Neuropsychiatric symptoms affect the majority of dementia patients. Past studies report high rates of potentially inappropriate prescribing of psychotropic medications in this population. We investigate differences in neuropsychiatric diagnoses and psychotropic medication prescribing in a local US cohort by sex and race.
Methods
We utilize Medicare claims and prescription fill records in a cohort of 100% Medicare North and South Carolina beneficiaries ages 50 and above for the year 2017 with a dementia diagnosis. We identify dementia and quantify diagnosis of anxiety, depression and psychosis using validated coding algorithms. We search Medicare claims for antianxiety, antidepressant and antipsychotic medications to determine prescriptions filled.
Results
Anxiety and depression were diagnosed at higher rates in White patients; psychosis at higher rates in Black patients. (P < .001) Females were diagnosed with anxiety, depression and psychosis at higher rates than males (P < .001) and filled more antianxiety and antidepressant medications than males. (P < .001) Black and Other race patients filled more antipsychotic medications for anxiety, depression and psychosis than White patients. (P < .001) Antidepressants were prescribed at higher rates than antianxiety or antipsychotic medications across all patients and diagnoses. Of patients with no neuropsychiatric diagnosis, 11.4% were prescribed an antianxiety medication, 22.8% prescribed an antidepressant and 7.6% prescribed an antipsychotic.
Conclusions
The high fill rate of antianxiety (benzodiazepine) medications in dementia patients, especially females is a concern. Patients are prescribed psychotropic medications at high rates. This practice may represent potentially inappropriate prescribing. Patient/caregiver education with innovative community outreach and care delivery models may help decrease medication use.
O'MahonyDGallagherPF. Inappropriate prescribing in the older population: need for new criteria. Age Ageing. 2008;37(2):138-141. doi:10.1093/ageing/afm189
2.
DelgadoJBowmanKClareL. Potentially inappropriate prescribing in dementia: a state-of-the-art review since 2007. BMJ Open. 2020;10(1):e029172. doi:10.1136/bmjopen-2019-029172
3.
SivananthanSNLavergneMRMcGrailKM. Caring for dementia: a population-based study examining variations in guideline-consistent medical care. Alzheimers Dement. 2015;11(8):906-916. doi:10.1016/j.jalz.2015.02.008
4.
By the 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American geriatrics society 2019 updated AGS beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2019;67(4):674-694.
5.
SteinbergMShaoHZandiP, et al.Point and 5-year period prevalence of neuropsychiatric symptoms in dementia: the Cache County Study. Int J Geriatr Psychiatr. 2008;23(2):170-177.
6.
ZahodneLBOrnsteinKCosentinoSDevanandDPSternY. Longitudinal relationships between Alzheimer disease progression and psychosis, depressed mood, and agitation/aggression. Am J Geriatr Psychiatr. 2015;23(2):130-140.
7.
KitamuraTKitamuraMHinoSTanakaNKurataK. Gender differences in clinical manifestations and outcomes among hospitalized patients with behavioral and psychological symptoms of dementia. J Clin Psychiatry.Dec;73(12):1548-1554.
8.
LeeJLeeKJKimH. Gender differences in behavioral and psychological symptoms of patients with Alzheimer's disease. Asian J Psychiatr. 2017;26:124-128.
9.
NagataTNakajimaSShinagawaS, et al.Psychosocial or clinico-demographic factors related to neuropsychiatric symptoms in patients with Alzheimer's disease needing interventional treatment: analysis of the CATIE-AD study. Int J Geriatr Psychiatr. 2017;32(12):1264-1271.
10.
MilaniSACantuPABerensonABKuoYFMarkidesKSRajiMA. Gender differences in neuropsychiatric symptoms among community-dwelling Mexican Americans aged 80 and older. Am J Alzheimers Dis Other Demen. 2021;36:15333175211042958.
11.
ResnickBGalikEMcPhersonRBoltzMVan HaitsmaKKolanowskiA. Gender differences in disease, function, and behavioral symptoms in residents with dementia. West J Nurs Res. 2021;28:1939459211018822.
12.
LennonJCAitaSLBeneVAD, et al.Black and White individuals differ in dementia prevalence, risk factors, and symptomatic presentation. Alzheimers Dement. 2021;18(8):1461-1471.
13.
