This article is more than 5 years old. Information may no longer be current.

Central nervous system polypharmacy has more than doubled over the last decade

Despite harms associated with central nervous system polypharmacy, its occurrence more than doubled from 2004 to 2013 among older adults, particularly with anxiety, insomnia or depression, according to data published in JAMA Internal Medicine.

“With each new revision of the Beers Criteria, the list of psychotropic medications considered potentially inappropriate in the elderly has grown,” Donovan T. Maust, MD, MS, from the department of psychiatry at the University of Michigan, Ann Arbor, and colleagues wrote. “While evidence builds concerning harms of [central nervous system] polypharmacy, little is known about the trends in relevant prescribing practices.”

To address this lack of information, Maust and colleagues analyzed data from the 2004 to 2013 National Ambulatory Medical Care Survey, including 97,910 patients aged 65 years or older. An outpatient visit was defined as a polypharmacy visit if the patient was counseled to initiate or continue three or more medications including antipsychotics, benzodiazepines, nonbenzodiazepine benzodiazepine receptor agonists, tricyclic antidepressants, selective serotonin reuptake inhibitors and opioids. The researchers recorded patient visit information on chronic medical conditions, time spent with physician and whether psychotherapy, stress management or other mental health counseling services were provided or ordered for up to three visits. Time trends in polypharmacy were assessed through logistic regression.

Results indicated that annual polypharmacy visits among the elderly rose from 1.5 million (95% CI, 1.12-1.87 million) in 2004 to 3.68 million (95% CI, 3.23-4.13 million) in 2013, increasing from 0.6% to 1.4% of visits (adjusted OR = 3.12; 95% CI, 2.28-4.28; P < .001). Rural visits had the greatest increase in central nervous system polypharmacy among demographic groups (aOR = 4.99; 95% CI, 2.67-9.33; P < .001), accounting for 16.6% of polypharmacy visits and 10.5% of nonpolypharmacy visits. In addition, women accounted for 68.1% and 55% of central nervous system polypharmacy and nonpolypharmacy visits, respectively.

Approximately 46% of polypharmacy visits did not include mental health or pain diagnoses, even though such diagnoses were more frequent in the polypharmacy group. Psychotherapy and stress management only accounted for 5.3% and 6.7% of polypharmacy visits, respectively. Polypharmacy visits with and without opioids were not significantly different in regards to demographics. An anxiety or depression diagnosis was more likely to occur in polypharmacy visits without opioids, while pain diagnosis was less likely to occur (15.3% vs. 38.5%; P = .01).

“Older adults have become more open to mental health treatment,” Maust and colleagues concluded. “Because of limited access to specialty care and a preference to receive treatment in primary care settings, it is unsurprising that mental health treatment has expanded in nonpsychiatric settings. The growth in polypharmacy in rural settings, where access to specialty mental health or pain care is particularly limited, is part of this broader trend.” – by Alaina Tedesco

Disclosure: Maust reports receiving support from the Beeson Career Development Award Program.