Half of US patients with advanced dementia are prescribed drugs of questionable benefit, study finds

More than half of patients with advanced dementia in US nursing homes are prescribed medicines of questionable benefit even though they have reached the end stage of the disease and have just a short time to live, a new study has found.

The article was published online on 8 September in JAMA Internal Medicine.1 Jennifer Tjia, of the University of Massachusetts Medical School in Worcester, Massachusetts, was the paper’s lead author.

In the study, Tjia and her colleagues used data from a prescriptions database maintained by a pharmacy that serves about half of the 1.3 million residents of long term care facilities in the United States and from another database, the Minimum Data Set (MDS), which contains clinical assessments of nursing home residents in all federally funded US nursing homes. The assessments included information about the residents’ medical, psychological, and cognitive status, as well as demographic information.

The researchers identified a sample of 5406 residents with advanced dementia whose prescription information was available and who had had full MDS assessments between 1 October 2009 and 30 September 2010. Half of them were age 85 or older, most were women, 13.4% lived in special dementia care units, and 69.9% had a “do not resuscitate” order.

Medicines of questionable benefit were defined as those that had been deemed “never appropriate” for advanced dementia patients in a previously published list derived by a Delphi consensus process.2 In that process a panel of 12 geriatricians drew up a list of medicines that were “always appropriate,” “sometimes appropriate,” “rarely appropriate,” or “never appropriate” for advanced dementia patients whose condition warranted palliative care. For example, the panel considered such drugs as antidiarrheals, laxatives, narcotic analgesics, and pressure ulcer products as “always appropriate”; blood pressure drugs, antidepressants, and antipsychotics as “sometimes appropriate”; and drugs for cytotoxic chemotherapy, lipid lowering medications, and anticholinesterase inhibitors—typically used to treat mild to moderate dementia—as “never appropriate.”

In the new study, however, Tjia and her colleagues found that 53.9% of the nursing home residents with advanced dementia were prescribed at least one medicine of questionable benefit. The most commonly prescribed of these were cholinesterase inhibitors, the dementia drug memantine hydrochloride, and lipid lowering agents. The average cost for these drugs over 90 days was $816 (£506; €630), or about one third of these patients’ medication costs, the researchers wrote. “Despite standards of care that call for minimizing interventions that are unnecessary or provide little benefit in order to focus on interventions that optimize quality of life, polypharmacy remains common in this population,” they wrote.

Residents who had oral problems were less likely to be prescribed a medicine of questionable benefit (adjusted odds ratio 0.68 (95% confidence interval 0.59 to 0.78)), as were those who were on a feeding tube (0.58 (0.48 to 0.70)), enrolled in a hospice (0.69 (0.58 to 0.82)), or had a “do not resuscitate” order (0.65 (0.57 to 0.75)).

Residents were more likely to be prescribed a medicine of questionable benefit if they were in a facility where more than 10% of residents were on feeding tubes (1.45 (1.12 to 1.87)) than those in which the prevalence of feeding tubes was only 0-5%.

Questionable medicine use was lowest (44.7%) in facilities in the Mid-Atlantic region, which includes New York, New Jersey, and Pennsylvania, and was highest (65%) in the West South Central region, which includes Arkansas, Louisiana, Oklahoma, and Texas.

In an invited commentary, Greg A Sachs of the Indiana University School of Medicine in Indianapolis, Indiana, wrote that the article “should cause all clinicians to reconsider their prescribing practices and other decision making for a broad population of patients late in life.”3

Identifying and discontinuing medicines of little benefit would spare patients the burden of taking these medicines and would reduce their risk of adverse drug effects, as well as reducing the burden on staff administering the drugs, Sachs wrote. “As few interventions can simultaneously achieve such outcomes for frail patients with dementia, reviewing medication lists and stopping nonbeneficial drug use should be a top priority for prescribers,” he added.