A new study reveals that despite guidelines, about one in four Medicare beneficiaries with dementia continue to receive brain-altering medications linked to falls and confusion. Prescribing rates have declined overall from 20% to 16% between 2013 and 2021, but those with cognitive impairment face higher risks. Researchers highlight the need for better documentation and alternatives to improve care safety.
Even after years of warnings, brain-altering drugs that can increase confusion, falls, and hospital stays remain common among dementia patients. Published on January 12 in the peer-reviewed journal JAMA, the research analyzed data from the Health and Retirement Study linked to Medicare fee-for-service claims, covering January 1, 2013, to December 31, 2021. Older adults were categorized by cognition: normal, cognitive impairment without dementia, and dementia.
The study examined five types of central nervous system-active medications: antidepressants with strong anticholinergic properties, antipsychotics, barbiturates, benzodiazepines, and non-benzodiazepine hypnotics. Overall, usage dropped from 20% to 16% across Medicare beneficiaries. However, rates were higher for those with impairments: 17% for normal cognition, nearly 22% for cognitive impairment without dementia, and 25% for dementia.
Specific trends showed benzodiazepines declining from 11.4% to 9.1%, non-benzodiazepine hypnotics from 7.4% to 2.9%, antipsychotics rising from 2.6% to 3.6%, anticholinergic antidepressants steady at 2.6%, and barbiturates slightly from 0.4% to 0.3%. Clinically justified prescriptions fell modestly from 6% to 5.5%, while likely inappropriate ones dropped more sharply from 15.7% to 11.4%.
"While this decline was encouraging, over two-thirds of patients receiving these prescriptions lacked a documented clinical indication in 2021," said senior author Dr. John N. Mafi, associate professor at UCLA's David Geffen School of Medicine. He noted higher prescribing among those with cognitive impairment, who are more vulnerable to side effects, underscoring opportunities to enhance care quality for millions of older Americans.
Lead author Dr. Annie Yang, from Yale's National Clinician Scholars Program and formerly a UCLA resident, advised: "While CNS-active prescriptions may be appropriate in some cases, it is important for older patients or their caregivers to work closely with their physicians to ensure that these medications are appropriate... and consider whether it might be safe to taper or stop the medication."
The study, funded by the National Institutes of Health and National Institute on Aging, was co-authored by researchers from UCLA, RAND, University of Michigan, and VA Greater Los Angeles Healthcare System. Limitations include exclusion of Medicare Advantage data and lack of details on certain clinical contexts like agitation.
