Changes in the Use of Long-Term Medications Following Incident Dementia Diagnosis

Abstract

Importance: Dementia is a life-altering diagnosis that may affect medication safety and goals for chronic disease management.

Objective: To examine changes in medication use following an incident dementia diagnosis among community-dwelling older adults.

Design, setting, and participants: In this cohort study of adults aged 67 years or older enrolled in traditional Medicare and Medicare Part D, patients with incident dementia diagnosed between January 2012 and December 2018 were matched to control patients based on demographics, geographic location, and baseline medication count. The index date was defined as the date of first dementia diagnosis or, for controls, the date of the closest office visit. Data were analyzed from August 2021 to June 2023.

Exposure: Incident dementia diagnosis.

Main outcomes and measures: The main outcomes were overall medication counts and use of cardiometabolic, central nervous system (CNS)-active, and anticholinergic medications. A comparative time-series analysis was conducted to examine quarterly changes in medication use in the year before through the year following the index date.

Results: The study included 266 675 adults with incident dementia and 266 675 control adults; in both groups, 65.1% were aged 80 years or older (mean [SD] age, 82.2 [7.1] years) and 67.8% were female. At baseline, patients with incident dementia were more likely than controls to use CNS-active medications (54.32% vs 48.39%) and anticholinergic medications (17.79% vs 15.96%) and less likely to use most cardiometabolic medications (eg, diabetes medications, 31.19% vs 36.45%). Immediately following the index date, the cohort with dementia had a greater increase in mean number of medications used (0.41 vs -0.06; difference, 0.46 [95% CI, 0.27-0.66]) and in the proportion of patients using CNS-active medications (absolute change, 3.44% vs 0.79%; difference, 2.65% [95% CI, 0.85%-4.45%]) owing to an increased use of antipsychotics, antidepressants, and antiepileptics. The cohort with dementia also had a modestly greater decline in use of anticholinergic medications (quarterly change in use, -0.53% vs -0.21%; difference, -0.32% [95% CI, -0.55% to -0.08%]) and most cardiometabolic medications (eg, quarterly change in antihypertensive use: -0.84% vs -0.40%; difference, -0.44% [95% CI, -0.64% to -0.25%]). One year after diagnosis, 75.2% of the cohort with dementia were using 5 or more medications (2.8% increase).

Conclusions and relevance: In this cohort study of Medicare Part D beneficiaries, following an incident dementia diagnosis, patients were more likely to initiate CNS-active medications and modestly more likely to discontinue cardiometabolic and anticholinergic medications compared with the control group. These findings suggest missed 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.

Figure 1.. Trends in Overall Medication Use

Each quarter represents the preceding 90 days. The vertical dotted line represents the last quarter of pharmacy fills prior to the index date. Corresponding time series analyses are presented in eTable 3 in Supplement 1. CNS indicates central nervous system.

Figure 2.. Trends in Use of Central Nervous System–Active and Anticholinergic Medications

Each quarter represents the preceding 90 days. The vertical dotted line represents the last quarter of pharmacy fills prior to the index date. Opioids and benzodiazepines are shown in eFigure 3 in Supplement 1; nonbenzodiazepine benzodiazepine receptor agonists are not shown due to low use in both cohorts. Corresponding time series analyses are presented in eTable 5 in Supplement 1.

Figure 3.. Change in Use of Central Nervous System (CNS)–Active and Anticholinergic Medications From the Index Date to the End of the Study Period

BZRA indicates nonbenzodiazepine benzodiazepine receptor agonist.

Figure 4.. Trends in Use of Cardiometabolic Medications

Each quarter represents the preceding 90 days. The vertical dotted line represents the last quarter of pharmacy fills prior to the index date. Diabetes medication trends are shown in eFigure 3 and the corresponding time series analyses in eTable 4 in Supplement 1.