Prevalence of Central Nervous System–Active Polypharmacy Among Older Adults With Dementia in the US

Maust, Donovan T.; Strominger, Julie; Kim, H. Myra; Langa, Kenneth M.; Bynum, Julie; Chang, Chiang Hua; Kales, Helen C.; Zivin, Kara; Solway, Erica; Marcus, Steven C.

doi:10.1001/jama.2021.1195

Cited by 65 publications

(70 citation statements)

References 42 publications

(79 reference statements)

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Medication lists reflect both continued or newly prescribed medications at each sampled outpatient visit, and it is not possible to determine longitudinal changes or decisions to discontinue medications. Finally, our measure of polypharmacy included both regular and as‐needed medications, which cannot be distinguished in NAMCS; this could have led to an overestimation of actual medication exposure, which may be better captured using other data sources 19 . Despite these potential limitations, NAMCS has been used historically in many studies 20,27,28 to provide national estimates of outpatient prescribing practices in the United States.…”

Section: Discussionmentioning

confidence: 99%

Polypharmacy among older adults with dementia compared with those without dementia in the United States

Growdon

Gan

Yaffe

et al. 2021

J American Geriatrics Society

View full text Add to dashboard Cite

Background/objectives In older persons with dementia (PWD), extensive medication use is often unnecessary, discordant with goals of care, and possibly harmful. The objective of this study was to determine the prevalence and medication constituents of polypharmacy among older PWD attending outpatient visits in the United States. Design Cross‐sectional analysis. Setting and participants PWD and persons without dementia (PWOD) aged ≥65 years attending outpatient visits recorded in the nationally representative National Ambulatory Medical Care Survey (NAMCS), 2014–2016. Measurements PWD were identified as those with a diagnosis of dementia on the NAMCS encounter form and/or those receiving an anti‐dementia medication. Visits with PWD and PWOD were compared in terms of sociodemographic, practice/physician factors, comorbidities, and prescribing outcomes. Regression analyses examined the effect of dementia diagnosis on contributions by clinically relevant medication categories to polypharmacy (defined as being prescribed ≥5 prescription and/or nonprescription medications). Results The unweighted sample involved 918 visits for PWD and 26,543 visits for PWOD, representing 29.0 and 780 million outpatient visits. PWD had a median age of 81 and on average had 2.8 comorbidities other than dementia; 63% were female. The median number of medications in PWD was eight compared with three in PWOD (p < 0.001). After adjustment, PWD had significantly higher odds of being prescribed ≥5 medications (AOR 3.0; 95% CI: 2.1–4.3) or ≥10 medications (AOR 2.8; 95% CI: 2.0–4.2) compared with PWOD. The largest sources of medications among PWD were cardiovascular and central nervous system medications; usage from other categories was generally elevated in PWD compared with PWOD. PWD had higher odds of receiving at least one highly sedating or anticholinergic medication (AOR 2.5; 95% CI: 1.6–3.9). Conclusion In a representative sample of outpatient visits, polypharmacy was extremely common among PWD, driven by a wide array of medication categories. Addressing polypharmacy in PWD will require cross‐cutting and multidisciplinary approaches.

show abstract

Section: Discussionmentioning

confidence: 99%

Polypharmacy among older adults with dementia compared with those without dementia in the United States

Growdon

Gan

Yaffe

et al. 2021

J American Geriatrics Society

View full text Add to dashboard Cite

show abstract

“…20,21 Such prescribing of antidepressants is part of the common polypharmacy seen in people with dementia in the community. 22 Mirtazapine, a noradrenergic and specific serotonergic antidepressant, is widely used in older people; from 2009 to 2014, in a study of 4•8 million antidepressant initiations in Europe, it was the antidepressant most commonly prescribed for older people and those with dementia. 23 We examined it as a treatment for depression in dementia in the HTASADD trial and found no evidence of efficacy for depression.…”

Section: Implications Of All the Available Evidencementioning

confidence: 99%

Study of mirtazapine for agitated behaviours in dementia (SYMBAD): a randomised, double-blind, placebo-controlled trial

