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A recent study investigates polypharmacy in people with dementia. Elena Eliachevitch/Getty Images
  • Experts say that older adults with dementia should limit the number of medications they take that act on the brain and central nervous system (CNS).
  • Using three or more such medications together places an individual at higher risk of adverse outcomes.
  • A study finds that nearly 1 in 7 older people with dementia who do not live in a nursing home take three or more of these medications.
  • The study examines the prescriptions that doctors have written for 1.2 million people with dementia.

Experts are clear that people aged 65 years or older should not simultaneously take three or more medicines that target the brain or CNS.

Such drugs often interact, potentially accelerating cognitive decline and increasing the risk of injury and death.

This guidance is especially relevant to people with dementia, who often take multiple pharmaceuticals to address their symptoms.

A recent study involving people with dementia found that almost 1 in 7 of the participants are taking three or more brain and CNS medications, despite experts’ warnings.

While the United States government regulates the dispensing of such medication in nursing homes, there is no equivalent oversight for individuals living at home or in assisted-living residences. The recent study focused on individuals with dementia who are not living in nursing homes.

The lead author of the study, geriatric psychiatrist Dr. Donovan Maust of the University of Michigan (UM) in Ann Arbor, explains how an individual can end up taking too many medications:

“Dementia comes with lots of behavioral issues, from changes in sleep and depression to apathy and withdrawal, and providers, patients, and caregivers may naturally seek to address these through medications.”

Dr. Maust expresses concern that too frequently, doctors prescribe too many medications. “It appears that we have a lot of people on a lot of medications without a very good reason,” he says.

The study paper appears in JAMA.

For the study, UM researchers examined the prescription of sleep medications, antipsychotics, antidepressants, opioid pain relievers, and anti-seizure drugs for nearly 1.2 million people with dementia, using their 2018 Medicare records.

While younger people may safely use these medications together, the concern is that age-related and dementia-related changes in brain chemistry may result in undesirable interactions.

Of the people in the study, 13.9% took three or more CNS-related medications for more than 1 month, which the study authors describe as “CNS-active polypharmacy.”

Prescriptions for these medications were common, with 831,017 individuals having received at least one of the drugs at least once during the year. Almost half of those studied — 535,180 — took one or two of these medications for more than 1 month.

In the CNS-active polypharmacy group, 92% took the most commonly prescribed class of drugs: antidepressants.

Anti-seizure medications were also common, with 62% of those in the CNS-active polypharmacy group taking them. Gabapentin (Neurontin), an epilepsy drug, dominated this category, with its prescribed use accounting for a third of all the days in the study period. The authors of the study suggest that this is for the drug’s known off-label use for pain and anxiety control.

About 41% of the CNS-active polypharmacy group also had prescriptions for benzodiazepines, such as lorazepam (Ativan).

A significant number of people taking three or more CNS medications in the study (47%) took antipsychotics.

Antipsychotics are not among the approved medications for dementia, but doctors may prescribe them, says Dr. Maust, to help manage agitation, sleep issues, and other problems. The most frequently prescribed antipsychotic in the study was quetiapine (Seroquel).

Dr. Maust notes the need for doctors to make a convincing case for the simultaneous prescribing of multiple brain and CNS medications. He states that “the evidence supporting the use of many of them in people with dementia is pretty thin, while there is a lot of evidence about the risks, especially when there are multiple medications layered on top of one another.”

Dr. Maust and his colleagues suggest that increased drug reviews by medical professionals could help identify negative interactions when people use three or more brain and CNS drugs together.

The current lack of information on the use of these drugs in dementia often leaves doctors in the position of having to make a difficult judgment call.

Doctors sometimes write prescriptions, says Dr. Maust, in hopes of helping an individual manage symptoms and thus avoid the need for long-term care. Avoiding this care is a particular aim during the COVID-19 pandemic, as long-term facilities have experienced high mortality rates.

Doctors may also prescribe medications to spare family members from witnessing distressing behaviors in a loved one who has dementia.

Dr. Maust suggests that families may have an expanded role to play in helping refine an individual’s treatment plan by keeping the doctor informed about any changes that they witness in the person’s symptoms and behavior.