Deprescribing efforts failing dementia patients, study finds

Researchers led by the Beth Israel Deaconess Medical Center, Boston, have examined how a dementia diagnosis impacts medication use patterns in older adults.

In a paper, "Changes in the Use of Long-Term Medications Following Incident Dementia Diagnosis," published in JAMA Internal Medicine, a large cohort study revealed several unexpected findings, including increased overall medication use in the year following an incident dementia diagnosis.

Despite the recognized importance of simplifying medication regimens and reducing the risk of adverse drug events in individuals with dementia, the study found that deprescribing guidelines and efforts are not effectively implemented at the expected levels. This suggests a potential gap in clinical practice, where deprescribing guidelines and efforts may not be effectively implemented in the care of patients with dementia.

Alzheimer's disease and related dementias affect millions of individuals in the US, leading to significant challenges in managing medications and treatment decisions. Older adults with dementia often have multiple chronic conditions, complicating their medication regimens. Existing clinical guidelines recommend tailoring treatments based on comorbidities, potential benefits, and patient goals. The impact of a dementia diagnosis on medication use patterns and deprescribing is not understood.

The study analyzed 266,675 adults with incident dementia and 266,675 as a control from a national sample of Medicare Part D beneficiary pharmacy claims from 2010 to 2019. New incident dementia cases were identified using validated diagnosis codes. Patients with dementia were matched with controls based on various demographic and medication-related factors. Medication use patterns were assessed before and after dementia diagnosis, and analysis was conducted to evaluate changes in medication use over time.

Specific prescription trends

Patients with dementia showed an increase in anti-dementia medications, which is expected as these drugs are prescribed explicitly for dementia management.

There was an unexpected increase in central nervous system-active medications following a dementia diagnosis. This contradicts professional guidelines and raises concerns, as these medications can adversely affect cognitive function and are not typically recommended. Many CNS-active medications have been identified as potentially inappropriate due to their association with increased risk of falls, worsening cognitive function, and other adverse drug events.

Some cardiometabolic medications, like antihypertensives and insulins, immediately increased use following diagnosis.

While anticholinergic medication use decreased slightly in the cohort with dementia, it was still being prescribed, even though these drugs are known to have potential adverse cognitive effects.

The authors conclude, "The 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."