Medication misuse and overuse in community-dwelling persons with dementia

Abstract

Background: Persons with dementia (PWD) have high rates of polypharmacy. While previous studies have examined specific types of problematic medication use in PWD, we sought to characterize a broad spectrum of medication misuse and overuse among community-dwelling PWD.

Methods: We included community-dwelling adults aged ≥66 in the Health and Retirement Study from 2008 to 2018 linked to Medicare and classified as having dementia using a validated algorithm. Medication usage was ascertained over the 1-year prior to an HRS interview date. Potentially problematic medications were identified by: (1) medication overuse including over-aggressive treatment of diabetes/hypertension (e.g., insulin/sulfonylurea with hemoglobin A1c < 7.5%) and medications inappropriate near end of life based on STOPPFrail and (2) medication misuse including medications that negatively affect cognition and medications from 2019 Beers and STOPP Version 2 criteria. To contextualize, we compared medication use to people without dementia through a propensity-matched cohort by age, sex, comorbidities, and interview year. We applied survey weights to make our results nationally representative.

Results: Among 1441 PWD, median age was 84 (interquartile range = 78-89), 67% female, and 14% Black. Overall, 73% of PWD were prescribed ≥1 potentially problematic medication with a mean of 2.09 per individual in the prior year. This was notable across several domains, including 41% prescribed ≥1 medication that negatively affects cognition. Frequently problematic medications included proton pump inhibitors (PPIs), non-steroidal anti-inflammatory drugs (NSAIDs), opioids, antihypertensives, and antidiabetic agents. Problematic medication use was higher among PWD compared to those without dementia with 73% versus 67% prescribed ≥1 problematic medication (p = 0.002) and mean of 2.09 versus 1.62 (p < 0.001), respectively.

Conclusion: Community-dwelling PWD frequently receive problematic medications across multiple domains and at higher frequencies compared to those without dementia. Deprescribing efforts for PWD should focus not only on potentially harmful central nervous system-active medications but also on other classes such as PPIs and NSAIDs.

Keywords: cognitive impairment; dementia; medication overuse; polypharmacy; potentially inappropriate medication.

Figure 1:

Mean number of medications identified as potentially problematic among community-dwelling older adults with and without dementia overall and by domain in the primary cohort matched on age, sex, comorbidity count, and year of assessment^a Abbreviations: STOPP-V2, Screening Tool of Older Persons’ Prescriptions Version 2 a As some medications were flagged under multiple domains (e.g., lorazepam under medications that negatively affect cognition, 2019 Beers, and STOPP-V2), we counted each medication only once when reporting the overall summary measure.

Figure 2:

Medications most frequently identified as potentially problematic among community-dwelling older adults with dementia in the primary cohort (n=1,441)^a a Certain medications could be flagged as potentially problematic in multiple ways. For example, proton pump inhibitors could be flagged based on use for >8 weeks in the absence of reason for continued use (e.g., diagnosis code for Barrett’s esophagus). Gabapentin could be flagged under the “medications that negatively affect cognition” domain (as a sedative-hypnotic) or through the 2019 Beers criteria (overlapping prescription of gabapentin/opioid or combination of ≥3 central nervous system active drugs). Non-steroidal anti-inflammatory drugs like meloxicam and naproxen could be flagged when used for prolonged durations (e.g., consecutive fills for >90 days), when used with certain diagnosis codes (e.g., gastric ulcer), in advanced chronic kidney disease, or when used with anticoagulants. Antihypertensives (e.g., metoprolol, clonidine) and antidiabetic agents (e.g., glipizide) could be flagged under the “over-aggressive treatment of chronic conditions” domain (e.g., systolic blood pressure <110 on antihypertensive without alternative indication), when used in combination with another medication (e.g., beta-blocker and verapamil/diltiazem), or when used in setting of specific conditions (e.g., beta-blocker with history of heart block).