A recent study published in JAMA reports that one in four Medicare beneficiaries with dementia is prescribed central nervous system (CNS)-active medications, despite longstanding clinical guidelines warning against this practice due to risks such as falls, confusion, and hospitalization. The research highlights a continued reliance on these drugs among individuals with cognitive impairment who are particularly vulnerable to adverse effects.
“While this decline was encouraging, over two-thirds of patients receiving these prescriptions lacked a documented clinical indication in 2021, the end of the study period, suggesting high levels of potentially inappropriate and harmful prescribing,” said Dr. John N. Mafi, associate professor-in-residence of medicine in the division of general internal medicine and health services research at the David Geffen School of Medicine at UCLA. “Compared with patients with normal cognition, we also found higher levels of prescribing among older adults with cognitive impairment, who face a higher risk of adverse effects from these drugs. These results underscore substantial opportunities to improve the quality and safety of care for millions of older Americans.”
The study analyzed survey data from the Health and Retirement Study linked to Medicare fee-for-service claims from January 2013 through December 2021. Researchers focused on five drug classes: antidepressants with strong anticholinergic properties, antipsychotics, barbiturates, benzodiazepines, and nonbenzodiazepine hypnotics.
Findings showed that CNS-active medications were prescribed for 17% of older adults with normal cognition, nearly 22% for those with cognitive impairment but without dementia, and about 25% for those diagnosed with dementia.
Prescription trends indicated declines in some drug classes over the nine-year period: benzodiazepines dropped from 11.4% to 9.1%, nonbenzodiazepine hypnotics fell from 7.4% to 2.9%, while antipsychotic medication prescriptions increased from 2.6% to 3.6%. Prescriptions for anticholinergic antidepressants remained steady at 2.6%, and barbiturate prescriptions slightly decreased from 0.4% to 0.3%.
The proportion of clinically justified prescriptions declined slightly from 6% in 2013 to 5.5% in 2021; likely inappropriate CNS-active prescriptions fell more significantly from 15.7% to 11.4%. Reductions were mainly attributed to fewer prescriptions for benzodiazepines and sleep medications.
The authors noted several limitations including unavailable Medicare Advantage data and missing clinical details such as agitation symptoms; the analysis also emphasized prevalence rather than cumulative exposure.
“While CNS-active prescriptions may be appropriate in some cases, it is important for older patients or their caregivers to work closely with their physicians to ensure that these medications are appropriate to their cases. When inappropriate, patients and their care teams should consider alternative treatments and consider whether it might be safe to taper or stop the medication,” said Dr. Annie Yang, a scholar in the National Clinician Scholars Program at Yale University who led this study as a UCLA internal medicine resident.
Other contributors included researchers affiliated with UCLA—a prominent public research institution known for its diverse academic programs and commitment to societal progress (official website)—RAND Corporation, University of Michigan, and VA Greater Los Angeles Healthcare System.
Funding was provided by the National Institutes of Health/National Institute on Aging (R01AG070017-01).
