Question Drug Prescribing in Advanced Dementia

Megan Brooks

September 10, 2014

More than half of nursing home residents with advanced dementia receive medications of "questionable" benefit, including cholinesterase inhibitors, typically given during earlier stages of dementia, and statins to lower cholesterol, a new study shows.

This practice has "substantial associated costs, both personal and monetary," lead author Jennifer Tjia, MD, Department of Quantitative Health Sciences, University of Massachusetts Medical School in Worcester, told Medscape Medical News.

"While Choosing Wisely marks a very important shift in the practice of medicine to recognize that 'less is more' in many cases, much more work needs to be done in this area for patients with life-limiting illness, such as advanced dementia," Dr. Tjia said.

The Choosing Wisely campaign is an initiative of the American Board of Internal Medicine Foundation with the aim to "spark conversations" between providers and patients about tests and procedures that should be questioned.

The new study was published online September 8 in JAMA Internal Medicine.

Minimize Intervention, Maximize Quality of Life

Advanced dementia is characterized by severe cognitive and functional impairment, with patients usually bedridden and unable to communicate. They often have problems with dysphagia and aspiration, yet most receive multiple medications daily.

For patients with life-limiting illness, the Institute of Medicine recommends minimizing interventions and focusing on maximizing quality of life, but Dr. Tjia and colleagues' study suggests that's the exception rather than the rule.

The researchers used a long-term care pharmacy database to study use of medications in 5406 nursing home residents with advanced dementia, along with associated costs.

They found that 2911 of these patients (53.9%) received at least 1 drug of questionable benefit, most commonly the dementia therapies cholinesterase inhibitors (36.4%) and memantine hydrochloride (25.2%).

Studies have shown minimal benefit for advanced dementia and potentially increased risk for syncope, hip fracture, arrhythmia, and urinary retention, the researchers point out. In a recent study, dementia medications were the drugs most often implicated in adverse drug events in patients with dementia, accounting for almost one third of all events, they say (Pharmacoepidemiol Drug Saf. 2013;22:952-960).

Dr. Tjia and colleagues found that cholesterol-lowering statins (22.4%) were also commonly prescribed, despite a recent labeling change by the US Food and Drug Administration warning that statins may be associated with memory loss and confusion, as well as increases in blood glucose levels and risk for type 2 diabetes mellitus.

"The accumulating evidence of risk in frail older adults should prompt thoughtful reconsideration of statin use in the face of the daily medication burden of many residents with advanced dementia," they advise.

The likelihood of receiving medications of questionable benefit was lower for patients with eating problems, a feeding tube, or do-not-resuscitate order or who had enrolled in hospice.

However, residents of nursing homes with high feeding tube use (>10%) were more apt to be given medications of dubious benefit than their peers who lived in nursing homes with less feeding tube use (5% or less).

The researchers say the average 90-day cost for a medication of questionable benefit was $816, which accounted for 35.2% of the total average 90-day medication expenditures for residents with advanced dementia.

Reconsider Practice

In a related commentary, Greg A. Sachs, MD, from Indiana University School of Medicine and Eskenazi Health, Indianapolis, says this study contributes to the literature and practice in 2 important ways.

"First, the study's strengths advance our understanding of medication prescribing practices for nursing home residents with advanced dementia. Second, the work by Tjia et al is part of the 'Less Is More' series in this journal and addresses the American Board of Internal Medicine Foundation's Choosing Wisely campaign and other initiatives aimed at curtailing the use of nonbeneficial and potentially harmful medications, tests, and treatments."

"This article should cause all clinicians to reconsider their prescribing practices and other decision making for a broad population of patients late in life," Dr. Sachs concludes.

The study was supported the Agency for Healthcare Research and Quality and the National Institute on Aging. One author reports having received an unrestricted research grant from Daiichi Sankyo Inc for an unrelated study. Dr. Sachs reports having received honoraria for serving on the National Pharmacy and Therapeutics Committee of CVS Caremark.

JAMA Intern Med. Published online September 8, 2014. Abstract Editorial


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