Dementia diagnosis associated with increased medication use

Patients diagnosed with dementia may be prescribed more medications, a recent study found.

To evaluate changes in medication use, researchers matched Medicare beneficiaries 67 years of age and older who received a diagnosis of incident dementia between January 2012 and December 2018 to controls based on demographic characteristics, geographic location, and baseline medication count. Administrative and pharmacy claims were obtained for Jan. 1, 2010, to Dec. 31, 2019, and prescription fill patterns of common central nervous system (CNS)-active, anticholinergic, and cardiometabolic medications were compared. The index date was the date of first dementia diagnosis, or the date of the closest office visit for controls. The study's main outcomes were overall medication counts and use of cardiometabolic, CNS-active, and anticholinergic medications. The authors used a comparative time-series analysis to examine quarterly changes in medication use in the year before through the year after the index date. The results were published Aug. 21 by JAMA Internal Medicine.

A total of 266,675 adults with incident dementia and 266,675 controls were included in the study. Mean age in both groups was 82.2 years, with 65.1% ages 80 years or older, and 67.8% were female. At baseline, use of CNS-active medications and anticholinergic medications was more likely in patients with incident dementia than controls (54.32% vs. 48.39% and 17.79% vs. 15.96%, respectively), while use of most cardiometabolic medications was less likely. The increase in mean number of medications used (0.41 vs. −0.06; difference, 0.46 [95% CI, 0.27 to 0.66]) and the proportion of patients using CNS-active medications (absolute change, 3.44% vs. 0.79%; difference, 2.65% [95% CI, 0.85% to 4.45%]) were greater immediately after the index date in the cohort with dementia versus controls, with the latter due mainly to increased use of antipsychotic, antidepressant, and antiepileptic agents. Decreased use of anticholinergic medications and most cardiometabolic agents was modestly higher in patients with dementia versus controls. More than three quarters of the cohort with dementia were taking at least five medications a year after diagnosis, a 2.8% increase from baseline.

The authors noted that they used billing diagnosis codes and prescription medication claims to determine diagnoses of dementia and medication use, respectively, and that their results are not generalizable beyond Medicare beneficiaries, among other limitations. “In this cohort study, Medicare beneficiaries with an incident dementia diagnosis were more likely to initiate CNS-active medications and slightly more likely to have cardiometabolic and anticholinergic medications discontinued compared with control patients,” they wrote. “These findings highlight opportunities to reduce burdensome polypharmacy by deprescribing long-term medications with high safety risks or limited likelihood of benefit or that may be associated with impaired cognition.”

An accompanying editorial said the time of first dementia diagnosis is “incredibly consequential” and should ideally prompt a critical assessment of decisions regarding medications. The editorialists called for comprehensive dementia care programs and nonpharmacological interventions, better guidelines for management of comorbidities after a dementia diagnosis, and adaptation of strategies for medication optimization in older adults to the specific context of dementia. “By focusing our efforts on designing comprehensive systems and approaches to care for people living with dementia and their caregivers, we can navigate a path of optimal prescribing decisions during the course of dementia,” the editorialists wrote.