From the Journals

Outpatient visits for CNS polypharmacy rising among elderly



The number of outpatient visits for CNS polypharmacy by adults aged 65 and older more than doubled between 2004 and 2013, especially among those who reside in rural areas, results from a large analysis of national data showed.

“With each new revision of the Beers Criteria, the list of psychotropic medications considered potentially inappropriate in the elderly has grown,” researchers led by Donovan T. Maust, MD, wrote in a research letter published online Feb. 13, 2017, in JAMA Internal Medicine. “Opioids have recently been included in a Beers measure of central nervous system polypharmacy. Prescribing related drug combinations also received increased regulatory attention when the U.S. Food and Drug Administration recently ordered a black box warning to alert patients of serious risks, including death, caused by opioids coprescribed with CNS depressants.”

An older woman lying in bed takes medication. iStock/
Dr. Maust of the department of psychiatry at the University of Michigan, Ann Arbor, and his associates analyzed data on 97,910 outpatients aged 65 and older from the National Ambulatory Medical Care Survey (NAMCS) from 2004 through 2013. Patients met Beers CNS polypharmacy criteria if three or more of the following medications were initiated or continued: antipsychotics, benzodiazepines, nonbenzodiazepine benzodiazepine receptor agonists, tricyclic antidepressants, selective serotonin reuptake inhibitors, and opioids. The researchers recorded up to three visit diagnoses and included information collected from NAMCS such as chronic medical conditions, whether psychotherapy was provided or ordered, whether stress management or other mental health counseling services were provided or ordered, and time spent with physician (JAMA Intern Med. 2017 Feb. 13 doi: 10.1001/jamainternmed.2016.9225).

Dr. Maust and his associates found that annual CNS polypharmacy visits by adults 65 years or older increased from 1.50 million in 2004 to 3.68 million in 2013, or 0.6% of visits in 2004 to 1.4% in 2013 (adjusted odds ratio of 3.12; P less than .001). The largest increases were observed among rural visits and those for visits with no mental health or pain diagnoses (aOR of 4.99 and 2.65, respectively.)

More than two-thirds of polypharmacy visits (68%) were by women, and 17% were by those who lived in rural areas. In addition, nearly half of polypharmacy visits studied (46%) included neither mental health nor pain diagnoses. No significant demographic differences were observed between polypharmacy visits with and without opioids. “Older adults have become more open to mental health treatment,” the researchers concluded. “Because of limited access to specialty care and a preference to receive treatment in primary care settings, it is unsurprising that mental health treatment has expanded in nonpsychiatric settings.”

Dr. Maust was supported by the Beeson Career Development Award Program. The other researchers reported having no financial disclosures.

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