Prevalence of Psychotropic and Opioid Prescription Fills Among Community-Dwelling Older Adults With Dementia in the US

Maust, Donovan T.; Strominger, Julie; Bynum, Julie; Langa, Kenneth M.; Gerlach, Lauren B.; Zivin, Kara; Marcus, Steven C.

doi:10.1001/jama.2020.8519

Cited by 42 publications

(42 citation statements)

References 7 publications

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“…In response to concerns of rising fatalities linked to gabapentinoid misuse and addiction, in 2019, the United Kingdom government imposed stricter controls on the prescription of gabapentinoids by reclassifying pregabalin and gabapentin as controlled drugs (i.e., Class C drugs in the UK's Misuse of Drugs Act) 31 . Despite this, gabapentinoid use remains widespread due to a lack of alternative therapies to treat persistent pain, even among people with dementia 3,32,33 . Our findings highlight additional problems associated with the use of gabapentinoids that should be considered.…”

Section: Discussionmentioning

confidence: 83%

Evidence of a gabapentinoid and diuretic prescribing cascade among older adults with lower back pain

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Giannakeas

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et al. 2021

J American Geriatrics Society

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Background/Objectives Gabapentinoids are commonly prescribed to relieve pain. The development of edema, an established adverse effect of gabapentinoids, may lead to a potentially harmful prescribing cascade whereby individuals are subsequently prescribed diuretics and exposed to diuretic‐induced adverse events. The frequency of this prescribing cascade is unknown. Our objective was to measure the association between new dispensing of a gabapentinoid and the subsequent dispensing of a diuretic in older adults with new low back pain. Design Population‐based cohort study. Setting Ontario, Canada. Participants A total of 260,344 community‐dwelling adults aged 66 years or older, newly diagnosed with low back pain between April 1, 2011, and March 31, 2019. Measurements Exposure status was assigned using dispensed medications in the 1 week after low back pain diagnosis. Older adults newly dispensed a gabapentinoid (N = 7867) were compared with older adults who were not newly dispensed a gabapentinoid (N = 252,477). Hazard ratios (HRs) with 95% confidence intervals (CIs) for dispensing of a diuretic within 90 days of follow‐up among older adults prescribed gabapentin relative to those who were not. Results Older adults newly dispensed a gabapentinoid had a higher risk of being subsequently dispensed a diuretic within 90 days compared with older adults who were not prescribed a gabapentinoid (2.0% vs. 1.3%). After covariate adjustment, new gabapentinoid users had a higher rate of being dispensed a diuretic compared with those not prescribed a gabapentinoid (HR: 1.44, 95% CI: 1.23, 1.70). The rate of diuretic prescription among new gabapentinoid users increased with increasing gabapentinoid dosages. Conclusions We have demonstrated the presence of a potentially inappropriate and harmful prescribing cascade. Given the widespread use of gabapentinoids, the population‐based scale of this problem may be substantial. Increased awareness of this prescribing cascade is required to reduce the unnecessary use of diuretics and the exposure of patients to additional adverse drug events.

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Section: Discussionmentioning

confidence: 83%

Evidence of a gabapentinoid and diuretic prescribing cascade among older adults with lower back pain

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Giannakeas

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et al. 2021

J American Geriatrics Society

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“…Antidepressants were the most common constituent medication class, consistent with their place as the psychotropic class most commonly prescribed both to older adults overall and those with dementia. 6,7 There is minimal high-quality evidence to support the efficacy of antidepressants to treat depression in patients with dementia. 26 Antidepressants may be prescribed for a variety of other indications based on varying levels of evidence; for example, to treat agitation, a use supported by the Citalopram for Agitation in Alzheimer Disease Study (CitAD) trial, 11 or to treat apathy, which resembles depression and is distressing to family but does not benefit from use of antidepressants.…”

Section: Discussionmentioning

confidence: 99%

“…The persons exposed to polypharmacy were significantly younger (median age, 79.4 years [IQR, 74.0-85.5 years] vs 84.7 years [IQR, 78.8-89.9 years] in the no exposure group, P < .001) with larger percentages of non-Hispanic white (86.2% vs 76.7% in the no exposure group, P < .001) and lowincome beneficiaries (36.2% vs 25.9% in the no exposure group, P < .001). In addition, the persons exposed to polypharmacy had a higher burden of medical comorbidity overall (median Elixhauser comorbidity score, 5 [IQR, [3][4][5][6][7] vs 3 [IQR, [1][2][3][4][5] in the no exposure group, P < .001). With the exception of cancer and cancer-related pain, the persons exposed to polypharmacy had a significantly higher prevalence of all individual clinical characteristics of interest, including noncancer pain, insomnia, psychiatric diagnoses, and seizure disorders (P < .001 for all).…”

