Dementia & Inappropriate Prescriptions: Study Highlights Ongoing Risks
- Despite decades of clinical guidelines cautioning against prescribing certain psychiatric and brain-sedating medications for older adults, they continue to be used at high rates, often inappropriately.
- However, people with cognitive impairment and dementia were still more likely to receive inappropriate prescriptions.
- In a hospital setting, these kinds of medications are sometimes seen as “an easy solution” for people with dementia and cognitive impairment, Dr.
Despite clinical guidelines, a new study shows people with dementia and cognitive impairment remain more likely to be prescribed potentially inappropriate psychiatric and sedating drugs.
Despite decades of clinical guidelines cautioning against prescribing certain psychiatric and brain-sedating medications for older adults, they continue to be used at high rates, often inappropriately. The recent study published in JAMA examined the electronic health records of more than 4,800 older adults between 2013 and 2021. Over the eight-year span, the number of individuals receiving potentially inappropriate medications declined by almost 4 percent.
However, people with cognitive impairment and dementia were still more likely to receive inappropriate prescriptions. One in four with dementia were prescribed at least one potentially inappropriate drug, and in 70 percent of cases, the medical record lacked any clinical justification. This suggests a significant opportunity to improve the quality and safety of care for older adults.
In a hospital setting, these kinds of medications are sometimes seen as “an easy solution” for people with dementia and cognitive impairment, Dr. Annie Yang, a researcher at Yale School of Medicine who led the study, told Being Patient. She expressed optimism that awareness about the risks of these medications is improving because their use is in decline.
Tracking inappropriate prescriptions
Every few years, the American Geriatrics Society updates its Beers Criteria, a set of clinical guidelines that flag risky medications for older adults. Several classes of drugs that appear on the list – including benzodiazepines like xanax, antipsychotics like clozapine, and some antidepressants like amitriptyline – increase the risk of delirium, falls, and hospitalizations.
Yet they’re frequently prescribed to older adults with cognitive impairment or dementia to manage agitation, anger, depression, sleeping problems, and pain. Researchers used Medicare claims data for prescriptions lasting 28 days or longer, based on a sample representative of more than 20 million Americans, to track these risky prescriptions over time.
By , about 17 percent of people without cognitive impairment or dementia were receiving at least one such prescription, compared to 21.7 percent with cognitive impairment and 25.1 percent with dementia. Benzos, like xanax and valium, were the most frequently prescribed. In most of the cases, the Medicare records didn’t include an appropriate indication for the prescription.
“For example, if they got an antipsychotic, did you have schizophrenia, which would be an appropriate reason,” Yang explained. “We couldn’t look across all the possible clinic indications, especially behavioral agitation, which is a little underdocumented.”
Some older adults may have been taking these medications for years, long before developing cognitive impairment or dementia. But as the side effects become more harmful with age, deprescribing them becomes challenging. “It takes enormous effort on the part of healthcare providers in time that they either don’t have or don’t want to spend,” Dr. Jerry Gurwitz, a geriatrician at UMass Chan Medical School, who wasn’t involved in the study, told Being Patient. “I think the biggest opportunities here for reducing use is never starting them if possible, and frankly, there is probably a small percentage of people who may need these medications.”
While there was a reduction in prescribing these drugs leading up to , it’s unclear whether the downward trend plateaued or continued. Gurwitz cautioned that some of the reductions might be offset by substitutions. Particularly in nursing homes, frail older adults might be switched to gabapentin or trazodone for sleep problems, which are just as risky.
“We know that prescribing these drugs to persons living with dementia has increased over the last ten years,” Dr. Christina Reppas-Rindlisbacher, a geriatrics and internal medicine specialist at Sinai Health and University Health Network, who was not involved in the study, told Being Patient.
Though researchers agree that reducing prescriptions of these potentially harmful medications could be beneficial, there aren’t any studies assessing whether reducing these prescriptions actually translates to benefits. For example, Gurwitz said, if reducing prescriptions was helpful a large study might then show a reduction in falls, delirium and other side effects.
How to treat agitation and other challenging symptoms
Most of these medications are used off-label and aren’t approved or extensively tested in older adults with dementia. “I think it’s very risky to prescribe a drug to an older person, there has been no study subjects in these trials like them,” Gurwitz said. Still, the medications might be helpful in certain cases. Yang recommends that families ask doctors about why medications are being prescribed and re-evaluate afterward whether they could be tapered off once the symptoms resolve.
The challenge is often systemic: Doctors often only have 20 minutes to sit with a patient and their family member. “It becomes, unfortunately, almost automatic, that the simplest, least time consuming thing is to prescribe a medication,” Gurwitz said.
Researchers are also working on developing safe, effective medications for treating psychiatric and sleep symptoms in dementia. In , Rexulti became the first drug approved for treating agitation with Alzheimer’s but it comes with a risk of increased mortality and as result carries a warning of this risk. Other drug developers including Bristol Myers-Squibb and Axsome Therapeutics are hoping their drugs are next to receive approval in the near future.
Non-drug approaches remain safe, frontline options although they are more time- and labor-intensive. They focus on figuring out how to meet a person’s underlying needs, including understanding why they might be lashing out or feel agitated. For example, making the home environment quieter, less cluttered, and well-lit — as well as attention to art and music — could have a calming influence.
“Sometimes pacing and restlessness can be managed by introducing structured exercise or giving a person meaningful tasks they may have enjoyed previously,” said Reppas-Rindlisbacher. “Reminiscence or validation therapy can often improve mood and reduce depressive symptoms.”
The right approach, experts cautioned, depends on the individual patient, their caregivers, and their living situation.