CohenCIMagaiC. Racial differences in neuropsychiatric symptoms among dementia outpatients. Am J Geriatr Psychiatr. 1999;7(1):57-63.
14.
KovalevaMAHigginsMDietrichMS, et al.Characteristics associated with neuropsychiatric symptoms in persons living with dementia and caregiver distress and diminished well-being. Journal of the American Association of Nurse Practitioners. 9000;34(4):656-665.
15.
MogaDCTaipaleHTolppanenAM, et al.A comparison of sex differences in psychotropic medication use in older people with alzheimer's disease in the US and Finland. Drugs Aging. 2017;34(1):55-65. doi:10.1007/s40266-016-0419-5
16.
QuanHSundararajanVHalfonP, et al.Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care. 2005;43(11):1130-1139.
17.
CochranGGordonAJLo-CiganicWH, et al.An examination of claims-based predictors of overdose from a large medicaid program. Med Care. 2017;55(3):291-298.
18.
WaldoDR. Accuracy and bias of race/ethnicity codes in the medicare enrollment database. Health Care Financ Rev. 2004;26:61-72.
19.
LivingstonGHuntleyJSommerladA, et al.Dementia prevention, intervention, and care: 2020 report of the Lancet Commission. Lancet. 2020;396(10248):413-446.
20.
DudasRMaloufRMcCleeryJDeningT. Antidepressants for treating depression in dementia. Cochrane Database Syst Rev. 2018;8:CD003944.
21.
SchneiderLSTariotPNDagermanKS, et al.Effectiveness of atypical antipsychotic drugs in patients with Alzheimer's disease. N Engl J Med. 2006;355(15):1525-1538.
22.
SchneiderLSDagermanKSInselP. Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials. JAMA. 2005;294(15):1934-1943.
23.
MuellerCHuntleyJStubbsB, et al.Associations of neuropsychiatric symptoms and antidepressant prescription with survival in alzheimer's disease. J Am Med Dir Assoc. 2017;18(12):1076-1081. doi:10.1016/j.jamda.2017.07.001
24.
DrummondNMcClearyLFreiheitE, et al.Antidepressant and antipsychotic prescribing in primary care for people with dementia. Can Fam Physician. 2018;64(11):e488-e497.
25.
HamedaniAGWeintraubDWillisAW. Medicare claims data underestimate hallucinations in older adults with dementia. Am J Geriatr Psychiatr. 2022;30(3):352-359. doi:10.1016/j.jagp.2021.07.018
26.
DyerAHMurphyCLawlorBKennellySPNILVAD Study Group. Cognitive outcomes of long-term benzodiazepine and related drug (BDZR) use in people living with mild to moderate alzheimer's disease: results from NILVAD. J Am Med Dir Assoc. 2020;21(2):194-200.
27.
MarkotaMRummansTABostwickJMLapidMI. Benzodiazepine use in older adults: dangers, management, and alternative therapies. Mayo Clin Proc. 2016;91(Issue 11):1632-1639.
28.
SinkKMCovinskyKENewcomerRYaffeK. Ethnic differences in the prevalence and pattern of dementia-related behaviors. J Am Geriatr Soc. 2004;52(8):1277-1283.
29.
CohenCIMcKenzieSERahmaniMSinghJProspereE. Historical changes in the severity of dementia and accompanying neuropsychiatric symptoms in persons presenting for evaluation in a multiracial urban dementia center. Alzheimer Dis Assoc Disord. 2012;26(4):352-357.
30.
LaVeistTAIsaacLAWilliamsKP. Mistrust of health care organizations is associated with underutilization of health services. Health Serv Res. 2009;44(6):2093-2105.
31.
Lillie-BlantonMBrodieMRowlandDAltmanDMcIntoshM. Race, ethnicity, and the health care system: public perceptions and experiences. Med Care Res Rev. 2000;57(Suppl 1):218-235.
32.
Duran-KiraçGUysal-BozkirÖUittenbroekRvan HoutHBroese van GroenouMI. Accessibility of health care experienced by persons with dementia from ethnic minority groups and formal and informal caregivers: a scoping review of European literature. Dementia. 2022;21(2):677-700.
33.
NielsenTRNielsenDSWaldemarG. Barriers to post-diagnostic care and support in minority ethnic communities: a survey of Danish primary care dementia coordinators. Dementia. 2020;19(8):2702-2713.
