Emergency settings more likely to initiate risky medications for seniors

Initial prescriptions for medications affecting cognition, such as antipsychotics, are disproportionately likelier to come from acute and post-acute settings such as emergency rooms, hospitals and skilled nursing facilities than they are from doctors' offices, new UCLA research suggests.

The largest proportion of these medications are prescribed for people with cognitive impairment, such as dementia, who are particularly susceptible to ill effects linked to these medications such as falls, confusion, and hospitalization.

Medications such as antipsychotics and benzodiazepines are known to affect cognition, increase delirium, and increase fall risk for older adults. In addition, prescriptions for these medications are "sticky" and persistent; for example, for older adults with dementia who are prescribed one of these medications affecting cognition, over half continue to take such a medication a year later."

Dr. Dan Ly, assistant professor of medicine, division of general internal medicine and health services research at the David Geffen School of Medicine at UCLA and the VA Greater Los Angeles and the lead author on the research letter

The findings will be published April 28 in the peer-reviewed journal JAMA Network Open.

There has been a push to reduce prescriptions of these cognition-altering medications, Ly said. "Our results suggest that efforts to reduce these prescriptions might have the greatest impact if we focus on acute and post-acute settings," he said.

The researchers analyzed data from the Health and Retirement Study (HRS) of adults aged 66 years and older linked to Medicare fee-for-service claims between Jan. 1, 2008 to Dec. 31, 2021. They looked at four medication classes: benzodiazepines, nonbenzodiazepine hypnotics, antipsychotics and anticholinergics. They examined the clinical setting where the prescription was first initiated, comparing initiations from acute and post-acute settings (that also included skilled nursing facilities) with initiations from doctors' offices.

Patients were grouped into one of three categories: No cognitive impairment; cognitive impairment, but not dementia (CIND); or dementia.

Overall, 14% of patients with no cognitive impairment, 17% of those with CIND, and 22% of people with dementia received a new prescription for one of the cognition affecting medications in acute and post-acute settings. Additionally, 38% of those with no cognitive impairment, 44% of those with CIND, and 51% of those with dementia continued using those medications a year later.

Compared with overall patient visits to such settings, a disproportionate number of these prescriptions were initiated in acute and post-acute settings. For instance, 43% of antipsychotic medications were initiated in acute and post-acute settings for patients with dementia while only 22% of overall patient visits were to such settings for patients with dementia.

"We were surprised by just how much more frequently medications affecting cognition were prescribed from non-office settings," Ly said. "We shed light on the locations of prescriptions for these medications, allowing for better targeting of interventions to reduce their prescribing."

The findings are limited by the researchers' assumption that the last setting the patients were in was where the prescriptions were initiated. The next step in the research is to examine the characteristics of providers who prescribe these medications more frequently, Ly said.

"This work builds on our prior research, which found that up to 70% of prescriptions for Central Nervous System-active medications lacked a documented clinical indication. That highlighted an urgent need to curb risky overprescribing," said Dr. John N. Mafi, associate professor of medicine at the Geffen School and the study's senior author. "Now, our latest study gives policymakers and clinicians a roadmap, pointing exactly to where they should target their interventions first: acute and post-acute care settings."