Study: Patients with advanced dementia continue receiving inappropriate medications

Nursing home residents with advanced dementia often receive medications of questionable benefit with costly consequences, according to a study published online September 8 in the Journal of the American Medical Association Internal Medicine.

In a nationwide study, UMass Medical School, Worcester, Mass., researchers studied 5,406 nursing home residents with advanced dementia. They found 54% were prescribed at least 1 medication of questionable benefit during the 90-day observation period between 2009 and 2010. The mean 90-day expenditure for medications with questionable benefit was $816, accounting for 35% of total average 90-day medication expenditures for residents with advanced dementia prescribed these medications.

Lead author Jennifer Tjia, MD, MSCE, and colleagues defined “medications of questionable benefit” as those deemed never appropriate in advance dementia according to the results of previously published research. The most common questionably beneficial medications used were cholinesterase inhibitors (33.8%), memantine (20.4%), and lipid-lowering agents (17.0%).

Data for the cross-sectional study were derived from the prescription-dispensing database of a national long-term care pharmacy that serves approximately half of the 1.3 million long-term care facility residents in the United States.

“Explicit guidelines for medication prescribing for chronic diseases at the end of life need to be developed, but the field is still waiting for ‘evidence’ to move this effort forward,” said lead author Jennifer Tjia, MD, MSCE, associate professor of quantitative health sciences. 

“In the absence of that evidence and those guidelines, we are still relying on expert opinion to determine prescribing appropriateness for most drugs used at the end of life,” said Dr Tjia. “Everyone deserves thoughtful medication review to determine whether a medication is consistent with these goals.  At the end of the day, prescribing decisions for patients with limited life expectancy should be driven by the patient’s and family’s goals of care.”

 Despite standards of care that call for minimizing unnecessary or minimally beneficial interventions in order to focus on interventions that optimize quality of life, polypharmacy remains common in this population, according to Dr Tjia.

Advanced dementia is characterized by severe cognitive impairment, complete functional dependence and difficulties swallowing and eating. The Institute of Medicine recommends reducing minimally beneficial interventions in patients with life-limiting illness.

Dr. Tjia said it is particularly important to minimize the use of questionably beneficial medications among patients in this population because swallowing and eating difficulties make medication administration burdensome and difficult for both the residents and the nursing home staff; adverse drug effects are common in patients with dementia; and they have frequent clinical complications associated with a high risk of 6-month mortality, and yet the time horizon to benefit from many medications prescribed exceeds this life expectancy.

The most common questionably beneficial medications used in this cohort of residents with advanced dementia were cholinesterase inhibitors and memantine. These are typically prescribed at earlier stages of dementia and a major goal of use is delaying institutional placement. However, the clinical value of these medications, even in early stage disease, has also recently come into question by the US Preventive Services Task Force.

While use in late stage dementia is common, even in the hospice setting where most hospice medical directors believe that antidementia medications are ineffective, clinical trial data reports minimal cognitive and functional benefit for advanced disease, researchers said. While proponents of continued antidementia medication use argue that discontinuation leads to cognitive and behavioral declines, data are inconclusive. Further, continued antidementia medication use without benefit places patients at excess risk of well-known adverse drug effects including fainting, hip fracture, arrhythmia, and urinary retention. Indeed, one national study showed that antidementia medications were the drugs most often implicated in adverse drug effects among patients with dementia, accounting for almost one-third of all adverse drug effects.

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