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Almost three quarters of older adults with dementia have prescribed prescriptions for drugs that act on their brain and nervous system but are not designed for dementia, a new study shows.
This is despite the particular risks such drugs pose to older adults – and the lack of evidence that they actually relieve the dementia-related behavior problems that often lead to a doctor's prescription in patients with Alzheimer's disease and related conditions. In fact, some of the drugs have been linked to worse cognitive symptoms in old adults.
The study looks at different classes of psychotropic drugs, including those that the federal government has actively encouraged nursing homes to use in residents with dementia. The new study suggests that prescribing needs to be reduced at home for people with dementia as well.
Overall, 73.5% of the study’s community-resident population completed at least one prescription for an antidepressant, opioid pain reliever, epilepsy medication, anxiety medication, or antipsychotic drug within one year.
The percentages were generally even higher among women, non-Hispanic white patients, people in their late 60s and early 70s, and people on low incomes.
The study was published in the journal JAMA and is based on data from 737,839 people with dementia. It is the first large-scale study of prescription fill patterns for psychoactive drugs outside of nursing homes and other long-term care facilities.
Almost half of the study participants were given an antidepressant, which may be prescribed to counter the withdrawal and apathy common in dementia, says lead author Dr. med. Donovan Mouse, a geriatric psychiatrist at the University of Michigan and VA Ann Arbor Health System. Unfortunately, antidepressants don't treat this aspect of dementia, he says.
Even so, the study shows that overall antidepressants are almost three times as likely to be prescribed in older adults.
Meanwhile, almost a quarter of adults with dementia filled at least one prescription for each of the other drug types studied.
"As a nation, our goal is to keep dementia patients in the community as much as possible. However, the use of these drugs seems to be just as high for them as for those who live in nursing homes," says Mouse, who specializes in patient support with dementia-related behavior problems at Michigan Medicine, UM's academic medical center. "Clinicians and nurses may need more support to provide non-drug approaches to preventing or treating the symptoms for which these drugs are likely to be prescribed."
None of the drug classes studied have received Food and Drug Administration approval for use in dementia, and Mouse says the evidence for their off-label use is little.
However, all drugs have specific risks for people in their 60s and older, including falls or addictions that can lead to withdrawal. Most are included in the list known as the Beer Criteria, which identifies drugs with additional risks for all older adults, not just those with dementia.
While there is limited evidence that antidepressants help people with dementia, Maus notes that someone who had depression prior to developing dementia could benefit from taking a drug that was previously effective for them was.
And while there is little evidence of any benefit, all of these drugs have side effects. For example, some people who take a new antidepressant may feel nauseous or feel a little "nervous". Unfortunately, it can be difficult for a person with dementia to convey such side effects to the loved one who cares for them. Instead, they may seem more excited – which leads to another prescription drug to calm them down.
While the current study does not look at polypharmacy – the use of multiple psychotropic drugs by the same patient – Mouse continues to investigate this problem in the Medicare data.
The long haul
Maus notes that of the 29% who received opioids, most of the time only one or two short-term prescriptions were filled out, which may indicate treatment for an injury or acute pain.
But those on other medications tended to fill out multiple prescriptions in the year Mouse and his colleagues studied. This included epilepsy drugs, which are sometimes prescribed to replace antipsychotics or to treat chronic pain.
Taking these medications for months is particularly risky, says Mouse. "A brain with dementia does its best to function as well as possible," he explains. "If we add a psychotropic drug to the mix, it may not be a helpful thing – and it carries risks."
A bright spot in the data, according to Mouse, is that only one in five of the dementia patients examined has filled out a prescription for an antipsychotic such as Abilify, Seroquel or Risperdal. Because of the safety risks associated with antipsychotics, they have received a great deal of attention, and professional guidelines such as "Smart Choices" for Physicians advise caution.
On the other hand, this class of drugs has more evidence than the others that it actually helps some patients with behavioral problems such as aggression. "So it's worrying that all of the other classes – which have fewer signs of benefit – are more widespread," says Mouse.
Better education needed
Mouse notes that not only do nurses and doctors understand the lack of evidence and the increased risks associated with psychoactive drugs, but they can also learn about the non-drug care strategies they use to address behavioral issues in the person they care for You may just need better education about the disease itself.
Access to support services through local, state, and federal agencies, including programs from the Area Agency on Aging, and through nonprofits like the Alzheimer's Association and AARP, could also help caregivers, he says.
“Apathy and withdrawal, and a tendency to get excited, are common symptoms of dementia,” he says. "And as much as health care providers want to help these patients and their family caregivers, these drugs are just not helpful enough to warrant this amount of prescriptions."
Are antipsychotics more dangerous than we think for people with dementia?
University of Michigan
These drugs carry risks and may not help, but many people with dementia still get them (2020, August 18)
accessed on August 18, 2020
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