Banerjee¹,

High²,

Stirling³

et al. 2021

The Lancet

View full text Add to dashboard Cite

Background Agitation is common in people with dementia and negatively affects the quality of life of both people with dementia and carers. Non-drug patient-centred care is the first-line treatment, but there is a need for other treatment when this care is not effective. Current evidence is sparse on safer and effective alternatives to antipsychotics. We assessed the efficacy and safety of mirtazapine, an antidepressant prescribed for agitation in dementia. MethodsThis parallel-group, double-blind, placebo-controlled trial-the Study of Mirtazapine for Agitated Behaviours in Dementia trial (SYMBAD)-was done in 26 UK centres. Participants had probable or possible Alzheimer's disease, agitation unresponsive to non-drug treatment, and a Cohen-Mansfield Agitation Inventory (CMAI) score of 45 or more. They were randomly assigned (1:1) to receive either mirtazapine (titrated to 45 mg) or placebo. The primary outcome was reduction in CMAI score at 12 weeks. This trial is registered with ClinicalTrials.gov, NCT03031184, and ISRCTN17411897.

show abstract

“…However, some recent reviews presented a more tempered perspective on AEs of nonbenzodiazepines receptor agonists, noting that over a quarter-century of use and tens of millions of doses taken in elderly people may imply that short-term use at appropriate dosing may be suitable in some cases [114]. Recent analyses of prescriptions derived from both commercial [115] and Medicare [116] databases suggested historical trends towards lower usage of zolpidem and the other "z-drugs" for sleep, suggesting a strong influence of the Beers criteria and existing observational studies in clinical practice.…”

Section: Benzodiazepines/site-specific Gamma-aminobutyric Acid Agonistsmentioning

confidence: 99%

“…Dosing of agents needs to be further clarified, especially in the AD population, where a narrow therapeutic window already exists because of concomitant medications, medical pathology, and compromised physiological reserves. Among community-dwelling Medicare recipients with dementia using multiple psychotropics, the most commonly used psychoactive medications included gabapentin, trazodone, and quetiapine [116], and much of the dosing was nocturnal, potentially to induce and/or maintain sleep. None of these medications have been subject to adequate clinical trial testing as hypnotics.…”

Section: Limitationsmentioning

confidence: 99%

Impact of Pharmacotherapy on Insomnia in Patients with Alzheimer’s Disease

Roland

Bliwise

2021

Drugs Aging

View full text Add to dashboard Cite

Insomnia is a pervasive sleep disorder affecting numerous patients across diverse demographical populations and comorbid disease states. Contributing factors are often a complex interaction of biological, psychological, and social components, requiring a multifaceted approach in terms of both diagnosis and management. In the setting of Alzheimer's disease, insomnia is an even more complicated issue, with a higher overall prevalence than in the general population, greater complexity of contributing etiologies, and differences in diagnosis (at times based on caregiver observation of sleep disruption rather than subjective complaints by the individual with the disorder), and requiring more discretion in terms of treatment, particularly in regard to adverse effect profile concerns. There also is growing evidence of the bidirectional nature of sleep disruption and Alzheimer's disease, with insomnia potentially contributing to disease progression, making the condition even more paramount to address. The objective of this review was to provide the clinician with an overview of treatment strategies that may have value in the treatment of disturbed sleep in Alzheimer's disease. Nonpharmacological approaches to treatment should be exhausted foremost; however, pharmacotherapy may be needed in certain clinical scenarios, which can be a challenge for clinicians given the paucity of evidence and guidelines for treatment in the subpopulation of Alzheimer's disease. Agents such as sedating antidepressants, melatonin, and site-specific γ-aminobutyric acid agonists are often employed based on historical usage but are not necessarily supported by high-quality trials. Newer agents such as dual orexin receptor antagonists have demonstrated some promise but still need further evaluation.

show abstract

Prevalence of Central Nervous System–Active Polypharmacy Among Older Adults With Dementia in the US

Cited by 65 publications

References 42 publications

Polypharmacy among older adults with dementia compared with those without dementia in the United States

Polypharmacy among older adults with dementia compared with those without dementia in the United States

Study of mirtazapine for agitated behaviours in dementia (SYMBAD): a randomised, double-blind, placebo-controlled trial

Impact of Pharmacotherapy on Insomnia in Patients with Alzheimer’s Disease

Contact Info

Product

Resources

About