Recent research highlights a troubling trend: despite longstanding guidelines that caution against the practice, around 25% of Medicare recipients diagnosed with dementia are still being prescribed medications that can alter brain function and lead to serious side effects such as falls, confusion, and increased hospitalization rates. This alarming finding is set to be published on January 12 in the peer-reviewed journal JAMA.
Over the course of a nine-year study, there was a slight decrease in the overall prescription rates of these risky medications among all Medicare beneficiaries, dropping from 20% to 16%. However, the issue persists particularly among those with cognitive impairments, who are at an even greater risk for the adverse effects associated with these drugs.
Dr. John N. Mafi, the senior author of the study and an associate professor-in-residence of medicine at the David Geffen School of Medicine at UCLA, pointed out that while the decline in prescriptions is a positive sign, a concerning two-thirds of patients receiving these medications lacked clear clinical justification by 2021, the final year of the study. This suggests a significant amount of potentially harmful prescribing practices still exists. "Older adults with cognitive impairment are more vulnerable to the negative impacts of these drugs compared to their cognitively healthy counterparts," Dr. Mafi noted. He emphasized that there are considerable opportunities to enhance the quality and safety of healthcare for millions of older Americans.
To conduct this study, researchers analyzed survey data from the Health and Retirement Study, linking it with Medicare fee-for-service claims to track the prescribing patterns of central nervous system (CNS)-active medications between January 1, 2013, and December 31, 2021. They specifically looked at three groups of older adults: those with normal cognition, individuals with cognitive impairment but no dementia, and those diagnosed with dementia.
The CNS-active medications examined included five categories: antidepressants with strong anticholinergic properties, antipsychotics, barbiturates, benzodiazepines, and non-benzodiazepine sedatives. The study found that CNS medications were prescribed to 17% of older adults with normal cognitive function, nearly 22% of those experiencing cognitive impairment without dementia, and about 25% of those with dementia.
When summarizing the trends in medication prescriptions among all Medicare fee-for-service beneficiaries, the following changes were noted:
- Benzodiazepine prescriptions decreased significantly from 11.4% to 9.1%.
- Non-benzodiazepine hypnotics, which are often used as sleep aids, saw a drop from 7.4% to 2.9%.
- Conversely, prescriptions for antipsychotic medications increased from 2.6% to 3.6%.
- Anticholinergic antidepressants remained stable at 2.6% throughout the study period.
- Barbiturate prescriptions experienced a minor reduction from 0.4% to 0.3%.
Notably, the proportion of clinically justified prescriptions saw a small decline from 6% in 2013 to 5.5% in 2021. Meanwhile, the rate of likely inappropriate CNS-active prescriptions fell sharply from 15.7% to 11.4%. This improvement was largely credited to the decrease in prescriptions of benzodiazepines and sleep medications, as well as a reduction in inappropriate prescriptions overall.
It’s important to acknowledge that the findings of this study may be limited due to the absence of Medicare Advantage data, which might omit relevant clinical information, such as patient agitation, and because the study primarily focused on prescription prevalence rather than cumulative medication exposure.
"While certain CNS-active medications may be suitable in specific cases, it's crucial for older patients or their caregivers to collaborate closely with healthcare providers to determine the appropriateness of these treatments for their individual situations. In cases where the medications are deemed unsuitable, patients and their care teams should explore alternative treatment options and consider whether it is safe to reduce or discontinue the medication altogether," advised Dr. Annie Yang, a scholar in the National Clinician Scholars Program at Yale University and the lead researcher for this study during her residency at UCLA.
The collaborative research team also included Mei Leng, Dr. Dan Ly, Chi-Hong Tseng, Dr. Catherine Sarkisian, and Nina Harawa from UCLA; Cheryl Damberg from RAND; and Dr. A. Mark Fendrick from the University of Michigan. Both Dr. Ly and Dr. Sarkisian are affiliated with the VA Greater Los Angeles Healthcare System.
Funding for the study was provided by the National Institutes of Health/National Institute on Aging under grant R01AG070017-01.
