Drugs 'wildly over-prescribed' for dementia, study finds

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People with dementia are far better off with non-drug treatments than the medications most commonly prescribed, according to a new Australian study.

The Australian reports that up to 48 per cent of the 100,000 aged care residents living with dementia are being prescribed antipsychotic drugs.

“More than half of those prescriptions have been found to be potentially inappropriate, raising questions about whether they are a form of ‘chemical restraint’.”

The report’s lead author, Associate Professor Stephen Macfarlane, said the study proved the impact of non-pharmaceutical treatments for nursing home residents with dementia “dwarfs that of antipsychotics”.

“It is real evidence of what should get traction in the future in terms of treatment options, but the majority of aged care residents with dementia are still prescribed antipsychotics.

“They are being wildly overprescribed.

“Estimates are that only 10 per cent of this prescribing is appropriate,” Dr Macfarlane said.

“It is often the case [that] there is a lack of efficacy and high rates of adverse effects, including falls, sedation and death.”

Dr Macfarlane was part of the world’s largest population-based study of dementia behaviour, examining 6000 Australians living with dementia in 2000 nursing homes.

It found that “almost all behaviours and psychological symptoms of dementia” could be best treated by non-pharmacological treatments. This includes “agitation, aggression, anxiety, delusions, hallucinations and disinhibition”.

The interventions that worked better than drugs included cognitive stimulation, activity planning and encouraging reminiscence, occupational therapy, aromatherapy and music therapy.

Read more: The link between sleep and dementia

A recent study published in the BMJ concluded that “non-drug interventions were found to be more efficacious than drug interventions for reducing symptoms of depression in people with dementia without a major depressive disorder”.

Examples of such treatments included massage, touch therapy and exercise.

So-called ‘social prescribing’ is gaining a foothold as more concerns arise over the prescribing of drugs to the elderly.

Study co-author Zahra Goodarzi, geriatrician and assistant professor of medicine at the University of Calgary, Canada, said: “The problem with prescribing medications in this patient population is that medications are associated with potentially catastrophic side-effects.

“Non-medication strategies, including animal therapy, exercise, cognitive stimulation, multidisciplinary care and reminiscence therapy, among others, reduce symptoms of depression in people with dementia in a clinically meaningful way,” she said.

“I hope to write many more prescriptions for non-medication interventions.”

Read more: Program improves cognition of people at risk of dementia

The Americans aren’t being left out. Last year, a US study found 73 per cent of older adults with dementia were being prescribed drugs that weren’t designed for dementia. In a one-year period, this included antidepressants, opioid painkillers, epilepsy drugs, anxiety medications and antipsychotics.

The University of Michigan Medicine website says the drugs were given to “community-dwelling” adults despite the special risks that such drugs carry for older adults and the lack of evidence that they actually ease dementia-related behaviour problems.

Some of the drugs prescribed have been linked to “worse cognitive symptoms” in older adults.

The rate of antidepressant prescribing was nearly triple the rate for older adults overall.

“Clinicians and caregivers may need more support to provide non-drug-based approaches to prevent or address the symptoms that these medications are probably being prescribed for,” said lead author Dr Donovan Maust, a geriatric psychiatrist at the University of Michigan.

“A brain that has dementia is doing its best to function as well as it can,” he explains. “If we add a psychotropic medication into the mix it may not be a helpful thing – and it comes with risks.”

All the prescribed drugs are associated with special risks to people aged 60 and older, including falls or “dependence that could lead to withdrawal”.

Side-effects include nausea or feeling “jittery”.

People with dementia might have difficulty explaining such side-effects to carers.

“Instead, they may appear more agitated – leading to another prescription medication to calm them.”

Dr Macfarlane says that in Australia part of the problem is staff and doctor education.

“Aged care staff are stretched at the best of times and they are under-trained for the complexities of offering these therapies, even if they have the time, which they don’t,” Dr Macfarlane said.

“Doctors are taught very little about dementia while they study, and GPs do no extra training in the field. Doctors are generally called on to prescribe, so that’s what they tend to do.”

In February, Dr Macfarlane and Dementia Centre director Associate Professor Colm Cunningham called for aged care providers and clinical teams to “ensure the prescribing of antipsychotics to people with dementia includes a plan to discontinue the drugs”.

Read more: How to reduce your risk of dementia

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Written by Will Brodie



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