Many people with dementia take risky drug combinations
Even though these antipsychotics aren’t approved for people with dementia, they’re often prescribed to these patients for restlessness and sleep issues, and more, notes Maust.
But two other drug classes were even more commonly prescribed to patients in the CNS polypharmacy group. Almost all (92%) of those taking at least three of the medications were taking an antidepressant, and 62% were taking an anticonvulsant.
A drug in the latter class, gabapentin, accounted for one-third of the daily prescription supply that study patients received during the study period.
Although gabapentin is approved to treat epilepsy, few of these seniors had seizure disorders. The vast majority of prescriptions were likely for other reasons, as it’s commonly prescribed off-label as a painkiller or to relieve anxiety, Maust says.
Another 41% of people in the three or more drug group were taking a benzodiazepine, such as lorazepam (Ativan), often used for anxiety or agitation in people with dementia.
Maust’s earlier work on benzodiazepine prescribing in the elderly focused on long term use, variation by geographical areaand the effects of national efforts to reduce the use of these drugs because of their risks.
New approaches needed
Maust says providers and caregivers have the right motivation to try to treat dementia-related behaviors through medication: to reduce distress in patients, and sometimes in caregivers as well.
Often the long-term goal is to allow the person with dementia to avoid having to move to a long-term care facility. The high number of deaths of people with dementia in these facilities during the COVID-19 pandemic could increase this motivation, he notes.
And the lack of information for clinicians about the use of these drugs in dementia makes each prescription a matter of judgment.
SEE ALSO: Incompatible medications can put seniors at risk, but many don’t see a pharmacist
But it’s important to know that prescribing a combination of drugs that might be safe for young people may be dangerous for older people. People with reduced cognitive abilities may be particularly susceptible to potential risks. Changes in brain chemistry and drug response that accompany age and dementia alter the response to these drug combinations.
For example, opioid painkillers already come with a black box warning against combining them with other drugs that affect the central nervous system, for any user. But these combinations can be especially risky in older people. Yet 32% of people in the study group were taking an opioid, most often hydrocodone.
Although people with dementia are given drugs that act on their central nervous system for behavioral reasons, these same drugs can accelerate their cognitive decline. For example, a clinical trial of the antidepressant citalopram (Celexa) as a way to treat dementia-related agitation showed that in just nine weeks, participants lost a measurable amount of cognitive ability.
“It is important that family members and providers communicate often about the symptoms that are occurring and what could be done with non-drug interventions such as physical therapy or sleep hygiene, as well as medications, to fix it,” says Maust. “Discuss the medications the patient is taking, why they are taking each one, and whether it is worth trying to reduce some of them, because the symptom that originally prompted the prescription may have be diminished over time.
In some cases, the drugs may even be prescribed in response to the distress a caregiver feels upon seeing their loved one behaving in a certain way. Connecting caregivers to resources through nonprofit organizations or their local aging agency could help them better support their loved ones.
Researchers are now looking at which providers prescribed each of the drugs to patients taking three or more drugs to look for patterns and opportunities to educate providers or build systems after hospitalizations or other events.
In addition to Maust, who is a member of the UM Institute for Healthcare Policy and Innovation and the VA Center for Clinical Management Research, the study was conducted by a team that includes IHPI members and staff Myra Kim, Sc.D., MA, Julie Bynum, MD, Kenneth Langa, MD, Ph.D., Chiang-Hua Chang, Ph.D., Kara Zivin, Ph.D., and Erica Solway, Ph.D., former professor of UM Psychiatry Helen Kales, MD, now at the University of California-Davis, and lead author Stephen Marcus, Ph.D. of the University of Pennsylvania.
The study was supported by a grant from the National Institute on Aging (AG056407).
Article quoted: “Prevalence of central nervous system – active polypharmacy in older adults with dementia in the United States”, JAMA. DOI:10.1001/jama.2021.1195