An estimated quarter of traditional Medicare beneficiaries with dementia are prescribed risky, brain-altering drugs despite years of clinical guidelines cautioning against the practice, a new study shows.
The drugs fall into five broad categories — including antidepressants, antipsychotics, antidepressants and barbiturates — that may leave older adults in a drowsy, confused fog that can make them less steady on their feet and more prone to falls. And while the study published Monday in JAMA found that overall prescriptions for these types of drugs for traditional Medicare beneficiaries fell from 2013 to 2021, their “potentially inappropriate” use was significantly higher for people who are cognitively impaired or have dementia compared to people whose cognition was normal.
More than any other group, according to the study, people with dementia were prescribed medications that are included on the Beers Criteria, a comprehensive list maintained by the American Geriatrics Society that details what drugs older people should avoid or use with caution.
These are “not trivial drugs,” said John N. Mafi, an internist and associate professor of medicine at UCLA’s David Geffen School of Medicine. Some “actually have an FDA black box warning because they almost double the risk of death in patients with dementia who take it.”
Why are certain drugs are more harmful for older adults?
The medications detailed in the study impact neurotransmitters that alter brain chemistry. Sometimes that is appropriate when treating mental health issues such as schizophrenia, bipolar disorder or other psychoses, said Annie Yang, an internist and research fellow in the National Clinician Scholars Program at Yale School of Medicine who led the study as resident physician at UCLA.
As people age, their ability to metabolize drugs changes and they become more “susceptible to the toxicities of drugs,” said Mafi, who was the study’s senior author. In addition, older adults often take multiple medications, and they may not interact well.
To find out how often older Americans were being prescribed these medications researchers analyzed the Health and Retirement Study, which is a nationally representative sample, linked to traditional Medicare claims for 4,842 people over 65. Researchers categorized participants by cognitive status — normal, mild impairment or dementia — while analyzing who received at least one 28-day prescription for one of these medications.
After adjusting for adjusting for age, health conditions and socioeconomic conditions to produce nationally representative estimates, they found across the entire 2013-2021 study period these brain-altering drugs were prescribed an average of 17 percent of the time across patients who were cognitively healthy, nearly 22 percent for cognitively impaired people without dementia and 25 percent for people with dementia.
“That’s a very high number,” Mafi said.
Why are they getting prescribed if they’re flagged as harmful?
In some cases, there can be appropriate uses for these medications in older adults. And the researchers also wanted to see if they could link their use to an appropriate clinical diagnosis, Yang said.
The study found the prescribing rate for people who had a documented medical need to be on one of these medications was stable over the last nine years while “potentially inappropriate prescriptions without a clinical indication” dropped by about 4 percent.
But the number of beneficiaries prescribed the drugs without a documented reason for treatment was almost double those with an indicated rationale, the study found.
“You would think it would be the opposite,” said Anupam Jena, the Joseph P. Newhouse professor of health care policy at Harvard Medical School.
That it’s not, he said, reveals two things. The first being the limitations of the data. These medications are used to treat some of the behavioral symptoms of dementia, such as agitation and combativeness behavior. These symptoms are often underreported in the Medicare claims data, which use limited diagnosis codes that often don’t reflect all the reasons doctors prescribed the medications.
Thus the claims data may not reflect all the reasons doctors prescribed the medications.
“We always have to be a little bit cautious” of studies that suggest “large numbers of patients are on drugs that are harmful to them,” said Jena, an internist at Massachusetts General Hospital who was not involved in the study. “That sort of presumes that the doctors don’t know that these drugs have risks” as opposed to understanding the risk-benefit trade off, he said.
The second thing the finding reveals, Jena said, is that the “threshold” for prescribing is “pretty high,” which he said, “speaks to the caution that the doctors are probably employing in the real world when deciding whether to prescribe that medication.”
But before doctors turn to drugs, the guidelines say the first line of defense “is non pharmacologic,” Mafi said. Similar to small children, some with dementia may be agitated for reasons they can’t express, such as hunger, fear, pain, thirst, boredom or constipation.
“There’s a very broad array of tools that you can do before reaching for these risky drugs,” but they require resources many people don’t have, he said.
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