Prescribing without a guide: A national study of psychotropic and opioid polypharmacy among persons living with dementia

PROJECT ABSTRACT The U.S. health care system is poorly equipped to deal with the growing number of persons living with dementia (PLWD) in the U.S. and their complex medical and psychosocial needs. While memory impairment is the cardinal feature of Alzheimer’s disease and related dementias (ADRD), behavioral and psychological symptoms (e.g., apathy, delusions, agitation) are common during all stages of illness and cause significant caregiver distress. Despite limited high-quality evidence of efficacy for pharmacological treatment, our work has shown that clinicians prescribe psychotropic medications to community-dwelling PLWD at rates that far exceed use in the general older adult population. Unfortunately, this includes a high burden of psychotropic and opioid (central nervous system [CNS]- active) polypharmacy (i.e., overlapping use of ≥3 medications from among antidepressants, antipsychotics, antiepileptics, benzodiazepines, nonbenzodiazepine benzodiazepine receptor agonist hypnotics, or opioids)— which is considered potentially inappropriate for older adults given serious associated risks including fall-related injury, impaired cognition, and respiratory suppression or death when involving opioids. Goal C-1 of the NIA’s Strategic Directions for Research highlights the need to improve safe use of medications for older adults, while the NIA ADRD Milestone 8.A Summit noted “a research and policy vacuum for interventions specifically aimed at improving life for persons with ADRD.” Minimizing CNS polypharmacy is a critical opportunity to improve safe medication use for PLWD, both through preventing new CNS polyRx and deprescribing—i.e., identifying and discontinuing drugs [where] existing or potential harms outweigh existing or potential benefits—among PLWD already exposed. However, the design of interventions to reduce CNS polypharmacy cannot proceed without understanding why clinicians decide to prescribe these medications. In this explanatory mixed methods study, we will first characterize patient characteristics associated with incident and continued CNS polyRx in a unique cohort of all community-dwelling Medicare beneficiaries living with dementia in the U.S., combining both traditional and managed Medicare. We will use these Medicare data to profile the CNS prescribing of the clinicians that care for these PLWD, and then, through a national survey and detailed follow-up qualitative interviews, we will characterize the prescribing decision-making process, including the underlying knowledge, norms, facilitators, and barriers associated with prescribing intent. Finally, with input from a multidisciplinary Expert Panel including a PLWD-caregiver dyad, we will identify critical remaining knowledge gaps and possible intervention targets. With the new insights gained, we will chart a way forward to address the critical but previously underrecognized challenge of potentially inappropriate CNS polypharmacy among PLWD living in the community.