Acetylcholinesterase or N-methyl-D-aspartate (NMDA) receptor antagonists may be utilized as preemptive medication before a formal diagnosis of Alzheimer disease and related dementias (ADRDs), according to study findings published in JAMA Network Open.

Nearly 5 million adults in the US have ADRDs, which affects both cognition and function. Changes in memory, decision-making, behavior, mood, depression, and anxiety are among the symptoms patients with ADRD experience, and typically, they’re pharmacologically managed, the researchers explained. The objective of the current study was to examine prescription drug fills for cognitive and behavioral symptoms of ADRD among patients enrolled in Medicare Advantage Part D (MAPD).

The researchers, affiliated with UnitedHealth group, analyzed OptumLabs medical and pharmacy claims data and identified adult patients enrolled in MAPD who were aged at least 65 years at ADRD diagnosis. They included individuals with more than 1 claim with primary, secondary, or tertiary ADRD code between January 2016 and October 2021 and at least 2 ADRD codes during the study period, with at least 1 year of enrollment before and after ADRD diagnosis. Individuals in long-term care facilities were excluded.


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The researchers analyzed data of 161,368 US individuals (aged median 83 years; 62.2% women; 79.2% White).

They found that acetylcholinesterase inhibitor fills increased from 15.3% prior to diagnosis to 35.5% after diagnosis. Fifty-three percent of fills were made by individuals with AD. NDMA receptor agonist fills roughly tripled (5.8% to 16.6%).

Antipsychotic fills rose from 5.6% to 12.8%. They more than doubled among individuals with Lewy body dementia (LBD) (12.2% to 29.7%).

Mood stabilizers and anticonvulsants rose about 3 percentage points. These prescription fills were most common among patients with Parkinson disease (24%), vascular dementias (21.2%), and LBD (20.1%).

The most common drugs used for behavioral and psychological symptoms of dementia (BPSD) were antidepressants (19.4% to 24.2%), especially among patients with frontotemporal dementia (21.1% to 30.6%) and LBD (23.4% to 28.9%).

Use of benzodiazepines and sedative-hypnotic-Z-drugs did not change significantly from before to after diagnosis.

Study limitations included the fact that the sample did not represent all US payers or individuals without insurance and the lack of distinction among dementia subtypes or off-label use for BPSD or on-label use for comorbidities. Also, fills may not accurately reflect prescriptions written or medication adherence.

“Evidence of polypharmacy (median, 11 prescriptions postdiagnosis) suggests opportunities to simplify medication regimens and minimize Beers criteria medications,” the researchers stated. Moreover, there is a need for ADRD care coordination across clinician specialties, they added.

“Primary care clinicians are uniquely positioned to manage complex medical regimens from multiple specialist consultants. Using evidenced-based recommendations, giving specific attention to deprescribing, may be associated with improved outcomes and reduced harm,” the researchers concluded.

Disclosure: All study authors declared affiliations with UnitedHealth Group. Please see the original reference for a full list of authors’ disclosures. 

Reference

Bangerter LR, Clark CN, Jarvis MS, et al. Medication fill patterns for cognitive and behavioral or psychological symptoms of Alzheimer disease and related dementias. JAMA Network Open. Published online June 1, 2022. doi:10.1001/jamanetworkopen.2022.15678