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"There just is not a lot of evidence that these medications are helpful in people with dementia. When I think about somebody who has dementia and the way the brain is changing, it seems like it's not a great thing to be exposing their brain to these drugs when the brain is already having trouble dealing with the changes going on from the dementia," said study author Dr. Donovan Maust, a geriatric psychiatrist from the University of Michigan and VA Ann Arbor Health System.
"Medications we use in patients of other ages work different in brains with dementia," he added.
Behavior changes are common in people with dementia. They may include irritability, anger or aggression, anxiety, depression or emotional distress, restlessness, delusions or hallucinations, and difficulty sleeping. These behaviors are primarily caused by progressive damage to brain cells. Other possible triggers of behavior issues include medications, environmental factors and other medical conditions, according to the Alzheimer's Association.
Maust said that prescribing practices have been studied in patients with dementia in nursing homes, but there was a lack of information on what types of drugs people with dementia are prescribed if they don't live in a nursing home.
The study included almost 740,000 people with dementia. They were all over 65 (average age was 82) and on Medicare. About 81% were white, 9% were black and 7% Hispanic. Most lived in urban areas.
The researchers found that 73.5% of them were prescribed a central nervous system-active medication, including opioids, antidepressants, antipsychotics, sedatives and anti-epileptic drugs (can be prescribed for pain or in place of an antipsychotic).
Researchers found that half were given an antidepressant -- a rate that's about triple what it is for older adults in the general population, the researchers noted. Maust said doctors may prescribe these when someone shows signs of withdrawal or apathy, but in dementia patients, those signs may be due to dementia, not depression.
"Initiation of activity and enjoyment of the activity isn't the same in someone with dementia, but it's easy to look at those symptoms and think they're depressed," Maust said.
Many of these drugs can raise risk of falls
The concern in taking an antidepressant is that they may make someone with dementia feel jittery. But patients also may have trouble telling a caregiver how they're feeling, which may make them seem agitated or angry. And that, Maust said, may then lead to another prescription to calm them down.
Thirty percent of the group was given an opioid prescription, though the researchers said these tended to be short-term prescriptions that were probably for acute pain.
Twenty-seven percent were given sedatives, 22% were given anti-epileptics and 22% were given prescriptions for antipsychotics.
In addition to potentially not helping someone with dementia, many of these medications come with a risk of falls, a common concern for all older adults.
So, why are these medications still being prescribed?
"I think it really speaks to how challenging dementia is to take care of. Many clinicians haven't had a lot of training specifically in dementia. Doctors are just trying to provide good care, and sometimes it feels as if we're not prescribing something, we're not helping. But doctors can help with listening, supporting and helping people get psychosocial support," Maust explained.
Rebecca Edelmayer is director of scientific engagement for the Alzheimer's Association. "There is an urgent need for more options. Behavioral and psychological symptoms can be very frustrating. Physicians are using what they have available to treat these symptoms," she said.
"It's not that physicians aren't well-intentioned, but not all psychoactive medications may be beneficial, and the risks may outweigh the benefits," said Edelmayer, who wasn't part of the study.
She said "person-centered care" is crucial. Before prescribing medications, it's important to do a thorough evaluation to see what might be causing someone's symptoms. If possible, try to solve their concerns without medications, but "if medications are the right solution, they should be on the table as a possibility," she said.
Edelmayer said there are a number of ongoing clinical trials for treatments of the psychological and behavioral symptoms of dementia. "There a lot of promise in the therapeutic pipeline," she said.
In the meantime, Maust said, "Caregivers should look at the list of medications that a loved one is taking and review it with the doctor. Think about whether something is helpful or not, and whether the drug could be used at a lower dose, or if someone should be tapered off it. Any kind of simplifying you can do to minimize medications for older adults is almost certainly safer."
The findings were published as a letter in the Aug. 18 Journal of the American Medical Association.
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