Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, PA, USA.
Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
J Gen Intern Med. 2023 Dec;38(16):3509-3516. doi: 10.1007/s11606-023-08250-z. Epub 2023 Jun 22.
Little is known about the prevalence or chronicity of prescriptions of central nervous system-active (CNS-active) medications in older Veterans.
We sought to describe (1) the prevalence and trends in prescription of CNS-active medications in older Veterans over time; (2) variation in prescriptions across high-risk groups; and (3) where the prescription originated (VA or Medicare Part D).
Retrospective cohort study from 2015 to 2019.
Veterans age ≥ 65 enrolled in the Medicare and the VA residing in Veterans Integrated Service Network 4 (incorporating Pennsylvania and parts of surrounding states).
Drug classes included antipsychotics, gabapentinoids, muscle relaxants, opioids, sedative-hypnotics, and anticholinergics. We described prescribing patterns overall and in three subgroups: Veterans with a diagnosis of dementia, Veterans with high predicted utilization, and frail Veterans. We calculated both prevalence (any fill) and percent of days covered (chronicity) for each drug class, and CNS-active polypharmacy (≥ 2 CNS-active medications) rates in each year in these groups.
The sample included 460,142 Veterans and 1,862,544 person-years. While opioid and sedative-hypnotic prevalence decreased, gabapentinoids exhibited the largest increase in both prevalence and percent of days covered. Each subgroup exhibited different patterns of prescribing, but all had double the rates of CNS-active polypharmacy compared to the overall study population. Opioid and sedative-hypnotic prevalence was higher in Medicare Part D prescriptions, but the percent of days covered of nearly all drug classes was higher in VA prescriptions.
The concurrent increase of gabapentinoid prescribing paralleling a decrease in opioid and sedative-hypnotics is a new phenomenon that merits further evaluation of patient safety outcomes. In addition, we found substantial potential opportunities for deprescribing CNS-active medications in high-risk groups. Finally, the increased chronicity of VA prescriptions versus Medicare Part D is novel and should be further evaluated in terms of its mechanism and impact on Medicare-VA dual users.
对于老年退伍军人中中枢神经系统活性（CNS-活性）药物的处方流行率或慢性率知之甚少。
我们旨在描述（1）随着时间的推移，老年退伍军人中 CNS-活性药物的处方流行率和趋势；（2）高危人群之间的处方差异；以及（3）处方的来源（VA 或 Medicare Part D）。
2015 年至 2019 年的回顾性队列研究。
年龄≥65 岁、参加 Medicare 和 VA 的退伍军人，居住在 Veterans Integrated Service Network 4（包含宾夕法尼亚州和周边几个州）。
药物类别包括抗精神病药、加巴喷丁类药物、肌肉松弛剂、阿片类药物、镇静催眠药和抗胆碱能药物。我们总体描述了处方模式，并在三个亚组中进行了描述：患有痴呆症的退伍军人、高预测使用率的退伍军人和虚弱的退伍军人。我们计算了每个药物类别在每年的流行率（任何配药）和天数覆盖率（慢性），以及这些群体中 CNS-活性药物联合使用（≥2 种 CNS-活性药物）的比率。
样本包括 460142 名退伍军人和 1862544 人年。虽然阿片类药物和镇静催眠药的流行率下降，但加巴喷丁类药物的流行率和天数覆盖率均有大幅增加。每个亚组的处方模式都不同，但与整个研究人群相比，所有亚组的 CNS-活性药物联合使用的比率都增加了一倍。Medicare Part D 处方中的阿片类药物和镇静催眠药的流行率较高，但几乎所有药物类别的天数覆盖率在 VA 处方中都较高。
加巴喷丁类药物的同时处方增加，而阿片类药物和镇静催眠药的处方减少，这是一个新现象，值得进一步评估患者的安全结果。此外，我们发现高危人群中有大量减少 CNS-活性药物的机会。最后，VA 处方与 Medicare Part D 相比，慢性程度增加是一个新现象，应进一步评估其机制及其对 Medicare-VA 双重使用者的影响。
