Leng, Dr. Dan Ly, Chi-Hong Tseng, Dr. Catherine Sarkisian, and Nina Harawa, all affiliated with UCLA. Cheryl Damberg from RAND and Dr. A. Mark Fendrick from the University of Michigan also contributed significantly. Notably, Dr. Ly and Dr. Sarkisian also hold affiliations with the VA Greater Los Angeles Healthcare System, lending their expertise from both academic and veteran healthcare settings. The research was generously supported by grants from the National Institutes of Health and the National Institute on Aging, under grant number R01AG070017-01, underscoring the national importance placed on understanding and improving the care of aging populations.
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