Drug prescriptions in older adults with dementia

The hallmark of dementia is loss of memory and other cognitive abilities. People with the condition can also experience depression, delusions, agitation, and other symptoms. These mental states can cause distress both to the people with dementia and their loved ones and caretakers.

Drugs to treat these symptoms are widely prescribed in people with dementia. However, few studies have shown a substantial benefit in this population. And these drugs all have effects on the brain and nervous system. The use of several such drugs at the same time, called polypharmacy, increases the risk of dangerous side effects. These range from an increased risk of falls to heart problems and even death.

Guidelines from professional societies advise against prescribing multiple drugs that affect the nervous system to older adults. But how common this practice is among adults with dementia living in the community—either alone or with their families or caretakers—has not been known.

To look more closely at these prescribing practices, researchers led by Dr. Donovan Maust from the University of Michigan examined Medicare claims data from 2018 for more than a million older adults with dementia. The team analyzed prescriptions for antidepressants, antipsychotics, antiepileptics, benzodiazepines, certain sleep aids, and opioids. Polypharmacy was defined as having prescriptions for three or more drugs for more than 30 consecutive days.

The study was funded by NIH’s National Institute on Aging (NIA). Results were published on March 9, 2021, in JAMA.

About 14% of the older adults in the study had prescriptions for three or more drugs that affect the nervous system for longer than a month. Nearly three-quarters received at least one such prescription.

Among those prescribed three or more of these drugs, almost 60% had the prescriptions for more than half a year. About 7% had the prescriptions for the full year studied.

Antidepressants were the most prescribed drug class, followed by antiepileptics (which may be prescribed to treat pain or anxiety) and antipsychotic drugs. The most prescribed polypharmacy combination included at least one antidepressant, an antiepileptic, and an antipsychotic. However, the study didn’t analyze why the medications were prescribed.

While some medication combinations are relatively safe in younger people, they may hasten cognitive decline when given to older adults with dementia. Considering the lack of evidence supporting polypharmacy in such people, these results raise concern.

“It's important for family members and providers to communicate often about what symptoms are happening, and what might be done with non-medication interventions such as physical therapy or sleep hygiene, as well as medications, to address them,” Maust says. “Talk about what medications the patient is on, why they’re on each one, and whether it might be worthwhile to try tapering some of them because the symptom that prompted the prescription originally might have waned over time.”