34.
ArandaMPKremerINHintonL, et al.Impact of dementia: health disparities, population trends, care interventions, and economic costs. J Am Geriatr Soc. 2021;69(7):1774-1783.
35.
LaneNELingVGlazierRHStukelTA. Primary care physician volume and quality of care for older adults with dementia: a retrospective cohort study. BMC Fam Pract. 2021;22(1):51.
36.
PowellDSKuoPLQureshiR, et al.The relationship of APOE ε4, race, and sex on the age of onset and risk of dementia. Front Neurol. 2021;12:735036.
37.
UngarLAltmannAGreiciusMD. Apolipoprotein E, gender, and Alzheimer's disease: an overlooked, but potent and promising interaction. Brain Imaging Behav. 2014;8(2):262-273.
38.
IsmailZCreeseBAarslandD, et al.Psychosis in Alzheimer disease — mechanisms, genetics and therapeutic opportunities. Nat Rev Neurol. 2022;18:131-144.
39.
TaoYPetersMEDryeLT, et al.Sex differences in the neuropsychiatric symptoms of patients with alzheimer's disease. Am J Alzheimers Dis Other Demen. 2018;33(7):450-457.
40.
XingYTangYJiaJ. Sex differences in neuropsychiatric symptoms of alzheimer's disease: the modifying effect of apolipoprotein E ε4 status. Behav Neurol. 2015;2015:275256.
41.
OlfsonMKingMSchoenbaumM. Benzodiazepine use in the United States. JAMA Psychiatr. 2015;72(2):136-142. doi:10.1001/jamapsychiatry.2014.1763
42.
MaclaganLCMaxwellCJHarrisDA, et al.Sex differences in antipsychotic and benzodiazepine prescribing patterns: a cohort study of newly admitted nursing home residents with dementia in ontario, Canada. Drugs Aging. 2020;37(11):817-827.
43.
RochhonPAPetrovicMCherubiniA, et al.Polypharmacy, inappropriate prescribing, and deprescribing in older people: through a sex and gender lens. The Lancet Healthy Longevity. 2021;2(5):E290-E300.
44.
XiongGLFilshteinTBeckettLAHintonL. Antipsychotic use in a diverse population with dementia: a retrospective review of the national alzheimer's coordinating center database. J Neuropsychiatry Clin Neurosci. 2015;27(4):326-332.
45.
RothenbergKGRajaramR. Advances in management of psychosis in neurodegenerative diseases. Curr Treat Options Neurol. 2019;21(1):3.
46.
GiebelCCationsMDraperBKomuravelliA. Ethnic disparities in the uptake of anti-dementia medication in young and late-onset dementia. Int Psychogeriatr. 2020;2:1-10.
47.
GraceELBurgioLDAllenRSDeCosterJAielloAEAlgaseDL. Caregiver and care recipient characteristics as predictors of psychotropic medication use in community-dwelling dementia patients. Aging Ment Health. 2016;20(12):1297-1304. doi:10.1080/13607863.2015.1075960
48.
SivananthanSPuyatJHMcGrailKM. Variations in self-reported practice of physicians providing clinical care to individuals with dementia: a systematic review. J Am Geriatr Soc. 2013;61:1277-1285.
49.
KjosavikSRRuthsSHunskaarS. Psychotropic drug use in the Norwegian general population in 2005: data from the Norwegian Prescription Database. Pharmacoepidemiol Drug Saf. 2009;18(7):572-578.
50.
LesterPEDharmarajanTSWeinsteinE. The looming geriatrician shortage: ramifications and solutions. J Aging Health. 2020;32(9):1052-1062.
51.
HasanTFTurnbullMTVatzKARobinsonMTMauricioEAFreemanWD. Burnout and attrition: expanding the gender gap in neurology?Neurology. 2019;93(23):1002-1008.
52.
MarcinkowskaMŚniecikowskaJFajkisNPaśkoPFranczykWKołaczkowskiM. Management of dementia-related psychosis, agitation and aggression: a review of the pharmacology and clinical effects of potential drug candidates. CNS Drugs. 2020;34(3):243-268.
53.
KawasCHCorradaMMWhitmerRA. Diversity and disparities in dementia diagnosis and care: a challenge for all of us. JAMA Neurol. 2021;78(6):650-652.
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