Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
Harvard Medical School, Boston, Massachusetts.
JAMA Intern Med. 2023 Oct 1;183(10):1098-1108. doi: 10.1001/jamainternmed.2023.3575.
Dementia is a life-altering diagnosis that may affect medication safety and goals for chronic disease management.
To examine changes in medication use following an incident dementia diagnosis among community-dwelling older adults.
DESIGN, SETTING, AND PARTICIPANTS: In this cohort study of adults aged 67 years or older enrolled in traditional Medicare and Medicare Part D, patients with incident dementia diagnosed between January 2012 and December 2018 were matched to control patients based on demographics, geographic location, and baseline medication count. The index date was defined as the date of first dementia diagnosis or, for controls, the date of the closest office visit. Data were analyzed from August 2021 to June 2023.
Incident dementia diagnosis.
The main outcomes were overall medication counts and use of cardiometabolic, central nervous system (CNS)-active, and anticholinergic medications. A comparative time-series analysis was conducted to examine quarterly changes in medication use in the year before through the year following the index date.
The study included 266 675 adults with incident dementia and 266 675 control adults; in both groups, 65.1% were aged 80 years or older (mean [SD] age, 82.2 [7.1] years) and 67.8% were female. At baseline, patients with incident dementia were more likely than controls to use CNS-active medications (54.32% vs 48.39%) and anticholinergic medications (17.79% vs 15.96%) and less likely to use most cardiometabolic medications (eg, diabetes medications, 31.19% vs 36.45%). Immediately following the index date, the cohort with dementia had a greater increase in mean number of medications used (0.41 vs -0.06; difference, 0.46 [95% CI, 0.27-0.66]) and in the proportion of patients using CNS-active medications (absolute change, 3.44% vs 0.79%; difference, 2.65% [95% CI, 0.85%-4.45%]) owing to an increased use of antipsychotics, antidepressants, and antiepileptics. The cohort with dementia also had a modestly greater decline in use of anticholinergic medications (quarterly change in use, -0.53% vs -0.21%; difference, -0.32% [95% CI, -0.55% to -0.08%]) and most cardiometabolic medications (eg, quarterly change in antihypertensive use: -0.84% vs -0.40%; difference, -0.44% [95% CI, -0.64% to -0.25%]). One year after diagnosis, 75.2% of the cohort with dementia were using 5 or more medications (2.8% increase).
In this cohort study of Medicare Part D beneficiaries, following an incident dementia diagnosis, patients were more likely to initiate CNS-active medications and modestly more likely to discontinue cardiometabolic and anticholinergic medications compared with the control group. These findings suggest missed opportunities to reduce burdensome polypharmacy by deprescribing long-term medications with high safety risks or limited likelihood of benefit or that may be associated with impaired cognition.
痴呆症是一种改变生活的诊断，可能会影响药物安全和慢性病管理目标。
研究在社区居住的老年人群中发生痴呆症后药物使用的变化。
设计、地点和参与者：在这项针对参加传统医疗保险和医疗保险 D 部分的 67 岁或以上成年人的队列研究中，在 2012 年 1 月至 2018 年 12 月期间诊断出的患有新发痴呆症的患者根据人口统计学、地理位置和基线药物计数与对照患者相匹配。索引日期定义为首次痴呆症诊断的日期，或对照患者的最近一次就诊日期。数据于 2021 年 8 月至 2023 年 6 月进行分析。
新发痴呆症诊断。
主要结果是总体药物计数以及使用心血管代谢、中枢神经系统 (CNS)-活性和抗胆碱能药物的情况。进行了比较时间序列分析，以检查索引日期前一年至后一年的药物使用季度变化。
这项研究包括 266675 名患有新发痴呆症的成年人和 266675 名对照成年人；两组中，65.1%的人年龄在 80 岁或以上（平均[标准差]年龄 82.2[7.1]岁），67.8%为女性。基线时，新发痴呆症患者比对照组更有可能使用 CNS-活性药物（54.32%比 48.39%）和抗胆碱能药物（17.79%比 15.96%），而不太可能使用大多数心血管代谢药物（例如，糖尿病药物，31.19%比 36.45%）。在索引日期后立即，痴呆症患者组使用的平均药物数量增加（0.41 比 -0.06；差值，0.46[95%CI，0.27-0.66]），使用 CNS-活性药物的患者比例增加（绝对变化，3.44%比 0.79%；差值，2.65%[95%CI，0.85%-4.45%]），原因是抗精神病药、抗抑郁药和抗癫痫药的使用增加。痴呆症患者组还适度减少了抗胆碱能药物的使用（使用量每季度变化，-0.53%比 -0.21%；差值，-0.32%[95%CI，-0.55%至-0.08%]）和大多数心血管代谢药物（例如，每季度降压药使用量变化：-0.84%比 -0.40%；差值，-0.44%[95%CI，-0.64%至-0.25%]）。诊断后一年，痴呆症患者组中有 75.2%的患者使用 5 种或更多药物（增加 2.8%）。
在这项医疗保险 D 部分受益人的队列研究中，与对照组相比，在诊断出新发痴呆症后，患者更有可能开始使用 CNS-活性药物，并且更有可能适度减少心血管代谢和抗胆碱能药物的使用。这些发现表明，通过停止使用具有高安全风险或获益有限或可能与认知障碍相关的长期药物，错过了减少负担过重的多药治疗的机会。
