75% of Older Adults With Dementia May Be On the Wrong Prescriptions

According to new research, nearly three quarters of older adults with dementia have filled prescriptions for medicines that act on their brain and nervous system, but that are not FDA-approved for dementia. Non-dementia drugs might be commonly prescribed to address behavioral symptoms of dementia, but in many cases, they are not only ineffective for dementia’s symptoms — they can also carry certain risks for older adults. Some have even been linked to further cognitive decline.

A new study from the University of Michigan, published this week in JAMA, is the first large-scale study of prescription-filling patterns for psychoactive medications outside of nursing homes and other long-term care facilities. The researchers looked at several classes of psychoactive drugs that have been prescribed both in nursing homes and at home to people living with dementia.

“Apathy and withdrawal, and a tendency to get agitated, are common symptoms of dementia,” lead author Dr. Donovan Maust, a geriatric psychiatrist at the University of Michigan and the VA Ann Arbor Healthcare System, said in a news release. “And as much as health care providers want to help these patients and their family caregivers, these medications are just not helpful enough to justify this amount of prescribing.”

Maust’s assessed Medicare prescription records data from 737,839 people with dementia over a one-year period, finding that 73.5% of the study’s community-based population filled at least one prescription for antidepressants, opioid painkillers, epilepsy drugs, anxiety medications or antipsychotic drugs.

According to the researchers, most of the 29% who received an opioid prescription only had one or two refills, indicating possible finite treatment for an injury. But those receiving other drugs tended to fill multiple prescriptions within the year period, including epilepsy drugs that are sometimes prescribed as substitutes for antipsychotic drugs or chronic pain treatments.

Maust said that nearly half of those in the study received an antidepressant — possibly prescribed to try to counteract the withdrawal and apathy often seen in dementia. He said that someone who lived with depression prior to the onset of their dementia could benefit from an antidepressant that worked for them in the past, but for the most part,  antidepressants don’t tend to be effective for dementia-based apathy or withdrawal.

Risks of Prescribing Off-Label Psychotropics for Dementia

“A brain that has dementia is doing its best to function as well as it can,” he said. “If we add a psychotropic medication into the mix it may not be a helpful thing — and it comes with risks.”

All of the drugs in Maust’s study are associated with risks to people in their 60s and older, such as increasing the likelihood of a fall, causing drug dependence that could lead to withdrawal, or side effects such as feeling “jittery,” which people living with dementia may struggle to articulate to their caregivers. This could instead manifest as agitation, which could lead to even more off-label prescriptions to address new behavioral changes.

For example, as many as 50 percent of dementia patients experience regular pain, but some prescription painkillers have been found to cause personality changes, confusion and sedation among other side effects, only making things worse.

Maust added that taking these prescriptions for prolonged periods of time — more than a single refill — carries risks as well.

Among the drugs evaluated in the study were antipsychotics such as Abilify, Seroquel or Risperdal, for which one in five of the study participants had filled a prescription. According to Maust, this class of drugs has more evidence than the others that it actually helps some patients with behavioral problems such as aggression. But while widely used (and alarmingly, widely misused), antipsychotics in people with dementia can lead to sedation and falls, they have been linked to higher rates of hospitalization among people with dementia, and studies suggest they may even double the speed at which brain function deteriorates.

The research team found that while these off-label prescriptions happen in long-term care facilities and nursing homes, they are also happening over the course of at-home care. Maust said better education about these prescriptions, their side effects, and dementia in general is needed, adding, “It is worrisome that all the other classes — which have less evidence of benefit — are all prescribed more widely.”