Dementia Patients Often Get Psychotropic Drugs, Opioids

Psychotropic drugs and opioids were prescribed frequently to adults with dementia, an analysis of community-dwelling Medicare beneficiaries showed.

Nearly 75% of older adults with dementia had at least one prescription for a central nervous system (CNS)-active medication -- antidepressant, opioid painkiller, epilepsy drug, anxiety medication, or antipsychotic drug -- filled in a 1-year period, reported Donovan Maust, MD, MS, of the University of Michigan in Ann Arbor, and co-authors in JAMA.

None of these drugs are approved in the U.S. to treat dementia or its behavioral symptoms and all are associated with adverse events among older adults, including falls, sedation, and increased risk of death, the researchers noted.

"There has been a lot of research and regulatory attention on 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," Maust told MedPage Today. "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."

"This is an important research letter that highlights an under-recognized problem," said Jennifer Watt, MD, PhD, of the University of Toronto, who was not involved with the study.

"Like persons with dementia living in nursing homes, older adults with dementia living in community settings are commonly prescribed medications for which we don't have strong evidence of benefit and we have growing evidence of potential harm," she told MedPage Today.

The analysis looked at 737,839 community-dwelling Medicare beneficiaries who had a dementia diagnosis on a claim for a face-to-face clinical encounter from October 1, 2014 through September 30, 2015. The researchers limited their analysis to people with Medicare Part D prescription drug coverage and 100 days or fewer in a nursing home during the observation period.

The group had an average age of 82 and two-thirds were women. In total, 73.5% were prescribed a CNS-active medication; prevalence was highest in women (75.3%) and among people who were 65 to 74 (80.6%), white (74.6%), or low-income (76.5%).

Top medications filled were two opioids: hydrocodone (Vicodin) at 13.5% and tramadol (Ultram) at 12.1%. Next were the antipsychotic quetiapine (Seroquel) at 12.0%, the antidepressant sertraline (Zoloft) at 11.3%, the anti-epileptic gabapentin (Neurontin) at 11.2%, and the anxiolytic lorazepam (Ativan) at 9.6%.

In total, 49.8% of patients filled antidepressant prescriptions, 29.8% filled prescriptions for opioids, 26.8% for anxiolytics, 21.9% for anti-epileptics, and 21.6% for antipsychotics. Dementia patients in rural areas were more likely to have a prescription filled for an opioid (34.6% vs 29.1%) than those in urban or suburban zip codes.

Opioid prescribing was at relatively low volumes, with a mean supply of 26 and 30 days per person for hydrocodone and tramadol, respectively. In contrast, the mean per-person supply of gabapentin was 240 days.

"This finding of the high rate of use of opioids and psychoactive medications in older patients is disturbing," said Jerry Avorn, MD, of Harvard Medical School in Boston, who also wasn't involved with the research. "The elderly are at higher risk of all medication side effects, particularly those that affect the brain," he noted.

"The high use of opioids is particularly distressing, as we should know by now that unless a patient has terminal disease, these drugs often do far more harm than good," Avorn told MedPage Today. "The findings point to the need for more programs to educate health care professionals on the need to use these powerful drugs more judiciously, especially in these vulnerable patients."

Clinicians can help adults with dementia and caregivers better understand potential benefits and harms of using these medications and teach them about "nonpharmacologic treatment alternatives that could be as efficacious without the same potential for harm," Watt added.

The study had several limitations, Maust and co-authors noted. The findings are based on prescribing patterns of several years ago and may not be generalizable to older adults in 2020. In addition, the researchers used prescription fills as a proxy for drug use and had no information about the appropriateness of prescriptions.

"It is interesting to note and perhaps not surprising that antipsychotics -- which have received the most attention in the wake of FDA black box warnings -- are the class prescribed the least," Maust observed. "But that also means that policies that focus only on that class are missing a lot of other prescribing that is occurring."

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