Even after years of medical guidelines advising caution, brain-altering medications linked to falls, confusion, and hospitalizations are still widely prescribed to people with dementia. New research published on January 12 in the peer-reviewed journal JAMA reports that about one in four Medicare beneficiaries with dementia receive these drugs.
Across the full Medicare population, prescribing of these medications has declined over time. During the nine-year study period, usage dropped from 20% to 16%. However, people with cognitive impairment continue to receive these medications at higher rates, even though they are more vulnerable to harmful side effects.
“While this decline was encouraging, over two-thirds of patients receiving these prescriptions lacked 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. John N. Mafi, associate professor-in-residence of medicine, division of general internal medicine and health services research, at the David Geffen School of Medicine at UCLA. “Compared with patients with normal cognition, we also found higher levels of prescribing among older adults with cognitive impairment, who face a higher risk of adverse effects from these drugs. These results underscore substantial opportunities to improve the quality and safety of care for millions of older Americans.”
How the Study Examined Medication Use
To better understand prescribing patterns, researchers analyzed survey data from the Health and Retirement Study and linked it to Medicare fee-for-services claims. They tracked the use of potentially inappropriate central nervous system (CNS)-active medications from January 1, 2013 through December 31, 2021. Older adults were grouped into three categories: those with 1) normal cognition, 2) cognitive impairment without dementia, and 3) dementia.
The analysis focused on five categories of CNS-active medications: antidepressants with strong anticholinergic properties, antipsychotics, barbiturates, benzodiazepines, and non-benzodiazepine hypnotics.
Higher Prescribing Rates Among Patients With Cognitive Impairment
The study found that CNS-active medications were prescribed to 17% of older adults with normal cognition. Use was higher among those with cognitive impairment but no dementia, affecting nearly 22% of that group. Among individuals with dementia, about 25% received these medications.
Prescription trends also differed by medication type among all Medicare fee-for-service beneficiaries:
- Benzodiazepines declined from 11.4% to 9.1%
- Nonbenzodiazepine hypnotics, commonly used as sleep drugs, fell from 7.4% to 2.9%
- Antipsychotic prescriptions increased from 2.6% to 3.6%
- Prescriptions for anticholinergic antidepressants remained steady at 2.6%
- Barbiturate use decreased slightly from 0.4% to 0.3%
Signs of Improvement and Ongoing Safety Concerns
Prescriptions considered clinically justified declined modestly, dropping from 6% in 2013 to 5.5% in 2021. At the same time, prescriptions viewed as likely inappropriate fell more sharply, from 15.7% to 11.4%. Much of this progress was linked to reduced use of benzodiazepines and sleep medications, along with fewer inappropriate prescriptions overall.
The researchers note several limitations to the findings. The study did not include Medicare Advantage data, may have missed certain clinical details such as agitation, and measured how common prescriptions were rather than the total amount of drug exposure over time.
“While CNS-active prescriptions may be appropriate in some cases, it is important for older patients or their caregivers to work closely with their physicians to ensure that these medications are appropriate to their cases. When inappropriate, patients and their care teams should consider alternative treatments and consider whether it might be safe to taper or stop the medication,” said Dr. Annie Yang, a scholar in the National Clinician Scholars Program at Yale University who led this study as a UCLA internal medicine resident.
Authors and Funding
The study was co-authored by Mei Leng, Dr. Dan Ly, Chi-Hong Tseng, Dr. Catherine Sarkisian, and Nina Harawa of UCLA, along with Cheryl Damberg of RAND and Dr. A. Mark Fendrick of University of Michigan. Ly and Sarkisian are also affiliated with VA Greater Los Angeles Healthcare System.
Funding for the research was provided by the National Institutes of Health and the National Institute on Aging (R01AG070017-01).