Dementia diagnosis is ‘underused opportunity’ to reduce polypharmacy

Key takeaways:

• Medicare beneficiaries with dementia discontinued cardiometabolic medications to an extent but increased use of CNS-active drugs.
• Dementia diagnosis is “an underused clinical opportunity” to adjust medications.

Patients with post-incident dementia were more likely to begin central nervous system medications and less likely to discontinue cardiometabolic and anticholinergic medications, reflecting missed deprescribing opportunities, according to researchers.

Timothy S. Anderson, MD, MAS, a clinician-investigator in the division of general medicine at Beth Israel Deaconess Medical Center, and colleagues wrote that “polypharmacy, the use of potentially inappropriate medications, and the use of central nervous system (CNS)-active medications are common in older adults with dementia and may be associated with further impairment of cognition, leading to worse patient outcomes.”

With little known about medication use patterns associated with incident dementia diagnoses, the researchers analyzed medication use among 266,675 community-dwelling adults with incident dementia and 266,675 patients in a control group.

Patient data were taken from a sample CMS administrative and pharmacy claims between 2010 and 2019. Of the total sample, 65.1% were aged 80 years and older, and 67.8% were women.

Compared with the control group, patients with incident dementia at baseline were:

• more likely to use CNS-active medications (54.32% vs. 48.39%);
• more likely to use anticholinergic medications (17.79% vs. 15.96%); and
• less likely to use cardiometabolic medications (31.19% vs. 36.45%).

Immediately following the date of diagnosis, the dementia group had higher increases in the mean number of medications used (difference = 0.46; 95% CI, 0.27%-0.66%) and in the proportion of patients using CNS-active medications (difference = 2.65%; 95% CI, 0.85%-4.45%) vs. the control group.

The dementia group also saw a quarterly use reduction in anticholinergic (difference = –0.58%, 95% CI, –1.15% to –0.01%) and cardiometabolic (–0.44%, 95% CI, –0.64% to –0.25%) medications, and a 2.8% decrease in the proportion of patients using five or more medications after 1 year.

The increase in CNS-active medications “likely reflects off-label use for behavioral and psychological symptoms of dementia despite limited evidence to support this practice,” Anderson and colleagues wrote in JAMA Network Open.

They added that although cardiometabolic prescriptions decreased — possibly because physicians attempted to reduce their patients’ medication burden — there was little or no reduction in high-risk drug classes.

The researchers concluded that improving prescribing safety and quality after a dementia diagnosis requires ”coordination between patients, caregivers, primary care physicians, pharmacists and specialists.”

“While life trajectories for patients with dementia are variable, newer mortality prediction models may help patients, clinicians, and caregivers make informed decisions about the likelihood of medication benefit,” they wrote. “Addressing medication safety proactively requires financial models to support care coordination as well as evidence-based interventions to support medication optimization strategies.”