Some 58% of seniors with probable or possible dementia had otherwise good to excellent health, yet more than half of the total took six or more regular medications - a habit that may, at best, strain insurance costs and budgets, and at worst may result in adverse drug interactions and poor outcomes, and even exacerbate cognitive symptoms.
But far from the seniors refusing to reduce their medications, which includes prescribed and over-the-counter drugs as well as supplements, a new study led by UC San Francisco reveals that 87% of them responded that they would be willing to stop at least one "if their doctor said it was possible."
In the study, researchers tracked a national sample of 422 seniors, representing 1.8 million Medicare beneficiaries, who were recruited by the National Health and Aging Trends Study (NHATS). Approximately three-quarters were 75-plus; 44% had possible dementia and 56% had probable dementia, the researchers reported in their study publishing in the Journal of the American Geriatrics Society on March 10.
Probable and possible dementia were determined by NHATS criteria, which included cognitive testing, reports from the participant or a proxy - typically a family member - that a doctor had said they had dementia, or responses relating to memory, orientation, judgment and function consistent with dementia from proxies, who represented 26% of participants.
Multiple Medications May Contribute to Misuse
In addition to adverse interactions and outcomes, polypharmacy also "contributes to challenges with adherence, since more complicated medication regimens require more time and attention, and increase the potential for making mistakes and inadvertent misuse," said first author Matthew Growdon, MD, an aging research fellow at the UCSF Division of Geriatrics and the San Francisco VA Medical Center.
"Many drugs may be especially harmful to older adults with cognitive impairment, such as benzodiazepines, used to treat anxiety, and oxybutynin, used to treat urinary incontinence. These drugs have sedating effects that increase the risk of delirium and can worsen dementia," he said.
Many drugs may be especially harmful to older adults with cognitive impairment, such as benzodiazepines, used to treat anxiety, and oxybutynin, used to treat urinary incontinence. These drugs have sedating effects that increase the risk of delirium and can worsen dementia.
While 87% of the participants said they were willing to stop at least one of their medications, this increased to 92% of participants who were taking six or more medications. In addition, 29% in this group agreed "that at least one medication was no longer necessary." This compares with 13% in participants taking less than six pills. Growdon attributes this finding to "a biomedical culture of prescribing," as well as "deference on the part of patients and physicians to the prescribing physician."
A study last year, led by Growdon and Michael Steinman, MD, co-senior author of the current study, found that the average number of medications among older adults with dementia was eight compared with three for older adults without dementia. This disparity may reflect "less coordination of care with multiple clinicians caring for the same patient, leading to more medications piling up," said Steinman, also of the UCSF Division of Geriatrics and the San Francisco VA Medical Center.
Cognitive Impairment May Lead to More Meds
"Additionally, treatment of cognitive impairment itself and its complications may lead to more medication use. This can include medications to help with memory and with mood, and medications for symptoms that people with cognitive impairment can increasingly face, like urinary incontinence," he said.
Other commonly prescribed drugs include vitamin D and calcium, and medications for high blood pressure, diabetes, constipation and arthritis, the authors noted.
"Our aim as geriatricians is to prescribe medications to help older people achieve their health and function goals, especially those with dementia," said co-senior author Kenneth Boockvar, MD, from the New Jewish Home, Icahn School of Medicine at Mount Sinai and James J. Peters VA Medical Center, Bronx. "We need to avoid or stop taking medications that do not further those goals. That's where deprescribing comes in."
Deprescribing is about medical optimization, "rather than taking away medications," said Growdon. "We should strive to ensure that the benefits outweigh risks, and that we are prescribing in line with goals of care, and taking into consideration factors in older adults, like frailty, multimorbidity, cognitive impairment and functional status. One thing this study can hopefully add is that patient/family resistance to deprescribing should not be seen as a barrier."
Co-authors: Edie Espejo, MA, Bocheng Jing, MS, W. John Boscardin, PhD, and Kristine Yaffe, MD, from UCSF and San Francisco VA Medical Center; Andrew R. Zullo, PharmD, PhD, from Brown University, Providence Veterans Affairs Medical Center and Lifespan - Rhode Island Hospital.
Funding: This work was supported by grant P01AG066605 from the National Institute 44 on Aging (NIA). Dr. Growdon was supported by the grant T32-AG000212 from the NIA. Dr. Zullo was supported by grants R01AG045441, RF1AG061221, 45 R01AG065722, and R21AG061632 from the NIA. Dr. Yaffe was supported by the grant 46 R35AG071916 from the NIA. Dr. Steinman was supported by grants 1R24AG064025 and 47 K24AG049057 from the NIA.
Conflicts of Interest: Dr. Zullo is supported by grant funding from Sanofi Pasteur to Brown University for work on infections and vaccinations in nursing home residents and infants. Dr. Steinman receives royalties from UpToDate and honoraria from the American Geriatrics Society.
