Nearly 75% of older Americans with dementia given drugs that don’t help them despite serious risks: Study
Close to three-quarters of older adults with dementia have filled prescriptions for medicines that act on their brain and nervous system, but are not designed for dementia, according to researchers. This is despite the special risks that such drugs carry for older adults, and the lack of evidence that they actually ease the dementia-related behavior problems that often prompt a doctor’s prescription in patients with Alzheimer's disease and related disorders, they argue. Some of the drugs have also been linked to worse cognitive symptoms in old adults, warns the research team from the University of Michigan, and the University of Pennsylvania School for Social Policy and Practice.
According to the investigators, none of the medications they studied has received US Food and Drug Administration (FDA) approval to treat dementia or its behavioral symptoms, and evidence for their off-label use is slim. All of the drugs are associated with adverse risks to people in their 60s and older, “including falls or dependence that could lead to withdrawal, as well as increased risk of death.” Most are included on the list “known as the Beers criteria, which identifies medications with extra risks for all older adults, not just those with dementia,” reveals analysis.
“There has been a lot of research and regulatory attention on the use of these medications for patients with dementia in long-term care settings, but their use in the community has been a real blind spot. We find that use is basically just as high as in long-term care, and far exceeds the evidence base supporting use for patients with dementia,” lead author Dr Donovan Maust, a geriatric psychiatrist at the University of Michigan and VA Ann Arbor Healthcare System, told MEA WorldWide (MEAWW).
From opioids and antipsychotics to antidepressants and anxiety medicines, the experts analyzed prescriptions among community-dwelling older adults with dementia in the US. Supported by the National Institutes of Health’s National Institute on Aging, the findings have been published in JAMA.
“As a nation, we have a goal of keeping dementia patients living in the community as much as possible. Clinicians and caregivers may need more support to provide non-drug based approaches to prevent or address the symptoms that these medications are probably being prescribed for,” says Maust, who specializes in helping patients with dementia-related behavioral issues at Michigan Medicine, University of Michigan’s academic medical center.
Dementia is a general term for conditions that cause loss of memory severe enough that they may impact a person’s ability to carry out daily activities. In the US, of those at least 65 years of age, there were an estimated 5 million adults with dementia in 2014 and the number is projected to be nearly 14 million by 2060.
What did the study find?
The authors identified “all fee-for-service Medicare beneficiaries” aged 65 years or older with a primary or secondary diagnosis of dementia on a claim for a face-to-face clinical visit between October 1, 2014, and September 30, 2015. The analysis is based on data from 737,839 people with dementia and is a largescale study of prescription-filling patterns for psychoactive medications outside of nursing homes and other long-term care facilities. The research team looked at several classes of psychoactive drugs, including ones that the federal government has actively encouraged nursing homes to limit using in residents with dementia. They suggest a need to reduce prescribing to people living at home with dementia, too.
In all, 73.5% of the study’s community-based population filled at least one prescription for an antidepressant, opioid painkiller, epilepsy drug, anxiety medication, or antipsychotic drug in one year, according to Medicare prescription records. The percentages generally were even higher among women (75.3%), non-Hispanic White patients (74.6%), people in their late 60s and early 70s (80.6% between 65 to 74 years), and people with low incomes (76.5%).
Nearly half of those in the study received an antidepressant, which might be prescribed to try to counteract the withdrawal and apathy often seen in dementia, says Maust. Unfortunately, antidepressants do not treat this aspect of dementia, he adds. Even so, the team found antidepressant prescribing at nearly triple the rate for older adults overall. For each of the other drug types studied, nearly a quarter of the adults with dementia filled at least one prescription.
“A total of 49.8% filled an antidepressant prescription and 29.8% an opioid, followed by anxiolytics (26.8%), antiepileptics (21.9%), and antipsychotics (21.6%). Associations between demographics and prescription fills (both prevalent and adjusted risk) were generally consistent in direction for individual drug classes: higher among females, non-Hispanic White, and low-income older adults,” the findings state. It further says, “The opioids hydrocodone (13.5%) and tramadol (12.1%) were the top medications filled. Per-person volumes for both were relatively low (medians of 2 prescriptions and 26 days for hydrocodone and 2 prescriptions and 30 days for tramadol). They were followed by a medication from each of the remaining classes: quetiapine (12.0%, antipsychotic), sertraline (11.3%, antidepressant), gabapentin (11.2%, antiepileptic), and lorazepam (9.6%, anxiolytic).”
While there is little evidence of benefit, all these medications have side effects, the researchers argue. For example, some people starting a new antidepressant can experience nausea or feel a little ‘jittery’. “Unfortunately, a person with dementia might have difficulty articulating such side effects to the loved one who takes care of them. Instead, they may appear more agitated, leading to another prescription medication to calm them,” the authors explain.
The research team says that of the 29% who received opioids, they most often filled just one or two short-term prescriptions, which may indicate the treatment of an injury or acute pain. But those receiving other drugs tended to fill multiple prescriptions in the year that the authors studied. This included epilepsy drugs that are sometimes prescribed as substitutes for antipsychotic drugs or to treat chronic pain. Taking these drugs for months on end is especially risky, says Maust. “A brain that has dementia is doing its best to function as well as it can. If we add a psychotropic medication into the mix it may not be a helpful thing, and it comes with risks,” he explains.
What can be done?
According to the researchers, work is needed to understand factors driving prescribing given scant evidence of benefit for adults with dementia. “I think perhaps clinicians and family members should revisit why patients are receiving medications like these and consider possibly stopping them, especially for patients on multiple such medications. Also, the extent of use suggests there might be room for better education about the pervasiveness of behavioral symptoms and alternative approaches to address them, especially given lack of benefit from these medications,” Maust told MEAWW.
In addition to helping caregivers and clinicians understand both the lack of evidence and the elevated risks that come with psychoactive medications, and to learn the non-drug caregiving strategies they can use to reduce behavioral issues in the person they are caring for, they may just need better education about the disease itself, he emphasizes.
Accessing support services through local, state, and federal agencies, including Area Agency on Aging programs, and nonprofits such as the Alzheimer's Association and AARP, could help caregivers too, the team suggests. “Apathy and withdrawal, and a tendency to get agitated, are common symptoms of dementia. And as much as healthcare providers want to help these patients and their family caregivers, these medications are just not helpful enough to justify this amount of prescribing,” explains Maust.