We wrote a new thing out in @JAMA_current examining the mind-bogglingly high rate of psychotropic and opioid use among older adults with #dementia in the community:
https://jamanetwork.com/journals/jama/article-abstract/2769458
Prescribing in long-term care settings has received a ton of research and policy attention, but in the community? Not so much. And yet from patients I see and anecdata from family friends, lots of prescribing in the community is definitely a thing.
So we looked at everybody in Medicare ≥65 with dementia who had Part D prescription drug coverage. We used the @AGSJournal Beers Criteria construct of "CNS-active" (as in central nervous system) meds, which covers psychotropics + opioids. What did we find?
Lots of prescribing--as in, 73.5% of all adults with dementia. Antidepressants the most (49.8%), followed by opioids (29.8%)
And here are the individual meds. Opioids are at the top of the list, but for relatively shorter duration. @DavidJuurlink might be interested to see that tramadol is #2 on the list. I know it's his favorite.
And another puzzler is gabapentin, at #5 on the list. From @mikejohansenmd work ( https://pubmed.ncbi.nlm.nih.gov/29297045/ ) we know use has been going up, but how on earth to justify this much use? Probably lots of off-label use for pain, but not great evidence ( https://pubmed.ncbi.nlm.nih.gov/30907944/ ).
Gabapentinoid Use in the United States 2002 Through 2015 - PubMed

This cohort study uses 2002-2015 Medical Expenditure Panel Survey data to characterize the use of gabapentinoids among the US adult population.

https://pubmed.ncbi.nlm.nih.gov/29297045/
Why should we care? There is very slim evidence that these medications are helpful for behavioral problems in dementia: https://pubmed.ncbi.nlm.nih.gov/25731881/ 
Assessment and management of behavioral and psychological symptoms of dementia - PubMed

Behavioral and psychological symptoms of dementia include agitation, depression, apathy, repetitive questioning, psychosis, aggression, sleep problems, wandering, and a variety of inappropriate...

https://pubmed.ncbi.nlm.nih.gov/25731881/
In contrast, they are associated with a host of harms, including:
death ( https://pubmed.ncbi.nlm.nih.gov/16234500/ )
worse cognition ( https://pubmed.ncbi.nlm.nih.gov/19207141/ , https://pubmed.ncbi.nlm.nih.gov/21572163/ )
falls ( https://pubmed.ncbi.nlm.nih.gov/19933955/ )
Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized...

Atypical antipsychotic drugs may be associated with a small increased risk for death compared with placebo. This risk should be considered within the context of medical need for the drugs, efficacy...

https://pubmed.ncbi.nlm.nih.gov/16234500/
It is basically impossible that the net benefit of all this prescribing outweighs the harms.

Thanks to co-authors Strominger, Bynum, Langa, @LaurenGerlach, @zivin, Steve Marcus and @Alzheimers_NIH for supporting out work.
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