A study published on January 12 in the journal JAMA indicates that approximately one in four Medicare beneficiaries diagnosed with dementia are prescribed central nervous system (CNS)-active medications. These medications are associated with adverse effects such as falls, confusion, and hospitalization. While the overall prescribing rate of these medications among all Medicare beneficiaries decreased over a nine-year period, individuals with cognitive impairment, including those with dementia, continue to receive these prescriptions at higher rates. The findings suggest an area for improving medication management and patient safety for older adults.
Study Overview
The research, led by Dr. Annie Yang, a scholar at Yale University who conducted the study as a UCLA internal medicine resident, with Dr. John N. Mafi, a senior author and associate professor at UCLA, analyzed prescribing patterns from January 1, 2013, to December 31, 2021. The study utilized survey data from the Health and Retirement Study linked to Medicare fee-for-service claims. It investigated the use of CNS-active medications across three groups of older adults: those with normal cognition, those with cognitive impairment without dementia, and those with dementia. Clinical guidelines generally advise against the use of these medications in individuals with cognitive impairment due to an elevated risk of adverse outcomes.
Key Findings on Prescribing Practices
During the study period, the overall prescription rate for CNS-active medications among all Medicare beneficiaries decreased from 20% to 16%. However, prescribing rates remained higher for older adults with cognitive impairment. In 2021, over two-thirds of patients receiving CNS-active prescriptions lacked a documented clinical indication, suggesting potentially inappropriate prescribing practices.
Specific prescribing rates by cognitive status were:
- Normal Cognition: 17% were prescribed CNS-active medications.
- Cognitive Impairment (without dementia): Nearly 22% were prescribed CNS-active medications.
- Dementia: Approximately 25% were prescribed CNS-active medications.
Medication Class Trends (2013-2021)
The study examined trends for five classes of CNS-active medications among all Medicare fee-for-service beneficiaries:
- Benzodiazepines: Declined from 11.4% to 9.1%.
- Non-benzodiazepine hypnotics (sleep drugs): Fell from 7.4% to 2.9%.
- Antipsychotic medications: Rose from 2.6% to 3.6%.
- Anticholinergic antidepressants: Remained at 2.6%.
- Barbiturates: Decreased slightly from 0.4% to 0.3%.
The observed decline in overall CNS-active prescriptions was largely attributed to reductions in benzodiazepine and non-benzodiazepine hypnotic prescriptions, particularly those identified as likely inappropriate. Clinically justified prescriptions decreased from 6% in 2013 to 5.5% in 2021, while likely inappropriately prescribed CNS-active medications saw a reduction from 15.7% to 11.4% during the same period.
Implications and Recommendations
The study identifies an ongoing need to review and potentially improve prescribing practices for older adults, particularly those with cognitive impairment. Dr. Annie Yang recommended that older patients and their caregivers collaborate with physicians to ensure the appropriateness of these medications. When prescriptions are deemed inappropriate, considering alternative treatments or a gradual tapering and cessation of the medication is advised.
Study Limitations
The research acknowledged several limitations, including the unavailability of Medicare Advantage data, the potential for missing clinical information within the datasets used, and a focus on prescribing prevalence rather than cumulative exposure to the medications.