New opioid use raises death risk 11-fold in those with dementia

Older adults who begin using opioid painkillers after a dementia diagnosis have a significantly greater risk of death—about 11-fold within the first two weeks, according to new research.

The risk of death continued beyond two weeks, but at a lower rate, said researchers in Denmark. They found a doubled death risk within 90 days of opioid initiation, and said doctors must seriously weigh the risks versus benefits of opioid use in elderly patients with dementia.

The study of all Danes diagnosed with Alzheimer's disease in a 10-year period also found that one-third of patients who began taking opioids died within 180 days of that first dose. About 6% of the non-opioid group died during that time.

"In our study, starting on an opioid after getting a dementia diagnosis was frequent and associated with a markedly increased risk of death, which is worrisome," co-author Dr. Christina Jensen-Dahm said in an Alzheimer's Association news release.

"The use of strong opioids has increased considerably over the past decade among older people with dementia. Our study shows the importance of careful evaluation of risk and benefits to the patient when considering initiating opioid therapy among elderly individuals with dementia," said Jensen-Dahm, of the Danish Dementia Research Centre at Copenhagen University Hospital.

When the opioids were fentanyl patches, nearly two-thirds of patients died within the first 180 days versus about 7% of those without opioid prescriptions.

Overall, the researchers found a fourfold increased excess death risk associated with opioids in the first six months even after adjusting for differences between groups.

Guidance from the U.S. Centers for Disease Control and Prevention says opioid therapy should only be considered for pain if benefits outweigh the risks.

"This is particularly important for older individuals with dementia," Jensen-Dahm said. "Opioids are known to have significant side-effects including sedation, confusion, respiratory depression and falls. Older adults with dementia have a severe brain disorder and are often frail. We suspect this is why they cannot tolerate opioids, but we do not know for certain and need to do more research to answer these questions."

Those in the study were 65 and older and diagnosed with dementia between 2008 and 2018. About 42% of them filled a prescription for an opioid.

Strong opioids like morphine and oxycodone (OxyContin) were associated with a sixfold increased death risk. This group also included ketobemidone (Ketogan), hydromorphone (Dilaudid, Exalgo), pethidine (Demerol), buprenorphine (Buprenex) and fentanyl.

"Opioids are very powerful drugs, and while we need to see additional research in more diverse populations, these initial findings indicate they may put older adults with dementia at much higher risk of death," said Dr. Nicole Purcell, a neurologist and Alzheimer's Association senior director, clinical practice.

"Pain should not go undiagnosed or untreated, in particular in people living with dementia who may not be able to effectively articulate the location and severity of the pain," Purcell added. "These new findings further emphasize the need for discussion between the patient, family and physician. Decisions about prescribing pain medication should be thought through carefully, and, if used, there needs to be careful monitoring of the patient."

Other drugs deemed excessively risky for older people are atypical antipsychotics, which nearly doubled the risk of death in people with dementia in prior research.

The findings were reported Tuesday in Amsterdam at the Alzheimer's Association International Conference. Findings presented at medical meetings should considered preliminary until published in a peer-reviewed journal.

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