Section: Characteristics Of Those Who Met the Criterion For Cns-active Polypharmacymentioning

confidence: 99%

“…2 Although memory impairment is the cardinal feature of dementia, behavioral and psychological symptoms (eg, apathy, delusions, agitation) are common during all stages of illness and cause significant caregiver distress. 3,4 Despite limited high-quality evidence of efficacy for pharmacological treatment, 5 clinicians regularly prescribe psychotropic medications to community-dwelling persons with dementia 6 in rates that far exceed use in the general older adult population. 7 Central nervous system (CNS)-active polypharmacy (defined as combinations of multiple psychotropic or opioid medications or both psychotropic and opioid medications) has increased among older adults overall.…”

mentioning

confidence: 99%

“…The limited data on CNS-active polypharmacy among persons with dementia are from Europe and do not include antiepileptic medications or opioids, thereby significantly underestimating the true extent of exposure to such combinations. [13][14][15] In light of pervasive psychotropic and opioid prescribing to persons with dementia in the US, 6 as well as the extent of CNS-active polypharmacy among older adults overall, 8 this analysis sought to determine the prevalence of polypharmacy among older adults with dementia living in the community, including the duration of exposure, the type of medication class combinations, and the most commonly prescribed individual medications.…”

mentioning

confidence: 99%

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

Maust

Strominger

Kim

et al. 2021

JAMA

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Changes in the Use of Long-Term Medications Following Incident Dementia Diagnosis

Anderson,

Ayanian,

Curto

et al. 2023

JAMA Intern Med

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ImportanceDementia is a life-altering diagnosis that may affect medication safety and goals for chronic disease management.ObjectiveTo examine changes in medication use following an incident dementia diagnosis among community-dwelling older adults.Design, Setting, and ParticipantsIn this cohort study of adults aged 67 years or older enrolled in traditional Medicare and Medicare Part D, patients with incident dementia diagnosed between January 2012 and December 2018 were matched to control patients based on demographics, geographic location, and baseline medication count. The index date was defined as the date of first dementia diagnosis or, for controls, the date of the closest office visit. Data were analyzed from August 2021 to June 2023.ExposureIncident dementia diagnosis.Main Outcomes and MeasuresThe main outcomes were overall medication counts and use of cardiometabolic, central nervous system (CNS)–active, and anticholinergic medications. A comparative time-series analysis was conducted to examine quarterly changes in medication use in the year before through the year following the index date.ResultsThe study included 266 675 adults with incident dementia and 266 675 control adults; in both groups, 65.1% were aged 80 years or older (mean [SD] age, 82.2 [7.1] years) and 67.8% were female. At baseline, patients with incident dementia were more likely than controls to use CNS-active medications (54.32% vs 48.39%) and anticholinergic medications (17.79% vs 15.96%) and less likely to use most cardiometabolic medications (eg, diabetes medications, 31.19% vs 36.45%). Immediately following the index date, the cohort with dementia had a greater increase in mean number of medications used (0.41 vs −0.06; difference, 0.46 [95% CI, 0.27-0.66]) and in the proportion of patients using CNS-active medications (absolute change, 3.44% vs 0.79%; difference, 2.65% [95% CI, 0.85%-4.45%]) owing to an increased use of antipsychotics, antidepressants, and antiepileptics. The cohort with dementia also had a modestly greater decline in use of anticholinergic medications (quarterly change in use, −0.53% vs −0.21%; difference, −0.32% [95% CI, −0.55% to −0.08%]) and most cardiometabolic medications (eg, quarterly change in antihypertensive use: –0.84% vs –0.40%; difference, –0.44% [95% CI, –0.64% to –0.25%]). One year after diagnosis, 75.2% of the cohort with dementia were using 5 or more medications (2.8% increase).Conclusions and RelevanceIn this cohort study of Medicare Part D beneficiaries, following an incident dementia diagnosis, patients were more likely to initiate CNS-active medications and modestly more likely to discontinue cardiometabolic and anticholinergic medications compared with the control group. These findings suggest missed opportunities to reduce burdensome polypharmacy by deprescribing long-term medications with high safety risks or limited likelihood of benefit or that may be associated with impaired cognition.

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Prevalence of Psychotropic and Opioid Prescription Fills Among Community-Dwelling Older Adults With Dementia in the US

Abstract: 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.

Cited by 42 publications

References 7 publications

Evidence of a gabapentinoid and diuretic prescribing cascade among older adults with lower back pain

Evidence of a gabapentinoid and diuretic prescribing cascade among older adults with lower back pain

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

Changes in the Use of Long-Term Medications Following Incident Dementia Diagnosis

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