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With each new revision of the Beers Criteria, the list of psychotropic medications considered potentially inappropriate in the elderly has grown. Opioids have recently been included in a Beers measure of central nervous system (CNS) polypharmacy. 1 Prescribing related drug combinations also received increased regulatory attention when the US Food and Drug Administration recently ordered a black-box warning to alert patients of serious risks, including death, caused by opioids coprescribed with CNS depressants. While evidence builds concerning harms of CNS polypharmacy, little is known about the trends in relevant prescribing practices.

Background/Objectives Central Nervous System (CNS)-active medication polypharmacy, defined by the Beers Criteria as ≥3 CNS-active medications, poses significant risks for older adults. Among adults ages ≥65 seen in U.S. outpatient medical practice, we determined patterns and trends in contributions to CNS polypharmacy of each medication class. Design The National Ambulatory Medical Care Survey (2004–2013). Setting U.S. outpatient medical care. Participants Visits by older adults to outpatient physicians (n=97,910). Exposure Patient visits including ≥3 CNS medications including antipsychotics, benzodiazepines, nonbenzodiazepine benzodiazepine receptor agonist hypnotics (NBRAs), tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and opioids. Measurements We determined the proportion of CNS polypharmacy contributed by each medication class during 2011–2013 and then used logistic regression to determine trends from 2004 to 2013 in the contribution of individual medication classes to such polypharmacy. Results Among recent CNS polypharmacy visits, 76.2% included opioids and 61.8% included benzodiazepines. Approximately two-thirds (66.0%) of the polypharmacy visits with benzodiazepines included opioids and approximately half (53.3%) of the polypharmacy visits with opioids included benzodiazepines. Between 2011 and 2013, opioid and benzodiazepine co-prescribing occurred at approximately 1.50 million visits (CI 1.23–1.78 million) annually. From 2004 (reference) to 2013, the proportion of polypharmacy visits with opioids rose from 69.6% to 76.2% (AOR 2.15 [CI 1.19–3.91], p=0.01), while the corresponding proportion that included benzodiazepines fell. Among the polypharmacy visits, the odds of SSRI, NBRA, and antipsychotic use were unchanged, while TCAs decreased. Conclusions Among older adults, the recent national increase in CNS polypharmacy appears to be largely driven by opioid use. Although concomitant use of opioids and benzodiazepines is associated with increased mortality, they are the most common contributors to CNS polypharmacy in older adults.

This pharmacoepidemiology study uses Medicare data to estimate US prescription fills for antidepressants, anxiolytics, antipsychotics, opioids, and antiepileptics among community-dwelling older adults with dementia in 2014-2015, and identifies the most commonly prescribed medications.

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Prolonged QT dispersion is a risk factor for cardiac arrhythmias and sudden death in patients with cardiac and peripheral artery diseases, but there is no study about prolonged QT dispersion in patients with ischaemic strokes. The insular cortex may play an important role in the genesis of cardiac arrhythmias and sudden death. In our study with 40 patients suffering from unilateral hemispheric ischaemic stroke, the QT dispersion was analysed and correlated to the location of the cerebral lesion. We found that in patients with involvement of the insular cortex, the QT dispersin is significantly longer than in those without insular involvement.

Background Antiepileptics are commonly prescribed to nursing home residents with Alzheimer's disease and related dementias (ADRD) but there is little scientific support for their use in this population. It is unclear whether different antiepileptics are targeting different indications. Methods Using the Minimum Data Set and Medicare data, including Part D pharmacy claims, we constructed annual cohorts of residents with ADRD with long‐term stays in nursing homes from 2015 to 2019. For each year, we measured the proportion of residents with ADRD in nursing homes nationwide with at least one antiepileptic prescription. We also measured trends in valproic acid, gabapentin, antipsychotic, and opioid prescribing. Finally, we examined how prescribing rates differed based on whether residents with ADRD had disruptive behaviors or reported pain. Results Our study sample includes 973,074 persons living with ADRD who had a long‐term stay in a nursing home, which was defined as at least 3 months. The proportion of residents with ADRD with at least one antiepileptic prescription increased from 29.5% in 2015 to 31.3% in 2019, which was driven by increases in the rate of valproic acid and gabapentin prescribing. Conversely, antipsychotic prescribing rates declined from 32.1% to 27.9% and opioid prescribing rates declined from 39.8% to 31.7%. The risk of valproic acid prescribing was 10.9 percentage points higher among residents with ADRD with disruptive behaviors, while the risk of being prescribed gabapentin was 13.9 percentage points higher among residents with ADRD reporting pain. Conclusions Antiepileptic prescribing among nursing home residents with ADRD is increasing, while antipsychotic and opioid prescribing is declining. Examining antiepileptic prescribing to residents with ADRD who had disruptive behaviors and/or reported pain suggests that two of the most common antiepileptics, valproic acid and gabapentin, are being used in clinically distinct ways. Antiepileptic prescribing of questionable risk–benefit for dementia care warrants further scrutiny.