Despite years of clinical guidelines warning against the practice, one in four Medicare beneficiaries with dementia are prescribed brain-altering drugs linked to falls, confusion and hospitalizations, according to new research to be published Jan. 12 in the peer-reviewed journal. GLASS.
While prescriptions for these drugs dropped from 20% to 16% during the nine-year study period among all Medicare beneficiaries, they continue to be prescribed to people with intellectual disabilities who are particularly prone to these side effects.
“Although this reduction was encouraging, over two-thirds of patients receiving these prescriptions did not have a documented clinical indication in 2021, the end of the study period, suggesting high levels of potentially inappropriate and harmful prescribing,” said senior author Dr. UCLA. “Compared with cognitively normal patients, we also found higher prescribing levels among older adults with cognitive impairment, who face a higher risk of adverse effects from these medications. These results highlight important opportunities to improve the quality and safety of care for millions of older Americans.”
For this study, researchers used survey data from the Health and Retirement Study linked to Medicare fee-for-service claims to identify central nervous system (CNS)-active prescribing patterns between January 1, 2013, and December 31, 2021 of potentially inappropriate CNS physiologic drugs prescribed to adults with 1) cognitive impairment without dementia and 3) dementia.
The CNS-active drugs studied included five classes of drugs: antidepressants with strong anticholinergic properties, antipsychotics, barbiturates, benzodiazepines, and non-benzodiazepine hypnotics.
While 17% of cognitively normal older adults were prescribed CNS drugs, nearly 22% of those with cognitive impairment but no dementia received the drugs. About 25% of the dementia group were prescribed CNS-active drugs.
Among all Medicare fee-for-service beneficiaries, prescribing trends by drug class were:
- Benzodiazepines decreased by 11.4% to 9.1%
- Non-benzodiazepine hypnotics, or hypnotics, fell from 7.4% to 2.9%
- Antipsychotic prescriptions rose from 2.6% to 3.6%
- Prescriptions for anticholinergic antidepressants remained at 2.6% during the study period
- Barbiturate prescriptions fell slightly from 0.4% to 0.3%
In addition, clinically justified prescriptions decreased from 6% in 2013 to 5.5% in 2021, while possibly inappropriately prescribed CNS drugs showed a significant decrease from 15.7% to 11.4%.
The improvement is largely due to reductions in prescriptions for benzodiazepines and sleep medications as well as inappropriate prescriptions.
Findings are limited by unavailable Medicare Advantage data, possibly missing clinical information such as stimulation and focusing on prevalence prescribing rather than cumulative exposure.
“While active CNS prescriptions may be appropriate in some situations, it is important for older patients or their caregivers to work closely with their physicians to ensure that these medications are appropriate for their situation. When they are inappropriate, patients and their care teams should consider alternative treatments and consider whether it may be safe to reduce or discontinue medication,” said Dr. Annie who led this study as an internal medicine resident at UCLA.
Co-authors of the study are Mei Leng, Dr. Dan Ly, Chi-Hong Tseng, Dr. Catherine Sarkisian and Nina Harawa of UCLA. Cheryl Damberg of RAND and Dr. A. Mark Fendrick of the University of Michigan. Ly and Sarkisian are also affiliated with the VA Greater Los Angeles Healthcare System.
The National Institutes of Health/National Institute on Aging (R01AG070017-01) funded the study.
