Medications that may adversely affect cognition in older patients were disproportionately initiated following acute or postacute care encounters compared with overall visit patterns, and many patients continued a medication in the same class 1 year later, according to a cross-sectional study published in JAMA Network Open.
Researchers analyzed Health and Retirement Study data linked to Medicare fee-for-service claims, including Part D prescription fills, from 2008 to 2021. The study included community-dwelling patients aged 66 years or older who had continuous Medicare Parts A, B, and D enrollment for at least 2 years and no prescription for the relevant medication class in the prior year.
The analysis included 4955 new medication-class initiations, representing an estimated 23.4 million first prescriptions among Medicare beneficiaries from 2009 to 2021. Medication classes from the Beers Criteria included benzodiazepines, nonbenzodiazepine hypnotics, antipsychotics, and anticholinergics. Patients were categorized as having no cognitive impairment; cognitive impairment, not dementia; or dementia.
Researchers inferred the initiation setting from the last clinical encounter before the first prescription fill. Acute or postacute settings included emergency department, inpatient, and skilled nursing facility encounters; office visits were the comparator.
Across all medication classes, 14% of patients with no cognitive impairment, 17% of patients with cognitive impairment, not dementia, and 22% of patients with dementia had initiations following acute or postacute care. Among patients with dementia who initiated antipsychotics, 43% had their most recent encounter in an acute or postacute setting, compared with 22% of their overall visits occurring in those settings.
Same-class medication use 1 year later was also common. Overall, 38% of patients with no cognitive impairment, 44% of patients with cognitive impairment, not dementia, and 51% of patients with dementia continued a medication in the same class. Among patients with dementia who initiated antipsychotics, 67% continued an antipsychotic-class medication 1 year later.
Adjusted analyses accounted for age, sex, race and ethnicity, socioeconomic indicators, year of initiation, cognitive status, medication class, and the interaction between cognitive status and medication class. The persistence analysis was limited to patients continuously enrolled in Medicare for the year after initiation.
The findings should be interpreted cautiously. The claims-based design could not confirm that the most recent encounter was the actual prescribing site, identify the prescribing clinician, determine clinical indication or appropriateness, or establish causality. The study also did not assess whether patients used the medications continuously throughout the year.
Still, the results suggest that transitions from acute or postacute care may be important points for medication review, particularly among patients with cognitive impairment or dementia.
“Efforts to reduce prescriptions of medications affecting cognition might have the greatest impact targeting prescriptions from acute or postacute settings,” wrote lead study researcher Dan P. Ly, MD, of VA Greater Los Angeles, and colleagues.
Disclosures: The study was funded by the National Institute on Aging, the US Department of Veterans Affairs Health Systems Research, and the National Center for Advancing Translational Sciences. Damberg reported receiving National Institute on Aging grants. Mafi reported grants from Arnold Ventures and the Commonwealth Fund, nonfinancial support from Milliman MedInsight, and unpaid consulting for the Agency for Healthcare Research and Quality. No other disclosures were reported.
Source: JAMA Network
